Introduction
Ongoing debate about the relevance of the “guideline approach,” vis-a-vis the “pathophysiologic
approach” may never cease.[1]
[2] However, it is disheartening to note that both these stands neglect the most important
people involved in diabetes management: The person with diabetes, the family, and
the treating physician.[3]
The person with diabetes
Each person with diabetes is unique, with an individual personality and background.
These personal characteristics modulate his or her response to the diagnosis of diabetes,
including coping mechanisms, healthcare-seeking behavior, healthcare utilization patterns,
and healthcare acceptance. This individual makeup can never be described adequately
in terms of beta cell function, insulin resistance, and other, newer facets of metabolic
dysfunction.
The bio-psychosocial model of health perhaps, is a more appropriate framework, through
which a person with diabetes can be approached and assessed. The bio-psychosocial
model encompasses not only currently highlighted biological or biochemical variables
but also focuses attention on other equally important aspects of health.[4]
[5]
Individual attitudes towards disease: The perceived severity of illness, the perceived
efficacy and safety of drug therapy, the ability and willingness to make necessary
change in lifestyle, to accept injectable therapy, and to self-monitor blood glucose
at optimal frequency, are equally important in diabetes praxis. The locus of control,
whether external or internal, and ability to communicate with the healthcare provider
also affects initial response to the diagnosis of diabetes.
The healthcare system
Practical concerns, including availability, accessibility, and affordability of health
care, specifically diabetes care, play an important role in deciding management. These
may differ from person to person. The relative availability, accessibility, and affordability
of various components of diabetes care may vary in different healthcare settings.
Some relatively less developed ′pay from pocket′ markets, for example, may allow unhindered
access to diabetes specialists, at low costs, but place a high premium on newer anti-diabetic
drugs. Other ′advanced′ nations may facilitate availability of the latest molecules
for diabetes therapy, but restrict access to specialists through long-waiting lists.
Again, some healthcare settings may offer cheap, easily accessible point of care testing,
even though glucometers for self-monitoring may be expensive. Other health care systems
may provide glucometers and ancillary supplies free of cost to people with diabetes
but regulate or discourage contact with laboratory technicians. This is unfortunate
because these paramedical staff can also be a vehicle for diabetes education. Some
healthcare settings may offer structured diabetes education courses, while in others,
education and counseling is integrated into routine medical care visits.
The family and society
The social environment of the person with diabetes, i.e., his or her family and community
impacts choice of therapy.[6] Examples of ′social modulation′ include motivation to try complementary and alternative
medicines, to practice doctor-shopping, and to incorporate lifestyle modification.
The physician
Apart from these factors, the treating physician too needs mention as factor in choosing
therapy for diabetes. Education, practical training, experience, with various classes
of drugs, exposure to currently guidelines and developments, and peer opinion all
serve to modulate prescription habits. Sulfonylureas may be safe in the hands of a
physician trained and experienced in their judicious use. This may be even safer if
the physician practices patient empowerment to the extent of explaining self-titration
of dose to the patient, to be done in cases of hypoglycemia. The same physician, however,
may not be skilled at using insulin analogues, perhaps because of lack of practical
experience or training.
The cumulative experience and confidence of diabetes care professional in prescribing
a particular molecule, or class of drug, is what we term as “physician′s metabolic
memory.” Individual physician metabolic memory as well as “collective physician metabolic
memory” (including opinion of peers, colleagues, and seniors) plays an important role
in deciding choice of therapy. This fact should not be frowned upon: On the contrary,
it should be encouraged. Optimal choice of pharmacotherapy dose not only entails just
an appropriate initial prescription, it also includes follow up, pharmaco-vigilance,
and careful watch for adverse events. It would be much safer for a person with diabetes
to take a drug whose side effects his or her physician is trained to recognize, rather
than a scenario where a “safer” drug is prescribed without ability for timely recognition
of side effects.
The path of logical empiricism
To bring the debate to a conclusion, we propose yet another approach, based on logical
empiricism. The phrase, logical empiricism, is taken from a school of science philosophy
which flourished in the early and mid-twentieth century. A call for the use of logical
empiricism has been made earlier in diabetology and in allied specialties as well.[7]
[8]
For a diabetes care professional, logical empiricism conveys exactly what it means:
Empirical therapy, based on logic or evidence. The astute diabetes care professional
knows the logic or evidence available, but uses it empirically, to suit the individual
and socio-economic needs of a person with diabetes,[7] In effect, therefore, logical empiricism become a synonym for person-centered care
or individualized/personalized care.
Logical empiricism is an extension of observation-based medicine or experience-based
medicine. Viewing the person with diabetes through a bio-psychosocial prism, the “logically
empirical” or “empirically logical” physician aims to craft a therapeutic regime most
suited for the particular clinical situation. She or he considers the unique background
of the person with diabetes, his or her family, and his or her society while planning
therapy.
From a pharmacological point of view, a few drugs which are extensively used in Asia
deserve mention here. The role of premixed insulin, alpha glucosidase inhibitors,
and sulfonylureas is consistently downplayed by western guidelines. This discrepancy
between practice and guidelines should stimulate discussion and debate. Perhaps Asian
and African diabetologists prescribe these drugs preferentially, because of a “collective
positive metabolic memory,” encouraged by positive therapeutic benefits noted in patients.
In other words, they practice a form of informal logical empiricism [empirical therapy,
based upon logic]? Perhaps western guideline-writers labor under their own metabolic
memory. Their guidelines are influenced by locally generated evidence, which may be
appropriate for their particular clinical scenario but not for others. Either way,
more introspection and more action is necessary.
How to cite this article: Kalra S, Gupta Y. Therapy in type 2 diabetes: A logical empiricism - based approach.
J Soc Health Diabetes 2014;2:109-11.
Source of Support: Nil
