Optimalisation de la prise en charge du patient diabetique de type 2: resultats de l'etude DREAM" en medecine generale."

This paper reports the results of the "DREAM" ("Diabetes REinforcement of Adequate Management") study performed among 42 general practitioners. A treatment algorithm was proposed to intensify the management of type 2 diabetic patients in case of poor control (HbA1C > 7.5% and fasting blood glucose > 140 mg/dl) before asking for an advice from a diabetologist. A total of 163 patients participated in the study: 84 men and 79 women, 59 +/- 10 years old; 5.2 +/- 6.1 years of known duration of diabetes; BMI: 30.7 +/- 5.8 kg/m2. Almost two thirds of patients received an antihypertensive agent, one third a lipid-lowering drug, and three quarters at least one antidiabetic agent: 22% a sulfonylurea, 18% metformin, 25% a combined oral therapy, 10% insulin (alone or in combination). At baseline, mean HbA1C averaged 7.1 +/- 2.2% (N: 4-6%), and 34% of patients had HbA1C > 7.5%. From these 163 patients, 100 were evaluated after 12 months, 57% being well controlled vs 36% at baseline. Among the 32 patients whose hypoglycaemic treatment was intensified, HbA1C level significantly decreased by almost 0.8% (p < 0.05). Despite precise guidelines, 55% of patients with HbA1C > 7.5% had no treatment adjustment, essentially in the group already on oral bitherapy or on insulin. Among the 65 patients evaluated after 24 months, the percentage of well controlled patients decreased to 44% (vs 51% after 12 months). The decision of switching to insulin was often delayed (no patient after 1 year and 2 patients only after 2 years). In conclusion, the "DREAM" study demonstrates the feasibility, but also the difficulty, of optimising the management of type 2 diabetic patients in general practice.