Personalised and patient-centred diabetes care

Abstract

This dissertation concerns various aspects of modern diabetes treatment, namely ‘personalised medicine’ based on the biological characteristics of the individual patient, and ‘patient-centred’ diabetes care with shared decision making. Part 1 focuses on the application of metabolomics and of the inflammatory markers hs-CRP and adiponectin in treatment selection. Part 2 covers the OPTIMAL study. Both studies were conducted among individuals who had participated in the ADDITION study. The ADDITION study evaluated the effect of intensive multifactorial treatment on cardiovascular morbidity and mortality in screen-detected type 2 diabetes patients. Regarding metabolomics, no metabolites were found that could predict for each individual patient whether metformin or sulphonylureas is the best choice to initiate treatment. We could demonstrate a significantly stronger reduction in hs-CRP levels in screen-detected type 2 diabetes patients who received more intensive treatment, compared to national guidelines, for their glucose, blood pressure, and cholesterol, over a period of six years. We advise an annual measuring of hs-CRP levels as additional information for patients and healthcare providers about treatment progress. Adiponectin was found to be unsuitable for this purpose. The cluster-randomised OPTIMAL study, conducted in 35 general practices, examined the effect of shared decision making on the achievement of treatment targets among 153 patients. After 24 months, 32% of patients who had determined target values through shared decision making with their general practitioner achieved their treatment goals for glucose, blood pressure, and cholesterol, compared to 26% at the start of the study. In the initial consultation, patients and general practitioners had roughly the same perception of their shared decision making (average difference of 2 on a scale of 0 - 45). However, after 24 months, patients reportedly experienced significantly less shared decision making. We conclude that both a personalised and a patient-centred approach can lead to improved diabetes care, yet the implementation is easier said than done.