Wednesday, August 22, 2012

Pain Plagues Patients with Type 2 Diabetes

About 4 in 10 adults with type 2 diabetes report acute and chronic pain, and close to one quarter report neuropathy, fatigue, depression, and sleep disturbance, according to a study of more than 13,000 adults conducted by researchers in California. Patients in the study reported significant pain and non-pain symptoms across the entire course of the disease, among all age groups, with prevalence increasing as people neared the end of their lives.

Writing in an early online edition of the Journal of General Internal Medicine the researchers — from the San Francisco VA Medical Center, the University of California, San Francisco, and the Kaiser Permanente Division of Research in Oakland, CA — report on the largest observational study to assess a full range of pain and non-pain symptoms among patients with type 2 diabetes, at various time points and by age, and the first to characterize the kinds of symptoms that patients experience [Sudore et al. 2012, ref below]. Here are study details:

In a survey/follow-up design, 13,171 adults with type 2 diabetes, aged 30 to 75 years answered a baseline survey in 2005–2006, at which time pain and non-pain symptoms were identified by self-report and medical record data. Followup status from baseline was assessed at several survival time points: ≤6 months, >6 to 24 months, or >24 months.

Mean age of participants was 60 years; 48% were women, and 43% were nonwhite. Acute pain was prevalent (42%) and 40% reported chronic pain, 25% fatigue, 24% neuropathy, 24% depression, 24% insomnia, and 16% physical/emotional disability. Symptom burden was relatively high at all survival time points, but was more common among those with shorter survival, P<0.001.

Adults ≥60 years of age who were alive >24 months reported more physical symptoms such as acute pain and dyspnea, whereas participants <60 years reported more psychosocial symptoms, such as depressed mood and insomnia. Adjustment for duration of diabetes and comorbidity reduced the association between age and pain, but did not otherwise change the results.

The researchers conclude that, in a diverse cohort of adults with type 2 diabetes, pain and non-pain symptoms were common among all patients, not only in those who were near the end of life. However, symptoms were more prevalent among patients with shorter survival times. Older adults reported more physical symptoms, whereas younger adults reported more psychosocial symptoms. Therefore, it is important that diabetes care management should include not only good cardiometabolic control, but also symptom palliation across the disease course.

In a press release [here] lead author Rebecca Sudore, MD, said, “Adults living with type 2 diabetes are suffering from incredibly high rates of pain and non-pain symptoms, at levels similar to patients living with cancer.” Coauthor Andrew J. Karter, PhD, added, “The field of diabetes has focused, and rightfully so, on decreasing patients’ blood sugar, blood pressure and cholesterol levels in an attempt to prevent complications such as cardiovascular disease, kidney failure, amputations, and blindness. However, our observations provide an important wake up call for clinicians to not wait until the latest stages of diabetes to focus on these patient-reported outcomes, but rather to consider early palliative care as part of usual chronic disease management.”

Sudore explained that palliative care for persons with serious illness provides an added layer of medical support besides regular disease management, with the goal of relieving symptoms and improving quality of life. She noted that other studies suggest that patients receiving palliative care live longer with a better quality of life. “Palliative care has already begun to be woven into the care provided to patients with cancer, heart failure and kidney failure,” she said. “Our results highlight the need to expand diabetes management to also include the palliative care model.”

REFERENCE: Sudore RL, Karter AJ, Huang ES, et al. Symptom Burden of Adults with Type 2 Diabetes Across the Disease Course: Diabetes & Aging Study. J Gen Int Med. 2012(Aug); online ahead of print [abstract here].

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