Are diabetes guidelines valid for people with multiple conditions?

A pen ticking off a checklist

Clinical practice guidelines tend to focus on diseases, not patients.  But what if, as is the case for more than 50% of people with a chronic condition, a patient has more than one thing wrong with them?  Is it safe to use the same tests or treatments?  Will they work in the same way?  Should the conditions be managed differently in the light of co-morbidity?

A new review analysed 20 different guidelines, in areas such as type 2 diabetes, arthritis and chronic respiratory conditions. They found that most guidelines have few recommendations that address co-morbidities, and that these recommendations tend to be based on poor quality evidence.  This may be because clinical trials often exclude patients with significant co-mordibity.

If we are to achieve patient-centred care, this is a serious problem that must be addressed by the individuals and groups that develop clinical practice guidelines and by clinical trials.

Appraisal hints

Users of this evidence should consider:

  • The representativeness of the guidelines they analysed
  • Was the review carried out prospectively, starting with a clear protocol that was adhered to throughout?
  • Whether they performed blind, independent analysis of the guidelines
  • The validity and importance of the outcome measures they used to characterise the extent to which guideline recommendations addressed co-morbidities.


The full text of this paper is available from the Public Library of Science.

Lugtenberg M, Burgers JS, Clancy C, Westert GP, Schneider EC. Current guidelines have limited applicability to patients with comorbid conditions: a systematic analysis of evidence-based guidelines. PLoS One. 2011;6(10):e25987. Epub 2011 Oct 20.


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I am an information scientist with an interest in making knowledge from systematic research more accessible to people who need it. This means you. I've been attempting this in the area of Evidence-Based Health Care since 1995. So far the results have been mixed. For some reason we expected busy clinicians to search databases and appraise papers instead of seeing patients. We also expected publishers to make the research freely available to the people who paid for it.. Ha! Hence The National Elf service.

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