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Cystic fibrosis‐related diabetes: the missing evidence

A number of years ago, I took over the cystic fibrosis-related diabetes clinic in Southampton when my predecessor retired. I did so with some trepidation as I had received no training in this area. However, recognizing the clinical need, I set out to learn what I could to ensure I could provide the care my patients deserved. The more I read, the more alarmed I became at the lack of high-quality evidence to support decisionmaking. Why were we diagnosing cystic fibrosis-related diabetes using standard diagnostic criteria when the glycaemic effects on the lungs occur at lower concentrations of glucose? What dietary advice should we offer, bearing in mind the conflict between the need for higher calories to maintain body weight and the need to avoid hyperglycaemia? How best should we monitor cystic fibrosis-related diabetes? What criteria should we use to determine the commencement of pharmacological treatment? Moreover, if needed, what is the best therapy [1]? In the end, I came to a resolution based on the guidance from the American Diabetes Association and Cystic Fibrosis Trust [2]. However, I never felt truly comfortable and wondered whether I was improving the outlook for my patients or just adding to their treatment burden. I read with interest the commentary by Roderick Warren, who had struggled with the same dilemmas [3]. In his careful analysis, Warren challenges the dogma surrounding insulin use in cystic fibrosis-related diabetes. These views go against the prevailing orthodoxy and so the commentary is accompanied by a further critique by Amanda Adler, who agrees the lack of evidence is challenging [4]. She concludes wisely by stating ‘in the absence of evidence proving whether or not treatment makes a difference, clinicians and people with cystic fibrosis and rising blood glucose values will together have to decide which is the greater error: to treat with insulin when it is not needed, or not to treat with insulin when it is needed?’