Introduction
The word “equipoise” is a versatile one. Used as a noun, it implies a “balance of
forces or interests,” or a “counterbalance or balancing force.” As a verb, it is used
to convey the act of balancing or counterbalancing.[1] The use of this word, however, has fallen dramatically over the past century. Is
this because the concept of equipoise is difficult to achieve?
In this editorial, we enumerate and discuss the domains of equipoise, as related to
diabetes care ([Table 1]), and wonder if equipoise will always be a slippery eel.
Table 1
Equipoise in diabetes
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Related to the patient
• Emotional equipoise
• Glycemic equipoise
• Vasculometabolic equipoise
Related to the professional
• Emotional equipoise
• Professional equipoise
Related to family/community
• Community equipoise
Related to interaction and treatment
• Therapeutic equipoise
• Information equipoise
• Equipoised intrusion
Related to cardiovascular trials
• Glycemic equipoise
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The Spectrum of Equipoise
The Spectrum of Equipoise
In diabetes care, experts have been using the terms “information equipoise,” “clinical
equipoise,” “glycemic equipoise,” and “emotional equipoise.”[2]
[3]
[4]
[5] We add to these, “vasculometabolic equipoise,” “equipoised intrusion,” and “community
equipoise.”
For the diabetes care professional, equipoise is a multifaceted construct. Equipoise
is a target, as well as a tool to achieve this target. In diabetes management, one
aims to create a stable health status, balancing glycemic control with the potential
risk of hypoglycemia.[6] This can be termed glycemic equipoise, though this phrase is used more often in
the context of cardiovascular outcomes trials.[4]
Equipoise as a Target
Management strategies also try to achieve an equipoise of other vasculometabolic markers,
including weight, blood pressure, and lipids. Mandate from regulatory agencies also
demands demonstration of cardiovascular equipoise, or safety, with newly developed
glucose-lowering drugs.[7] Put together, the state of a comprehensive diabetes control can be termed as vasculometabolic
equipoise. This implies that all vascular and metabolic aspects of health are given
equally efficiently. In a similar fashion, endocrine equipoise may be taken to mean
optimal “glucocrinological” health, balancing the function of all endocrine glands
in addition to the pancreas.
Apart from the biomedical markers discussed earlier, there is a need to ensure emotional
equipoise, or good psychosocial health, in persons living with diabetes. Such persons
should be able to view diabetes as a part of life, and to ensure that it does not
disturb the equilibrium of their personal or social life.[8] The family in particular, and society at large, should be encouraged to view persons
living with diabetes with equipoise, offering them the same opportunities that their
peers get. Such a state can be described as community equipoise.
Equipoise as a Tool
To achieve this target, one needs to use equipoise as a tool. The diabetes care professional
should remain emotionally equipoised or balanced, when confronted with challenging
patients or difficult situations.[8] She or he should endeavor to ensure information equipoise with the patient, so that
shared decision making can be practiced in a responsible patient-centric manner. Information
equipoise between two partners implies that both have access to similar information
and knowledge.[9] This, in turn, fosters similar attitudes and promotes similar decisions, thus facilitating
taking concordance in management plans.
At times, diabetes therapy may intrude unnecessarily into a patient’s life. In such
cases, one must balance the advantages of tight glycemic control with the overall
impact of disease on quality of life. A fair compromise would be to aim for equipoised
intrusion, that is, balancing the rigidity of therapy with the flexibility of lifestyle.
Equipoise in Summary
It is thus clear that the construct of equipoise embraces multiple stakeholders: the
person living with diabetes (emotional equipoise, glycemic equipoise, and vasculometabolic
equipoise), the diabetes care professional (emotional equipoise and professional equipoise),
the family, and the community (community equipoise). It also addresses the physician–patient
relationship (information equipoise and nature of treatment [equipoise intrusion]).
The adjective has also been used with reference to cardiovascular outcome trials (glycemic
equipoise) ([Table 1]).
Equipoise in Therapeutics
Equipoise in Therapeutics
More often than not, one is faced with multiple management options, all of which have
their advantages and limitations. This represents a situation of “therapeutic equipoise,”
and is best handled by discussing various options with these patients. There is much
more to equipoise, therefore, than what meets the eye. The dismal status of diabetes
care across the world shows that we are far from reaching optimal balance in our fight
against the epidemic. Till we create a synergistic and sustained, effort to understand
this multidimensional balance, equipoise will remain a slippery eel.
