Individualizing Comprehensive Diabetes Care | Feature

New clinical practice guidelines from the American Association of Clinical Endocrinologists emphasize the importance of individualized care when developing comprehensive care plans for patients with diabetes.

Patients with diabetes suffer from multiple comorbidities and complications and frequently experience decreased quality of life, as well as earlier mortality. About one-third of Americans have diabetes or prediabetes, according to the American Association of Clinical Endocrinologists (AACE), based on data from the CDC. Through early recognition, patients with diabetes can achieve a higher quality of life by being diagnosed appropriately (Table 1) and by receiving intensive interventions to get patients to treatment goals safely.

Several medical societies and associations have established clinical guidelines that address the prevention, diagnosis, and/or management of diabetes. Most offer a plethora of useful information, but it can be challenging for clinicians to find specific information that they need easily and quickly. With this in mind, along with awareness that much has changed in diabetes care in recent years, AACE created the 2011 Medical Guidelines for Clinical Practice for Developing a Diabetes Mellitus Comprehensive Care Plan. “We decided to simplify the guidelines,” says co-chair Yehuda Handelsman, MD, FACP, FACE, FNLA. “We identified 20 important questions and chose 23 of the country’s top leaders in those areas to answer them.” The guidelines provide roughly five pages of answers per subject matter. A more in-depth executive summary provides specific answers to each of the 20 questions.

A Comprehensive Approach to Diabetes

Previous guidelines from AACE and other groups have identified diabetes-related issues like blood pressure, heart disease, and lipids. However, Dr. Handelsman says these documents usually do not stress that clinicians should cover all of these domains when they see patients. “Only about 40% to 50% of the population with diabetes reaches reasonable blood glucose control,” he says. “For blood pressure goals, only about 50% to 60% reach goal, and the rate is about 50% for lipids. Importantly, control of all three of these factors is only about 10% to 12% among patients with diabetes. The hope is that the comprehensive care guidelines developed by AACE will encourage providers to treat patients beyond the achievement of appropriate glucose levels.”

Personalized Diabetes Care

An important strategy that the AACE guidelines emphasize is that one size does not fit all when it comes to managing patients. “We do not believe that there’s an average patient and that everyone’s like the average patient,” explains Dr. Handelsman. “That’s the equivalent of saying everyone has 2.3 kids or that everyone makes $60,000 per year. Greater efforts are needed by clinicians to spend extra time and individualize goals based on the patient’s unique characteristics and risk factors. Developing a personalized treatment plan based on individualized goals will ultimately enhance care and hopefully improve outcomes for this growing patient population.”

“The hope is that the comprehensive care guidelines developed by AACE will encourage providers to treat patients beyond the achievement of appropriate glucose levels.”

The AACE guidelines were developed with the belief that the majority of patients are able to reach a target A1C level of 6.5% or less, provided this can be done safely. A1C levels may vary based on patients’ risk for developing hypoglycemia, liver disease, weight gain, or other diabetes-related issues. “We recognize that some patients with diabetes or prediabetes may be younger, have the disease for a shorter time, or do not have any other comorbid conditions,” Dr. Handelsman says. “There is also a group of people who are very sick and have many diabetes-related comorbidities. They’re frail, are prone to low blood sugars, and have short longevity. For these patients, clinicians need to be guided more by clinical sense, expertise, and knowledge rather than defined one-size-fits- all goals. The important thing to remember is there isn’t a cookie-cutter approach to this disease. By thoroughly and comprehensively seeking to get patients to target levels of diabete-srelated comorbidities, the likelihood of long-term benefits increases.”

Teamwork Matters

The new AACE guidelines include an entire section on the utilization of multidisciplinary team approaches to diabetes care, placing much stress on the need for diabetes education and the use of dieticians, physiologists, podiatrists, and others as patients with diabetes receive care (Table 2). This may require that physicians take extra steps to create and establish these teams. “Physicians should be prepared with other team members so that patients with diabetes have immediate access to cardiologists, eye doctors, neuropathy and kidney specialists, diabetes self-management educators, dieticians, and fitness centers or gyms. Expecting patients to seek out these physicians on their own after a diabetes diagnosis is unrealistic. By being prepared with this multidisciplinary team, the chances of improving quality of life and diabetes-related outcomes increase substantially.”

 

 

 

Additional Resources:

Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011;17(Suppl 2):1-53. Available at http://aace.metapress.com/content/t7g5335740165v13/fulltext.pdf.

Younis N, Williams S, Ammori B, Soran H. Role of aspirin in the primary prevention of cardiovascular dis­ease in diabetes mellitus: a meta-analysis. Expert Opin Pharmacother. 2010;11:1459-1466.

Richelsen B, Tonstad S, Rössner S, et al. Effect of orlistat on weight regain and cardiovascular risk factors follow­ing a very-low-energy diet in abdominally obese patients: a 3-year randomized, placebo-controlled study. Diabetes Care. 2007;30:27-32.

Gillies CL, Abrams KR, Lambert PC, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ. 2007;334:299.

Duckworth W, Abraira C, Moritz T, et al; VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009;360:129-139.

 

 

 

Physician's Weekly for Current Medical News, Events & Issues