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Several years ago, the American Diabetes Association and the European Association for the Study of Diabetes convened a group that developed consensus recommendations for antihyperglycemic therapy in non-pregnant adults with type 2 diabetes. Since that time, more information on the benefits and risks of glycemic control has emerged. In addition, there is new evidence on the efficacy and safety of several new drug classes as well as the withdrawal and the restriction of others. Furthermore, experts are suggesting that greater attention be paid to moving toward approaches to care that are more individualized and patient-centered.
New guidelines on the management of hyperglycemia have been published concurrently in the April 19, 2012 online editions of Diabetes Care and Diabetologia. “Guidelines are constantly in a state of evolution based on new information,” says Vivian A. Fonseca, MD. “This document reflects recent data and availability on multiple treatment options for a variety of patients. In addition, the American Diabetes Association updates its overall standards of care every January. These new guidelines take a more holistic approach, focusing on treating people as individuals and understanding that treatments need to be based on each patient’s characteristics and circumstances.”
Greater Focus on Patient-Centered Care
Historically, many experts have preferred using algorithm- based management plans to ensure that they are offering treatment consistent with guidelines. Others have favored flexible treatment options based on specific pathophysiology. The new guidelines on managing hyperglycemia in type 2 diabetes are less prescriptive and more patient-centered, according to Dr. Fonseca. “Rather than using only clearly defined treatment algorithms, recommendations are tailored to individual patient needs, preferences, and tolerances.” There is flexibility based on differences in age and disease course. Other factors affecting treatment plans include specific symptoms, hypoglycemia risk, comorbid conditions, weight, race and ethnicity, gender, and lifestyle (Table 1).
According to the recommendations, most individuals with type 2 diabetes should be started on metformin, but therapies should be changed based on patient-specific factors if A1C goals are not being met within 3 months. Diabetes education should be provided for all patients. These curricula should offer information on dietary interventions and emphasize the importance of increased physical activity and weight management.
Glucose Goals Based on Individualization
There has been an evolution in ADA recommendations regarding optimal blood glucose goals. On the basis of findings from ACCORD and other studies, an A1C goal has been set at 7% in general, but with some individualization. “For patients with advanced cardiovascular disease, reduced life expectancy, and multiple medical problems, the goal may be higher,” Dr. Fonseca says. “For patients who are newly diagnosed and very motivated to tackle their disease, the goal may be lower.”
Experts recognize that many people with diabetes will need multiple therapies. “Unfortunately, there are currently no good studies available that compare the various treatment strategies we have at our disposal,” says Dr. Fonseca. “It’s critical that more comparative, evidence-based studies on managing hyperglycemia in type 2 diabetes are conducted in the future. Our current evidence base is relatively lean, especially beyond metformin use as monotherapy [Table 2].”
In the meantime, decisions on therapy should be based on individual factors exhibited by patients. These include willingness to self-inject, risk of hypoglycemia, or need for weight loss, among others. “If specific, individualized treatment options fail, we must then try another option,” Dr. Fonseca says. In an effort to make the guidelines more patient-centric, there is no “onesize- fits-all” decision pathway.
Hyperglycemia Guidelines: A Helpful Asset
Dr. Fonseca says the new guidelines may be easier for physicians to implement because they provide greater flexibility in patient care. “The new recommendations offer a road map rather than a single pathway of care,” he says. “Guidelines from the American Diabetes Association and other well-respected organizations are fairly widely implemented, and we’re beginning to see the benefits of the wide distribution of these recommendations. Over the past 10 to 15 years, A1C levels have been dropping, and we’re also seeing lower rates of diabetes-related blindness, retinopathy, dialysis, and amputation. However, while these points are encouraging, many patients with type 2 diabetes are still developing these outcomes. We have a ways to go, but these guidelines will hopefully assist our efforts and provoke more research in the future.”
Readings & Resources (click to view)
Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012 Apr 19 [Epub ahead of print]. Available at: http://care.diabetesjournals.org/content/early/2012/04/17/dc12-0413.full.pdf+html.
American Diabetes Association. Standards of Medical Care in Diabetes—2012. Diabetes Care. 2011;35:S11-S63. Available at: http://care.diabetesjournals.org/content/35/Supplement_1/S11.full.
Bergenstal RM, Bailey CJ, Kendall DM. Type 2 diabetes: assessing the relative risks and benefits of glucose-lowering medications. Am J Med. 2010;123:374.e9-374.e18.
Nyenwe EA, Jerkins TW, Umpierrez GE, Kitabchi AE. Management of type 2 diabetes: evolving strategies for the treatment of patients with type 2 diabetes. Metabolism. 2011;60:1-23.
Nolan JJ. Consensus guidelines, algorithms and care of the individual patient with type 2 diabetes. Diabetologia. 2010;53:1247-1249.
Blonde L. Current antihyperglycemic treatment guidelines and algorithms for patients with type 2 diabetes mellitus. Am J Med. 2010;123(Suppl):S12-S18.
Skyler JS, Bergenstal R, Bonow RO, et al; American Diabetes Association; American College of Cardiology Foundation; American Heart Association. Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. Diabetes Care. 2009;32:187-192.
Yudkin JS, Richter B, Gale EA. Intensified glucose control in type 2 diabetes: whose agenda? Lancet. 2011;377:1220-1222.
Nathan DM, Buse JB, Davidson MB, et al; American Diabetes Association; European Association for the Study of Diabetes. Medical management of hyperglycaemia in type 2 diabetes mellitus: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia. 2009;52:17-30.