COMMENTARY

New Guidelines Clarify Treatment for Type 2 Diabetes

ADA/EASD Issues First Comprehensive Guidelines on Hyperglycemia in Type 2 Diabetes

Anne L. Peters, MD, CDE

Disclosures

April 20, 2012

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Hi. I'm Dr. Anne Peters from the University of Southern California. I'm here today to talk about the new position statement on the management of hyperglycemia in patients with type 2 diabetes that is being published by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).

I'm particularly proud of this position statement because I was honored to be a part of the committee that created it. I'm going to give you a little bit of the inside scoop about how we wrote this position statement and then I'm going to tell you what I think it means.

The ADA and the EASD felt that we needed a formal, officially approved set of guidelines -- a position statement -- on how to treat type 2 diabetes. We never really had this before. They chose 5 individuals from the United States and 5 from Europe and had us meet over the past 2-plus years. We had face-to-face meetings, conference calls, and thousands of revisions to this document to really figure out what we thought was the best path for treating patients with type 2 diabetes.

These guidelines differ from others in a variety of ways. The first and most fundamental way in which they differ is that they are much less proscriptive than other guidelines. Our first premise is that this is about the patient, that these should be patient-centered guidelines, and that we should be providing patient-centered care. As a corollary to that, it also means that we need to set up individual targets for patients. I think each of us can think of patients in our practices who could and should achieve and maintain an A1c that is even below 6.5%, as close to normal as possible. Then there are others who are older, have comorbidities, and are not able to safely get their A1c level down that low, so we raised their targets. I think the notion of adjusting targets, individualizing targets, is key to this position statement.

Moving on to treatment, we all know that the first line of therapy for all patients with type 2 diabetes is diet and exercise, which needs to persist throughout the treatment of each patient. It also needs to be coupled with education because patients need to understand this disease and how to treat it. They need to be partners in their care.

There is the occasional patient who will respond to lifestyle therapy alone and will not need medication, and that's great. But for most patients, the first step will involve using metformin, and we all know the myriad of reasons why metformin is a tried-and-true, great first-line drug. The next step is the hard step. We don't have good comparative trials to tell us what that next step should be.

We say to choose your drug based on what you and the patient think is right. The second step can be a dipeptidyl peptidase-4 inhibitor, it can be a glucagon-like peptide-1 (GLP-1) receptor agonist, it can be a thiazolidinedione, it can be a sulfonylurea agent, or it could be basal insulin. You can try anything next depending on what suits the circumstance. Then there is the third step. Eventually, patients may need insulin alone, although in many cases, patients should still be on some sort of oral agent, and the combination of a GLP-1 receptor agonist and insulin is quite effective in many cases.

If a patient needs a more intensive insulin regimen, then we recommend adding 1 or 2 -- maybe even 3 -- doses of mealtime insulin. As one progresses, you increasingly have to look at patient factors and the ability to adhere to a variety of different treatment regimens involving insulin. We provide a figure that looks at complexity, simplicity, and response to different insulin therapies.

In the manuscript, Figure 2 outlines all of these choices. Then we say, "Okay, we are giving the universe of choices and not really giving a lot of guidance, but we'll give you some algorithm, some approaches to treating different kinds of patients." We give you steps that a patient in whom you are trying to avoid hypoglycemia should follow. We give you steps for how to approach a patient for whom weight loss may be the most significant concern. We give you steps for treating a patient for whom cost may be a predominant factor.

We try to help guide you through a variety of different clinical scenarios in order to get your individual patient to the target that is most appropriate for that patient. I know we are going to get a lot of feedback, comments good and bad, about what we have done. There is no one-size-fits-all; there is no pleasing everybody. However, having been part of this process, I really believe that we have exhaustively reviewed the available data.

We know that there are lots of gaps in the existing data. We tried to fill them in with expert opinion. We leave you with the task of making sure you know each and every drug, how to use them individually as well as together, and, with the notion that it is most important, that you work with each patient to create a program of care that suits that patient and helps him to get safely to his own goal.

This has been Dr. Anne Peters for Medscape. Thank you.

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