ADA/EASD issue new hyperglycemia management guidelines

Laurie Barclay

April 19, 2012

Alexandria, VA and Düsseldorf, Germany - The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have issued a joint position statement emphasizing patient-specific treatment of hyperglycemia in those with type 2 diabetes[1]. The new guidelines are reported online April 19, 2012 in Diabetes Care and Diabetologia.

"All guidelines are in a state of evolution based on new information, and the overall standard of care is updated every January," Dr Vivian Fonseca (Tulane University School of Medicine, New Orleans, LA), ADA president of medicine and science, said in a telephone interview.

The last guidelines specific to management of hyperglycemia were published about four to five years ago, and more recent developments have been incorporated into the new guidelines, he said.

The impetus underlying the new guidelines was the growing complexity and controversy surrounding contemporary glycemic management in patients with type 2 diabetes. Factors complicating management include the increasing number and variety of available pharmacotherapy, issues regarding potential adverse effects, and new uncertainties concerning the effects of intensive glycemic control on macrovascular complications.

Fonseca explained that there has been a small change in what the optimal blood glucose goal should be. On the basis of findings from ACCORD and other studies, the ADA has set the HbA1c goal at 7% in general, but with some individualization.

"For patients with advanced cardiovascular disease, reduced life expectancy, and multiple medical problems, for example, the goal may be higher," Fonseca said. "For patients who are newly diagnosed and very motivated, the goal may be lower."

Another recent change underlying the new guidelines is the recognition that many people with diabetes will need multiple agents. For example, the dipeptidyl peptidase-4 (DPP4) inhibitors have become available since the last hyperglycemia guideline was published.

Patient-centered management

Rather than using clearly defined algorithms, the new guidelines are less prescriptive and more patient-centered. Recommendations are tailored to individual patient needs, preferences, and tolerances and are based on differences in age and disease course. Other factors affecting individualized treatment plans include specific symptoms, comorbid conditions, weight, race/ethnicity, sex, and lifestyle.

"We start with metformin, and if the patient is not meeting goal in three months, we change therapy based on patient-specific factors," said Fonseca, who was not involved in writing the new guidelines.

"There have been no good studies comparing all available treatment strategies, so we base the decision on individual factors such as willingness to self-inject or need for weight loss. If that fails, we try another option. There is no clear-cut decision tree as there was in the previous hyperglycemia guideline, because this guideline is more patient-centric."

The position statement mandates diabetes education for all patients, to be administered to individuals or groups. The curriculum should highlight dietary intervention and the key role of increased physical activity and weight management, when appropriate.

Key points

Key recommendations in the new ADA/EASD statement include the following:

  • Glycemic targets and treatments to lower glucose must be individualized according to specific patient characteristics.

  • The mainstay of any type 2 diabetes treatment program is still diet, exercise, and education.

  • Metformin is the preferred first-line drug, in the absence of contraindications.

  • Data are limited regarding use of agents other than metformin. A reasonable approach is combination therapy with one to two additional oral or injectable agents, with the goal of minimizing side effects to the extent possible.

  • To maintain glycemic control, many patients will ultimately need insulin monotherapy or in combination with other medications.

  • Whenever possible, the patient should participate in all treatment decisions, focusing on their preferences, needs, and values.

  • A major treatment goal must be comprehensive cardiovascular risk reduction.

"The new guideline should actually be easier for physicians to implement because there is greater flexibility in management, offering a road map rather than a single path," Fonseca concluded. "The ADA guidelines in general are already fairly widely implemented, and we are seeing benefits from that. Over the past 10 to 15 years, HbA1c has been dropping, and over the past year, there has started to be a drop in rates of diabetes-related blindness, retinopathy, dialysis, and amputation. But there still remain a large number of patients with these outcomes, so we still have a ways to go."

Fonseca states that he has no conflicts of interest regarding the new guidelines. He has been involved in research trials funded by Novo Nordisk, Sanofi , Eli Lilly, Reata, Abbott, Mesoblast, Pan-American Laboratory, and Takeda. He has been a consultant for Takeda, Novo Nordisk, S anofi, Eli Lilly, Pan-American Laboratory, Dai i chi-Sankyo, Xoma, Astra Zeneca, Abbott, Bristol-Myers Squibb, and GlaxoSmithKline. Disclosures for the authors of the statement are listed in the paper.

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