COMMENTARY

Choosing Type 2 Diabetes Guidelines: 'Shop' Carefully

Aus Alzaid, MD

Disclosures

March 09, 2020

These are exciting times in the treatment of type 2 diabetes. If I were to single out two recent developments that have made the biggest impact on diabetes practice today, the first would be the concept of the patient-centered approach to treatment.

We now know that integrating patients' wishes and personal circumstances and actively inviting patients into the decision-making process are indispensable to the treatment of type 2 diabetes. Therapeutically, patient-centered care is as important as—if not more important than—the choice of medications we decide to prescribe.

The second important development with the biggest impact is, of course, the remarkable results of cardiovascular outcomes trials, which led to the successful introduction of new classes of medications that have enriched and expanded the choice of therapies available for the treatment of type 2 diabetes.

Momentous times call for momentous changes: It's time to revise and recalibrate treatment options to be in tune with new evidence that has come to light.

So, who do we turn to for advice, to help us understand the new revelations and achieve an accurate and reliable interpretation of the evidence at hand? Well, we have to fall on some professional guidance for direction, and we need to know how to properly follow it.

What Does It Mean to 'Follow' Guidelines?

Are you looking at more than the medications algorithm page of the guidelines document? Caring for people with diabetes is much more than the mere prescription of diabetes drugs. Valuable information is provided in guidelines on patient education, clinical nutrition, physical activity, and so on. Moreover, reading the fine print of the document often uncovers the big assumptions made in the simplified algorithms version.

At a recent diabetes conference, I asked the audience if they were following professional guidelines. Almost everyone responded by raising their hand. But when I subsequently asked how many had actually read the entire guidelines document, only a few kept their hands up.

Looking at the colorful medications algorithms page and memorizing its contents is not "following guidelines." If you want to serve your patients best, you need to read the rest.

But Which Do We Choose?

More than one set of reputable guidelines are available for implementation in diabetes practice (eg, American Diabetes Association/European Association for the Study of Diabetes, National Institute for Health and Care Excellence, World Health Organization). Some may be more visible, but not necessarily better, than others. No single set of guidelines can be considered supreme or universal. Therefore, it's important to "shop" carefully for the set of guidelines most suitable for your patients.

We take our time when we shop for random personal items. Imagine shopping for a medication or an injection that you have to take every day for the rest of your life, with all of the associated side effects, costs, and personal hardship. Our patients trust us as physicians to shop properly on their behalf. We must live up to these expectations and explore diligently all of the available options.

Published guidelines vary considerably in strength and quality, so we must be sure to pick the best quality guidelines to suit our practice. The AGREE II instrument is a popular scientific tool used to assess the methodological rigor and transparency with which a guideline is developed. Its scoring system is independent of the status or political clout of the organization issuing the guidelines. Most professional guidelines have already been appraised using the AGREE II method. So, find out the AGREE II quality score of the guidelines you have in mind before you apply them to your practice.

It has always puzzled me how the recommended medications can vary so widely among the different guidelines even though the scientific evidence used is exactly the same. Interpretation of the evidence is definitely in the eye of the beholder, so we must look carefully at the people behind the guidelines in terms of professional experience, scientific integrity, and ethical independence.

Aus Alzaid, MD, is a consultant diabetologist in Saudi Arabia. He has published widely in a variety of medical journals, including Diabetes Care, Diabetologia, the Journal of Clinical Endocrinology and Metabolism, and the Lancet.

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