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ADA/EASD: Personalized treatment best approach to hyperglycemia in type 2 diabetes
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The American Diabetes Association and the European Association for the Study of Diabetes have collaborated to update guidelines on the management of hyperglycemia in nonpregnant adults with type 2 diabetes. The guidelines are based on a patient-centered approach; according to the task force, individualized treatment is the cornerstone of success.
“The novel position statement on the management of hyperglycemia in type 2 diabetes was commissioned because the last similar treatment algorithm is more than 3 years old, and a lot of new insights have been generated that required an update,” Michael A. Nauck, MD, PhD, head of the Diabeteszentrum Bad Lauterberg in Harz, Germany, and a member of the joint task force, said in an interview.
Michael A. Nauck
Although several guidelines on the management of hyperglycemia have been developed, the ADA and European Association for the Study of Diabetes found it necessary to update these recommendations based on new evidence of risks and benefits of glycemic control, evidence on safety and efficacy of new drug classes, the withdrawal and restriction of other drug classes and the increasing need for a more patient-centered approach to care.
According to the ADA, to reduce the incidence of macrovascular disease, HbA1c should be lowered to less than 7% in most patients. However, data from type 2 diabetes cardiovascular trials have demonstrated that not all patients benefit from aggressive glucose maintenance, again pointing toward a more individualized approach to treatment. In considering patient desires and values, the following factors may be taken into account when choosing an HbA1c target: patient attitude and expected treatment efforts; risks potentially associated with hypoglycemia, other adverse events; disease duration; life expectancy; important comorbidities; established vascular complications; and resources and support systems.
“Both the European and American diabetes societies felt that for strong recommendations in favor (or against) certain diabetes medications, the evidence is not strong enough and that choices and preferences will differ with different patients, their characteristics and attitudes. Thus, in contrast to previous statements, the present one is based on a patient-centered approach,” Nauck said.
The group discussed therapeutic options, including lifestyle interventions to change physical activity levels and food intake; oral agents and noninsulin injectables, as well as insulin. According to the guidelines, when it comes to prescribing oral agents and noninsulin injectables, agent- and patient-specific properties, such as dosing frequency, side effect profiles, cost and other benefits, are often used to guide drug selection.
In terms of insulin, the group wrote: “Ideally, an insulin treatment program should be designed specifically for an individual patient, to match the supply of insulin to his or her dietary/exercise habits and prevailing glucose trends, as revealed through self-monitoring. Anticipated glucose-lowering effects should be balanced with the convenience of the regimen, in the context of an individual’s specific therapy goals.”
Metformin is the optimal first-line drug, unless there are established contraindications, they wrote. After metformin, however, data are limited. The authors recommend combination therapy with the addition of one to two oral or injectable agents, with the goal of reducing side effects when possible. Insulin therapy, whether alone or in combination, will ultimately be required to maintain glucose control for many patients.
“Regarding treatment options, [the document] lists all commonly used medications with all their properties (positive and negative), and gives all the information to make good choices based on priorities (ie, avoiding hypoglycemia at all costs) and preferences,” Nauck said. “The authors hope this is valuable information to assist physicians treating patients with type 2 diabetes in ‘practicing the art of medicine.’”
When making treatment decisions, additional considerations include age, weight, sex/racial/ethnic/genetic differences and comorbidities, such as coronary artery disease, heart failure, chronic kidney disease, liver dysfunction and hypoglycemia.
Overall, they wrote, comparative evidence for antihyperglycemic treatment of type 2 diabetes is lacking, and there is a considerable need for high-quality, comparative-effectiveness research on costs and outcomes important to patients, including quality of life and the avoidance of life-limiting complications such as cardiovascular disease. – by Stacey L. Fisher
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Disclosures: Dr. Nauck has received research grants to his institution from AstraZeneca, Boehringer Ingelheim, Eli Lilly & Co., GlaxoSmithKline, Merck Sharp & Dohme, Novartis Pharma, Novo Nordisk, Roche and Tolerx. He has received consulting and travel fees or honoraria for speaking from AstraZeneca, Berlin-Chemie, Boehringer Ingelheim, Bristol-Myers Squibb, Diartis, Eli Lilly & Co., F. Hoffmann-La Roche Ltd, Intarcia Therapeutics, Merck Sharp & Dohme, Novo Nordisk, Sanofi-Aventis Pharma and Versartis.