This article is more than 5 years old. Information may no longer be current.
New consensus statement on the medical management of type 2 diabetes
Click Here to Manage Email Alerts
A consensus statement by the American Diabetes Association and European Association for the Study of Diabetes was recently released on the management of type 2 diabetes. After reading the document, I admit that I have mixed feelings about these recommendations. I asked several endocrinologist friends and colleagues their thoughts.
The range of opinions I heard was remarkable. Comments ranged from “straightforward,” “cost effective” and “based on the best evidence” all the way to “based purely on cost” and “taking a step backward 10 years.”
The algorithm begins with Tier 1 or well-validated core therapies. These interventions are considered to be the most established and cost-effective treatments for type 2 diabetes. Tier 1 is further stratified into steps 1, 2 and 3.
Step 1 consists of lifestyle intervention and metformin. There is no controversy regarding step 1. Most of us agree that lifestyle change and metformin should remain the foundation of the initial management of type 2 diabetes.
If lifestyle intervention and metformin fail to achieve or maintain glycemic goals within two or three months, the authors recommend the addition of a second medication, either basal insulin or sulfonylureas (step 2). Insulin is the most potent agent we have to lower HbA1c. There is no limit to the amount that may be used to control glucose. Sulfonyureas have the advantage of being less expensive and have more rapid onset than other oral agents. However, the authors point out that the maintenance of glycemic targets is not as good as with metformin or a thiazolidinediones.
Step 3, intensive insulin therapy is advised if other interventions fail to achieve glycemic targets. I agree that if two or three oral agents and especially if basal insulin have failed, it is unlikely that the addition of another oral agent will have much effect, other than adding to the cost of therapy. A challenge, however, will be convincing our patients to accept intensive insulin therapy, particularly if it is soon after diagnosis.
Pioglitazone or exenatide (Byetta; Amylin, Lilly) are considered to be Tier 2, or less well-validated therapies. These are to be used based on the discretion of the clinician under specific circumstances such as a desire to avoid hypoglycemia or to promote weight loss.
Other agents, including alpha-glucosidase inhibitors, glinides, pramlintide (Symlin, Amylin) and DDP-IV inhibitors, were not included in the algorithm because of intolerable side effects, cost, limited clinical data or relative lack of efficacy compared with other interventions. A surprise was the unanimous recommendation to avoid rosiglitazone altogether, even after admitting that the evidence regarding rosiglitazone and cardiovascular risk is inconclusive.
I am ambivalent about these recommendations. I strongly agree with the authors’ advice to focus on well-validated, cost-effective therapies. However, newer agents may offer benefits beyond only glycemic control. Such therapies still have a place in the management of type 2 diabetes and should not be eliminated entirely.
Dr. Repas discloses that he has received honoraria from or has been on the speakers' bureaus of Abbott Laboratories, Daiichi Sankyo, Eli Lilly & Co, GlaxoSmithKline, Merck & Co Inc, Novo Nordisk, Pfizer, Sanofi-Aventis and Takeda.
Diabetes Care. 2008;31:1-11.