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New Position Papers on Type 2 Diabetes Management

One document offers a sensible treatment algorithm; the other offers perspective on the relation between glycemic control and macrovascular complications.

The January issue of Diabetes Care includes two papers with considerable practical relevance for primary care.

The first document is a "position statement" from the American Diabetes Association (ADA), the American Heart Association, and the American College of Cardiology. Until lately, the conventional wisdom had been that intensive glycemic control probably prevents cardiovascular complications in patients with type 2 diabetes. But, in three randomized trials published recently and reviewed in Journal Watch (JW Dec 29 2008), intensive glycemic control did not lower rates of cardiovascular events compared with standard treatment. In this paper, researchers examine the three trials in detail, noting that (1) study subjects generally were older adults with long-standing diabetes, (2) most subjects had known cardiovascular disease or multiple risk factors, and (3) the difference in glycemic control between intensively treated and control subjects was perhaps too small to show large differences in outcomes. Thus, intensive control still might lower macrovascular risk in younger patients with newly diagnosed type 2 diabetes, and better glycemic control might still benefit patients whose diabetes is very poorly controlled (e.g., those with glycosylated hemoglobin [HbA_1c] >10%); both of these patient populations were underrepresented in the trials. The authors concluded that, although target HbA_1c <7% remains appropriate for many patients (e.g., to prevent microvascular complications, such as retinopathy), "less stringent A_1c goals . . . may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbid conditions or those with longstanding diabetes in whom the general goal is difficult to attain.. . ."

The second document, a "consensus statement" from the ADA and the European Association for the Study of Diabetes, presents treatment algorithms for patients with type 2 diabetes. The authors support an HbA_1c target <7%, but they also acknowledge that this goal is "not appropriate or practical for some patients." Their algorithm begins with lifestyle changes and metformin (Step 1), and suggests addition of insulin or sulfonylurea when necessary (Step 2). Patients in whom diabetes remains inadequately controlled should be switched from sulfonylurea to insulin (if they haven’t received insulin yet), or should have their insulin regimen intensified if they’re already using insulin (Step 3). The authors consider other oral agents (e.g., thiazolidinediones, GLP-1 agonists, and DPP-4 inhibitors) to be less-well-validated therapies that should be used only in selected clinical settings, and they recommend against using rosiglitazone (Avandia).

Comment: Clinicians who care for patients with diabetes should review these sensibly written papers. They are available without charge at Diabetes Care 2009; 32:187 and Diabetes Care 2009; 32:193.

— Allan S. Brett, MD

Published in Journal Watch General Medicine February 3, 2009

Citation(s):

Skyler JS et al. Intensive glycemic control and the prevention of cardiovascular events: Implications of the ACCORD, ADVANCE, and VA Diabetes trials: A position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. Diabetes Care 2009 Jan; 32:187.

• Original article (Subscription may be required)
• Medline abstract (Free)

Nathan DM et al. Medical management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy: A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009 Jan; 32:193.

• Original article (Subscription may be required)
• Medline abstract (Free)