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		Literature Compendium

Current Concepts in Type 2 Diabetes

Volume 2
The Appropriate Application of Oral Pharmacological Therapy, Non-Insulin Injectable Agents, and Insulin in the Management of Type 2 Diabetes

Chapter 1
Guidelines to Management of Hyperglycaemia in Type 2 Diabetes

Management of the individual with Type 2 diabetes requires a multi-disciplinary team effort. Moreover, the primary care provider must take a systematic approach to the evaluation and management of the individual. The goals of therapy are to correct the metabolic abnormalities of diabetes and to prevent the development of microvascular and macrovascular complications. Recognized treatment guidelines developed by well-known organizations and regulatory authorities are useful for (1) ensuring quality of care, (2) disseminating clinical pathways that reflect the changing responsibilities of the primary care team, and (3) integrating new classes of glucose-lowering agents into practice algorithms. In particular, the availability of newer agents, many of which may be used alone or in combination with traditional drugs, has increased the therapeutic choices available to clinicians. Practice guidelines are a useful means of ensuring the most appropriate use of the newer agents.

Clinical practice guidelines for the management of Type 2 diabetes are based primarily on the results of well-designed randomized controlled trials. Current evidence supports the benefit of optimizing the levels of blood glucose, blood pressure, and lipids in individuals with Type 2 diabetes. Aggressive management of diabetes has been recognized as the primary means of reducing the risk of long-term complications and mortality. This chapter is an overview of consensus practice guidelines issued in 2006 by the American Diabetes Association (ADA) in conjunction with the European Association for the Study of Diabetes (EASD),¹ the International Diabetes Federation (IDF),² and the American College of Endocrinology (ACE) in conjunction with the American Association of Clinical Endocrinologists (AACE).³

The ADA/EASD guidelines¹ are based on clinical trials evaluating various modalities of treatment and on the clinical experience and judgement of the authors, all of whom are experts in the field of diabetes. The guidelines were developed by the Professional Practice Committee of the ADA and by an ad hoc committee of the EASD. They focus on the effectiveness of various therapeutic regimens in lowering glycaemia. Key characteristics of specific diabetes drug classes and lifestyle interventions are reviewed. Algorithms of care are based on a stepped-care approach. With regard to combination therapy, the ADA/EASD guidelines recommend that the synergy of particular drug combinations and other interactions should be considered. In general, the greatest synergy is said to be achieved by using 2- and 3-drug combinations with different mechanisms of action.

The IDF guidelines² present evidence-based recommendations, stratified by level of care. Standard care is defined as ‘evidence-based care which is cost-effective in most nations with a well developed service base, and with health-care funding systems consuming a significant part of national wealth’. Minimal care is defined as ‘the lowest level of care that anyone with diabetes should receive’. Finally, comprehensive care is defined as including ‘the most up-to-date and complete range of health technologies that can be offered to people with diabetes, with the aim of achieving best possible outcomes’. The IDF guidelines were developed by the IDF Clinical Guidelines Task Force. They are globally directed and focus primarily on general principles of therapy.

The ACE/AACE guidelines³ presented in this chapter focus on outpatient management, are evidence-based, and, like the IDF guidelines, present general principles of care rather than specific algorithms. They were developed by the ACE/AACE Diabetes Recommendations Implementation Writing Committee after a 2-day consensus conference attended by USA and international diabetes experts. The guidelines provide evidence-based answers to the following 6 questions: (1) Are we in the medical community intervening early enough to address glycaemic control and insulin resistance in glucose-intolerant states? (2) Is HbA_1c the most important measure of glycaemic control? What is the effect of glycaemic excursions on the development and progression of complications? (3) Are the current glycaemic targets achievable? (4) How important is glycaemic control in reducing macrovascular complications? (5) How can current therapies and interventions be implemented to achieve glycaemic control? (6) What resources are available to support more widespread implementation of the glycaemic guidelines?

The 3 sets of guidelines presented in this chapter are, for the most part, consistent with regard to general practice recommendations, all of which are evidence-based. There is some variability with regard to target HbA_1c levels. The ADA/EASD guidelines present the most specific practice recommendations and offer algorithms of care for the metabolic management of Type 2 diabetes, for the implementation of anti-diabetic interventions as monotherapy, and for the initiation and adjustment of insulin therapy in individuals with Type 2 diabetes. Despite differences in specific recommendations found in these guidelines, the ultimate clinical goals are to maintain normoglycaemia, reduce HbA_1c, and prevent or slow the progression of the devastating complications of Type 2 diabetes. Clinicians have at their disposal a large armamentarium of anti-diabetic agents, as well as considerable latitude in the choice of timing of therapy.

Because printed material often lags behind on-line information, the reader should review the guidelines available at the websites of professional diabetes associations to stay current on optimal practices for prevention and management of Type 2 diabetes. The ADA has a site at http://www.diabetes.org/home.jsp; the IDF, at http://www.idf.org/; and ACCE, at http://test.aace.com/org/. Not included in this compendium but of interest to the reader is a series of 3 Diabetes Road Maps that can be found at the AACE website that present steps to prevent Type 2 diabetes and to achieve glycaemic control in the treatment-naïve and treated individual with Type 2 diabetes.

References

1. Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2006;29:1963-1972.

2. IDF Clinical Guidelines Task Force. Global Guideline for Type 2 Diabetes: recommendations for standard, comprehensive, and minimal care. Diabet Med. 2006;23:579-593.

3. Lebovitz HE, Austin MM, Blonde L, et al. ACE/AACE consensus conference on the implementation of outpatient management of diabetes mellitus: consensus conference recommendations. Endocr Pract. 2006;12(suppl 1):6-12.

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The Literature Compendium is funded by an educational grant from Pfizer Inc.

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