A position statement on management of type 2 diabetes released earlier this year by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) takes a more tailored approach for each patient rather than the "one size fits all" directives of previous guidelines. Under the new recommendations, which were published in the journals Diabetes Care and Diabetology, health care providers are urged to take individualized factors such as age, diabetes severity and progression, possible impact of other diseases, gender, and lifestyle into account.
Complications of diabetes such as heart disease, blindness, amputations, and death have been on the downswing in recent years, but the organizations hope that the new recommendations can help reduce adverse events even further. The introduction of several new diabetes drugs, and their side effects, are among the reasons that the ADA and EASD has issued the statement. Another key factor, according to the joint statement, was concern about the impact of maintaining strict control on blood glucose levels and risk of complications.
"The wide range of [recent] pharmacological choices, along with conflicting data about some of those choices, and differences in how patients respond to medications, makes it difficult to prescribe a single treatment regimen based on an algorithm that is designed to work for everyone," said Vivian Fonseca, MD, President, Medicine & Science of the American Diabetes Association. "What's more," said Fonseca, "patients may not be able to continue long-term with a treatment program that isn't working for them, whether it's because of side effects from the medication, issues of convenience or lifestyle, or even a matter of financial resources…if we encourage people to work with their health care providers to find an individualized personal plan that works well for them and fits their lifestyle and personal needs, it has a higher chance for success in controlling glucose and decreasing the risk of long term complications."
Different types of diabetes with different causes all lead to a high level of glucose in the blood with subsequent complications. In healthy people, the pancreas makes insulin, a hormone that helps transport glucose into cells for use as energy. People with type 2 diabetes aren't able to make use of the insulin they have (known as insulin resistance), which can lead to a lack of glycemic control, an inability to control blood glucose levels, whereas people with type 1 diabetes don't make enough insulin. Up to 95% of people diagnosed with diabetes have type 2, previously known as non-insulin-dependent diabetes mellitus or adult-onset diabetes. Risk factors for type 2 diabetes include older age, obesity, family history of diabetes, physical inactivity, and race/ethnicity.
Tailoring the A1c Target for the Individual
Measurement of A1c, also known as hemoglobin A1c or glycated hemoglobin, is an important component of managing diabetes. The test is an indication of blood glucose levels over the previous 2 to 3 months. Prior to the new recommendations for glycemic control, the target value for A1c was less than 7.0% in both type 1 and type 2 diabetes, and this is still true for most diabetics. An A1c result below this level indicates good glycemic control and a lower risk of diabetic complications.
Recognizing that this target may not be ideal or realistic for all type 2 diabetics, the ADA and EASD now urge that the target A1c prescribed for an individual take several factors into account. These include length of time since diagnosis, the presence of other diseases as well as diabetes complications (e.g., vision impairment or loss, kidney damage), risk of complications from low blood glucose (hypoglycemia), and whether or not the person has a support system and health care resources readily available. For example, a person with heart disease who has lived with type 2 diabetes for many years without diabetic complications may have a higher A1c target (e.g., 7.5%-8.0%) set by their doctor, while someone who is otherwise healthy and just diagnosed may have a lower target (e.g., 6.0%-6.5%) as long as low blood sugar is not a significant risk.
Treatment plans should also be individualized, according the policy statement, taking into account a person's particulars. Key recommendations include diabetes education for all patients with a focus on dietary interventions and physical exercise and weight management assistance, if needed.
The ADA and EASD urge doctors to involve the patient as much as possible in developing a treatment regimen to help keep patients motivated about staying on top of their care. "Patient involvement in the medical decision making constitutes one of the core principles of evidence-based medicine," notes the statement. "In a shared decision-making approach, clinician and patient act as partners, mutually exchanging information and deliberating on options, in order to reach a consensus on the therapeutic course of action. There is good evidence supporting the effectiveness of this approach. Importantly, engaging patients in health care decisions may enhance adherence to therapy."
For diabetics wanting to become more informed and more involved in decisions about care, take notes or even have a trusted person with you to take them whenever you see your doctor for a diabetes checkup, and be sure to ask any questions you have regarding your condition.
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(Published online April 19, 2012) Inzucci S, et. al. Management of Hyperglycemia inType2 Diabetes: A Patient-Centered Approach. Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Available online at http://care.diabetesjournals.org/content/early/2012/04/17/dc12-0413.full.pdf+html through http://care.diabetesjournals.org. Accessed November 2012.
(April 19, 2012) Barclay L. ADA/EASD Issue New Hyperglycemia Management Guidelines. Medscape News article. Available online at http://www.medscape.com/viewarticle/762322 through http://www.medscape.com. Accessed November 2012.
(September 6, 2012) Centers for Disease Control and Prevention. Basics About Diabetes. Available online at http://www.cdc.gov/media/presskits/aahd/diabetes.pdf through http://www.cdc.gov. Accessed November 2012.
(April 19, 2012) Weiss D. ADA Issues New Type 2 Diabetes Treatment Guidelines. Pharmacy Times. Available online at http://www.pharmacytimes.com/news/ADA-Issues-New-Type-2-Diabetes-Treatment-Guidelines through http://www.pharmacytimes.com. Accessed November 2012.