News Article
Guidelines Offer Type 2 Diabetes Treatment Pathway
The newly revised type 2 diabetes treatment algorithm released jointly by the American Diabetes Association and the European Association for the Study of Diabetes is expected to help clarify decisions about current therapeutic options.
"The major target and intent of the consensus algorithm was to help the busy nonspecialists, who provide care for the vast majority of patients with type 2 diabetes, to select the most effective, acceptable, and cost-effective interventions from the now numerous choices available," Dr. David M. Nathan said in an interview.
"The algorithm should be helpful and apply to anyone providing care to persons with diabetes," said Dr. Nathan, chair of the consensus panel that developed the recommendations, and director of the general clinical research center and of the diabetes center at Massachusetts General Hospital, Boston.
The consensus statement, published online October 22 in the journals Diabetes Care and Diabetologia, updates the treatment algorithm that initially was published in 2006, taking into account newer medications and recent scientific data on previously recommended drugs (Diabetes Care 2008 Oct. 22 [doi:10.2337/dc08-9025]; Diabetologia 2008 Oct. 22 [doi:10.1007/s00125-008-1157-y]).
The new guidelines emphasize the achievement and maintenance of near normoglycemia (hemoglobin A
"Our consensus is that an Hb
The algorithm classifies treatments as tier 1 or tier 2 interventions. Tier 1 interventions are well-validated core therapies that are the most effective and cost-effective for achieving glycemic goals. "The tier 1 algorithm is the preferred route of therapy for most patients with type 2 diabetes," the authors wrote.
According to the tier 1 algorithm, the first step in treating newly diagnosed type 2 diabetes should be to initiate lifestyle changes. "Lifestyle interventions to improve glucose, blood pressure, and lipid levels, and to promote weight loss or at least avoid weight gain, should remain an underlying theme throughout the management of type 2 diabetes, even after medications are used," the consensus group wrote.
But lifestyle changes are not enough to achieve or maintain goals in most patients with type 2 diabetes, they acknowledged. Therefore, metformin therapy should be started concurrently with lifestyle intervention at diagnosis, unless there are contraindications. Metformin should be titrated to its maximally effective dose over 1-2 months as tolerated.
When lifestyle changes and the maximal tolerated dose of metformin do not achieve or maintain glycemic goals, another medication should be added, either within 2-3 months of the initiation of therapy or at any time when the target Hb
When lifestyle changes, metformin, and either sulfonylurea therapy or basal insulin are still not sufficient to achieve target glycemia, the next step is to start or intensify insulin therapy. When insulin injections are started, be sure to discontinue, or taper and discontinue, sulfonylurea therapy or glinides. A third oral medication can be considered - particularly if the Hb
Tier 2 therapies are not as well validated but may be added to lifestyle changes and metformin in selected clinical settings. These include pioglitazone or the glucagonlike peptide 1 agonist exenatide. "Rosiglitazone is not recommended," the authors wrote. The addition of a sulfonylurea may be considered if these interventions are not effective in achieving a target Hb
In the setting of uncontrolled diabetes with catabolism, insulin therapy in combination with lifestyle intervention is the treatment of choice.
Dr. Nathan and each of his coauthors acknowledged several significant financial relationships with pharmaceutical companies.
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