A joint position paper by American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) questions the veracity of a one size fits all specific A1C target for non-pregnant patients with type 2 diabetes. Instead it suggests focusing on individually targeted glycemic goals based on a series of patient attributes including patient desires and attitudes toward treatment, potential for hypoglycemia, disease duration, life expectancy, co-morbidities, vascular complications and patient resources.
The table below indicates the order and intensity of importance of factors to consider when deciding on individual patient treatment goals. In addition to glycemic control the position statement recommends clinicians and patients take into account cardiovascular risk management due to the high morbidity load this places on patients with type 2 diabetes.
The report appearing in the April 19 2012 issue of Diabetes Care also re-emphasized the importance of dietary and physical activity approaches and suggested that highly motivated patients who are initially diagnosed with an A1C under 7.5% be given a 3 to 6 month trial of lifestyle before initiating drug therapy.
In addition, while noting that the available oral pharmaceutical agents have some variation in their ability to lower A1C, the authors concluded that all of the agents available are in the same ball park in their efficacy. Therefore, the decision of second or third drug to add as should be based on patient co-morbidities and drug side- effect profiles.
The report emphasized the following key points.
- Glycemic targets and glucose-lowering therapies must be individualized.
- Diet, exercise, and education remain the foundation of any type 2 diabetes treatment program.
- Unless there are prevalent contraindications, metformin is the optimal first-line drug.
- After metformin, there are limited data to guide us. Combination therapy with an additional 1–2 oral or injectable agents is reasonable, aiming to minimize side effects where possible.
- Ultimately, many patients will require insulin therapy alone or in combination with other agents to maintain glucose control.
- All treatment decisions, where possible, should be made in conjunction with the patient, focusing on his/her preferences, needs, and values.
- Comprehensive cardiovascular risk reduction must be a major focus of therapy.
The authors also made a number of recommendations about treatment for patients with type 2 diabetes who have many other medical problems.
For those of advanced age and co-morbidities who cannot meet lower A1C goals with simple strategies the group recommends a higher target A1C of 7.5- 8.0.
For people with heart failures, while recommending the avoidance of thiazolidinedones (TZDS) such as Actos® and Avandia® (since they can potentate fluid overload) they suggested that metformin may not be as problematic a choice of medication in this population as previously believed. In patients with minimal to moderate ventricular dysfunction, stable cardiovascular status and normal renal function, it could be considered.
There were also some guidelines adjustments for people with kidney disease. . Many oral agents are cleared through the kidneys and doses need to be reduced for those with renal impairments. Glyburide, a drug which stays in the body for a long time, should be avoided in this population due to its potential to cause sustained hypoglycemia. Here again metformin is being given another look. Currently metformin use is discouraged in patients with serum creatinine (a laboratory value that measures kidney function) levels above 1.5 in males and 1.4 in females. However, the authors recommend considering the advice of National Institute for Health and Clinical Excellence (NICE) guidelines which allow the use of metformin with a kidney filtration rate as little as 30 mL/min, with dose reduction advised at 45 mL/min.