Clinical Question

What guidelines can help to determine individual treatment goals and treatments for patients with new or established type 2 diabetes mellitus?

Bottom Line

This statement from American and European diabetes societies suggests that tighter control of hyperglycemia be attempted only in patients with a recent diagnosis and a low risk of hypoglycemia; who have a long life expectancy with few or no comorbidities, including cardiovascular disease; and who are highly motivated and have readily available resources and support systems. The aim should be less stringent control for everyone else. Every patient should be started on metformin; if further glucose control is needed after three months, a second drug can be added, with a third drug added after another three months. Which ones should you add? The guideline says there is little difference. Base your choice on cost, patient preference, and your own familiarity. (Level of Evidence = 5)

Synopsis

The American Diabetes Association and the European Association for the Study of Diabetes have issued a second position statement focusing on when and how to individualize treatment in patients with type 2 diabetes. As before, the groups suggest individualizing not only treatments but treatment goals, perhaps in some surprising ways. Citing lack of benefit and/or risk of harm with lower A1C targets (less than 7%), the societies suggest many situations in which treatment goals may be much higher without setting a ceiling. The following patient characteristics, for example, support less stringent goals:

• High risk of hypoglycemia

• Long-standing disease duration

• Shorter life expectancy

• The presence of important comorbidities, including established vascular complications

• Lack of adherence or less motivation

• Limited resources and support systems

Metformin is the cornerstone of treatment to achieve control. If it is not effective, the guidelines suggest any of six other drug classes, citing the differences in effectiveness to be too small to matter. Similarly, a third drug, if needed, can be tailored to individual patients according to their preferences. A chart showing these options can be found at http://tinyurl.com/T2DM2015.

Study design: Practice guideline

Funding source: Foundation

Setting: Various (guideline)

Reference: InzucchiSEBergenstalRMBuseJBet alManagement of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care2015; 38( 1): 140– 149.