Patient-centered care is the guiding principle of the management of hyperglycemia in patients with type 2 diabetes, according to a joint position statement released by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).
Compared with 2008 ADA-EASD treatment algorithm, the new position statement is not as prescriptive and calibrates treatment targets to patient needs while individualizing the treatment options. It also acknowledges the role of lifestyle changes prior to initiating metformin therapy.
The features of the new statement were reviewed by Silvio E. Inzucchi, MD, a co-author of the position statement, at the 72nd scientific sessions of the American Diabetes Association.
The statement is published in Diabetes Care (2012;35:1364-1379) and Diabetologia (2012;55:1577-1596). The position statement covers the array of antihyperglycemic agents available, the risks and benefits of tight glycemic control in various patient populations, drug safety, and patient-centered care.
A patient-centered approach is one that provides care “that is respectful of and responsive to individual patient preferences, needs, and values—ensuring that patient values guide all clinical decisions,” said Dr. Inzucchi, in quoting from the position statement.
First, the patient’s preferred level of involvement should be gauged. Although decision-making is shared, the final decisions regarding lifestyle choices ultimately lie with the patient, he said. Where possible, therapeutic choices should be explored.
He admits that the burden of treatment for some patients with complex chronic comorbidities reduces their capacity to collaborate in their care. In such instances, care must be minimally disruptive to be effective. The treating physician should establish the weight of the burden, encourage coordination in clinical practice, acknowledge the comorbidity, and prioritize from the patient perspective.
The position statement recommends a glycemic target of <7% for glycated hemoglobin (HbA1c) when instituting antihyperglycemic therapy. Plasma glucose targets should be <130 mg/dL pre-prandial and <180 mg/dL post-prandial.
“Individualization is key,” said Dr. Inzucchi, and professor of medicine (endocrinology), clinical director, Section of Endocrinology, and director, Yale Diabetes Center, New Haven, Conn. The HbA1c targets are lower for younger, healthier patients (target: 6.0% to 6.5%) than they are for older patients who have comorbidities and may be prone to hypoglycemia (target: 7.5% to 8.0%+). Therapy should be selected and titrated to avoid hypoglycemia.
According to the report, “the aims of controlling glycemia are to avoid acute osmotic symptoms of hyperglycemia, to avoid instability in blood glucose over time, and to prevent/delay the development of diabetes complications without adversely affecting quality of life. Information on whether specific agents have this ability is incomplete; an answer to these questions requires long-term, large-scale clinical trials—not available for most drugs.”
General recommendations for antihyperglycemic therapy are to start with metformin. There are little data to guide therapy after metformin. Combination therapy with 1 or 2 additional oral agents or injectable is reasonable. “Ultimately, many patients will require insulin therapy alone or in combination with other agents to maintain glucose control,” the report’s authors wrote.
The ADA-EASD committee recommended initial dual combination therapy when HbA1c is >9%, said Dr. Inzucchi.
All treatment decisions should be made in conjunction with the patient, focusing on patient preferences, needs, and values. Diabetes education is mandated for all patients, administered either to individuals or groups. The education program should focus specifically on dietary intervention and increased physical activity. Periodic counseling should also be integrated into the program.
Consider Risk of Hypoglycemia, Effect of Intervention on Weight
The position statement makes the case for less stringent HbA1c targets for some patients. For older adults who have a reduced life expectancy, a higher burden of cardiovascular disease, a reduced glomerular filtration rate, and are more likely to be compromised from hypoglycemia, targets should be less ambitious, perhaps an HbA1c of 7.5% to 8.0% if lower targets are not easily achieved, he said, and a focus on drug safety.
The patient’s weight should be addressed, and the effect of each intervention on body weight should be considered. Metformin has a neutral or slightly beneficial effect on weight, but it appears to be just as effective in lean individuals. Glucagon-like peptide-1 (GLP-1) receptor agonists are associated with a reduction in weight, sometimes substantial. In lean patients, the possibility of latent autoimmune diabetes in adults should be considered, he said.
In addition to managing hyperglycemia, comprehensive cardiovascular risk reduction “must be a major focus of therapy,” the report’s authors wrote.
“In very preliminary reports, therapy with GLP-1 receptor agonists and DPP-4 inhibitors has been associated with improvement in either cardiovascular risk or risk factors, but there are no long-term data regarding clinical outcomes.”