One rule for one and one for another with diabetes

By Sally Robertson, B.Sc.Oct 12 2012

A joint consensus statement from the European Association for the Study of Diabetes (EASD) and the American Diabetes Association encourages a shift in attitude over glycemic management in Type 2 diabetes.

The position statement, which was presented at the 48th Annual Meeting of the EASD in Berlin, Germany, says that advice must be personalized rather than working on a "one size fits all" basis.

"We cannot consider just pathophysiology and just HbA1c [glycated hemoglobin] lowering efficacy when treating a diabetes patient. If that patient experiences a side effect they cannot tolerate, then they will not take their pill," said co-chair for the Position Statement Writing Group, Sylvio Inzucchi, from Yale University, New Haven, USA.

It has generally been recommended previously that intensive antihyperglcemic glycemic therapy should focus on achieving an HbA1c level below 7%. However, as noted in the statement, "not everyone benefits from aggressive glucose management."

Co-chair David Matthews from the University of Oxford in the UK told medwireNews he hopes that the new statement will mean that in the future "organizations like NICE [National Institute for Health and Clinical Excellence] and the government won't make any numerical target."

"We have deliberately written this so that you can't take any numerical target out of it at all," he explained.

Although some people think this is a big disadvantage, the numerical targets have only stood primary care clinicians in good stead in terms of getting averages down, said Matthews. In individual cases they are serving us badly, with "some physicians making crazy judgements on the basis that if they can get people one side or other of a target, it makes the difference between whether they get £ 10 [US$ 16; € 12] from the government or nothing, in terms of quality outcome frameworks and so on, and that's not in the best interest of the patient."

The statement, jointly published in Diabetologia and Diabetes Care, does not recommend any significant changes with regard to specific treatment options, with diet and exercise remaining the cornerstone of any initial therapy.

But it points out that clinical advice is often based on primary source evidence and that this type of evidence emerges only from clinical trial findings in highly selected patients using limited strategies.

"This does not address the range of choices available, or the order of use of additional therapies," notes Matthews.

"The algorithmic approach has finally, in our view, had its day - we can't do that anymore. For example, if you've got someone who's pretty old and may have a hypoglycemic event, and then they do, and then they aspirate, that could be the end of their life… and for those people there's a range of drugs available now."

The target glycemic level should take into account various factors including patients' attitudes and expected treatment efforts, the risks associated with hypoglycemia and other adverse events, disease duration, life expectancy, comorbidities, established vascular complications, and the resources and support that are available to the patient, outlines the statement.

The writing group also want the statement to encourage clinicians to have much more constructive discussions with their patients.

"All treatment decisions should be made with the patients," said Inzucchi. "The focus should really be about the patients' preferences, their needs, and their values about the disease."

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