Friday, May 18, 2012

Diabetes management- " any target could (should ) reflect an agreement between patient and physician"

Management of Hyperglycemia in Type 2 Diabetes : A Patient Centered Approach

Position Statement of the American Diabetes Association (ADA) and
the European Association for the Study of Diabetes (EASD)

This position statement was published on line April19, 2012 by the American diabetes Association.  I am not sure when the printed version will become available. I recommend that every patient with type 2 diabetes  read all 12 pages of this paper. It is full of  charts graphs and information that will improve your understanding of this complex disease . This  paper will enhance your ability to become a full partner in your diabetes care.

I took this one little section, Antihyperglycemic Therapy , and started high lighting the areas that I felt were worth emphasis.  You will notice almost every thing is highlighted. It is worth reading every line. I have added my brief comments on the right side.

 ANTIHYPERGLYCEMIC                                                                               comments
Glycemic targets                                                             Correcting your A1c to <7  has the most impact in reducing the risk of eye,
                                                                                       Nerve and kidney damage.
The ADAs Standards of Medical Care in 
Diabetesrecommends lowering HbA1c
to ,7.0% in most patients to reduce the
incidence of microvascular disease (42).

This can be achieved with a mean plasma                                  This is a good answer to a common question. What is my goal for before and after meal glucose ?
glucose of ;8.38.9 mmol/L (;150160
mg/dL); ideally, fasting and premeal glucose
should bemaintained at,7.2mmol/L
(,130 mg/dL) and the postprandial glucose
at ,10 mmol/L (,180 mg/dL).

More stringent HbA1c targets (e.g., 6.0                                  This is good information to know when setting your target goals
6.5%) might be considered in selected
patients (with short disease duration, long
life expectancy, no significant CVD) if this
can be achieved without significant hypoglycemia
or other adverse effects of treatment

(20,43). Conversely, less stringent                                          This is more good information to know when you are setting your target goals.
HbA1c goalsde.g., 7.58.0% or even
slightly higherdare appropriate for patients
with a history of severe hypoglycemia,
limited life expectancy, advanced complications,
extensive comorbid conditions and
those inwhomthe target is difficult to attain
despite intensive self-management education,
repeated counseling, and effective
doses of multiple glucose-lowering agents,
including insulin (20,44).

The accumulated results from the                                            One size does not fit all!
aforementioned type 2 diabetes cardiovascular
trials suggest that not everyone
benefits from aggressive glucose management.
It follows that it is important to
individualize treatment targets (5,3436).
The elements that may guide the clinician
in choosing an HbA1c target for a specific
patient are shown in Fig. 1. As mentioned
earlier, the desires and values of the
patient should also be considered, since
the achievement of any degree of glucose
control requires active participation and
commitment (19,23,45,46).

  Indeed, any                                                                   This is the headline . I did change could to should
target could reflect an agreement between
patient and clinician. 

An important related
concept is that the ease with which more
intensive targets are reached influences
treatment decisions; logically, lower targets
are attractive if they can be achieved
with less complex regimens and no or
minimal adverse effects.

 Importantly, utilizing                                                       This happens and needs to be changed.
the percentage of diabetic patients
who are achieving an HbA1c ,7.0% as a
quality indicator, as promulgated by various
health care organizations, is inconsistent
with the emphasis on individualization

Have fun , Be Smart and read very line of this position statement by The ADA  and ESDA. It is worth your time.
David Calder,MD

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Your comments and questions are appreciated. David Calder,MD