Management of Hyperglycemia in Type 2 Diabetes: A Patient Centered Approach
Position statement of the American Diabetes Association and the European Association for the study of Diabetes
I recommend that you read the full document available from the American Diabetes Association. I plan to review and comment on 2 to 3 pages a day. These guidelines have done an excellent job of putting into words the activities that are occurring every day in physicians , diabetes educations and dietitians offices around the world .
Page 1 summary
You are officially recognized as a full partner in your health care
People with Type 2 diabetes are at increased risk of heart disease
The introduction points out " this document refers to glycemic control; yet this needs to be pursued within a multifactorial risk reduction framework". Preventing heart disease requires aggressive management of multiple risk factors, Blood pressure, lipids , aspirin use and smoking cessation also.
Patient - centered approach
Patient-centered care is defined as an approach to " providing care that is respectful of and responsive to individual patients preferences , needs, and values and ensuring that patient values guide all clinical decisions."
" in a shared decision -making approach, clinicians and patients act as partners, mutually exchanging information and deliberating on option , in order to reach a consensus on the therapeutic course of action "
Page 2 summary
younger people with shorter duration of diabetes who achieve A1c targets of <6.5 without significant hypoglycemia may have a lower risk of developing cardiovascular disease
This page reminds us of the reality of Type 2 diabetes being a leading cause of cardiovascular disorders , blindness , end- stage kidney failure , amputations , and hospitalizations.
They also review the hope and benefits of our current treatment by reviewing four studies results :
* UKPDS( UK prospective study )
- results from reducing A1c from 7.9 to 7 ( treated with sulfonylurea or insulin )
a signficant reduction in the risk for developing eye , nerve and kidney damage
a non- signficant reduction in risk for cardiovascu;ar disease
-results from treatment with metformin :
fewer patients experienced heart attacks and had an overall
-10 year followup of the intensive treatment group:
A1c had increased slightly but all intensive treatment groups had a reduction in heart attacks and
* Three other studies in 2008 ,ACCORD and VADT had treatment goals of A1c <6 and ADVANCE
with treatment goals of A1c of <6.5. None of these studies showed any significant reduction in
cardiovascular risk in the treatment groups.
They did demonstrate a significant increase in the risk of hypoglycemia in the treatment groups.
The ACCORD study had a 22 % increase in total mortality in the patients in the intensive treatment
group. ( goal A1c <6 ) The increased mortality in this group seem to occur in older patients
struggling to achieve an A1c of < 6 .
There were suggestions that younger people with shorter duration of diabetes and without
cardiovascular disease benefited from the more intensive therapy.
* finally a meta-analysis of these trials suggest that for every 1 % decrease in A1c may be associated
with a 15 % relative risk reduction in non fatal myocardial infarction, but without any benefits on
stroke are all-cause mortality
Tomorrow- Treatment decisions
Have Fun , Be Smart and become a full informed partner in your health care
David Calder, MD