The European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) have published new guidelines on the treatment of type 2 diabetes It has, for the first time, put the patient at the heart of the clinical decision-making process.
The guidelines are the focus of a session at this year’s annual meeting of EASD in Berlin, Germany that is being held from1-5, 2012.
The new position statement is less prescriptive than previous guidelines, advocates more patient involvement and gives guidance on the rational approach to the choice of therapy. This choice will now combine the best available evidence from literature with the clinician’s expertise and the patient’s own inclinations.
Patient-centred care is defined as “an approach to providing care that is respective and responsive to individual patient preferences, needs and values, ensuring that the patients’ own values guide all clinical decisions”. EASD and ADA emphasise that this should be the organising principal underlying healthcare for individuals with diabetes (and any chronic disease). “Given the uncertainties in terms of type and sequence of therapies, this approach is particularly appropriate in type 2 diabetes,” says Professor Andrew Boulton, EASD President.
The new recommendations of EASD and ADA are asking not only for individualised interventions in type 2 diabetes but discuss the individualised goals as well. While general recommendations regarding the intensiveness of glycaemic therapy focused in the past on a HbA1c target below seven per cent, this new statement emphasises the pragmatic viewpoint that goals must be individualised. The precise glycaemic target should take into account several factors including patient’s attitude and expected treatment efforts, the risk potentially associated with glycaemia and other adverse effects, disease duration, life expectancy, other co-morbidities, established vascular complications, and the patient’s own resources and support system. For example, some patients may feel that the weight gain associated with a particular diabetes therapy is unacceptable, and want other options considered. Others may consider risk of hypoglycaemia as something they want their therapy to address.
“The overarching goal should be to reduce blood glucose concentrations safely to a range that will substantially minimise long-term complications, but, always keeping in mind the potential adversities with treatment burden, particularly in the elderly who are more often exposed to multiple drug treatments,” says Professor Boulton.
This statement issued by the two leading academic associations in diabetes research points out that there is a need for numerous studies in specific subgroups of people of different ages and with different stages of diabetes, in order to assess the various possible combinations of glucose lowering therapies.
Other key points from the new guidelines:
- Diet, exercise and education remain the foundation of any type 2 diabetes treatment programme
- Unless there are prevalent contraindications, metformin is the optimal first-line drug
- After metformin, there are limited data to guide treatment. Combination therapy with an additional 1 or 2 oral or injectable agents is reasonable, aiming to minimise side effects where possible
- Ultimately, many patients will require insulin therapy alone or in combination with other agents to maintain glucose control
- Comprehensive cardiovascular risk reduction must be a major focus of therapy
Source: Lancet