Re: new treatment changes in type 2

October 29, 2008

Here we go again. " Maintaining glycemic levels as close to the nondiabetic

range as possible has been demonstrated to have a powerful beneficial effect on

diabetes-specific

microvascular complications, including retinopathy, nephropathy, and neuropathy,

in the setting of type 1 diabetes; in type 2 diabetes, " Every time I read such

a statement, and believe me the ADA and the EADS both make these types of

statements time after time.

Yes I am talking about Associations who should be the vanguards for the

diabetic's health. Practically every time they advocate an A1C level of 7.0, as

they do in the article below. Every time such statements drive me up the wall.

Why? you may ask. Because they do not feel we have the sense or the desire to

know what a normal non-diabetic A1C level is!

I am here to tell you what it is, because I feel you have enough sense to

understand what it is. I have even confirmed my recommendation on what a normal

non-diabetic A1C level actually is. I wrote to Mendosa, a diabetes expert

who maintains a web page, and he says I am right. I advocate the normal

non-diabetic A1c is between an A1c of 4.2-5.2, and Mendosa told me it is

closer to 4.5-5.0. In other words the normal non-diabetic A1C level is a hell

of a lot closer to 5.0 than it is to 7.0.

Believe me when I say that getting to a normal non-diabetic level is unlikely

when just advocating drugs as the correct path to follow.

Insulin, a normal substance, works every time it is tried. Yet you never hear

of them advocating such an extreme measure as using insulin. I wonder why?

new treatment changes in type 2

New Major Changes in Recommendations for the Treatment of Type 2 Diabetes by

ADA and EASD

The American Diabetes Association (ADA) and the European Association for the

Study of Diabetes (EASD) have issued an updated consensus statement on the

management of hyperglycemia in patients with type 2 diabetes.

The updated statement, which focuses on the new classes of medications

available to patients, is published conjointly in the October 22 Online First

issue

of Diabetes Care and the October 22 issue of Diabetologia. The article will

also appear in the December print issue of Diabetes Care.

M. , MD, from the Diabetes Center of Massachusetts General

Hospital in Boston, and colleagues writes, " The epidemic of type 2 diabetes and

the

recognition that achieving specific glycemic goals can substantially reduce

morbidity have made the effective treatment of hyperglycemia a top priority. " ï¿½

" While the management of hyperglycemia, the hallmark metabolic abnormality

associated with type 2 diabetes, has historically taken center stage in the

treatment of diabetes, therapies directed at other coincident features, such

as dyslipidemia, hypertension, hypercoagulability, obesity, and insulin

resistance,

have also been a major focus of research and therapy.ï¿½

Maintaining glycemic levels as close to the nondiabetic range as possible has

been demonstrated to have a powerful beneficial effect on diabetes-specific

microvascular complications, including retinopathy, nephropathy, and

neuropathy, in the setting of type 1 diabetes; in type 2 diabetes, more

intensive

treatment strategies have likewise been demonstrated to reduce microvascular

complications. "

The new statement updates a consensus algorithm for the medical management of

type 2 diabetes published in August 2006. At that time, the authors recognized

the need to update the algorithm based on the availability of new

interventions and new evidence to validate their use, while recognizing the

risks of

changing the algorithm too often or without justification.

The principles used to develop the algorithm and its major features are still

upheld in the latest revision. Although the January 2008 update to the consensus

algorithm specifically addressed safety issues surrounding the

thiazolidinediones, the current update highlights new classes of medications for

which more

clinical data and wider experience are now available.

" Selection of the individual agents should be made on the basis of their

glucose-lowering effectiveness and other characteristics, " the statement authors

write. " However, when adding second antihyperglycemic medications, the synergy

of particular combinations and other interactions should be considered.

In general, antihyperglycemic drugs with different mechanisms of action will

have the greatest synergy; insulin plus metformin is a particularly effective

means of lowering glycemia while limiting weight gain. "

Specific principles of management offered in the consensus statement are as

follows:

list of 4 items

â€¢ An important therapeutic goal in type 2 diabetes is to achieve and to

maintain near-normoglycemia (hemoglobin A1c level < 7.0%).

â€¢ The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

â€¢ When target glycemic goals are not achieved or maintained with the above

first-line therapy, other medications should be added rapidly, and new regimens

should be initiated.

â€¢ In patients who do not reach target goals with the above regimens, early

addition of insulin therapy should be considered.

list end

Step 1 is lifestyle intervention and use of metformin because of its effect on

glycemia, absence of weight gain or hypoglycemia, good tolerability profile,

and relatively low cost. Lifestyle changes should aim to improve glucose

levels, blood pressure, and lipid levels, and to promote weight loss or at least

to avoid weight gain. As tolerated, metformin should be titrated to its

maximally effective dose at 1 to 2 months.

Step 2 is to add another medication, either insulin or a sulfonylurea, within

2 to 3 months of starting step 1 or at any time when target hemoglobin A1c

level is not achieved or if metformin is contraindicated or poorly tolerated.

For patients who have hemoglobin A1c level of more than 8.5% or symptoms

secondary to hyperglycemia, insulin is preferred, typically a basal

(intermediate- or long-acting) insulin.

Step 3 involves further adjustments by starting or intensifying insulin

therapy with additional injections that might include a short- or rapid-acting

insulin

given before selected meals to curtail postprandial hyperglycemia. Insulin

secretagogues (sulfonylurea or glinides) should be discontinued, or tapered

and then discontinued, once insulin injections are started.

The tier 2 algorithm consists of less well-validated therapies that may be

considered in selected clinical settings, such as in patients with hazardous

jobs that would make hypoglycemia particularly dangerous. In these patients,

adding exenatide or pioglitazone may be considered, although rosiglitazone

is not recommended.

For patients who need to lose weight and in whom hemoglobin A1c level is close

to target (< 8.0%), exenatide may be considered. If these interventions do

not achieve target hemoglobin A1c level or are not tolerated, adding a

sulfonylurea may be helpful, or tier 2 interventions should be stopped and basal

insulin started.

Although the amylin agonists, alpha-glucosidase inhibitors, glinides, and

dipeptidyl peptidase 4 inhibitors are not included in the 2 tiers of preferred

agents, they may be appropriate for selected patients. Compared with the

first- and second-tier agents, their efficacy to lower glucose is less or

equivalent,

they are relatively expensive, and clinical data regarding their use are

limited.

" Type 2 diabetes is epidemic, " the statement authors conclude. " Its long-term

consequences translate into enormous human suffering and economic costs;

however,

much of the morbidity associated with long-term microvascular and neuropathic

complications can be substantially reduced by interventions that achieve

glucose levels close to the nondiabetic range. Although new classes of

medications and numerous combinations have been demonstrated to lower glycemia,

current-day management has failed to achieve and maintain the glycemic levels

most likely to provide optimal healthcare status for people with diabetes. "

Practice Pearls

list of 2 items

â€¢ In type 2 diabetes, an important therapeutic goal is to achieve and to

maintain hemoglobin A1c levels less than 7.0%. For most patients, step 1 is

lifestyle

intervention and metformin. When this fails to achieve or maintain target

glycemic goals, other medications should be added rapidly, and new regimens

should

be started. Step 2 is to add another medication, either insulin or a

sulfonylurea. In step 3, insulin therapy is started or intensified.

â€¢ The tier 2 algorithm using less well-validated therapies may be considered

in selected patients. For those in whom hypoglycemia would be particularly

dangerous, exenatide or pioglitazone may be added, but rosiglitazone is not

recommended. Exenatide may be considered for patients who need to lose weight

and in whom hemoglobin A1c level is close to target (< 8.0%),

list end

Diabetes Care. 2008;31:1-11. Published online October 22, 2008. Diabetologia.

Published online October 22, 2008.

==============================

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This article originally posted

October 28, 2008

and appeared in

Issue 440

New Major Changes in Recommendations for the Treatment of Type 2 Diabetes by

ADA and EASD

The American Diabetes Association (ADA) and the European Association for the

Study of Diabetes (EASD) have issued an updated consensus statement on the

management of hyperglycemia in patients with type 2 diabetes.

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October 29, 2008

Oh I have one even better. My mom, bless her heart, has a doctor who gave

her the blood test results a couple of weeks ago, where her hemoglobin A1c

was 8.1, and he said " keep up the good work. " I about gagged. I said " Mom,

8.1 is NOT good, how on earth could he sit there and tell you that? " I told

her what the reading SHOULD be and she just said " well, he's the doctor, he

should know. " When I told her that too many doctors just don't know, she

blocked out on the subject saying " everybody keeps telling me something

different things, I'm just so confused. " It's enough to make her give up

trying, but try she just doesn't do hard enough, but it's HER life.. I could

cringe though thinking this doc gives her a clean bill of health with 8.1!

Good God Almighty! And she wonders why she feels as cruddy as she does most

of the time...

But it will keep her on pills which will make Big Pharma happy.

Bill Powers

October 29, 2008