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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. " �

" 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.�

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

• An important therapeutic goal in type 2 diabetes is to achieve and to

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

• The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

• 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.

• 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

• 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.

• 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.

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

Advertisement

One tablet, once daily, proven to deliver 24-hour glycemic control. Learn

more.

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being forced to pay for their own testing supplies and price is becoming more

important, but often times affordable meters have been perceived (rightly

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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.

Diabetes In Control Sponsors

http://www.diabetesincontrol.com/aserver/adclick.php?n=a8e6d6c1

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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

Link to comment
Share on other sites

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

Link to comment
Share on other sites

I thought the article mentioned the use of insulin.

Dave

God doesn't hate sinners, just sin!

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. " �

" 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.�

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

• An important therapeutic goal in type 2 diabetes is to achieve and to

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

• The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

• 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.

• 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

• 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.

• 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.

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

Advertisement

One tablet, once daily, proven to deliver 24-hour glycemic control. Learn

more.

http://ad.doubleclick.net/clk;195729505;25588705;w

Send to Friend

| Share |

Print |

Category |

Home

Have a comment?

Post it here.

Visit the NEW Diabetes In Control Blog.

Click Here!

There are no comments to this article at this time.

Be the first!

Browse by Feature Writer & Article Category

A. Lee Dellon, MD |

Beverly Price |

Birgitta I. Rice, MS |

Did You Know |

Dr. Bernstein |

Dr. Jakes, Jr. |

Dr. Varon, DDS |

Dr. Fred Pescatore |

Dr. Walter Willett |

Education |

S. Freedland |

Evan D. Rosen |

Facts |

Features |

Ginger Kanzer- |

Items for the Week |

, MD |

ph M. Caporusso |

a Sandstedt |

Plunkett |

Leonard Lipson, M.A. |

Lester A. Packer |

Diane |

New Products |

Newsflash |

Chous, M.A., OD |

Philip A. Wood PhD |

R. |

Sheri R. Colberg PhD |

Sherri Shafer |

Steve Pohlit |

Studies |

Test Your Knowledge |

Theresa L. Garnero |

Tools |

Vickie R. Driver |

M. Volpone |

This Week's Blog |

Press Releases |

Search Articles On Diabetes In Control

Article Title:

and/or Description:

imageField

Diabetes In Control Sponsors

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

New Product

TRUE2go and TRUEresult

Home Diagnostics TRUE2go and TRUEresult Glucose Meters

TRUE2go and TRUEresult bring together, ease of use, no coding and accurate

results with a price that your patients can afford. More and more patients are

being forced to pay for their own testing supplies and price is becoming more

important, but often times affordable meters have been perceived (rightly

or wrongly) to be of lower quality than the biggest national brands.

Read more »

Print This Week's Newsletter

Download This Week's Newsletter

Newsletter is in Adobe format

If you don't have Adobe Acrobat Reader, you can download it for Free

here.

Free CE Available

CE Programs On Diabetes Available

here

alltop

Flash movie start

http://www.diabetesincontrol.com/aserver/adclick.php?bannerid=67 & zoneid=1 & source\

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t%2Fen_US%2Fweb_form%2FDCM_web_form_01.htm

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link region type: RECT

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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.

Diabetes In Control Sponsors

http://www.diabetesincontrol.com/aserver/adclick.php?n=a8e6d6c1

Flash movie end

Sign up for our FREE Weekly Newsletter

Current Issue

Past Issue

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Privacy /

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Add us to your favorite news reader

addtogoogle

addtomsm

addtomyyahoo

Link to comment
Share on other sites

Too much of the time, people with diabetes (and high A1C readings) don't

necessarily feel all that bad. They go along for years feeling reasonably okay,

and after 20 years--bam!! Then it's too late.

Dave

God doesn't hate sinners, just sin!

RE: new treatment changes in type 2

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

Link to comment
Share on other sites

Too much of the time, people with diabetes (and high A1C readings) don't

necessarily feel all that bad. They go along for years feeling reasonably okay,

and after 20 years--bam!! Then it's too late.

Dave

God doesn't hate sinners, just sin!

RE: new treatment changes in type 2

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

Link to comment
Share on other sites

Excuse me. The article did mention insulin.

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. " �

" 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.�

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

• An important therapeutic goal in type 2 diabetes is to achieve and to

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

• The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

• 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.

• 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

• 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.

• 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.

Diabetes In Control Sponsors

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Yes, it did mention insulin; insulin plus metformen or just insulin as abasal

and short acting as needed.

Re: new treatment changes in type 2

Excuse me. The article did mention insulin.

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. " �

" 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.�

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

• An important therapeutic goal in type 2 diabetes is to achieve and to

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

• The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

• 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.

• 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

• 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.

• 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.

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

Advertisement

One tablet, once daily, proven to deliver 24-hour glycemic control. Learn more.

http://ad.doublecli <http://ad.doubleclick.net/clk;195729505;25588705;w>

ck.net/clk;195729505;25588705;w

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Ginger Kanzer- |

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, MD |

ph M. Caporusso |

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Plunkett |

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Lester A. Packer |

Diane |

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Chous, M.A., OD |

Philip A. Wood PhD |

R. |

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TRUE2go and TRUEresult bring together, ease of use, no coding and accurate

results with a price that your patients can afford. More and more patients are

being forced to pay for their own testing supplies and price is becoming more

important, but often times affordable meters have been perceived (rightly

or wrongly) to be of lower quality than the biggest national brands.

Read more »

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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.

Diabetes In Control Sponsors

http://www.diabetes

<http://www.diabetesincontrol.com/aserver/adclick.php?n=a8e6d6c1>

incontrol.com/aserver/adclick.php?n=a8e6d6c1

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That statement ticked me off too Harry. Too many docs think if you run a low

A1C, you will always be going a low BG-and this is not true.

Re: new treatment changes in type 2

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. " �

" 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.�

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

• An important therapeutic goal in type 2 diabetes is to achieve and to

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

• The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

• 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.

• 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

• 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.

• 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.

Diabetes In Control Sponsors

http://www.diabetes

<http://www.diabetesincontrol.com/aserver/adclick.php?n=a8e6d6c1>

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Hi Bill:

What is that doctor trying to do with your mom? Wow! even I know that is too

high. Some doctors have such busy practices that they are vertually working an

assembly line. My doctor and I were talking about that very thing as she wants

to get herpatient base down. She says she has too many patients. Your mom's

doctor sounds scarry. As I was reading that note I could just about hear you

telling your mom what you did.

I hope she can see her way through her confusion to get the right treatment.

All we can do is pray that it happens soon.

Terrie with Eunice and Shandar looking for a black kitten.

contact info:

MSN: shineydog@...

private email: shineydog@...

list email: devendawg@...

RE: new treatment changes in type 2

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

Link to comment
Share on other sites

Hi Bill:

What is that doctor trying to do with your mom? Wow! even I know that is too

high. Some doctors have such busy practices that they are vertually working an

assembly line. My doctor and I were talking about that very thing as she wants

to get herpatient base down. She says she has too many patients. Your mom's

doctor sounds scarry. As I was reading that note I could just about hear you

telling your mom what you did.

I hope she can see her way through her confusion to get the right treatment.

All we can do is pray that it happens soon.

Terrie with Eunice and Shandar looking for a black kitten.

contact info:

MSN: shineydog@...

private email: shineydog@...

list email: devendawg@...

RE: new treatment changes in type 2

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

Link to comment
Share on other sites

The article also said 7.0 is " near normoglycemia " not that it is ...

Here in Canada the CDA recommends below 7.0 for everyone, and below 6.0 for

those who can manage it safely. I'm surprised the ADA doesn't have dual

recommendations like that, since some people are at risks that others aren't.

Jen

Re: new treatment changes in type 2

Excuse me. The article did mention insulin.

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. " �

" 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.�

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

• An important therapeutic goal in type 2 diabetes is to achieve and to

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

• The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

• 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.

• 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

• 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.

• 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.

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

Advertisement

One tablet, once daily, proven to deliver 24-hour glycemic control. Learn

more.

http://ad.doubleclick.net/clk;195729505;25588705;w

Send to Friend

| Share |

Print |

Category |

Home

Have a comment?

Post it here.

Visit the NEW Diabetes In Control Blog.

Click Here!

There are no comments to this article at this time.

Be the first!

Browse by Feature Writer & Article Category

A. Lee Dellon, MD |

Beverly Price |

Birgitta I. Rice, MS |

Did You Know |

Dr. Bernstein |

Dr. Jakes, Jr. |

Dr. Varon, DDS |

Dr. Fred Pescatore |

Dr. Walter Willett |

Education |

S. Freedland |

Evan D. Rosen |

Facts |

Features |

Ginger Kanzer- |

Items for the Week |

, MD |

ph M. Caporusso |

a Sandstedt |

Plunkett |

Leonard Lipson, M.A. |

Lester A. Packer |

Diane |

New Products |

Newsflash |

Chous, M.A., OD |

Philip A. Wood PhD |

R. |

Sheri R. Colberg PhD |

Sherri Shafer |

Steve Pohlit |

Studies |

Test Your Knowledge |

Theresa L. Garnero |

Tools |

Vickie R. Driver |

M. Volpone |

This Week's Blog |

Press Releases |

Search Articles On Diabetes In Control

Article Title:

and/or Description:

imageField

Diabetes In Control Sponsors

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

New Product

TRUE2go and TRUEresult

Home Diagnostics TRUE2go and TRUEresult Glucose Meters

TRUE2go and TRUEresult bring together, ease of use, no coding and accurate

results with a price that your patients can afford. More and more patients are

being forced to pay for their own testing supplies and price is becoming more

important, but often times affordable meters have been perceived (rightly

or wrongly) to be of lower quality than the biggest national brands.

Read more »

Print This Week's Newsletter

Download This Week's Newsletter

Newsletter is in Adobe format

If you don't have Adobe Acrobat Reader, you can download it for Free

here.

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here

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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.

Diabetes In Control Sponsors

http://www.diabetesincontrol.com/aserver/adclick.php?n=a8e6d6c1

Flash movie end

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Link to comment
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The article also said 7.0 is " near normoglycemia " not that it is ...

Here in Canada the CDA recommends below 7.0 for everyone, and below 6.0 for

those who can manage it safely. I'm surprised the ADA doesn't have dual

recommendations like that, since some people are at risks that others aren't.

Jen

Re: new treatment changes in type 2

Excuse me. The article did mention insulin.

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. " �

" 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.�

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

• An important therapeutic goal in type 2 diabetes is to achieve and to

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

• The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

• 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.

• 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

• 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.

• 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.

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

Advertisement

One tablet, once daily, proven to deliver 24-hour glycemic control. Learn

more.

http://ad.doubleclick.net/clk;195729505;25588705;w

Send to Friend

| Share |

Print |

Category |

Home

Have a comment?

Post it here.

Visit the NEW Diabetes In Control Blog.

Click Here!

There are no comments to this article at this time.

Be the first!

Browse by Feature Writer & Article Category

A. Lee Dellon, MD |

Beverly Price |

Birgitta I. Rice, MS |

Did You Know |

Dr. Bernstein |

Dr. Jakes, Jr. |

Dr. Varon, DDS |

Dr. Fred Pescatore |

Dr. Walter Willett |

Education |

S. Freedland |

Evan D. Rosen |

Facts |

Features |

Ginger Kanzer- |

Items for the Week |

, MD |

ph M. Caporusso |

a Sandstedt |

Plunkett |

Leonard Lipson, M.A. |

Lester A. Packer |

Diane |

New Products |

Newsflash |

Chous, M.A., OD |

Philip A. Wood PhD |

R. |

Sheri R. Colberg PhD |

Sherri Shafer |

Steve Pohlit |

Studies |

Test Your Knowledge |

Theresa L. Garnero |

Tools |

Vickie R. Driver |

M. Volpone |

This Week's Blog |

Press Releases |

Search Articles On Diabetes In Control

Article Title:

and/or Description:

imageField

Diabetes In Control Sponsors

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

New Product

TRUE2go and TRUEresult

Home Diagnostics TRUE2go and TRUEresult Glucose Meters

TRUE2go and TRUEresult bring together, ease of use, no coding and accurate

results with a price that your patients can afford. More and more patients are

being forced to pay for their own testing supplies and price is becoming more

important, but often times affordable meters have been perceived (rightly

or wrongly) to be of lower quality than the biggest national brands.

Read more »

Print This Week's Newsletter

Download This Week's Newsletter

Newsletter is in Adobe format

If you don't have Adobe Acrobat Reader, you can download it for Free

here.

Free CE Available

CE Programs On Diabetes Available

here

alltop

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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.

Diabetes In Control Sponsors

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I know it is not true. Every week I run two or maybe three low blood sugars.

The cure for this is popping one or two candies or glucose tablets.

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. " �

" 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.�

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

• An important therapeutic goal in type 2 diabetes is to achieve and to

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

• The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

• 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.

• 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

• 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.

• 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.

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

Advertisement

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being forced to pay for their own testing supplies and price is becoming more

important, but often times affordable meters have been perceived (rightly

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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.

Diabetes In Control Sponsors

http://www.diabetes

<http://www.diabetesincontrol.com/aserver/adclick.php?n=a8e6d6c1>

incontrol.com/aserver/adclick.php?n=a8e6d6c1

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Terrie,

Unfortunately, too many doctors are very old-school and just don't see the

significance of a " normal " A1c level; they haven't been trained very well in

diabetes management and then they go out into practice and never update

their information. But yes, it's an assembly line kind of thing, as she is

the unfortunate member of a Kaiser plan, and I think most of us know that

you don't pick your doctors in that plan. As such, there's no guarantee of

getting a good one and forget trying to fight for a better doctor. My mom is

already 82 and just doesn't feel like she has much time left so there's no

point in her fighting hard at this point, though I keep telling her it's

never too late to have at least some good days before she checks out. I

seriously doubt I will be able to convince her to do anything further, she

will just go along with the program like so many sheep in the herd to be led

down the path of Big Pharma and do " whatever the doctor says. " Though I love

my mom dearly, thre are others who I can " mentor " who will use my advice,

whose lives I hope I can enhance, and who want the advice.

Bill

Link to comment
Share on other sites

Terrie,

Unfortunately, too many doctors are very old-school and just don't see the

significance of a " normal " A1c level; they haven't been trained very well in

diabetes management and then they go out into practice and never update

their information. But yes, it's an assembly line kind of thing, as she is

the unfortunate member of a Kaiser plan, and I think most of us know that

you don't pick your doctors in that plan. As such, there's no guarantee of

getting a good one and forget trying to fight for a better doctor. My mom is

already 82 and just doesn't feel like she has much time left so there's no

point in her fighting hard at this point, though I keep telling her it's

never too late to have at least some good days before she checks out. I

seriously doubt I will be able to convince her to do anything further, she

will just go along with the program like so many sheep in the herd to be led

down the path of Big Pharma and do " whatever the doctor says. " Though I love

my mom dearly, thre are others who I can " mentor " who will use my advice,

whose lives I hope I can enhance, and who want the advice.

Bill

Link to comment
Share on other sites

Actually, I thought the ADA was recommending 6.5, with some possibility of

coming down to 6.0. Did I dream this?

Dave

God doesn't hate sinners, just sin!

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. " �

" 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.�

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

• An important therapeutic goal in type 2 diabetes is to achieve and to

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

• The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

• 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.

• 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

• 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.

• 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.

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

Advertisement

One tablet, once daily, proven to deliver 24-hour glycemic control. Learn

more.

http://ad.doubleclick.net/clk;195729505;25588705;w

Send to Friend

| Share |

Print |

Category |

Home

Have a comment?

Post it here.

Visit the NEW Diabetes In Control Blog.

Click Here!

There are no comments to this article at this time.

Be the first!

Browse by Feature Writer & Article Category

A. Lee Dellon, MD |

Beverly Price |

Birgitta I. Rice, MS |

Did You Know |

Dr. Bernstein |

Dr. Jakes, Jr. |

Dr. Varon, DDS |

Dr. Fred Pescatore |

Dr. Walter Willett |

Education |

S. Freedland |

Evan D. Rosen |

Facts |

Features |

Ginger Kanzer- |

Items for the Week |

, MD |

ph M. Caporusso |

a Sandstedt |

Plunkett |

Leonard Lipson, M.A. |

Lester A. Packer |

Diane |

New Products |

Newsflash |

Chous, M.A., OD |

Philip A. Wood PhD |

R. |

Sheri R. Colberg PhD |

Sherri Shafer |

Steve Pohlit |

Studies |

Test Your Knowledge |

Theresa L. Garnero |

Tools |

Vickie R. Driver |

M. Volpone |

This Week's Blog |

Press Releases |

Search Articles On Diabetes In Control

Article Title:

and/or Description:

imageField

Diabetes In Control Sponsors

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

aserver/adview

New Product

TRUE2go and TRUEresult

Home Diagnostics TRUE2go and TRUEresult Glucose Meters

TRUE2go and TRUEresult bring together, ease of use, no coding and accurate

results with a price that your patients can afford. More and more patients are

being forced to pay for their own testing supplies and price is becoming more

important, but often times affordable meters have been perceived (rightly

or wrongly) to be of lower quality than the biggest national brands.

Read more »

Print This Week's Newsletter

Download This Week's Newsletter

Newsletter is in Adobe format

If you don't have Adobe Acrobat Reader, you can download it for Free

here.

Free CE Available

CE Programs On Diabetes Available

here

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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.

Diabetes In Control Sponsors

http://www.diabetesincontrol.com/aserver/adclick.php?n=a8e6d6c1

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Actually, I thought the ADA was recommending 6.5, with some possibility of

coming down to 6.0. Did I dream this?

Dave

God doesn't hate sinners, just sin!

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. " �

" 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.�

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

• An important therapeutic goal in type 2 diabetes is to achieve and to

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

• The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

• 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.

• 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

• 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.

• 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.

Diabetes In Control Sponsors

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Jen,

Where the article said " less than 7.0 " for the A1c, I'd prefer seeing it

more like " less than 6.0 " to be closer to normal. At least that gets the

person closer to a workable baseline. Being at 7.0 is just too far up there

IMHO.

Bill Powers

Link to comment
Share on other sites

I think we should work on getting more people below 7.0 before lowering that

target even more. Last I heard I think it was less than 25% of people with

diabetes actually meeting the " below 7.0 " target. I think the national

average here in Canada is 8.7 and in the States it's even worse at 9.2, or

so I think I've read.

I know some people can get into the 5s and maintain that, but I haven't yet

broken 6.5 more than once (and that was while having a lot of lows), so for

now below 7.0 is fine with me. I will continue to work to get below 6.5,

though. I think below 6.0 would be very tough for a lot of people, and there

is not a lot of evidence to support the idea that 5.5 is much better than

6.5, unless of course I have missed it.

Jen

RE: new treatment changes in type 2

Jen,

Where the article said " less than 7.0 " for the A1c, I'd prefer seeing it

more like " less than 6.0 " to be closer to normal. At least that gets the

person closer to a workable baseline. Being at 7.0 is just too far up there

IMHO.

Bill Powers

Link to comment
Share on other sites

I think we should work on getting more people below 7.0 before lowering that

target even more. Last I heard I think it was less than 25% of people with

diabetes actually meeting the " below 7.0 " target. I think the national

average here in Canada is 8.7 and in the States it's even worse at 9.2, or

so I think I've read.

I know some people can get into the 5s and maintain that, but I haven't yet

broken 6.5 more than once (and that was while having a lot of lows), so for

now below 7.0 is fine with me. I will continue to work to get below 6.5,

though. I think below 6.0 would be very tough for a lot of people, and there

is not a lot of evidence to support the idea that 5.5 is much better than

6.5, unless of course I have missed it.

Jen

RE: new treatment changes in type 2

Jen,

Where the article said " less than 7.0 " for the A1c, I'd prefer seeing it

more like " less than 6.0 " to be closer to normal. At least that gets the

person closer to a workable baseline. Being at 7.0 is just too far up there

IMHO.

Bill Powers

Link to comment
Share on other sites

I think the people who set these standards and make recommendations just

don't want to scare people and discourage them. They might be afraid that

if they tell people to get and stay below 6.0 they'll get so discouraged

they'll just give up. I think it's the same when articles are written about

how much exercise should be done to lose weight. People quickly hear 60 to

90 minutes a day and give up figuring they can't do it. So now only 30

minutes is recommended because it sounds more realistic.

I'm just guessing here, but this theory makes sense to me.

Becky

_____

From: blind-diabetics

[mailto:blind-diabetics ] On Behalf Of Jesso

Sent: Wednesday, October 29, 2008 11:14 PM

To: blind-diabetics

Subject: RE: new treatment changes in type 2

I think we should work on getting more people below 7.0 before lowering that

target even more. Last I heard I think it was less than 25% of people with

diabetes actually meeting the " below 7.0 " target. I think the national

average here in Canada is 8.7 and in the States it's even worse at 9.2, or

so I think I've read.

I know some people can get into the 5s and maintain that, but I haven't yet

broken 6.5 more than once (and that was while having a lot of lows), so for

now below 7.0 is fine with me. I will continue to work to get below 6.5,

though. I think below 6.0 would be very tough for a lot of people, and there

is not a lot of evidence to support the idea that 5.5 is much better than

6.5, unless of course I have missed it.

Jen

RE: new treatment changes in type 2

Jen,

Where the article said " less than 7.0 " for the A1c, I'd prefer seeing it

more like " less than 6.0 " to be closer to normal. At least that gets the

person closer to a workable baseline. Being at 7.0 is just too far up there

IMHO.

Bill Powers

No virus found in this incoming message.

Checked by AVG - http://www.avg.com

Version: 8.0.175 / Virus Database: 270.8.4/1754 - Release Date: 10/29/2008

5:27 PM

Link to comment
Share on other sites

Part of the reason the 7.0 number is used is that in the DCCT, which was a

huge study of people with type 1 diabetes run from 1983 until 1992 comparing

intensive management with more lax management and its impact on

complications, the A1c level achieved by the " intensive " group was about

7.0, and that achieved by the other group was around 9.0 I believe. The goal

for the study had actually been for the intensive group to reach an A1c of

6.1, but no one could do it. If you look at numbers from that study there is

a HUGE reduction in the number of complications that happen between having

an A1c of 9.0 and one of 7.0. I would wager that there is also a reduction

for an A1c of 6.0 versus 7.0, though less so than for an A1c of 7.0 versus

8.0, or 8.0 versus 9.0. There is also probably a benefit for an A1c of 5.0

versus 6.0, but for many people 5.0 is an impossible goal to maintain

without having diabetes either take over their life, or experiencing too

many lows. I can count the number of type 1s I know with A1c's below 5.5 on

one hand, and many of them have lows far more frequently than I would

tolerate (as frequently as twice or more a day in some cases).

I do think 6.5 would be a reasonable goal. That is the goal I'm aiming for.

Just my two cents' worth.

Jen

RE: new treatment changes in type 2

I think the people who set these standards and make recommendations just

don't want to scare people and discourage them. They might be afraid that

if they tell people to get and stay below 6.0 they'll get so discouraged

they'll just give up. I think it's the same when articles are written about

how much exercise should be done to lose weight. People quickly hear 60 to

90 minutes a day and give up figuring they can't do it. So now only 30

minutes is recommended because it sounds more realistic.

I'm just guessing here, but this theory makes sense to me.

Becky

Link to comment
Share on other sites

Part of the reason the 7.0 number is used is that in the DCCT, which was a

huge study of people with type 1 diabetes run from 1983 until 1992 comparing

intensive management with more lax management and its impact on

complications, the A1c level achieved by the " intensive " group was about

7.0, and that achieved by the other group was around 9.0 I believe. The goal

for the study had actually been for the intensive group to reach an A1c of

6.1, but no one could do it. If you look at numbers from that study there is

a HUGE reduction in the number of complications that happen between having

an A1c of 9.0 and one of 7.0. I would wager that there is also a reduction

for an A1c of 6.0 versus 7.0, though less so than for an A1c of 7.0 versus

8.0, or 8.0 versus 9.0. There is also probably a benefit for an A1c of 5.0

versus 6.0, but for many people 5.0 is an impossible goal to maintain

without having diabetes either take over their life, or experiencing too

many lows. I can count the number of type 1s I know with A1c's below 5.5 on

one hand, and many of them have lows far more frequently than I would

tolerate (as frequently as twice or more a day in some cases).

I do think 6.5 would be a reasonable goal. That is the goal I'm aiming for.

Just my two cents' worth.

Jen

RE: new treatment changes in type 2

I think the people who set these standards and make recommendations just

don't want to scare people and discourage them. They might be afraid that

if they tell people to get and stay below 6.0 they'll get so discouraged

they'll just give up. I think it's the same when articles are written about

how much exercise should be done to lose weight. People quickly hear 60 to

90 minutes a day and give up figuring they can't do it. So now only 30

minutes is recommended because it sounds more realistic.

I'm just guessing here, but this theory makes sense to me.

Becky

Link to comment
Share on other sites

Hi to all:

I can recall a time when thenormal levels were 6.0 I did not know any better.

Now, I do.

I learn quickly.

Terrie with Eunice and Shandar looking for a black kitten.

contact info:

MSN: shineydog@...

private email: shineydog@...

or list email: devendawg@... 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. " �

" 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.�

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

• An important therapeutic goal in type 2 diabetes is to achieve and to

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

• The initial treatment approach to type 2 diabetes should include lifestyle

intervention and use of metformin.

• 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.

• 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

• 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.

• 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.

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

Advertisement

One tablet, once daily, proven to deliver 24-hour glycemic control. Learn

more.

http://ad.doubleclick.net/clk;195729505;25588705;w

Send to Friend

| Share |

Print |

Category |

Home

Have a comment?

Post it here.

Visit the NEW Diabetes In Control Blog.

Click Here!

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Browse by Feature Writer & Article Category

A. Lee Dellon, MD |

Beverly Price |

Birgitta I. Rice, MS |

Did You Know |

Dr. Bernstein |

Dr. Jakes, Jr. |

Dr. Varon, DDS |

Dr. Fred Pescatore |

Dr. Walter Willett |

Education |

S. Freedland |

Evan D. Rosen |

Facts |

Features |

Ginger Kanzer- |

Items for the Week |

, MD |

ph M. Caporusso |

a Sandstedt |

Plunkett |

Leonard Lipson, M.A. |

Lester A. Packer |

Diane |

New Products |

Newsflash |

Chous, M.A., OD |

Philip A. Wood PhD |

R. |

Sheri R. Colberg PhD |

Sherri Shafer |

Steve Pohlit |

Studies |

Test Your Knowledge |

Theresa L. Garnero |

Tools |

Vickie R. Driver |

M. Volpone |

This Week's Blog |

Press Releases |

Search Articles On Diabetes In Control

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Diabetes In Control Sponsors

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New Product

TRUE2go and TRUEresult

Home Diagnostics TRUE2go and TRUEresult Glucose Meters

TRUE2go and TRUEresult bring together, ease of use, no coding and accurate

results with a price that your patients can afford. More and more patients are

being forced to pay for their own testing supplies and price is becoming more

important, but often times affordable meters have been perceived (rightly

or wrongly) to be of lower quality than the biggest national brands.

Read more »

Print This Week's Newsletter

Download This Week's Newsletter

Newsletter is in Adobe format

If you don't have Adobe Acrobat Reader, you can download it for Free

here.

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CE Programs On Diabetes Available

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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.

Diabetes In Control Sponsors

http://www.diabetesincontrol.com/aserver/adclick.php?n=a8e6d6c1

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