Guest guest Posted October 29, 2008 Report Share Posted October 29, 2008 Here we go again. " Maintaining glycemic levels as close to the nondiabetic range as possible has been demonstrated to have a powerful beneficial effect on diabetes-specific microvascular complications, including retinopathy, nephropathy, and neuropathy, in the setting of type 1 diabetes; in type 2 diabetes, " Every time I read such a statement, and believe me the ADA and the EADS both make these types of statements time after time. Yes I am talking about Associations who should be the vanguards for the diabetic's health. Practically every time they advocate an A1C level of 7.0, as they do in the article below. Every time such statements drive me up the wall. Why? you may ask. Because they do not feel we have the sense or the desire to know what a normal non-diabetic A1C level is! I am here to tell you what it is, because I feel you have enough sense to understand what it is. I have even confirmed my recommendation on what a normal non-diabetic A1C level actually is. I wrote to Mendosa, a diabetes expert who maintains a web page, and he says I am right. I advocate the normal non-diabetic A1c is between an A1c of 4.2-5.2, and Mendosa told me it is closer to 4.5-5.0. In other words the normal non-diabetic A1C level is a hell of a lot closer to 5.0 than it is to 7.0. Believe me when I say that getting to a normal non-diabetic level is unlikely when just advocating drugs as the correct path to follow. Insulin, a normal substance, works every time it is tried. Yet you never hear of them advocating such an extreme measure as using insulin. I wonder why? new treatment changes in type 2 New Major Changes in Recommendations for the Treatment of Type 2 Diabetes by ADA and EASD The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have issued an updated consensus statement on the management of hyperglycemia in patients with type 2 diabetes. The updated statement, which focuses on the new classes of medications available to patients, is published conjointly in the October 22 Online First issue of Diabetes Care and the October 22 issue of Diabetologia. The article will also appear in the December print issue of Diabetes Care. M. , MD, from the Diabetes Center of Massachusetts General Hospital in Boston, and colleagues writes, " The epidemic of type 2 diabetes and the recognition that achieving specific glycemic goals can substantially reduce morbidity have made the effective treatment of hyperglycemia a top priority. " � " 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. 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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\ = & dest=http%3A%2F%2Fwww.disetronic-usa.com%2Fdstrnc_us%2Frewrite%2FgeneralConten\ t%2Fen_US%2Fweb_form%2FDCM_web_form_01.htm Sign up for our FREE Weekly Newsletter Current Issue Past Issue Diabetes In Control. News and Information for Medical Professionals News and Information for Medical Professionals Search Diabetes In Control http://www.diabetesincontrol.com/newsite_sept2008/DinCart/production%20art/butns\ earch.gif Current Spotlight Newsletter Current Spotlight Newsletter Spotlight Product Reviews Spotlight Product Reviews New Products New Products Archive Archive About Us About Us Contact Us Contact Us Advertising Advertising Current Studies Current Studies Previous Studies Previous Studies Request Insight Svcs Request Insight Svcs Newsflash Newsflash Diabetes News Diabetes News Features Features Continuing Education Continuing Education Test Your Knowledge Test Your Knowledge Tools for your Practice Tools for your Practice link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT Send to Friend | Share | Print | Category | Home 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 production art/butnsignup Privacy / Advertising With Us / Contact Us Entries (RSS News) Add us to your favorite news reader addtogoogle addtomsm addtomyyahoo Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 29, 2008 Report Share Posted October 29, 2008 Oh I have one even better. My mom, bless her heart, has a doctor who gave her the blood test results a couple of weeks ago, where her hemoglobin A1c was 8.1, and he said " keep up the good work. " I about gagged. I said " Mom, 8.1 is NOT good, how on earth could he sit there and tell you that? " I told her what the reading SHOULD be and she just said " well, he's the doctor, he should know. " When I told her that too many doctors just don't know, she blocked out on the subject saying " everybody keeps telling me something different things, I'm just so confused. " It's enough to make her give up trying, but try she just doesn't do hard enough, but it's HER life.. I could cringe though thinking this doc gives her a clean bill of health with 8.1! Good God Almighty! And she wonders why she feels as cruddy as she does most of the time... But it will keep her on pills which will make Big Pharma happy. Bill Powers Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 29, 2008 Report Share Posted October 29, 2008 Oh I have one even better. My mom, bless her heart, has a doctor who gave her the blood test results a couple of weeks ago, where her hemoglobin A1c was 8.1, and he said " keep up the good work. " I about gagged. I said " Mom, 8.1 is NOT good, how on earth could he sit there and tell you that? " I told her what the reading SHOULD be and she just said " well, he's the doctor, he should know. " When I told her that too many doctors just don't know, she blocked out on the subject saying " everybody keeps telling me something different things, I'm just so confused. " It's enough to make her give up trying, but try she just doesn't do hard enough, but it's HER life.. I could cringe though thinking this doc gives her a clean bill of health with 8.1! Good God Almighty! And she wonders why she feels as cruddy as she does most of the time... But it will keep her on pills which will make Big Pharma happy. Bill Powers Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 29, 2008 Report Share Posted October 29, 2008 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\ = & dest=http%3A%2F%2Fwww.disetronic-usa.com%2Fdstrnc_us%2Frewrite%2FgeneralConten\ t%2Fen_US%2Fweb_form%2FDCM_web_form_01.htm Sign up for our FREE Weekly Newsletter Current Issue Past Issue Diabetes In Control. News and Information for Medical Professionals News and Information for Medical Professionals Search Diabetes In Control http://www.diabetesincontrol.com/newsite_sept2008/DinCart/production%20art/butns\ earch.gif Current Spotlight Newsletter Current Spotlight Newsletter Spotlight Product Reviews Spotlight Product Reviews New Products New Products Archive Archive About Us About Us Contact Us Contact Us Advertising Advertising Current Studies Current Studies Previous Studies Previous Studies Request Insight Svcs Request Insight Svcs Newsflash Newsflash Diabetes News Diabetes News Features Features Continuing Education Continuing Education Test Your Knowledge Test Your Knowledge Tools for your Practice Tools for your Practice link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT Send to Friend | Share | Print | Category | Home 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 production art/butnsignup Privacy / Advertising With Us / Contact Us Entries (RSS News) Add us to your favorite news reader addtogoogle addtomsm addtomyyahoo Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 29, 2008 Report Share Posted October 29, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 29, 2008 Report Share Posted October 29, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 29, 2008 Report Share Posted October 29, 2008 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. 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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\ = & dest=http%3A%2F%2Fwww.disetronic-usa.com%2Fdstrnc_us%2Frewrite%2FgeneralConten\ t%2Fen_US%2Fweb_form%2FDCM_web_form_01.htm Sign up for our FREE Weekly Newsletter Current Issue Past Issue Diabetes In Control. News and Information for Medical Professionals News and Information for Medical Professionals Search Diabetes In Control http://www.diabetesincontrol.com/newsite_sept2008/DinCart/production%20art/butns\ earch.gif Current Spotlight Newsletter Current Spotlight Newsletter Spotlight Product Reviews Spotlight Product Reviews New Products New Products Archive Archive About Us About Us Contact Us Contact Us Advertising Advertising Current Studies Current Studies Previous Studies Previous Studies Request Insight Svcs Request Insight Svcs Newsflash Newsflash Diabetes News Diabetes News Features Features Continuing Education Continuing Education Test Your Knowledge Test Your Knowledge Tools for your Practice Tools for your Practice link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT Send to Friend | Share | Print | Category | Home This article originally posted October 28, 2008 and appeared in Issue 440 New Major Changes in Recommendations for the Treatment of Type 2 Diabetes by ADA and EASD The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have issued an updated consensus statement on the management of hyperglycemia in patients with type 2 diabetes. 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Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 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. 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Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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. ============================== 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 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.diabetes <http://www.diabetesincontrol.com/aserver/adclick.php?bannerid=67 & zoneid=1 & sourc\ e= & dest=http%3A%2F%2Fwww.disetronic-usa.com%2Fdstrnc_us%2Frewrite%2FgeneralConte\ nt%2Fen_US%2Fweb_form%2FDCM_web_form_01.htm> incontrol.com/aserver/adclick.php?bannerid=67 & zoneid=1 & source= & dest=http%3A%2F%2\ Fwww.disetronic-usa.com%2Fdstrnc_us%2Frewrite%2FgeneralContent%2Fen_US%2Fweb_for\ m%2FDCM_web_form_01.htm Sign up for our FREE Weekly Newsletter Current Issue Past Issue Diabetes In Control. News and Information for Medical Professionals News and Information for Medical Professionals Search Diabetes In Control http://www.diabetes <http://www.diabetesincontrol.com/newsite_sept2008/DinCart/production%20art/butn\ search.gif> incontrol.com/newsite_sept2008/DinCart/production%20art/butnsearch.gif Current Spotlight Newsletter Current Spotlight Newsletter Spotlight Product Reviews Spotlight Product Reviews New Products New Products Archive Archive About Us About Us Contact Us Contact Us Advertising Advertising Current Studies Current Studies Previous Studies Previous Studies Request Insight Svcs Request Insight Svcs Newsflash Newsflash Diabetes News Diabetes News Features Features Continuing Education Continuing Education Test Your Knowledge Test Your Knowledge Tools for your Practice Tools for your Practice link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT Send to Friend | Share | Print | Category | Home 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 Flash movie end Sign up for our FREE Weekly Newsletter Current Issue Past Issue production art/butnsignup Privacy / Advertising With Us / Contact Us Entries (RSS News) Add us to your favorite news reader addtogoogle addtomsm addtomyyahoo Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Flash movie start http://www.diabetesincontrol.com/aserver/adclick.php?bannerid=67 & zoneid=1 & source\ = & dest=http%3A%2F%2Fwww.disetronic-usa.com%2Fdstrnc_us%2Frewrite%2FgeneralConten\ t%2Fen_US%2Fweb_form%2FDCM_web_form_01.htm Sign up for our FREE Weekly Newsletter Current Issue Past Issue Diabetes In Control. News and Information for Medical Professionals News and Information for Medical Professionals Search Diabetes In Control http://www.diabetesincontrol.com/newsite_sept2008/DinCart/production%20art/butns\ earch.gif Current Spotlight Newsletter Current Spotlight Newsletter Spotlight Product Reviews Spotlight Product Reviews New Products New Products Archive Archive About Us About Us Contact Us Contact Us Advertising Advertising Current Studies Current Studies Previous Studies Previous Studies Request Insight Svcs Request Insight Svcs Newsflash Newsflash Diabetes News Diabetes News Features Features Continuing Education Continuing Education Test Your Knowledge Test Your Knowledge Tools for your Practice Tools for your Practice link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT Send to Friend | Share | Print | Category | Home 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 production art/butnsignup Privacy / Advertising With Us / Contact Us Entries (RSS News) Add us to your favorite news reader addtogoogle addtomsm addtomyyahoo Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Flash movie start http://www.diabetesincontrol.com/aserver/adclick.php?bannerid=67 & zoneid=1 & source\ = & dest=http%3A%2F%2Fwww.disetronic-usa.com%2Fdstrnc_us%2Frewrite%2FgeneralConten\ t%2Fen_US%2Fweb_form%2FDCM_web_form_01.htm Sign up for our FREE Weekly Newsletter Current Issue Past Issue Diabetes In Control. News and Information for Medical Professionals News and Information for Medical Professionals Search Diabetes In Control http://www.diabetesincontrol.com/newsite_sept2008/DinCart/production%20art/butns\ earch.gif Current Spotlight Newsletter Current Spotlight Newsletter Spotlight Product Reviews Spotlight Product Reviews New Products New Products Archive Archive About Us About Us Contact Us Contact Us Advertising Advertising Current Studies Current Studies Previous Studies Previous Studies Request Insight Svcs Request Insight Svcs Newsflash Newsflash Diabetes News Diabetes News Features Features Continuing Education Continuing Education Test Your Knowledge Test Your Knowledge Tools for your Practice Tools for your Practice link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT Send to Friend | Share | Print | Category | Home 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 production art/butnsignup Privacy / Advertising With Us / Contact Us Entries (RSS News) Add us to your favorite news reader addtogoogle addtomsm addtomyyahoo Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 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 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.diabetes <http://www.diabetesincontrol.com/aserver/adclick.php?bannerid=67 & zoneid=1 & sourc\ e= & dest=http%3A%2F%2Fwww.disetronic-usa.com%2Fdstrnc_us%2Frewrite%2FgeneralConte\ nt%2Fen_US%2Fweb_form%2FDCM_web_form_01.htm> incontrol.com/aserver/adclick.php?bannerid=67 & zoneid=1 & source= & dest=http%3A%2F%2\ Fwww.disetronic-usa.com%2Fdstrnc_us%2Frewrite%2FgeneralContent%2Fen_US%2Fweb_for\ m%2FDCM_web_form_01.htm Sign up for our FREE Weekly Newsletter Current Issue Past Issue Diabetes In Control. News and Information for Medical Professionals News and Information for Medical Professionals Search Diabetes In Control http://www.diabetes <http://www.diabetesincontrol.com/newsite_sept2008/DinCart/production%20art/butn\ search.gif> incontrol.com/newsite_sept2008/DinCart/production%20art/butnsearch.gif Current Spotlight Newsletter Current Spotlight Newsletter Spotlight Product Reviews Spotlight Product Reviews New Products New Products Archive Archive About Us About Us Contact Us Contact Us Advertising Advertising Current Studies Current Studies Previous Studies Previous Studies Request Insight Svcs Request Insight Svcs Newsflash Newsflash Diabetes News Diabetes News Features Features Continuing Education Continuing Education Test Your Knowledge Test Your Knowledge Tools for your Practice Tools for your Practice link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT Send to Friend | Share | Print | Category | Home 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 Flash movie end Sign up for our FREE Weekly Newsletter Current Issue Past Issue production art/butnsignup Privacy / Advertising With Us / Contact Us Entries (RSS News) Add us to your favorite news reader addtogoogle addtomsm addtomyyahoo Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 alltop Flash movie start http://www.diabetesincontrol.com/aserver/adclick.php?bannerid=67 & zoneid=1 & source\ = & dest=http%3A%2F%2Fwww.disetronic-usa.com%2Fdstrnc_us%2Frewrite%2FgeneralConten\ t%2Fen_US%2Fweb_form%2FDCM_web_form_01.htm Sign up for our FREE Weekly Newsletter Current Issue Past Issue Diabetes In Control. News and Information for Medical Professionals News and Information for Medical Professionals Search Diabetes In Control http://www.diabetesincontrol.com/newsite_sept2008/DinCart/production%20art/butns\ earch.gif Current Spotlight Newsletter Current Spotlight Newsletter Spotlight Product Reviews Spotlight Product Reviews New Products New Products Archive Archive About Us About Us Contact Us Contact Us Advertising Advertising Current Studies Current Studies Previous Studies Previous Studies Request Insight Svcs Request Insight Svcs Newsflash Newsflash Diabetes News Diabetes News Features Features Continuing Education Continuing Education Test Your Knowledge Test Your Knowledge Tools for your Practice Tools for your Practice link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT Send to Friend | Share | Print | Category | Home 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 production art/butnsignup Privacy / Advertising With Us / Contact Us Entries (RSS News) Add us to your favorite news reader addtogoogle addtomsm addtomyyahoo Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 alltop Flash movie start http://www.diabetesincontrol.com/aserver/adclick.php?bannerid=67 & zoneid=1 & source\ = & dest=http%3A%2F%2Fwww.disetronic-usa.com%2Fdstrnc_us%2Frewrite%2FgeneralConten\ t%2Fen_US%2Fweb_form%2FDCM_web_form_01.htm Sign up for our FREE Weekly Newsletter Current Issue Past Issue Diabetes In Control. News and Information for Medical Professionals News and Information for Medical Professionals Search Diabetes In Control http://www.diabetesincontrol.com/newsite_sept2008/DinCart/production%20art/butns\ earch.gif Current Spotlight Newsletter Current Spotlight Newsletter Spotlight Product Reviews Spotlight Product Reviews New Products New Products Archive Archive About Us About Us Contact Us Contact Us Advertising Advertising Current Studies Current Studies Previous Studies Previous Studies Request Insight Svcs Request Insight Svcs Newsflash Newsflash Diabetes News Diabetes News Features Features Continuing Education Continuing Education Test Your Knowledge Test Your Knowledge Tools for your Practice Tools for your Practice link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT Send to Friend | Share | Print | Category | Home 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 production art/butnsignup Privacy / Advertising With Us / Contact Us Entries (RSS News) Add us to your favorite news reader addtogoogle addtomsm addtomyyahoo Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 30, 2008 Report Share Posted October 30, 2008 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. 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News and Information for Medical Professionals News and Information for Medical Professionals Search Diabetes In Control http://www.diabetesincontrol.com/newsite_sept2008/DinCart/production%20art/butns\ earch.gif Current Spotlight Newsletter Current Spotlight Newsletter Spotlight Product Reviews Spotlight Product Reviews New Products New Products Archive Archive About Us About Us Contact Us Contact Us Advertising Advertising Current Studies Current Studies Previous Studies Previous Studies Request Insight Svcs Request Insight Svcs Newsflash Newsflash Diabetes News Diabetes News Features Features Continuing Education Continuing Education Test Your Knowledge Test Your Knowledge Tools for your Practice Tools for your Practice link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT link region type: RECT Send to Friend | Share | Print | Category | Home This article originally posted October 28, 2008 and appeared in Issue 440 New Major Changes in Recommendations for the Treatment of Type 2 Diabetes by ADA and EASD The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have issued an updated consensus statement on the management of hyperglycemia in patients with type 2 diabetes. 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