Re: new treatment changes in type 2

[Guest guest]

Well, I tel all of you what, I will take any information and or help you want to

give me. I am still learning and trying to update my info.

Terrie with Eunice and Shandar looking for a black kitten

contact MSN: shineydog@...

private email: shineydog@...

list email: devendawg@...

RE: new treatment changes in type 2

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

[Guest guest]

Well, I tel all of you what, I will take any information and or help you want to

give me. I am still learning and trying to update my info.

Terrie with Eunice and Shandar looking for a black kitten

contact MSN: shineydog@...

private email: shineydog@...

list email: devendawg@...

RE: new treatment changes in type 2

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

[Guest guest]

I did not feel any different at 5.8 should I? I know when my friend was

alive she tested my blood a few times and it was down at 4.something, I don't

recall what, and I did feel a little tired, but I put it down to going into

Vancouver which I hate doing.

is now in a better place. Cancer got her in the end, not the diabetes.

They were just keeping her comfortable at the time, not worrying about her blood

sugars. She was not getting her insulin either.

Why was that I asked the nurse. Then I asked our doctor. She explained it to

me, but I still think she should have gotten a little insulin.

Then she might have felt a bit better. I don't know.

Terrie with Eunice and Shandar. I am looking for a black kitten.

Contact info:

MSN: shineydog@...

private email: shineydog@...

list email: devendawg@...

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

[Guest guest]

I did not feel any different at 5.8 should I? I know when my friend was

alive she tested my blood a few times and it was down at 4.something, I don't

recall what, and I did feel a little tired, but I put it down to going into

Vancouver which I hate doing.

is now in a better place. Cancer got her in the end, not the diabetes.

They were just keeping her comfortable at the time, not worrying about her blood

sugars. She was not getting her insulin either.

Why was that I asked the nurse. Then I asked our doctor. She explained it to

me, but I still think she should have gotten a little insulin.

Then she might have felt a bit better. I don't know.

Terrie with Eunice and Shandar. I am looking for a black kitten.

Contact info:

MSN: shineydog@...

private email: shineydog@...

list email: devendawg@...

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

[Guest guest]

I often wonder if the people who set these limits are themselves diabetic.

I wonder where they draw the line if they aren't. If they are, then that is a

different thing.

I am very curious about that. That is food for thought.

Terrie with Eunice and Shandar. I am looking for a black kitten.

contact:

MSN: shineydog@...

private email: shineydog@...

list email: devendawg@...

. .

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

[Guest guest]

I often wonder if the people who set these limits are themselves diabetic.

I wonder where they draw the line if they aren't. If they are, then that is a

different thing.

I am very curious about that. That is food for thought.

Terrie with Eunice and Shandar. I am looking for a black kitten.

contact:

MSN: shineydog@...

private email: shineydog@...

list email: devendawg@...

. .

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

[Guest guest]

I often wonder if the people who set these limits are themselves diabetic.

I wonder where they draw the line if they aren't. If they are, then that is a

different thing.

I am very curious about that. That is food for thought.

Terrie with Eunice and Shandar. I am looking for a black kitten.

contact:

MSN: shineydog@...

private email: shineydog@...

list email: devendawg@...

. .

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

[Guest guest]

Could someone please educate this newbi about what an A.1 is? I am not sure I

am understanding it. I can usually figure out what is being talked about by the

context of what is being said, but I amsorry, I am lost.

ahahahahah Not hard to do.

Terrie with Eunice and Shandar. I amlooking for a black kitten.

contact info:

MSN: shineydog@...

private email: shineydog@...

list email: devendawg@... 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

[Guest guest]

Could someone please educate this newbi about what an A.1 is? I am not sure I

am understanding it. I can usually figure out what is being talked about by the

context of what is being said, but I amsorry, I am lost.

ahahahahah Not hard to do.

Terrie with Eunice and Shandar. I amlooking for a black kitten.

contact info:

MSN: shineydog@...

private email: shineydog@...

list email: devendawg@... 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

[Guest guest]

Hi Terrie,

Your A1c is a measurement of your average blood sugars over the last three

months. It is determined by having a blood test.

Cheers,

Brett.

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

[Guest guest]

Hi Terrie,

Your A1c is a measurement of your average blood sugars over the last three

months. It is determined by having a blood test.

Cheers,

Brett.

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

[Guest guest]

As Bret mentioned, the A1C is an average of your blood sugar over the prior 3

months. I'm forgetting, but I believe you said you are not a diabetic. Did

your doctor suggest you might become diabetic? He or she could have only made

such a statement if he/she had performed an A1C, and it showed it was above the

norm, and/or you are overweight and perhaps diabetes runs in your family. If

I'm not mistaken, anyone who is overweight has a multiple factor times greater

possibility of getting type 2 diabetes. You are very wise in taking aggressive

steps early on to head off type 2 diabetes, so keep those questions coming.

Dave

God doesn't hate sinners, just sin!

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

[Guest guest]

As Bret mentioned, the A1C is an average of your blood sugar over the prior 3

months. I'm forgetting, but I believe you said you are not a diabetic. Did

your doctor suggest you might become diabetic? He or she could have only made

such a statement if he/she had performed an A1C, and it showed it was above the

norm, and/or you are overweight and perhaps diabetes runs in your family. If

I'm not mistaken, anyone who is overweight has a multiple factor times greater

possibility of getting type 2 diabetes. You are very wise in taking aggressive

steps early on to head off type 2 diabetes, so keep those questions coming.

Dave

God doesn't hate sinners, just sin!

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

[Guest guest]

As Bret mentioned, the A1C is an average of your blood sugar over the prior 3

months. I'm forgetting, but I believe you said you are not a diabetic. Did

your doctor suggest you might become diabetic? He or she could have only made

such a statement if he/she had performed an A1C, and it showed it was above the

norm, and/or you are overweight and perhaps diabetes runs in your family. If

I'm not mistaken, anyone who is overweight has a multiple factor times greater

possibility of getting type 2 diabetes. You are very wise in taking aggressive

steps early on to head off type 2 diabetes, so keep those questions coming.

Dave

God doesn't hate sinners, just sin!

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

[Guest guest]

There is a huge difference between a type1 diabetic and a type2 diabetic.

Namely the type1 diabetic may not get the warning signals that an impending low

blood sugar level is approaching, whereas in most type2 diabetics they get the

warning signals. This is a big difference, and not to be misunderstood. This

is why the A1c level is usually set at a higher level in the type1 diabetic than

compared to the type2 diabetic. In fact in some type1's they are unconscious

before they know they are experiencing a low sugar level. I would say this is a

big significant difference.

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

[Guest guest]

There is a huge difference between a type1 diabetic and a type2 diabetic.

Namely the type1 diabetic may not get the warning signals that an impending low

blood sugar level is approaching, whereas in most type2 diabetics they get the

warning signals. This is a big difference, and not to be misunderstood. This

is why the A1c level is usually set at a higher level in the type1 diabetic than

compared to the type2 diabetic. In fact in some type1's they are unconscious

before they know they are experiencing a low sugar level. I would say this is a

big significant difference.

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

[Guest guest]

There is a huge difference between a type1 diabetic and a type2 diabetic.

Namely the type1 diabetic may not get the warning signals that an impending low

blood sugar level is approaching, whereas in most type2 diabetics they get the

warning signals. This is a big difference, and not to be misunderstood. This

is why the A1c level is usually set at a higher level in the type1 diabetic than

compared to the type2 diabetic. In fact in some type1's they are unconscious

before they know they are experiencing a low sugar level. I would say this is a

big significant difference.

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

[Guest guest]

You have to know the difference in the measures you make and take. For instance

with a regular glucose monitor measures the bs level in either mohls or moles or

milligrams per deciliter. The UK measures things in moles whereas the USA

measures things in milligrams per deciliter. To convert from one reading to the

other requires you to use the number 18 to either multiply or divide. For

instance a mole reading of 6.0 in the UK is the same as a reading of 108 in USA

readings. I prefer USA readings since the measurement is finer. For instance

there is a difference of 18 points between a mole reading of 5.0 and a mole

reading of 6.0.

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

[Guest guest]

You have to know the difference in the measures you make and take. For instance

with a regular glucose monitor measures the bs level in either mohls or moles or

milligrams per deciliter. The UK measures things in moles whereas the USA

measures things in milligrams per deciliter. To convert from one reading to the

other requires you to use the number 18 to either multiply or divide. For

instance a mole reading of 6.0 in the UK is the same as a reading of 108 in USA

readings. I prefer USA readings since the measurement is finer. For instance

there is a difference of 18 points between a mole reading of 5.0 and a mole

reading of 6.0.

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

[Guest guest]

Terrie

An A1C is a test done at your doctor's office. They draw blood and send it

to the lab. It gives an average of how your blood sugars have been over the

past few months. Some doctors like to test every three months, some every

four months. This does not mean you should stop testing your own sugar

level at home, but apparently the A1C averages things out. Someone else on

this list I'm sure will give you a more detailed explanation.

Becky

_____

From: blind-diabetics

[mailto:blind-diabetics ] On Behalf Of Terrie

Sent: Thursday, October 30, 2008 2:02 AM

To: blind-diabetics

Subject: Re: new treatment changes in type 2

Could someone please educate this newbi about what an A.1 is? I am not sure

I am understanding it. I can usually figure out what is being talked about

by the context of what is being said, but I amsorry, I am lost.

ahahahahah Not hard to do.

Terrie with Eunice and Shandar. I amlooking for a black kitten.

contact info:

MSN: shineydoghotmail (DOT) <mailto:shineydog%40hotmail.com> com

private email: shineydogshaw (DOT) <mailto:shineydog%40shaw.ca> ca

list email: devendawgshaw (DOT) <mailto:devendawg%40shaw.ca> ca ----- Original

Message -----

From: Jesso

To: blind-diabetics@ <mailto:blind-diabetics%40yahoogroups.com>

yahoogroups.com

Sent: Wednesday, October 29, 2008 8:39 PM

Subject: RE: new treatment changes in type 2

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

[Guest guest]

Thankyou Bret.

I am glad to know that I was sort of on the right track, but not being sure, I

wanted to make sure.

Terrie with Eunice and Shandar.

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

[Guest guest]

Thankyou Bret.

I am glad to know that I was sort of on the right track, but not being sure, I

wanted to make sure.

Terrie with Eunice and Shandar.

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

[Guest guest]

Thankyou Bret.

I am glad to know that I was sort of on the right track, but not being sure, I

wanted to make sure.

Terrie with Eunice and Shandar.

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

[Guest guest]

Well, Dave, if 5.8 is not being a diabetic I don't know as much as I should.

and, yes it does run in the family. My mom told me about an uncle that had

diabetes I am a little over weight, but not by much.

Hope that will help you in some way.

Terrie with Eunice and Sshander

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

[Guest guest]

Well, Dave, if 5.8 is not being a diabetic I don't know as much as I should.

and, yes it does run in the family. My mom told me about an uncle that had

diabetes I am a little over weight, but not by much.

Hope that will help you in some way.

Terrie with Eunice and Sshander

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