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Glycemia management in type 2 diabetes.


Last month, a consensus panel representing the American Diabetes Association and European Association for the Study of Diabetes published revised recommendations for management of hyperglycemia in patients with type 2 diabetes (INTERNAL MEDICINE NEWS, Jan. 15, 2009, p. 1), based on data published since similar recommendations were first published in 2006 and updated in 2008 to address safety issues associated with thiazolidinediones.


Control of blood sugar, to levels as close as possible to normal, has been shown in multiple studies of patients with type 1 diabetes to reduce the microvascular complications of retinopathy, neuropathy, and nephropathy. Studies of intensive treatment of type 2 diabetes patients have, likewise, shown reductions in microvascular complications. Unfortunately, trials to date have not shown a reduction in cardiovascular disease with intensive glycemic control in patients with type 2 diabetes.

Many drugs are available for treatment of glycemia in type 2 diabetes, but not many studies have explored the differential effectiveness of individual agents or combinations of agents. Thus, comparisons and recommendations are made based on the relative efficacy, costs, and side effects of the drugs and the recommendations of the consensus panel.


The American Diabetes Association recommends a hemoglobin [A.sub.1c] level under 7%, and the International Diabetes Federation has established a goal of less than 6.5%. The consensus of the guideline group is that action to initiate or change treatment should be undertaken for any patient with an Hb[A.sub.1c] above 7%.

Patient education is important in diabetes management and should address diet, medication adjustment, glucose targets and how to reach them, the management of hypoglycemia, and self-monitoring.

Lifestyle interventions to decrease weight and increase activity levels should be included in the management plan for nearly all patients, and should be the first step in the management of all with new-onset type 2 diabetes. Unfortunately, these efforts alone are rarely successful in the long-term maintenance of glycemic control to target levels.

In conjunction with lifestyle changes, metformin therapy should be begun when type 2 diabetes is diagnosed unless contraindications exist. The dosage should be increased stepwise to a maximal effective dose over 1-2 months, as tolerated. The addition of other glucose-lowering drugs should be considered if symptomatic hyperglycemia persists.

If diet and exercise plus metformin does not allow the patient to achieve glucose goals within 3 months, step 2 treatment, including the addition of a second medication, is suggested. If the Hb[A.sub.1c] remains over 8.5%, or if extreme hyperglycemia is present even with metformin and lifestyle changes, the consensus group recommends adding an intermediate- or long-acting insulin (basal insulin). If the Hb[A.sub.1c] is lower than 8.5% but still above 7%, either insulin or a sulfonylurea may be added.

If the combination of lifestyle, metformin, and a sulfonylurea (or basal insulin) is ineffective in reaching glycemic targets, step 3 treatment, consisting of multiple injections of a short- or rapid-acting insulin with meals, is recommended. Discontinuation of the sulfonylurea and/or other insulin secretagogues is recommended with intensive insulin treatment. If the Hb[] is near target levels (below 8%), adding a third oral agent instead of insulin may be considered but is not preferred, as it is usually more costly for the patient and is no more effective.

Treatment with alternative second-tier regimens may be warranted in selected patients, such as those who are at particular risk of hypoglycemia. If these alternative second-tier regimens are not tolerated or are ineffective, a sulfonylurea or basal insulin should be substituted.

Patients who have severely uncontrolled diabetes--including those with an Hb[] higher than 10%, fasting glucose above 250 mg/dL, random glucose greater than 300 mg/dL, symptomatic diabetes, and/or diabetes with ketonuria--should be treated initially with insulin therapy in addition to lifestyle interventions. Rapid titration of insulin is most likely to achieve control quickly. Some of these patients may ultimately be able to control their diabetes with oral regimens, while others may be found to have unrecognized type 1 diabetes.

Amylin agonists, [alpha]-glucosidase inhibitors, glinides, and dipeptidyl peptidase-4-inhibiting drugs are not recommended for initial type 2 diabetes management in most patients, as they do not lower glucose better than the recommended agents, have limited data supporting their use, and/or carry excessive cost.

The consensus group recommends against the use of rosiglitazone because of data suggesting greater cardiovascular risks and increased risk of bone fractures in women.

Control of other risk factors for microvascular and cardiovascular complications of diabetes, such as hypertension and dysliplidemia, is recommended in accord with other published guidelines.


Nathan DM, et al. Medical management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy. Diabetes Care 2009;32:193-203.

DR. GOLDEN (left) is professor of medicine and public health and DR. HOPKINS is program director for the internal medicine/pediatrics combined residency program at the University of Arkansas, Little Rock. Write to Dr. Golden and Dr. Hopkins at our editorial offices or

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Author:Golden, William E.; Hopkins, Robert H.
Publication:Internal Medicine News
Date:Feb 1, 2009
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