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Current global guidelines for type 2 diabetes treatment

Current global guidelines for type 2 diabetes treatment

Diabetes is a global conundrum but a global approach to treatment is not necessarily the correct answer

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder.

The global prevalence of diabetes in adults (20–79 years old) in 2013 was 8.3% (382 million people), according to a report by the International Diabetes Federation. This is expected to rise to 10.1% (over 592 million people) by 2035.1 Most people with T2DM are aged between 40 and 59 years.

In diabetes, disrupted insulin secretion and/or insulin action results in high blood glucose levels. Patients with diabetes that is not properly controlled are at risk of developing chronic complications affecting eyes, kidneys, peripheral nerves and heart.2 These complications have an adverse impact on health-related quality of life (HRQoL).

Management of complications contributes heavily to overall expenditure in T2DM.3,4 To prevent or delay complications, promote long-term health and thus reduce treatment costs, optimal glycaemic, blood pressure and lipid control are all essential.

There are many treatment guidelines for T2DM around the world. Included here are the recommendations by the World Health Organization (WHO),5 the American Diabetes Association in conjunction with the European Association for the Study of Diabetes6 and the Latin American Association of Diabetes (ALAD).7

Diabetes treatment involves behavioural and/or pharmacological measures. Lifestyle interventions such as diet and exercise can be effective, but are often insufficient for long-term maintenance of normoglycaemia.

Some guidelines recommend pharmacological treatment combined with behavioural changes as soon as diagnosis of T2DM is confirmed.

WHO recommendations5

  • Start treatment with lifestyle modification (diet and exercise).
  • Metformin can be used as a first-line oral antidiabetic agent in T2DM patients uncontrolled by diet only and who do not have renal insufficiency, liver disease or hypoxia.
  • A sulphonylurea can be given to patients in whom metformin is contraindicated or does not improve glycaemic control.
  • Those with uncontrolled fasting plasma glucose despite maximal doses of metformin or sulphonylurea should be referred to the next level of care (such as combination therapy).

 

ADA and EASD recommendations6

  • Metformin is the preferred initial pharmacological agent for T2DM (if not contraindicated and if tolerated).
  • In patients newly diagnosed with T2DM and with markedly symptomatic and/or elevated blood glucose levels or HbA1c, consider initiating insulin (as mono- or combination therapy).
  • If non-insulin monotherapy at maximum tolerated dose does not achieve or maintain the HbA1c target over 3 months, a second oral agent – a glucagon-like peptide-1 receptor agonist or basal insulin – can be added.
  • A patient-centered approach should be used to guide choice of pharmacological agents. Consider: efficacy; cost; potential side-effects; patient’s body weight, comorbidities, hypoglycaemia risk, preference.
  • Due to the progressive nature of T2DM, many patients will go on to receive insulin therapy.

 

ALAD recommendations for Latin America7

  • Start treatment with oral antidiabetic agents in everyone with T2DM who has not achieved their glycaemic goals after 3–6 months of lifestyle modifications.
  • Metformin should be the first-line oral agent of choice in everyone with T2DM. And particularly in those with clinically significant overweight (BMI >27 kg/m2).
  • Sulphonylureas can be considered first-line in normal-weight patients or those in whom metformin is contraindicated.
  • Meglitinides can be considered as alternatives to sulphonylureas when risk of hypoglycaemia can worsen comorbidities. However, these agents are more expensive than traditional first-line agents.
  • Thiazolidinediones can be considered as alternatives to metformin in overweight patients. However, again the cost of these agents is higher and therapy may be associated with a moderate weight increase.
  • Acarbose is an alpha glycosidase inhibitor that is less effective in reducing hyperglycaemia than other oral antidiabetic agents. It should only be considered as monotherapy in patients with mild elevations of blood sugar, especially post-prandial elevations.
  • Dipeptidylpeptidase-4 enzyme inhibitors can be considered as an alternative treatment choice for patients with intolerance or contraindications to metformin. Clinical experience with this agent is limited.
  • Changing from mono- to combination therapy should be done when the preset goal of metabolic control with the average dose of a single drug has not been reached within 2–3 months. Combination therapy has been shown to be more effective than monotherapy, with lower risk of side-effects.
  • Combination therapy should be considered from the start if it is believed (from the individual’s clinical condition) that monotherapy will fail to achieve good glycaemic control in 3–6 months.
  • In T2DM patients with a fasting blood glucose >240 mg/dl and / or HbA1c ≥8.5%, initial combination therapy should be considered. Such regimens can be:

            - Metformin with sulphonylurea

            - Metformin with thiazolidinedione

            - Thiazolidinedione with sulphonylurea

            - Gliptin with metformin or thiazolidinedione

 

Diabetes is a global problem. Treatment guidelines have the same aim: to treat the condition (usually in primary care) in the most effective, practical and affordable way.

While global guidelines in T2DM are useful, they are not always adaptable to specific regions, such as Latin America.

Socio-economic aspects are important considerations in the preparation of T2DM treatment algorithms.

The ultimate goal of T2DM treatment is to achieve optimal glycaemic control with available resources.

References

  1. International Diabetes Federation. IDF Diabetes Atlas. 6th ed. Brussels, Belgium: International Diabetes Federation; 2013.
  2. Ban CR, Twigg SM. Fibrosis in diabetes complications: pathogenic mechanisms and circulating and urinary markers. Vasc Health Risk Manag. 2008;4:575–96.
  3. Bottomley JM, T2ARDIS Steering Committee Managing care of type 2 diabetes. Learnings from T2ARDIS. Br J Diabetes Vasc Dis. 2001;1:68–72.
  4. Williams R, Van Gaal L, Lucioni C. Assessing the impact of complications on the costs of Type II diabetes. Diabetologia. 2002;45:S13–7.
  5. World Health Organization. Guidelines for primary health care in low-resource settings. Available at: http://apps.who.int/iris/bitstream/10665/76173/1/9789241548397_eng.pdf?ua=1 (accessed August 8, 2015).
  6. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: A patient-centered approach: update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2015;38:140–9.
  7. Asociacion Latinoamericana de Diabetes (ALAD). Guías ALAD de diagnóstico, control y tratamiento de la Diabetes Mellitus Tipo 2. Available at: http://alad-latinoamerica.org/phocadownload/guias%20alad.pdf (accessed August 8, 2015).

Ruy Lyra

Professor of Endocrinology
Federal University of Pernambuco
Pernambuco, Brazil
Type 2 diabetes
T2DM
Treatment guidelines
global guidelines
regional guidelines
World Health Organization (WHO)
american diabetes association
European Association for the Study of Diabetes
Latin American Association of Diabetes (ALAD)
recommendations
quality of life
glycaemic control
diet and exercise
pharmacological treatment
monotherapy
combination therapy
Latin America
socio-economic factors