Diabetes Type 2 - '10 Practical Steps' aim to help physicians and patients reach treatment goals

In the face of an emerging worldwide epidemic of type 2 diabetes, the Global Partnership for Effective Diabetes Management today launched the first global recommendations designed to help physicians overcome common barriers to achieving recommended treatment goals for diabetes management. Despite increasingly stringent clinical practice guidelines, more than 60 percent of those with type 2 diabetes currently have glucose levels above the recommended targets (HbA1c less than 6.5 percent), putting them at increased risk for serious complications such as cardiovascular disease - the leading cause of diabetes-related death.1,2


The Global Partnership for Effective Diabetes Management, a multidisciplinary task force of internationally respected diabetes experts from leading institutions and diabetes organisations worldwide, recognised that current treatment strategies were not sufficient to get patients to achieve glucose goals. Their global call to action, including "10 Practical Steps to Better Glucose Control", is published in the November issue of the International Journal of Clinical Practice. The publication supports appeals from the International Diabetes Federation and the American Association of Clinical Endocrinologists, who call for physicians to partner with patients to achieve a treatment goal of HbA1c 6.5 percent or less.3,4


"Because of the progressive nature of type 2 diabetes, the longer patients remain uncontrolled, the more extensive the diabetes-related damage such as blindness and kidney failure, and the harder it is to keep glucose levels in check. With the vast majority of people with type 2 diabetes not at recommended treatment goals, the stakes are high," said Professor Stefano Del Prato, chair of the Global Partnership for Effective Diabetes Management and professor of endocrinology and metabolism and chief of the Section of Diabetes, both at the University of Pisa. "However it isn't easy to get patients to currently recommended treatment glucose targets and physicians need practical guidance. Our "10 Practical Steps" were specifically developed to address the current gap between treatment guidelines and therapeutic practice. Given the escalating global epidemic of type 2 diabetes, a sense of urgency and proactive management strategies are required to get more patients to recommended goals."


Move from reactive, stepwise approach to proactive strategy


Most physicians rely on a "stepwise approach" to control blood glucose levels in people with type 2 diabetes that begins with diet and exercise, followed by treatment with a single oral anti-diabetic drug, where the dose is often slowly increased to maximal effect, and then to combination drug therapy, if necessary.5 With the stepwise approach, it can take up to 21 months for patients who are not at glucose goal to move from single therapy to combination therapy.6 However, earlier use of a combination of drugs with complementary actions has been shown to be effective in getting patients to target glucose levels, reducing complications and delaying disease progression.7,8















The Global Partnership advocates a proactive approach to the management of type 2 diabetes, calling for earlier use of combination therapy, in parallel with diet and exercise reinforcement. The recommendations provide specific action points for when changes in treatment strategy should be considered, for example, newly diagnosed patients should be treated intensively so as to achieve target HbA1c less than 6.5 percent within 6 months of diagnosis, and for currently diagnosed patients who are not at target HbA1c less than 6.5 percent within 3 months, combination therapy should be considered.


Numbers too big to ignore


The fourth or fifth leading cause of death in most developed countries, diabetes has reached epidemic proportions in many developing and newly industrialised nations.2 Complications from diabetes, such as coronary artery and peripheral vascular disease, stroke, diabetic neuropathy, amputations, renal failure and blindness are resulting in increasing disability, reduced life expectancy and enormous health costs for virtually every society.9 The total cost of diabetes is ???29 billion in Europe9 and $132 billion in the US,10 and complications are the single factor with the largest impact on cost (75 percent of people with diabetes die of cardiovascular disease11).9


"The trend of escalating diabetes prevalence will no doubt lead to an immense financial burden in many countries unless urgent action is taken to prevent both diabetes and its complications," said Professor Del Prato.


Despite widespread publication of new glucose guidelines calling for lower treatment targets, several large scale studies have shown that current management of glycaemia is falling significantly short of recommended treatment goals. In fact, there was little improvement in the proportion of patients achieving good glucose control in the US National Health and Nutrition Examination Survey (NHANES) III (1998 and 1994) and the NHANES 1999-2000.12 In NHANES and the CODE 2 Europe study, only 37% and 31% of patients respectively achieved glucose control.1,12


Practical advice to help patients get to goal


The Global Partnership developed their "10 Practical Steps" - as well as a companion piece that outlines supporting evidence - as part of the Control to Goal programme, an integrated diabetes education and support initiative for healthcare professionals that addresses the roadblocks to effective diabetes management. The recommendations of the Global Partnership focus on the following four areas:


Achieving good glucose control
1- Aim for good glycaemic control, defined as HbA1c < 6.5 percent*

2- Monitor HbA1c every three months in addition to regular glucose self-monitoring

3- Aggressively manage hyperglycaemia, dyslipidaemia and hypertension with the same intensity to obtain the best patient outcome

4- Refer all newly diagnosed patients to a unit specialising in diabetes care where possible





Targeting the underlying pathophysiology of type 2 diabetes


1- Address the underlying pathophysiology, including treatment of insulin resistance





Earlier and intensive treatment with combination therapies


1- Treat patients intensively so as to achieve target HbA1c < 6.5 percent* within 6 months of diagnosis

2- After 3 months, if patients are not at target HbA1c < 6.5 percent*, consider combination therapy

3- Initiate combination therapy or insulin immediately for all patients with HbA1c
>= 9 percent at diagnosis

4- Use combinations of oral antidiabetic agents with complementary mechanisms of action





Using a multidisciplinary team


1. Implement a multi- and interdisciplinary team approach to diabetes management to encourage patient education and self care and share responsibility for patients achieving glucose goals





*Or fasting/pre-prandial glucose