Diabetes management is becoming less “glucocentric” than it used to be, according to Dr. Helena W. Rodbard.
Dr. Rodbard is the chairperson of the task force that wrote the new clinical practice guidelines on the management of diabetes issued by the American Association of Clinical Endocrinologists. Instead of talking only about how to keep blood glucose at the ideal level, the new guidelines provide more emphasis on lifestyle—in terms of prevention of diabetes—as well as the importance of managing blood pressure and lipids, she said in an interview.
In addition, previous guidelines did not include much information on diabetes complications, particularly microvascular complications, and diabetes management in the hospital setting, both topics of separate sections of the new guidelines. There are also sections on nutrition, screening and diagnosis, glycemic management in type 1 and type 2 diabetes, diabetes and pregnancy, and patient safety in diabetes care.
The guidelines were published in a supplement to Endocrine Practice that was mailed to AACE members and journal subscribers in July (Endocr. Pract. 2007;13[Suppl 1]), and are a result of almost 3 years of work by the task force, which was made up of endocrinologists specializing in diabetes, Dr. Rodbard said.
The final recommendations in the guidelines represent a consensus among the task force members, and were also approved by the AACE board of directors.
These guidelines are distinct from the “Road Maps for the Prevention and Treatment of Type 2 Diabetes” recently released by AACE. The road maps are not guidelines, but instead provide specific treatment algorithms and focus more on glycemic control.
The guidelines include a section on the medical management of diabetes, which contains reviews of the different drugs available, their indications for use, their advantages and disadvantages, and their expected impact on reducing in HbA1c levels.
They do not specifically recommend any one drug or class of drugs as a first-line treatment, but instead, they focus on the importance of individualizing treatment, Dr. Rodbard explained.
“We don't have a cookbook approach because every patient is different, and we list the different medications, the indications for each drug, and which subset of patients can benefit from one versus the other medication,” she said.
That approach contrasts with the American Diabetes Association, which last year endorsed a consensus algorithm that recommended metformin along with lifestyle interventions for newly diagnosed type 2 diabetes.
“That may be appropriate for many, perhaps most patients with type 2 diabetes, but definitely not for everybody,” Dr. Rodbard noted. “It is up to the judgement of the physician to make a decision about whether metformin would or would not be the right drug for an individual patient.”
The task force was able to add a statement close to the publication date regarding a recent meta-analysis reporting an increased risk of myocardial infarction associated with rosiglitazone therapy (N. Engl. J. Med. 2007 [Epub doi:10.1056/NEJMoa072761]). Despite the controversy over the meta-analysis and the unresolved issues, “we felt we had to say something about it, although we tried to keep a very balanced opinion in that regard and are not recommending that patients stop the medication,” Dr. Rodbard said.
The statement, which appears in the glycemic management section, says that “definitive resolution regarding the magnitude and statistical and clinical significance of these findings” will require further analyses, including the results of an ongoing phase III study expected to be completed in 2009.
The guidelines also list peripheral fractures in women among the adverse effects of thiazolidinediones (TZDs), a reference to findings showing an increased rate of peripheral fractures in women taking either rosiglitazone or pioglitazone (“Second TZD Connected to Excess Fractures in Women,” April 2007, p. 1).
In the section on glycemic management, AACE recommends a glycemic target that includes an HbA1c equal to or below 6.5%, a fasting plasma glucose concentration below 110 mg/dL, and a 2-hour postprandial glucose concentration below 140 mg/dL, values that AACE has advocated in the past. The glycemic goals in the guidelines are consistent with previous AACE consensus conferences and a position statement regarding these targets, said Dr. Paul S. Jellinger, a task force member and a past president of both AACE and the American College of Endocrinology, who is in private practice in Hollywood, Fla.
The guidelines are a “very nice blend of evidence-based and evidence-ranked statements, which also reflect the extensive clinical experience of the task force members,” he added. Written with the clinician in mind, “we expect this will be a source of clinically useful information” for any clinician involved in the care of people with diabetes, he said.