Is your patient on target? Optimizing diabetes management

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Applied Evidence

Is your patient on target? Optimizing diabetes management

J Fam Pract. 2014 August;63(8):442-451

By

Kathryn M. Harmes, MD

Christine T. Cigolle, MD, MPH

As new evidence emerges and guidelines are frequently revised, optimizing diabetes treatment with an eye toward HbA1c, blood pressure, and lipid goals becomes increasingly complex. Here’s help.

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References

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4. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359:1577-1589.

5. Gerstein HC, Miller ME, Byington RP, et al; Action to Con- trol Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358:2545-2559.

6. Ismail-Beigi F, Craven T, Banerji MA, et al; ACCORD Trial Group. Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. Lancet. 2010;376:419-430.

7. Gerstein HC, Miller ME, Genuth S, et al; ACCORD Study Group. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med. 2011;364:818-828.

8. Bonds DE, Miller ME, Bergenstal RM, et al. The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study. BMJ. 2010;340:b4909.

9. Duckworth W, Abraira C, Moritz T, et al; VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009;360:129-139.

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11. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66.

12. International Diabetes Foundation Clinical Guidelines Task Force. Global Guideline for Type 2 Diabetes. International Diabetes Federation. Brussels, Belgium; 2012.

13. Handelsman Y, Mechanick JI, Blonde L, et al; AACE Task Force for Developing Diabetes Comprehensive Care Plan. Ameri- can Association of Clinical Endocrinologists Medical Guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan: executive summary. Endocr Pract. 2011;17(suppl 2):S1-S53

14. Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572.

15. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713.

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17. Cushman WC, Evans GW, Byington RP, et al; ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575-1585.

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PRACTICE RECOMMENDATIONS

› Aim for a glycated hemoglobin of <7% for most nonpregnant patients with type 2 diabetes, with a less stringent target for those with severe hypoglycemia, limited life expectancy, advanced micro- or macrovascular complications, and/or extensive comorbidities. B
› Attempt to treat patients with diabetes and hypertension to a target blood pressure<140/90mm Hg. B
› Prescribe statin therapy regardless of baseline lipid levels for all patients who have diabetes and are between the ages of 40 and 75years. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE › Dennis D, age 63, was recently diagnosed with diabetes. his glycated hemoglobin (HbA1c) is 7.8%, his blood pressure (BP) is mildly elevated (145/95 mm Hg), and his body mass index (BMI) is 28.5, but his low-density lipoprotein (LDL) cholesterol is 100 mg/dl, his high-density lipoprotein (HDL) cholesterol is 52 mg/dL, and he has no history of cardiovascular disease (CVD). After an unsuccessful attempt to treat him with lifestyle modification, it is time to initiate diabetes therapy.

Other than an alpha-blocker for benign prostatic hyperplasia and a prostaglandin for glaucoma, Mr. D takes no other medications. You prescribe metformin 500 mg twice daily and consider what else to add to keep his diabetes well controlled. Should you prescribe an antihypertensive? And, despite the patient’s normal lipid levels, should he begin taking a statin?

The challenge faced by primary care physicians? Using the latest recommendations in a way that addresses the entire clinical picture, including the patient's age and overall health status, priorities, and preferences.Type 2 diabetes has been extensively studied in rigorous randomized controlled trials (RCTs). While studies have provided ample evidence in support of optimal treatment, differing interpretations of the findings are reflected in consensus guidelines developed by expert panels that don’t always see eye to eye on what diabetes treatment targets should be and how best to prevent micro- and macrovascular complications.

What’s more, recommendations continue to be updated as new data emerge. In February 2014, the Joint Committee on Prevention, Evaluation, and Treatment of High Blood Pressure (JCN 8) revised its target for patients with diabetes to <140/90 mm Hg (from <130/80 mm Hg).¹ This is likely to lead to revisions in other leading consensus guidelines, as well.

Thus, primary care physicians managing the care of patients with diabetes face the challenge of using the latest recommendations in a manner that addresses the entire clinical picture, considering each patient’s age and overall health status, priorities, and preferences. We developed this evidence-based review and guide- line summary with that in mind.

HbA1c target: How low should you go? 

The Diabetes Control and Complications Trial (DCCT), published nearly 20 years ago, studied patients with type 1 diabetes, and found that intensive insulin therapy (HbA1c ≤6%) delayed the onset of retinopathy, nephropathy, and neuropathy.² However, there was an important adverse effect of such intensive therapy: Patients in this group suffered from severe hypoglycemic episodes 3 times more frequently than those in the usual care group. Nonetheless, the microvascular benefits of intensive control observed in those with type 1 diabetes were thought to be similar for patients with type 2 diabetes.

The United Kingdom Prospective Diabetes Study (UKPDS), published in 1999, was the first major study to investigate targets for glucose control in patients with type 2 diabetes.³ Participants treated intensively (mean HbA1c goal, 7%) had a 25% reduction in microvascular complications, including the need for retinal photocoagulation, com- pared with those on standard control (mean HbA1c, 7.9%). There was also a nonsignificant trend toward a reduction in macrovascular complications in the intensive therapy group, but no difference in overall mortality rate.³

A 10-year follow-up of the UKPDS showed that while baseline differences in HbA1c between the 2 groups were lost by one year, reductions in microvascular complications continued to occur in the intensive treatment group.⁴ Reductions in myocardial infarction (MI) and death emerged over time, a possible legacy effect (ie, the result of intense treatment early in the course of the disease).

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, published in 2008, studied patients at risk for CVD, defined by either a prior history of CVD or ≥2 other cardiovascular risk factors.⁵ Participants, all of whom had poorly controlled type 2 diabetes (mean HbA1c, 8.1%), were randomized to either intensive treatment (HbA1c goal, <6%) or standard therapy (HbA1c goal, 7%-7.9%). The study was discontinued after a mean follow-up of 3.5 years, when those in the intensive therapy group were found to have a higher mortality rate.⁵