Management of Hyperglycemia in Type 2 Diabetes

In 2012, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) published a position statement on the management of hyperglycemia in patients with type 2 diabetes (1,2). This was needed because of an increasing array of antihyperglycemic drugs and growing uncertainty regarding their proper selection and sequence. Because of a paucity of comparative effectiveness research on long-term treatment outcomes with many of these medications, the 2012 publication was less prescriptive than prior consensus reports. We previously described the need to individualize both treatment targets and treatment strategies, with an emphasis on patient-centered care and shared decision making, and this continues to be our position, although there are now more head-to-head trials that show slight variance between agents with regard to glucose-lowering effects. Nevertheless, these differences are often small and would be unlikely to reflect any definite differential effect in an individual patient.

The ADA and EASD have requested an update to the position statement incorporating new data from recent clinical trials. Between June and September of 2014, the Writing Group reconvened, including one face-to-face meeting, to discuss the changes. An entirely new statement was felt to be unnecessary. Instead, the group focused on those areas where revisions were suggested by a changing evidence base. This briefer article should therefore be read as an addendum to the previous full account (1,2).

Glycemic Targets

Glucose control remains a major focus in the management of patients with type 2 diabetes. However, this should always be in the context of a comprehensive cardiovascular risk factor reduction program, to include smoking cessation and the adoption of other healthy lifestyle habits, blood pressure control, lipid management with priority to statin medications, and, in some circumstances, antiplatelet therapy. Studies have conclusively determined that reducing hyperglycemia decreases the onset and progression of microvascular complications (3,4). The impact of glucose control on cardiovascular complications remains uncertain; a more modest benefit is likely to be present, but probably emerges only after many years of improved control (5). Results from large trials have also suggested that overly aggressive control in older patients with more advanced disease may not have significant benefits and may indeed present some risk (6). Accordingly, instead of a one-size-fits-all approach, personalization is necessary, balancing the benefits of glycemic control with its potential risks, taking into account the adverse effects of glucose-lowering medications (particularly hypoglycemia), and the patient’s age and health status, among other concerns. Figure 1 displays those patient and disease factors that may influence the target for glucose control, as reflected by HbA1c. The main update to this figure is the separation of those factors that are potentially modifiable from those that are usually not. The patient’s attitude and expected treatment efforts and access to resources and support systems are unique in so far as they may improve (or worsen) over time. Indeed, the clinical team should encourage patient adherence to therapy through education and also try to optimize care in the context of prevailing health coverage and/or the patient’s financial means. Other features, such as age, life expectancy, comorbidities, and the risks and consequences to the patient from an adverse drug event, are more or less fixed. Finally, the usual HbA1c goal cut-off point of 7% (53.0 mmol/mol) has also been inserted at the top of the figure to provide some context to the recommendations regarding stringency of treatment efforts.

Modulation of the intensiveness of glucose lowering in type 2 diabetes. Depiction of patient and disease factors that may be used by the practitioner to determine optimal HbA1c targets in patients with type 2 diabetes. Greater concerns regarding a particular domain are represented by increasing height of the corresponding ramp. Thus, characteristics/predicaments toward the left justify more stringent efforts to lower HbA1c, whereas those toward the right suggest (indeed, sometimes mandate) less stringent efforts. Where possible, such decisions should be made with the patient, reflecting his or her preferences, needs, and values. This “scale” is not designed to be applied rigidly but to be used as a broad construct to guide clinical decision making. Based on an original figure by Ismail-Beigi et al. (59).