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Treatment Guidelines Favor Early Metformin Then Insulin for Type 2 Diabetes

Posted: Wednesday, August 09, 2006

Metformin should be prescribed along with lifestyle intervention as soon as patients are diagnosed with type 2 diabetes and if A1c cannot be brought down to below 7%, within 2-3 months, then insulin as the second-line drug.

That comes from the authors of a new consensus algorithm endorsed by the American Diabetes Association.

Based on evidence gleaned from well-controlled trials and the expert opinions of diabetes specialists, the document stresses the importance of promptly diagnosing type 2 diabetes and achieving an A1c level as close to the nondiabetic range as possible (less than 6%) or, at a minimum, to less than 7%. The statement was published in the August issue of the journal Diabetes Care (2006;29:1–10).

Insulin also features prominently in the document as an intervention to be considered expeditiously in patients who veer from a tightly targeted glycemic goal. A hemoglobin A1c level of 7% or greater “should serve as a call to action to initiate or change therapy,” the consensus panel said.

Delays in achieving control typically occur when medications are reserved for patients who have not responded to efforts to promote exercise, dietary adjustments, and weight loss, the panel said. “For most individuals with type 2 diabetes, lifestyle interventions fail to achieve or maintain metabolic goals.”

The algorithm also advocates adding basal insulin, a sulfonylurea, or a thiazolidinedione (glitazone) within 2–3 months of the initiation of therapy or “at any time” that A1c levels are 7% or greater.

The strong recommendation to consider insulin as a second-line drug “was a little surprising, since few people do it,” said consensus panel member Dr. Mayer B. Davidson, of Charles R. Drew University of Medicine and Science, Los Angeles. But such a change in clinical practice could be “very effective,” he said in an interview.

The guidelines contain detailed advice for initiating and adjusting insulin regimens, the complexity of which may contribute to delays in aggressive therapy that could optimize patient outcomes.

If a combination of lifestyle changes, metformin, and a second-line drug fail to achieve glycemic control, the algorithm endorses adding another of the second-line choices (basal insulin, a sulfonylurea, or glitazone) or intensifying insulin therapy.

“Although three oral agents can be used, initiation and intensification of insulin therapy is preferred based on effectiveness [and] expense,” the authors noted in the algorithm approved by the Professional Practice Committee of the American Diabetes Association (ADA) and an ad hoc committee of the European Association for the Study of Diabetes.

Consensus panel members deplored the lack of “high-quality evidence” comparing diabetes drugs head to head, adding that “there are insufficient data at this time to support a recommendation of one class of glucose-lowering agents or one combination of medications over others with regard to … complications.” They therefore focused on the effectiveness of drug classes in lowering glycemic levels as the “overarching principle” guiding their choice of first- and second-line agents.

Pramlintide, exenatide, a-glucosidase inhibitors, and the glinides were not included in the algorithm “owing to their generally lower overall glucose-lowering effectiveness, limited clinical data, and/or relative expense,” although the authors acknowledged that they might be “appropriate choices in selected patients.”

Diabetes experts within and outside the ADA applauded the guidelines committee led by Dr. David M. Nathan, director of the diabetes center at Massachusetts General Hospital and professor of medicine at Harvard Medical Center, both in Boston.
“Aggressive control of glucose is incredibly important in the care of our patients,” said Dr. Hellman, clinical professor of medicine at the University of Missouri-Kansas City.
He also agreed with the new algorithm's emphasis on aggressive treatment of type 2 diabetes in the first year after diagnosis, including the early integration of insulin into the treatment regimen. The most important message to primary care physicians is to hit the disease hard, early on, he emphasized.
“Deterioration is more common when physicians wait a long time to gradually accelerate the treatment.”
Indeed, “heightened uncertainty regarding the most appropriate means of treating this widespread disease,” was one of the driving forces behind the development of the algorithm, the authors noted.
“Although numerous reviews on the management of type 2 diabetes have been published in recent years, practitioners are often left without a clear pathway of therapy to follow,” they wrote.



Source: Diabetes In Control: Diabetes Care (2006;29:1–10).Aug, 2006

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