In a new joint position statement, the American Diabetes Association and European Association for the Study of Diabetes have recommended that physicians take an individualized, tailored approach when it comes to treating those with Type 2 diabetes. In the United States, an estimated 26 million people are living with this condition.
The new guidelines replace an algorithm, or step-by-step procedure, originally written by the two organizations in 2006 (and updated in 2008) to help advise health-care providers on how to choose between treatment options for people with Type 2. The earlier versions of the guidelines were created when less data was available on several widely used classes of diabetes drugs, such as DPP-4 inhibitors (Januvia [generic name sitagliptin], Onglyza [saxagliptin], and Tradjenta [linagliptin]) and GLP-1 agonists (Byetta [exenatide], Victoza [liraglutide], Bydureon [exenatide XR]), and recommended choosing from among insulin, sulfonylureas, thiazolidinediones, and Byetta if the first-line treatment options of lifestyle, diet, and metformin were not effective.
The new guidelines still recommend lifestyle interventions, including increased physical activity and improved diet, as the first step in treatment, and they still prescribe metformin as the first-line drug option. After that, however, rather than recommending specific classes of medicines, the statement discusses the various risks and benefits of the available drug classes and urges health-care providers to take this information into account to create customized treatment plans for their patients. For instance, information about the increased risk of bone fracture from medicines in the thiazolidinedione class (Actos [pioglitazone] and Avandia [rosiglitazone]) would be relevant when tailoring a plan for a postmenopausal woman.
According to Vivian Fonseca, president of the American Diabetes Association, “The wide range of pharmacological choices, along with conflicting data about some of those choices, and differences in how patients respond to medications, makes it difficult to prescribe a single treatment regimen based on an algorithm that is designed to work for everyone.”
The guidelines also suggest that blood glucose goals need to be individualized, and note that most people with Type 2 diabetes will ultimately need insulin therapy, either alone or in combination with other medicines, to maintain control of their diabetes.
In an e-mail to MedPage Today, David Nathan, MD, suggested that the new recommendations “provided relatively little guidance,” but added that this is not necessarily a bad thing, since the guidelines provide in-depth information about the various treatment options and leave the final choice about what’s most appropriate for an individual up to his doctor.