New Guidelines Recommend Tailored Approach to Type 2

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.

For more information, see the article “New Diabetes Guideline Urges Tailored Therapy” (free registration required) or download a copy of the guidelines from the journal Diabetes Care.

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  • jim snell

    gott in himmal. Holy Hannah – finally some intelligent comment besides the usual baffegab.

    Some key comments:

    Patience centered approach

    Evidence-based advice
    depends on the existence of primary
    source evidence.

    Any rise in glycemia is the net result of
    glucose influx exceeding glucose outflow
    from the plasma compartment. In the fasting
    state, hyperglycemia is directly related
    to increased hepatic glucose production.
    In the postprandial state, further glucose
    excursions result from the combination
    of insufficient suppression of this glucose
    output and defective insulin stimulation
    of glucose disposal in target tissues, mainly
    skeletal muscle. (Amazing – finally identifying Liver issues.)

    Metformin is most widely used first-line type 2 diabetes drug; its mechanism of action predominately involves reducing hepatic (liver) glucose production (54,55). No kidding! Finally an accurate answer.

    I am impressed with this report, its depth and comment. There has been far too much mis-information previously peddled. Also the patient centered/evidence based approach offers real chance for improvement in cures and care.

  • Betty Newby

    Metforman was the worst drug I have ever used! I have never been so sick in my whole life. It is about they realized all type 2 are not created equal!

  • jim snell

    Iam unclear how your dosage was set up.

    For me the huge dosages 2000 mg at a crack made me sick and pin in butt and did no good.

    It turns out due to research smaller doses 500 to 700 mg spread around clock do a better job than single huge doses that can make one sick and cause problems.

    your comments do not provide clue how you were taking/using.

    The best effects from metformin come from met up to strength in blood that causes liver to pull back release.

    Residuals and dosages above that simply hammer body in short run and only stick around the same 1 to 3 hours.

    And yes, there are those met is not ideal.

  • Karen

    I have been taking the metformin 850 mg/2/day and have great results. My AIC was 14 and after 3 months of good diet, taking med correctly, I am now 6.2 and metformin reduced to 500mg. I am continuing my diet. I believe there may be cases where met doesn’t work, but I must be very lucky!!