This week, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) updated their recommendations for how Type 2 diabetes should be treated. The new guidelines have been published online in the journals Diabetes Care and Diabetologia and will be published in print in the January 2009 issue of Diabetes Care.
Treatment recommendations were originally published in 2006 to guide health-care providers on how to bring down high blood glucose levels in people with Type 2 diabetes. According to a statement released this week by the ADA and EASD, the latest revisions “tak[e] into account new medications that have come on the market and the most current scientific data regarding previously recommended drugs.”
The revised treatment protocol looks like this:
- Step 1—Lifestyle changes (such as diet and exercise) and treatment with the drug metformin
- Step 2—If blood glucose goals are not met within three months with Step 1 alone, one of the following options should be added:
- Option A (preferred)—Basal (long-acting) insulin or a sulfonylurea drug
- Option B—The thiazolidinedione drug pioglitazone (brand name Actos) or the GLP-1 agonist exenatide (Byetta).
Option A is considered “well validated,” since insulin and sulfonylureas have a long track record of safely treating Type 2 diabetes, while the treatments in Option B have not been around as long. However, David Nathan, M.D., chair of the panel of experts that issued the updated treatment guidelines, stated that the Option B drugs are valuable if hypoglycemia is a major concern (since insulin and sulfonylureas have a greater risk of causing hypoglycemia than pioglitazone and exenatide).
- Step 3: If blood glucose goals are not met with Step 1 and Step 2, then basal insulin should be added if it has not already been started, followed by more intensive insulin treatment as necessary.
The new guidelines recommend that people newly diagnosed with Type 2 diabetes see their doctors every three months, as did the old guidelines. The goal is to allow timely assessments and treatment adjustments so that people can rapidly achieve and maintain near-normal blood glucose and HbA1c levels.
The major differences in this revision of treatment guidelines are the following:
- The removal of rosiglitazone (Avandia), the other drug in the thiazolidinedione class, from the list of recommended second-step drug options; and
- The addition of GLP-1 agonists to the list of second-step drug options.
Rosiglitazone has been in the news frequently over the last year because of associations with heart attack, congestive heart failure, and bone fractures. The latter two side effects have also been associated with pioglitazone, though pioglitazone does not appear to increase risk of heart attack.
You can download a PDF of the Diabetes Care article outlining the revised guidelines and the research behind them here.