New Guidelines Promote Better Management of Diabetes

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

Diabetes is a complex and multifactorialdisorder that affectsa large portion of the population.Therefore, it is imperative forhealth care professionals to continueto increase awareness about diabetes,the risk factors associated with thedisease, as well as the importance ofobtaining continual medical care andthe crucial role that self-managementplays in reducing or preventing thecomplications associated with managingdiabetes. As more treatmentoptions and tools become available formaking the management of diabeteseasier, a collaborative effort betweenhealth care professionals and patients,coupled with patient education, arestill fundamental in effectively controllingthis condition.

According to statistics from theNational Institute of Diabetes andDigestive and Kidney Diseases, an estimated23.6 million individuals in theUnited States have diabetes. Of thistotal, 17.9 million individuals have beenformally diagnosed, while an estimated5.7 million individuals remain undiagnosed.¹ An estimated 5% to 10% ofcases are classified as type 1 diabetes,while the remainder are attributed totype 2 diabetes.¹ Furthermore, at least57 million individuals are considered tohave prediabetes, and the prevalencehas significantly increased in recentyears.^2,3 In 2007, 1.6 million new casesof diabetes were diagnosed in individualsaged 20 years and older.^1,3 In 2004,the World Health Organization (WHO)projected that by 2030, the worldwideprevalence of diabetes could actuallydouble, thus affecting an estimated366 million individuals, representing4.4% of the world’s population.⁴

Diabetes is considered to be thesixth leading cause of death.³ Due tothe many complications associatedwith uncontrolled diabetes, such asmacrovascular complications (eg, coronaryartery disease, peripheral arterialdisease, and stroke), microvascularcomplications (eg, retinopathy, neuropathy,and nephropathy), hypoglycemiaor hyperglycemia, periodontal diseases,and increased risk of developinginfections, the overall risk of deathfor individuals with diabetes is twiceas high when compared with thosewithout diabetes.^1,4 Individuals withdiabetes are 2 to 4 times more likelyto develop cardiovascular disease.5Cardiovascular disease is consideredto be the major cause of morbidityand mortality among individuals withdiabetes, and the cardiovascular risksassociated with diabetes account for65% of deaths among individuals withdiabetes.^6,7 Diabetes is considered theleading cause of blindness in individualsbetween the ages of 20 and 74,end-stage renal disease, and the mostfrequent cause of nontraumatic lowerlimbamputations.¹

In January 2009, the AmericanDiabetes Association released their2009 Standards of Medical Care forDiabetes, which is intended to providehealth care professionals with essentialinformation regarding diabetes care,its treatment, and tools to evaluateand manage diabetes.⁸ Additionally, inOctober 2008, the American DiabetesAssociation (ADA) and the EuropeanAssociation for the Study of Diabetes(EASD) published a consensus statementregarding the management ofhyperglycemia in patients with type2 diabetes. The primary goal of theupdates to the consensus algorithm isto assist health care providers in managingthe progressive nature of type2 diabetes. The algorithm providesguidelines for selecting the most therapeuticallyeffective treatment options,while also taking into considerationthe most cost-effective treatment.^9,10

The revised guidelines stress theimportance of obtaining and maintaininga hemoglobin A1C (HbA1C) levelof less than 7%.^9,10 The consensusalso states that when patients haveHbA1C levels of 7% or more, medicationtherapy should be changedto achieve desired levels. While theguidelines also stress the importanceof treating A1C, weight should not beundervalued—80% to 90% of patients with type 2 diabetes are overweight orobese.^9,10 Modest weight loss (~4 kg)has beneficial effects on glucose levelsand improves cardiovascular riskfactors.^9,10

Patients should routinely visit theirprimary health care providers to enabletimely assessments of the patientresponse to therapy and make adjustments.Because type 2 diabetes is acomplex disorder that, without propertreatment, can cause multiple longtermcomplications, effective managementof blood glucose levels, as wellas prevention or reduction of potentialcomplications, may often requirecombination therapy. The ADA/EASDalgorithm describes a stepped careapproach to treat the elevated levelsof blood glucose and HbA1C levels. Theupdated guidelines are divided into 2tiers of recommended treatment.

Tier 1, which is divided into 3 steps,involves well-validated core therapiesand is considered to be the bestestablished and most cost-effectivetherapeutic strategy for achieving optimalglycemic goals.^9,10 Step 1 involveslifestyle interventions and metformin.If targeted glycemic goals are notachieved or maintained, then Step 2involves adding another medicationsuch as insulin or a sulfonylurea. Iflifestyle interventions, metformin, andsulfonylurea or basal insulin do notresult in achievement of target glycemia,the next step should be to initiateor intensify insulin therapy.¹⁰

Traditionally, insulin therapy inpatientswith type 2 diabetes wasnot considered until diet, exercise,and treatmentwith oral antidiabetesagents had failed to maintain normalglycemic control.¹¹ Increasing evidencesupports using insulin therapy early onin the treatment of diabetes to normalizeglycemic control and emulatenormal physiologic insulin secretion.Attaining glycemic control has beenshown to delay or prevent diseaseassociatedcomplications.¹¹

Tier 2 of the consensus algorithmconsists of therapies that are notas well confirmed as those in tier 1and may be used for patients withinselected clinical settings, such aswhen hypoglycemia is undesirable,as in individuals with hazardous jobs.Recommended therapies include theuse of the newer agent, exenatide,which is a glucagon-like peptide-1(GLP-1) agonist, or thiazolidinedione(TZD). The TZD specifically named inthe algorithm is pioglitazone. The newguidelines do not recommend the useof rosiglitazone.^9,10 Exenatide also maybe considered if promotion of weightloss is needed and the hemoglobinA1C level is close to target (<8%).

The addition of a sulfonylurea maybe considered if these interventionsare not effective in achieving optimalHbA1C levels or not tolerated.Alternatively, the tier 2 interventionsshould be stopped and basal insulininitiated. Currently, exenatide is theonly GLP-1 agonist on the market;however, other GLP-1 agonists areunder development and in variousphases of clinical studies. The guidelinestates that although there is farless published data on exenatide, itappears to lower HbA1C by 0.5 to 1percentage points, primarily by loweringpostprandial blood glucose levels.10Exenatide suppresses glucagon secretionand slows gastric motility. It is notassociated with hypoglycemia, but hasa high incidence of gastrointestinalside effects.¹⁰

Various clinical studies have demonstratedthe impact that glycemiccontrol has on preventing or reducingcomplications of diabetes. Routinemonitoring of blood glucose levels hasbeen shown to be important for controllingdiabetes.¹² The updated algorithmfor the management of hyperglycemiawill assist health care providerswith effective care and individualizedtreatment plans for patients. Theearly initiation of insulin and the useof newer agents like the GLP-1 agonistdemonstrate that the treatmentoptions for diabetes are changing. Asmore treatments emerge, so do theopportunities to help patients bettermanage diabetes.

Over the past decade, the emergenceof new treatment options,including oral antidiabetes agents andother agents such as the GLP-1 agonistand insulin analogs, have beenadvantageous to achieving blood glucosecontrol.¹³

Pharmacists are in a pivotal positionto be a valuable resource for patientswith diabetes, especially those whoare newly diagnosed, because thediagnosis may be overwhelming.Pharmacists also can identify patientsat risk for type 2 diabetes (eg, obesity,having a sedentary lifestyle, history ofgestational diabetes, those with elevatedtriglycerides, etc) and encouragethem to get tested since a late diagnosiscan lead to an increased risk ofcomplications and may require moreintensive therapy.

During counseling, pharmacists canuse this opportunity to reiterate thatdiabetes requires continuing medicalcare and self-monitoring to preventfurther complications. Pharmacistscan encourage patients, especiallythose on multiple medications, touse medication reminder devices toprevent missed doses and enroll inautomatic refill programs for medications.To increase patient compliance,when appropriate, pharmacistscan make clinical recommendationsto physicians about prescribing combinationoral antidiabetes agents withonce- or twice-a-day dosing intervals,including GLP-1 agonists or a longactinginsulin. Health care professionalscan empower patients with thetools needed to effectively managediabetes, and assist patients in takingcontrol of their diabetes beforeit takes control of them. A proactiveand aggressive approach to treatingdiabetes increases the likelihood ofsuccessful management.

References

• National Diabetes Statistics. National Institute of Diabetes and Digestive and Kidney Diseases web site www.diabetes.niddk.nih.gov/dm/pubs/statistics/#allages. Accessed December 30, 2008.
• Votey Scott , Peters Anne. Diabetes Mellitus Type 2 A Review. Medscape website. www.emedicine.medscape.com/article/766143-overview Accessed December 31,2008
• Unger Jeff , Moriarity Cynthia. Preventing type 2 diabetes. Prim Care. 2008; 35(4):645-62.
• Wild S., Roglic G., Green A., Sicree R. and King, H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004; 27(5):1047-53.
• Diabetes and Cardiovascular Disease. American Heart Association website. www.americanheart.org/presenter.jhtml?identifier=3044762. Accessed January 2, 2009.
• Stancoven Amy , McGuire Darren. Preventing macrovascular complications in type 2 diabetes: glucose control and beyond. Am J Cardiol. 2007; 99(11A):5H-11H.
• Diabetes and Cardiovascular Disease. American Diabetes Association website. www.diabetes.org/diabetes-statistics/heart-disease.jsp. Accessed January 8, 2009.
• American Diabetes Association Standards of Medical Care in Diabetes 2009. Diabetes Care. 2009; 32 Suppl 1:S6-12.
• ADA/EASD Statement: Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy. Diabetes News Diabetes Life website. www.dlife.com/diabetes-news/2008/10/adaeasd_statement_medical_mana.html. Accessed January 2, 2009.
• Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, Zinman B. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy ADA /EADS statement. Diabetes Care 2008;31(12)
• Funnell MM, Kruger DF. Type 2 diabetes: treat to target. Nurse Pract. 2004 ;29(1):11-5, 19-23
• Tibaldi, J. Initiating and intensifying insulin therapy in type 2 diabetes mellitus. Am J Med 2008; 121(6 Suppl):S20-9.
• Gerich, John. The importance of tight gylcemic control. Am J Med. 2005; 118(Suppl 9A):7S-11S