Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes

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Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes
2006
Nathan DM, Buse JB, Davidson MB
Diabetes Care

Abstract
Background:
The dramatic increases in the incidence of type 2 diabetes and the recognition that achieving specific glycemic goals can substantially reduce morbidity have made the effective treatment of hyperglycemia a top priority. The development of new classes of blood glucose–lowering medications to supplement the older therapies, such as lifestyle-directed interventions, insulin, sulfonylureas, and metformin, has increased the treatment options for type 2 diabetes. A consensus approach to the management of hyperglycemia in the nonpregnant adult was described to aid health care providers in selecting the most appropriate interventions for patients with type 2 diabetes.

Overview:
The primary goal of therapy is to achieve and maintain glucose levels as close to the nondiabetic range as possible For the individual patient, the American Diabetes Association (ADA) has recommended that the HbA1c (A1C) level should be as close to normal (<6%) as possible without significant hypoglycemia. The consensus in this report is that an A1C of 7% or greater should signal the need to initiate or change therapy with the goal of achieving an A1C level as close to the nondiabetic range as possible or, at a minimum, decreasing the A1C to less than 7%. The salutary effects of therapy on longterm complications in type 2 diabetes appear to be based predominantly on the level of glycemic control achieved rather than on any other attributes of the interventions used to achieve glycemic goals. It is reasonable to judge and compare blood glucose–lowering medications, and the combinations of these agents, mainly on the basis of the A1C levels that are achieved and on their specific side effects, tolerability, and expense. One important intervention that is likely to improve the probability that a patient will have better longterm control of diabetes is to make the diagnosis early, when the metabolic derangements associated with diabetes are usually less severe. Oral hypoglycemic regimens that do not include sulfonylureas are not likely to cause hypoglycemia and thus usually do not require self-monitoring of blood glucose. If the recommended levels of fasting and preprandial A1C are not consistently obtained, or if the A1C level remains above the desired target, postprandial levels may be checked. The postprandial levels should be less than 180 mg/dL (10 mmol/L) to achieve A1C levels in the target range. The proposed algorithm for management of type 2 diabetes is based on 3 steps (Fig 2). The consensus is that, as a first step, metformin therapy should be initiated in concurrence with lifestyle intervention at diagnosis. In the second step, another medication should be added within 2 to 3 months of the initiation of therapy or at any time in which the A1C goal is not achieved. As a third step, the addition of a third oral agent could be considered if the A1C is close to the goal (<8.0%).

Conclusions:
The longterm consequences of the type 2 diabetes epidemic will involve enormous human suffering and economic costs. Much of the morbidity associate with the longterm complications of this disease can be significantly reduced with interventions that achieve glucose levels close to the nondiabetic range.

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