Diabetes treatment guidelines stress individualized care

The American Diabetes Assn. recommends that physicians take a less prescriptive but more patient-centered approach to managing hyperglycemic patients with type 2 diabetes.

Doctors should focus on patients’ individual needs, preferences and tolerances as well as age and disease progression, say the new guidelines, developed by the ADA and the European Assn. for the Study of Diabetes. The recommendations, published in the April 19 online edition of Diabetes Care, update the two associations’ 2009 guidelines on the subject (link).

Individualized care is key to treating patients with the disease, said Silvio Inzucchi, MD, co-guideline author and a professor of medicine at the Yale School of Medicine in Connecticut. He also is director of the Yale Diabetes Center.

“In the older, more infirm patient, a more conservative, less aggressive approach may be best,” Dr. Inzucchi said in an email. “In younger, healthier patients, it may pay to be more rigorous. It all involves clinical judgment and, importantly, bringing the patient into that discussion.”

The ADA said the guidelines address the wide disparities among patients seeking diabetes treatment, and that the recommendations should improve outcomes.

“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 designed to work for everyone,” according to a statement by Vivian Fonseca, MD, ADA president of medicine and science. “If we encourage people to work with their health care providers to find an individualized personal plan that works well for them and fits their lifestyle and personal needs, it has a higher chance for success in controlling glucose and decreasing the risk of long-term complications.”

Eighteen million adults 20 and older have been diagnosed with diabetes, up from 9 million in 1997, according to a study published in the Jan. 3 issue of Circulation (link).

Type 2 diabetes remains a leading cause of cardiovascular disorders, blindness and end-stage renal failure, according to the ADA. It also is associated with increased risk of cancer, cognitive decline, chronic liver disease and other disabling conditions.

Tailoring education to older patients, others

The recommendations say all patients should receive standardized diabetes education with a focus on dietary interventions and physical activity. While therapeutic lifestyle change should be encouraged, counseling also should be integrated into the treatment program.

Lifestyle modification can be implemented across all age groups, but the guidelines say doctors should focus on drug safety when prescribing anti-hyperglycemic agents to older patients. Closer watch over medications helps protect against heart failure, renal dysfunction and bone fractures, among other conditions. Health professionals should conduct an intensive lifestyle intervention in obese patients with particular consideration given to combination drug therapy.

Co-guideline author John Buse, MD, PhD, hopes that the recommendations provide physicians with a more practical outline to help manage diabetic patients.

“There’s literally thousands of publications every year on the management of type 2 diabetes,” said Dr. Buse, a professor at the University of North Carolina at Chapel Hill School of Medicine and director of the UNC Diabetes Care Center. “The primary care doctor in 21st-century America and in Europe is going to be extremely challenged in keeping up with all the new developments. Hopefully, these guidelines will help primary care providers and other busy clinicians put a huge amount of literature into perspective in a way that’s useful for patient care.”