Louis Kuritzky, MD; Benjamin J. Epstein, PharmD, BCPS; and Frank Lavernia, MD
Abstract: Good control of diabetes provides meaningful microvascular risk reduction; yet, patients with type 2 diabetes mellitus commonly languish at unsatisfactory levels of glycated hemoglobin (HbA1c) for protracted periods. A variety of factors contribute to this clinical inertia, as clinicians tend to be too conservative in their treatment of patients who are not achieving glycemic control.
Available clinical data suggest the near-maximal blood glucose reduction achievable with use of most antidiabetic agents typically occurs within several weeks of treatment initiation. Based on this time course of action, we propose that optimal glycemic control can be attained within 180 days of treatment initiation by advancing antihyperglycemic therapy more rapidly than typical current practice. Our approach builds on current recommendations, though it seeks to redefine standard management of type 2 diabetes by placing greater emphasis on the timing of treatment intensification. We recommend the total period patients spend with uncontrolled hyperglycemia be minimized by shortening the number of steps along the treatment intensification ladder. This can be achieved by establishing combination therapy early in cases where baseline HbA1c levels are markedly elevated, including the prompt addition of basal insulin therapy when it becomes apparent that oral agents alone are unlikely to attain glycemic goals.
In light of the many possible treatment paths available for patients with type 2 diabetes, and the newer agents continually being developed, simple straightforward algorithms cannot replace the need for individualized management and clinical judgment. However, what we propose are some general principles for advancing therapy more rapidly to ensure more patients with type 2 diabetes reach recommended glycemic targets in a more timely fashion than is typical in today’s routine clinical practice. We suggest that, with the use of time course-directed therapy, most patients with type 2 diabetes should be able to attain reasonable glycemic control within the first 180 days of starting clinical care. Our approach builds on currently accepted recommendations but seeks to redefine standard management of type 2 diabetes by placing greater emphasis on the timing of treatment intensification. The total time patients spend with uncontrolled hyperglycemia should be reduced by initiating combination therapy, advancing the dosages of existing agents more aggressively, and quickly adding insulin therapy.
Regardless of the therapeutic agent chosen, more timely and aggressive intervention by health care providers can significantly improve glycemic control and long-term outcomes for many patients with type 2 diabetes. This can translate into reduced risk of kidney, nerve, and eyesight dysfunction, as well as cardiovascular diseases.