Groups Call for ‘Uncompromising’ Diabetes Care

Get them to target and keep them there! ADA is calling for the use of the Fasting Blood Glucose for Diagnosis and the AACE is calling for the Oral Glucose Tolerance Test.

Diabetes must be managed with an “uncompromising insistence to treat to target,” according to new guidelines issued by the American College of Endocrinology and the American Association of Clinical Endocrinologists.

The document is aimed at putting a stop to the common practice of letting diabetic patients languish for months or even years with high hemoglobin A1c levels before stepping up therapy. It also places increased emphasis on postprandial glucose values in addition to fasting levels, and on the use of combination therapy along with lifestyle intervention.

Treatment targets—a hemoglobin A1c value of 6.5% or less (lower than the target of less than 7% recommended by the American Diabetes Association), fasting/preprandial glucose levels less than 110 mg/dL, and 2-hour postprandial glucose less than 140 mg/dL—were first issues by the AACE in 2002 (Endocr. Pract. 2002;8[suppl. 1]:40-82).

“We prefer to get them to target from day 1 and keep them there,” Jaime A. Davidson, M.D., an endocrinologist at the University of Texas, Dallas, said at a press briefing following a 2-day consensus conference.

Given recent data suggesting that postprandial glucose values may begin to rise sooner than fasting glucose in the evolution of diabetes, the AACE panel also recommended that the diagnosis of diabetes be made with a 2-hour oral glucose tolerance test (OGTT) in individuals at high risk, rather than with an initial fasting blood sugar screen. Conference co-organizer Paul S. Jellinger, M.D., acknowledged that this might be somewhat controversial. But “finding a normal [fasting] blood sugar in a high-risk individual or even impaired fasting glucose (100-110 mg/dL) will miss many patients,” explained Dr. Jellinger, president of the American College of Endocrinology.

The American Diabetes Association disagrees. The ADA’s expert committee discussed this issue at its meeting prior to the publication of its own report, which lowered the normal fasting blood glucose from 110 mg/dL to 100 mg/dL (Diabetes Care 2005;28[suppl. 1]:S37-S42). “They continue to feel that the best first test is the fasting. The 2-hour OGTT should be used if a question remains after getting the fasting,” Nathaniel G. Clark, M.D., national vice president of clinical affairs for the ADA, told this newpaper.

But experts do agree that significant cardiovascular disease develops years before the onset of diabetes and is strongly associated with hyperglycemia.

The landmark U.K. Prospective Diabetes Study was among the first to link reductions in hemoglobin A1c with a lower risk of cardiovascular end points (BMJ 2000;321:405-12), and a large metaanalysis showed that the progressive relationship between glucose levels and cardiovascular risk extends even below the diabetic threshold (Diabetes Care 1999;22:233-40).

“If we don’t diagnose early and treat to target, we miss an important opportunity to prevent complications later in life,” said Dr. Davidson, who chaired the AACE conference.

Data also show that prevention of diabetes is possible in people identified with impaired glucose tolerance (IGT). In both the U.S. Diabetes Prevention Program (N. Engl. J. Med. 2002;346;393-403) and the Finnish Diabetes Intervention study (N. Engl. J. Med. 2001;344;1343-50) lifestyle intervention led to a 58% reduction in the progression of IGT to type 2 diabetes.
Pharmacologic therapy—including metformin, acarbose, troglitazone, and orlistat—also has been shown to reduce the risk of progression to diabetes. Of those drugs, only orlistat is approved for the prevention of type 2 diabetes.

Although the AACE does not advocate the off-label use of the other agents, the new guidelines note that in at least one of the studies, the STOP-NIDDM, the reduction of postprandial glucose levels with acarbose significantly reduced the incidence of cardiovascular events in addition to delaying the progression of IGT to diabetes (Lancet 2002;359;2072).

The STOP-NIDDM trial was one of several pointing to the importance of postprandial glucose values, which have until recently received less attention than fasting glucose. Data such as those from a recent French study suggest that postprandial glucose tends to be elevated early on in the disease, whereas fasting hyperglycemia increases gradually with worsening of diabetes (Diabetes Care 2003;26:881-5).
In a subanalysis of the STOP-NIDDM trial, acarbose slowed the progression of intimal-medial thickness in subjects with IGT, the first placebo-controlled, prospective study to show that counterbalancing of postprandial hyperglycemia may be vasoprotective (Stroke 2004;35:1073-8).

The guidelines cite the current “fragmented” health care delivery system as a major contributor to suboptimal care, and point to more optimal chronic care models. The International Diabetes Center in Minneapolis, for example, has developed a diabetes group education system that has been shown to be as effective as one-on-one counseling and to achieve significant cost savings.
Another model in which diabetes educators are based in primary care practices in Western Pennsylvania has also shown positive early outcomes. (See below .)

Later this year, the AACE plans to develop a “road map” for clinicians, to be available at the organization’s Web site (www.aace.com). Among information sources listed is www.betterdiabetescare.nih.gov, designed to help health care professionals in their practices.

Consensus Panel Recommendations

Detect and treat impaired glucose tolerance for the purpose of preventing type 2 diabetes and potentially reducing cardiovascular disease.

• Utilize currently recognized profiles to identify patients at risk for type 2 diabetes, and perform a 2-hour oral glucose tolerance test.
• Promptly start education and appropriate therapy for risk reductions.

Adopt an uncompromising “treat-to-target” approach to achieve and maintain glycemic goals in patients with diabetes.

• Initiate early treatment and persistent titration to safely achieve and maintain glycemic targets in patients with diabetes.
• Address postprandial glucose as well as fasting glucose levels to safely achieve target HbA1c.
• Minimize glucose excursions throughout the 24-hour period.
• Utilize therapy that is physiologic to address multiple defects.
• Combine pharmacologic treatment with medical nutrition therapy and other lifestyle intervention as initial therapy when appropriate.

Promote tools for self-management.

• Allocate necessary resources to support the provision of patient-centered, team care.
• Provide diabetes education.
• Use self-monitoring of blood glucose to support therapeutic decisions and enhance patient education.
• Support a chronic care model in the treatment of diabetes.

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