Diabetes treatment algorithm sets goals, time limits



A new evidence-based diabetes management algorithm looks at the disease from a holistic view, tailoring a treatment plan to fit each patient’s comorbid risks and treatment goals.

The algorithm, a project of the American Association of Clinical Endocrinologists, highlights obesity as a crucial factor in both diabetes prevention and treatment. Weight management should be an integral part of an overall plan designed to reduce morbidity, mortality, and disability in the majority of patients with type 2 diabetes who are obese, according to a document published in the March/April issue of Endocrine Practice (2012;19:327-36).

Dr. George Grunberger

"This is something that’s never been done before," said Dr. George Grunberger, a member of the task force that formulated the document and founder of the Grunberger Diabetes Institute, Bloomfield Hills, Mich. "It’s a totally different concept that looks at all aspects of diabetes. We now know that treating diabetes doesn’t just mean treating blood sugar. It means looking at nutrition, obesity, and cardiovascular risk factors as a whole."

The algorithm still uses 6.5% or lower as the cutoff point for hemoglobin A1c in patients who are otherwise healthy. But that goal can be individualized at higher numbers for those with concurrent illness and who are at risk for hypoglycemia.

Another new facet of the document is its prioritization of drug choices, Dr. Grunberger said in an interview. "What we did that is different, and maybe controversial, is to indicate to clinicians and patients some kind of order of preference," in drug therapy. "One problem with the previous algorithms has been that all the drugs are listed, but there’s no advice on which one to pick when. Good pharmacotherapy isn’t just an accident. There is an order of preference."

Organized in a colorful graphic, the algorithm indicates drug preference in the familiar stepwise manner, beginning with the lowest-risk drugs – metformin and acarbose – for prediabetes, moving on to combinations and drugs with a higher side effect profile as needed, until the patient reaches a predetermined blood sugar goal.

The algorithm is time bound as well, Dr. Grunberger noted. "Clinical inertia is a big problem in diabetes treatment. We tend to get to one treatment step and then not move, so that years later, a patient is still taking the same drug and not at goal. These steps have specific time limits of 2 or 3 months. If by that time you haven’t made progress, then it’s on to the next step."

The basic glycemic control algorithm, for example, begins with lifestyle modifications for everyone. The initial medication choices are stratified by HbA1c at entry – less than or greater than 7.5%, and greater than 9.0%. Each treatment path starts with drugs usually deemed safest. The algorithm recommends specific drug combinations as treatment intensifies. Each pathway has a 3-month window to explore the regimen’s effect. If that time expires without reaching the HbA1c goal, then the algorithm moves the patient to the next treatment level.

Unsuccessful triple therapy, or entry with an HbA1c of more than 9%, calls for basal insulin. Again, the algorithm specifies the order of treatment based on glucose levels. For a level of less than 8%, it calls for a total daily insulin dosage of 0.1-0.2 U/kg. For a blood sugar above 8%, the dosage is 0.2-0.3 U/kg. Both dosages should be titrated every 2-3 days to reach the glycemic goal. If the goal isn’t met, the algorithm moves on to prandial insulin at a total daily dosage of 0.3-0.5 U/kg.

Obesity management is a foundation treatment for all patients who are overweight. It starts with lifestyle modification, then moves through pharmacologic treatment and finally into surgical options.

The algorithm also tackles cardiovascular risk reduction, including lipid and blood pressure management, Dr. Grunberger said.

"An obese patient with dyslipidemia, high blood pressure, and diabetes is a ticking time bomb. All of these things need to be considered and treated together."

Dr. Grunberger is on the speakers board and scientific advisory panels for several pharmaceutical companies that manufacture diabetes treatment medications. He has also received research grants from a number of these companies.

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