Treating type 2 diabetes: Targeting the causative factors
Successful combinations. The combination of sulfonylurea and metformin has proven effective in many studies.22,51,52 One study showed that initial treatment with glyburide/metformin improved glycemic control better than either glyburide or metformin monotherapy (SOR: A).53,54 The addition of the non-SU secretagogues repaglinide and nateglinide to metformin significantly improved glycemic control, with repaglinide showing superiority over nateglinide.55 A TZD added to a sulfonylurea has also significantly improved A1c and fasting blood sugar results.56 Patients whose diabetes was inadequately controlled with diet alone or diet plus a sulfonylurea showed improvement with the addition of the AGI miglitol, compared with addition of placebo.57 The AGI acarbose has shown to be an effective addition to diet, metformin, sulfonylurea, and insulin.58 A TZD added to metformin has also been shown to improve glycemic control.59 A non-SU added to patients inadequately controlled with a TZD has also been effective.60
The early addition of insulin when maximal sulfonylurea therapy is inadequate has been effective.61-63 When introducing insulin, a nighttime regimen of NPH or glargine, 10 units at bedtime, is an appropriate dose (SOR: C). This is easier and less costly than often assumed, and helps improve glycemic control.64 Most patients require combination therapy as their disease progresses.39
FIGURE 3
Glycemic control in type 2 DM
Improving Outcomes
Cumulative survey data reveal a wide gap between guideline recommendations and the care patients receive.65 One study showed that physicians initiated treatment changes only after the A1c level had reached 9.0% or higher instead of the 8.0% level recommended by ADA.66 How can the quality of management be improved?
In private practices and institutions, many interventions have been shown to improve outcomes in diabetes mellitus. Education measures work, and they include chart audits, reminder cards, pharmacist collaboration, flow sheets, and nursing initiatives.67,68 Effective disease-management programs have also used clinical guidelines, outcomes reporting, coverage of glucose meters and strips, and the support of clinical leadership.69
Computerized systems that track patients and recommended laboratory tests have improved screening rates and glycemic and blood pressure control.70 Monitoring patients’ readiness to change has allowed targeted education to improve A1c levels.71 Continuity of care has also improved the quality of disease control by increasing adherence to recommended tests and exams.72
Acknowlegments
The authors thank Marie Hamer, RN, for her continuous diabetes quality improvement efforts and Jean Camarata for her editorial and reference acquisition assistance.
Corresponding author
John E. Sutherland, MD, Northeast Iowa Family Practice Residency Program, University of Iowa College of Medicine, 2055 Kimball Avenue, Waterloo, Iowa 50702. E-mail: jsutherl@neimef.org.
