Tailoring treatment to the individual in type 2 diabetes practical guidance from theGlobal Partnership for Effective Diabetes Management

Abstract

Good glycaemic control continues to be the most effective therapeutic manoeuvre to reduce the risk of development and/or progression of microvascular disease, and therefore remains the cornerstone of diabetes management despite recent scepticism about tight glucose control strategies. The impact on macrovascular complications is still a matter of debate, and so glycaemic control strategies should be placed in the context of multifactorial intervention to address all cardiovascular risk factors. Approaches to achieve glycaemic targets should always ensure patient safety, and results from recent landmark outcome studies support the need for appropriate individualisation of glycaemic targets and of the means to achieve these targets, with the ultimate aim to optimise outcomes and minimise adverse events, such as hypoglycaemia and marked weight gain. The primary goal of the Global Partnership for Effective Diabetes Management is the provision of practical guidance to improve patient outcomes and, in this article, we aim to support healthcare professionals in appropriately tailoring type 2 diabetes treatment to the individual. Patient groups requiring special consideration are identified, including newly diagnosed individuals with type 2 diabetes but no complications, individuals with a history of inadequate glycaemic control, those with a history of cardiovascular disease, children and individuals at risk of hypoglycaemia. Practical guidance specific to each group is provided.

Individualized glycaemic targets and pharmacotherapy in type 2 diabetes

“…7 The study duration of these trials (3.5-5.6 years) may have been too short for any significant benefits of tight glycaemic control on CV outcomes to become apparent (as opposed to the 10-year follow-up in the UKPDS). 16 Furthermore, the patients enrolled in the shortterm studies had a history of poorly controlled long-standing Table 1.…”

“…diabetes together with either micro-or macrovascular complications, [13][14][15] and were therefore at higher risk of negative outcomes than their counterparts in the UKPDS (newly diagnosed patients with no prior CV events). 7 A meta-analysis of the UKPDS, Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROactive), ADVANCE, ACCORD and VADT studies found that intensive therapy achieving a modest 0.9% (10 mmol/mol) reduction in HbA 1c was associated with a 17% reduction in non-fatal MI and a 15% reduction in coronary heart disease (CHD) compared with conventional therapy. 17 Further meta-analyses have also evaluated the effectiveness of good glycaemic control in preventing or delaying the onset of macrovascular complications and provide potential explanations for the lack of apparent benefits seen in landmark trials.…”

“…7 An additional consideration in this patient population is the impact of pharmacological therapies on weight, with sulphonylureas (SUs), thiazolidinediones (TZDs) and insulin associated with weight gain, 8 whereas weight neutral agents or those associated with weight loss 8 would appear more preferable. 24 Practical guidance for newly diagnosed overweight or obese individuals • Implement a multifactorial management plan, including diet and lifestyle intervention to achieve a healthy weight, and appropriate treatment to combat CV risk factors such as dyslipidaemia and hypertension.…”

“…Whereas trials have consistently reported a reduction in microvascular complications with intensive glycaemic control, 2-6 a reduction in macrovascular complications with this approach remains the subject of debate. 7 A main outcome of such a discussion is the appreciation that a 'one-size-fits-all' strategy for managing type 2 diabetes will not provide a great deal of treatment success. Such an approach does not take into consideration the heterogeneity of the patient population (i.e.…”

Treatment urgency: The importance of getting people with type 2 diabetes to target promptly

“…Although the benefits of intensive and early glycemic control are well-documented [20,21], current management of glycemia is suboptimal and not enough people achieve their glucose targets [22]. In fact, as few as 25% of patients achieve their blood glucose goals in some T2DM populations [23] while an analysis from the USA showed that 35% of individuals were not reaching personalized goals [24].…”