Clinicians treating patients with type 2 diabetes should take a patient-centered approach and put a greater emphasis on patient education, according to new guidelines outlined in a joint statement from American and European diabetes associations.
Silvio Inzucchi MD, an endocrinologist and director of the Yale Diabetes Center, was lead author of the guidelines for the American Diabetes Association and the European Association for the Study of Diabetes. The task force put in several years of planning, discussion and review before formulating the guidelines, which were published concurrently online in April in their journals, Diabetes Care and Diabetologia.
“It’s the first time that the notion of individualization of therapy took a front-and-center position in diabetes guidelines. Other guidelines have mentioned the fact that you need to take into account variability between patients, but we actually built our recommendations around this tenet,” says Dr. Inzucchi.
Pay attention to individual differences
The new guidelines are less prescriptive than those previously in place. They emphasize:
- Treatment based on individual patient needs, preferences and tolerances
- Acknowledgement of differences in age and disease progression
- The key role of diabetes education, in individual or group settings, focusing on dietary intervention and the importance of increased physical activity, as well as weight management, when appropriate
- Individualized treatment plans built around a patient’s specific symptoms, co-morbidities, disease duration, weight, racial/ethnic/gender differences and lifestyles
“The guidelines incorporate a couple of emerging concepts. The first is that blood sugar targets in patients aren’t ‘one-size-fits-all’. So physicians need to individualize the aggressiveness by which they approach each patient’s blood sugar levels,” Dr. Inzucchi said. Clinical trials over the past few years have shown that tight glucose control is not for everyone—one study showed there were increased mortality issues after aggressive treatment in older patients with underlying cardiovascular issues.
“The second concept has to do with individualizing not only of the glucose target, but also the strategy to achieve that target,” he says, explaining that new drugs have come out in the past several years with various capabilities, but there have been mounting concerns about their potential side effects.
Help patients make choices
“If there was a study that showed a clear benefit of one vs. another drug, that would end up in the guidelines,” Dr. Inzucchi says. “But that’s generally not what our review of the literature revealed.” Since diabetes medications are taken long term, he says patients themselves also need to play a greater role in making choices about their treatment. For instance, a patient who has gastrointestinal problems may want to avoid a long term medication that could cause gastric distress.
Dr. Inzucchi hopes that primary care providers will take special note of the guidelines, since they know their patients best and play a central role in treating the 26 million people who have diabetes. “I think it’s critical for all clinicians to make sure their patients are involved in their treatment decisions to the degree that they’d like to be involved. “If patients don’t buy into long-term decisions about chronic disease management, they may not take the medications on a regular basis, particularly if they experience side effects early on.
Geralyn Spollett, APRN, associate director of the Yale Diabetes Center, says, “The guidelines are much more supportive of primary care and in reality will offer more assistance to those MDs who see lots of patients with diabetes in determining medication choices. While the algorithms written in the past may have seemed more prescriptive, in fact, they were not.” Previous statements presented medication choices as being equal and provided limited guidance as to which drug may fit the patient best, she says.
Controversy over best treatment
Vivian Fonseca, MD, president, Medicine & Science of the American Diabetes Association, says that having a more patient-centered focus better reflects the reality of what happens when a patient seeks diabetes treatment.
“Diabetes is a complex disease that manifests differently in different people, and the best way for one person to manage it may not work for someone else. If we encourage people to work with their health care providers to find an individualized personal plan that works well for them and fits their lifestyle and personal needs, it has a higher chance for success in controlling glucose and decreasing the risk of long term complications,” he says.