Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy
A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes
- David M. Nathan, MD1,
- John B. Buse, MD, PHD2,
- Mayer B. Davidson, MD3,
- Robert J. Heine, MD4,
- Rury R. Holman, FRCP5,
- Robert Sherwin, MD6 and
- Bernard Zinman, MD7
- 1Diabetes Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- 2University of North Carolina School of Medicine, Chapel Hill, North Carolina
- 3Clinical Trials Unit, Charles R. Drew University, Los Angeles, California
- 4Diabetes Center, VU University Medical Center, Amsterdam, the Netherlands
- 5Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University, Oxford, U.K.
- 6Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
- 7Departments of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Canada
- Address correspondence and reprint requests to David M. Nathan, MD, Diabetes Center, Massachusetts General Hospital, Boston, MA 02114. E-mail: dnathan{at}partners.org
- CVD, cardiovascular disease
- DCCT, Diabetes Control and Complications Trial
- GLP-1, glucagon-like peptide 1
- SMBG, self-monitoring of blood glucose
- TZD, thiazolidinedione
- UKPDS, U.K. Prospective Diabetes Study
The epidemic of type 2 diabetes in the latter part of the 20th and in the early 21st century, and the recognition that achieving specific glycemic goals can substantially reduce morbidity, have made the effective treatment of hyperglycemia a top priority (1–3). While the management of hyperglycemia, the hallmark metabolic abnormality associated with type 2 diabetes, has historically had center stage in the treatment of diabetes, therapies directed at other coincident features, such as dyslipidemia, hypertension, hypercoagulability, obesity, and insulin resistance, have also been a major focus of research and therapy. Maintaining glycemic levels as close to the nondiabetic range as possible has been demonstrated to have a powerful beneficial impact on diabetes-specific complications, including retinopathy, nephropathy, and neuropathy in the setting of type 1 diabetes (4,5); in type 2 diabetes, more intensive treatment strategies have likewise been demonstrated to reduce complications (6–8). Intensive glycemic management resulting in lower HbA1c (A1C) levels has also been shown to have a beneficial effect on cardiovascular disease (CVD) complications in type 1 diabetes (9,10); however, the role of intensive diabetes therapy on CVD in type 2 diabetes remains under active investigation (11,12). Some therapies directed at lowering glucose levels have additional benefits with regard to CVD risk factors, while others lower glucose without additional benefits.
The development of new classes of blood glucose–lowering medications to supplement the older therapies, such as lifestyle-directed interventions, insulin, sulfonylureas, and metformin, has increased the treatment options for type 2 diabetes. Whether used alone or in combination with other blood glucose–lowering interventions, the availability of the newer agents has provided an increased number of choices for practitioners and patients and heightened uncertainty regarding the most appropriate means of treating this widespread disease. Although numerous reviews on the …
