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Goals of Treatment for Type 2 Diabetes Mellitus
Last Reviewed: September 28, 2010
DPP-4 and Its Inhibitors in Type 2 Diabetes
– Introduction/Short-Term Goals
– Long-Term Goals/Conclusion
– References
Release date: October 2010
Chapter 3
Chapter 4
Chapter 5
DPP-4 and Its Inhibitors in Type 2 Diabetes
Medical Writer: Lauren Cerruto
Editor-in-Chief: Alan J. Garber, MD, PhD
Introduction
There is clear need for more aggressive management of type 2 diabetes mellitus (T2DM), which accounts for 90% to 95% of all diabetes cases.1 Persons with diabetes are up to four times more likely to die of heart disease and up to four times more likely to have a stroke than people without diabetes.2 Diabetes is the number one cause of kidney failure and new cases of blindness.2 Up to 70% of patients with diabetes have nervous system damage, and diabetes accounts for more than 60% of nontraumatic lower-limb amputations.2 Persons with diabetes are about twice as likely to die as same-aged persons without diabetes.2 Furthermore, recent data show considerable room for improvement in achieving recommended treatment goals.3
Short-Term Goals
Early and aggressive glycemic control is the primary goal of diabetes management. Glycated hemoglobin A1c (HbA1c) should be maintained as close to normal as possible without inducing hypoglycemia.1 It should be noted that there is no true threshold for reduction of complications.4 Risk of complications increases continuously with increases in HbA1c.4 Every 1% reduction in HbA1c reduces the risk of diabetes-related death by 21%, the risk of myocardial infarction by 14%, and the risk of microvascular complications by 37% with no risk threshold found at any time point.4 That said, various organizations have established target glycemic levels (Table 1), although they recommend individualizing treatment goals for T2DM.1,5,6 Fueled by contradictory results from recent trials (ADVANCE, VADT, ACCORD, and the UKPDS 10-year follow-up), debate continues over the benefits of intensive glycemic control with regard to cardiovascular events and mortality.7,8 However, in Dr. Garber's opinion, clinicians should not be reluctant to pursue glycemic control because of presumed lack of benefit. He notes that the controversy is limited only to benefits with regard to cardiovascular risk reduction whereas benefits of glycemic control with regard to microvascular risk reduction have been established.
Table 1. Glycemic Target Levels
Pharmacologic therapy should be titrated and adjusted until all glycemic goals are met.1 If they are not met within 2 to 3 months, more intensive therapy should be initiated.1 Combination therapy is appropriate if patients do not reach their goals on monotherapy or if attainment of target HbA1c levels with monotherapy is considered unlikely based on baseline level. The AACE algorithm can help guide treatment adjustments.
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