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Management of hyperglycemia in type 2 diabetes - a patient-centered approach - position statement of the ADA and EASD
Glycemic management in type 2 diabetes mellitus has become increasingly complex and, to some extent, controversial, with a widening array of pharmacological agents now available, mounting concerns about their potential adverse effects and new uncertainties regarding the benefits of intensive glycemic control on macrovascular complications. Many clinicians are therefore perplexed as to the optimal strategies for their patients.
As a consequence, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a joint task force to examine the evidence and develop recommendations for antihyperglycemic therapy in nonpregnant adults with type 2 diabetes. Several guideline documents have been developed by members of these two organizations and by other societies and federations. However, an update was deemed necessary because of contemporary information on the benefits/risks of glycemic control, recent evidence concerning efficacy and safety of several new drug classes, the withdrawal/restriction of others, and increasing calls for a move toward more patient-centered care.
American Association of Clinical Endocrinologists’ Comprehensive Diabetes Management Algorithm 2013
This new algorithm for the comprehensive manage- ment of persons with type 2 diabetes mellitus (T2DM) has been developed to provide clinicians with a practical guide that considers the whole patient, the spectrum of risks and complications for the patient, and evidence-based approaches to treatment. In addition to advocating for gly- cemic control so as to reduce microvascular complications, this document focuses on obesity and prediabetes as the underlying risk factors for diabetes and associated macro- vascular complications.
Estão estas inovações terapêuticas ao dispor dos diabéticos portugueses? A resposta é sim e não. Segundo o Observatório da Diabetes 2015 a prevalência da diabetes é de 13,1% da população portuguesa (20-70 anos) dos quais 5,7% não sabem que são diabéticos. A diabetes tipo 1 é o tipo menos frequente de diabetes mas atinge pessoas em idades mais frágeis (crianças e adolescentes), e obriga à administração diária de várias injecções de insulina para toda a vida. A diabetes tipo 2 é mais comum em pessoas adultas e obesas e o tratamento inicial é emagrecer e antidiabéticos orais.
Diabetes mellitus is a complex, chronic illness requiring continuous medical care with multifactorial risk reduction strategies beyond glycemic control. Ongoing patient self-management education and support are critical to preventing acute complications and reducing the risk of long-term complications. Significant evidence exists that supports a range of interventions to improve diabetes outcomes.
The Standards of Care recommendations are not intended to preclude clinical judgment and must be applied in the context of excellent clinical care and with adjustments for individual preferences, comorbidities, and other patient factors.
Nonnutritive sweeteners - current use and health perspectives - a scientific statement from the AHA and ADA
By definition, NNS, otherwise referred to as very low-calorie sweeteners, artificial sweeteners, noncaloric sweeteners, and intense sweeteners, have a higher intensity of sweetness per gram than caloric sweeteners such as sucrose, corn syrups, and fruit juice concentrates. As a caloric sweetener replacement, they are added in smaller quantities; hence, they provide no or few calories. In our current food supply, NNS are widely used in thousands of beverages and other food products such as diet soft drinks, yogurts, desserts, and gum.
The present statement from the American Heart Association and the American Diabetes Association addresses the potential role of nonnutritive sweeteners (NNS) in helping Americans to adhere to this recommendation in the context of current usage and health perspectives. he focus of the statement is on the 6 NNS: aspartame, acesulfame-K, neotame, saccharin, sucralose and stevia.
Management of hyperglycemia in hospitalized patients in non-critical care setting - an endocrine society clinical practice guideline
Hyperglycemia is a common, serious, and costly health care problem in hospitalized patients. Observational and randomized controlled studies indicate that improvement in glycemic control results in lower rates of hospital complications in general medicine and surgery patients. Implementing a standardized sc insulin order set promoting the use of scheduled basal and nutritional insulin therapy is a key intervention in the inpatient management of diabetes. We provide recommendations for practical, achievable, and safe glycemic targets and describe protocols, procedures, and system improvements required to facilitate the achievement of glycemic goals in patients with hyperglycemia and diabetes admitted in non-critical care settings.
Continuous glucose monitoring - an Endocrine Society clinical practice guideline
he Task Force evaluated three potential uses of CGM: 1) real-time CGM in adult hospital settings; 2) real-time CGM in children and adolescent outpatients; and 3) real-time CGM in adult outpatients. The Task Force used the best available data to develop evidence-based rec- ommendations about where CGM can be beneficial in maintaining target levels of glycemia and limiting the risk of hypoglycemia. Both strength of recommendations and quality of evidence were accounted for in the guidelines.
AACE medical guidelines for developing a diabetes mellitus comprehensive care plan
This CPG will complement and extend existing CPGs available in the literature, as well as previously pub- lished American Association of Clinical Endocrinologists DM CPGs. When a routine consultation is made for DM management, these new guidelines advocate that a comprehensive approach is taken and suggest that the clinician should move beyond a simple focus on glycemic control. This comprehensive approach is based on the evi- dence that although glycemic control parameters (hemoglobin A1c, postprandial glucose excursions, fasting plasma glucose, glycemic variability) have an impact on cardiovascular disease risk, mortality, and quality of life, other factors also affect clinical out- comes in persons with DM.These are clinical practice guidelines for developing a diabetes mellitus comprehensive care plan. The mandate for this CPG is to provide a practical guide for comprehensive care that incorporates an integrated consideration of microvascular and macrovascular risk rather than an isolated approach focusing merely on glycemic control.
Statement by the AACE Consensus Panel on continuous glucose monitoring
￼daysT.Over the past 10 years, continuous glucose monitoring (CGM) has evolved from being a research tool to a device useful in daily clinical practice. Designed to successfully improve glucose control without the addition of medica- tion, CGM provides information about glucose concentration, direction, and rate of change over a period of several days.
Statement by the AACE Consensus Panel on insulin pump management
Insulin pumps have come of age. With their prolifera- tion in medical practices, some guidance is necessary for prospective and current prescribers to ensure their optimal and safe use. This document summarizes the current state- of-the-art of continuous subcutaneous insulin delivery available to patients requiring intensive insulin manage- ment to control their diabetes mellitus. Appropriate patient selection is critical and must be followed by thorough as- sessment of their knowledge of diabetes management prin- ciples. Likewise, selection of a provider is critical and only those whose practice can assume full responsibility for the comprehensive pump management program should offer it. Patient diabetes education and a pump training plan must be implemented by a multidisciplinary team under direction of an experienced endocrinologist/diabetologist to address gaps in patient knowledge. The importance of periodic reevaluation and retraining is stressed. Physicians prescribing insulin pumps for their patients should have a round-the-clock system in place to answer patients’ con- cerns about pump problems.
2010 consensus statement on the worldwide standardization of the hemoglobin A1C measurement
Glycated hemoglobin concentrations (most commonly hemoglobin A1C; HbA1c) reflect time-averaged blood glucose during the previous 2–3 months and are used as the gold standard for long-term follow-up of glycemic control. Standardization with common calibration was first proposed in 1984. It was only after the publication of the Diabetes Control and Complications Trial (DCCT) study in 1993, however, that the issue of international standardization of HbA1c measurements became an important objective for scientists and clinicians.
AACE Statement on the Use of Hemoglobin A1c for the Diagnosis of Diabetes
The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) have evaluated the role of hemoglobin A1c (A1C) for the diagnosis of type 2 diabetes (diabetes). The American Diabetes Association 2010 Clinical Practice Recommendations endorse the use of A1C of 6.5% or higher as the primary criterion for the diagnosis of diabetes. The rationale for the use of A1C for diagnosis of diabetes is based on data showing that retinopathy occurs in individuals with an A1C ≥6.5% at approximately the same rate as in individuals who are diagnosed on the basis of the current fasting and postchallenge glucose criteria. A 10% risk for retinopathy has historically served as the benchmark for diagnosing the presence of diabetes.
Hyperglycemic crises in adult patients with diabetes
Diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS) are the two most serious acute metabolic complications of diabetes. DKA is responsible for more than 500,000 hospital days per year at an estimated annual direct medical expense and indirect cost of 2.4 billion USD. The triad of uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketone concentration characterizes DKA. HHS is characterized by severe hyperglycemia, hyperosmolality, and dehydration in the absence of significant ketoacidosis. These metabolic derangements result from the combination of absolute or relative insulin deficiency and an increase in counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). Most patients with DKA have autoimmune type 1 diabetes; however, patients with type 2 diabetes are also at risk during the catabolic stress of acute illness such as trauma, surgery, or infections. This consensus statement will outline precipitating factors and recommendations for the diagnosis, treatment, and prevention of DKA and HHS in adult subjects.
American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control
People with diabetes are more likely to be hospitalized and to have longer durations of hospital stay than those without diabetes. A recent survey estimated that 22% of all hospital inpatient days were incurred by people with diabetes.
There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes. Cohort studies as well as a few early randomized controlled trials suggested that intensive treatment of hyperglycemia improved hospital outcomes.
Intensive glycemic control and the prevention of cardiovascular events - implications of the ACCORD, ADVANCE, and VA diabetes trials
Diabetes is defined by its association with hyperglycemia-specific microvascular complications; however, it also imparts a two- to fourfold risk of cardiovascular disease. Although microvascular complications can lead to significant morbidity and premature mortality, by far the greatest cause of death in people with diabetes is CVD.
Because of ongoing uncertainty regarding whether intensive glycemic control can reduce the increased risk of CVD in people with type 2 diabetes, several large long-term trials were launched in the past decade to compare the effects of intensive versus standard glycemic control on CVD outcomes in relatively high-risk participants with established type 2 diabetes. In 2008, two of these trials, ADVANCE and VADT, were completed and showed no significant reduction in cardiovascular outcomes with intensive glycemic control. A third trial, ACCORD, terminated its glycemic control study early due to the finding of increased mortality in participants randomized to a strategy of very intensive glycemic control with a target A1C of <6%. The findings of these three major trials led the ADA, with representatives of the American Heart Association (AHA) and the American College of Cardiology (ACC), to reexamine the recommendations for glycemic targets in patients with diabetes, the majority of whom have type 2 diabetes.
American College of Endocrinology position statement on the insulin resistance syndrome
The clinical consequences of insulin resistance and compensatory hyperinsulinemia, the Insulin Resistance Syndrome, are increasingly appreciated as posing a major public health problem. Currently recognized clinical man- ifestations of the Insulin Resistance Syndrome include atherosclerotic cardiovascular disease (CVD), hyperten- sion, polycystic ovary syndrome (PCOS), and nonalco- holic steatohepatitis, and the list continues to expand. Despite the recognition of the importance of this syn- drome, identifying individuals who have the Insulin Resistance Syndrome is difficult, as there is no simple clinically available test to diagnose it. Our task force was created by AACE and the American College of Endocrinology (ACE) to work toward this consensus and so to provide guidance to clinicians and the many others involved in and affected by the Insulin Resistance Syndrome. This is an area in rapid evolution, so progress will consist of many small incremental steps, of which the efforts of our task force are but one.