Implementing intensified treatment strategies for patients with type 2 diabetes mellitus.(Report)

Primary care physicians play central roles in the management of patients with diabetes, providing care for approximately 90% to 95% of adult patients with type 2 diabetes mellitus (DM). (1) Treatment goals are well established, although treatment guidelines continue to evolve in response to new evidence and advances in therapy. Clinicians face significant challenges in managing this multi-faceted and complex disease. Less than 12% of diagnosed patients reach treatment goals for blood glucose, cholesterol, and blood pressure (BP). (2)

Treatment typically begins with the use of single-agent pharmacotherapy in conjunction with lifestyle modifications. As the disease progresses, other pharmacologic agents are added as treatment is intensified to achieve target goals. This CME activity examines the clinical uncertainties resulting from disease progression and provides recommendations for the long-term management of patients with type 2 DM.

 
   PATIENT CASE Eric, age 45 years, presents 
   to his family physician, Dr Moore, for his first routine 
   examination in 7 years. Eric would not have 
   scheduled this visit had his wife not insisted that 
   he discuss his 8-1b weight gain over the past year 
   and seek prompt initiation of an exercise regimen. 
   Eric notes that he wakes nightly to urinate and 
   asks if this is normal. Family history is notable for 
   a brother with type 2 DM. 
 
   Physical examination reveals Eric is 5 
   feet, 9 inches tall and weighs 180 lb, with 
   a body mass index (BMI) of 26.6 kg/[m.sup.2]. 
   His blood pressure (BP) is 138/88 mm Hg. 
   Other than the somewhat overweight body 
   habitus, ophthalmologic, neck, cardiovascular, 
   abdominal, extremity/skin, and neurologic 
   examination results are normal. 
 
   Because of Eric's age, reported 
   inactivity, and slightly elevated BMI and 
   BP, laboratory work is ordered. Results 
   show several abnormalities: fasting glucose 
   (FG) of 165 mg/dL; high-density 
   lipoprotein cholesterol (HDL-C), 45 mg/ 
   dL; low-density lipoprotein cholesterol 
   (LDL-C), 110 mg/dL; total cholesterol 
   (TC), 189 mg/dL; triglycerides (TG), 170 
   mg/dL; creatinine, 0.9 mg/dL; urinalysis, 
   no albumin and trace glucose; and electrocardiogram, 
   normal. Repeat FG is 162 
   mg/dL. Dr Moore orders a glycosylated 
   hemoglobin test (A1C), which shows a 
   level of 7.8%. 

Issues for clinicians

Eric's infrequent medical care history-not uncommon for men in his age group-presents an additional treatment issue. Aggressive blood glucose regulation is essential to prevent diabetes complication; normalization of blood glucose is the cornerstone of disease management. The goal for every patient is to normalize AIC levels to less than 7% within 3 months while avoiding hypoglycemia, particularly severe hypoglycemia. (3)

Type 2 DM is a well-recognized consequence of insulin resistance and its resultant syndrome, with other components that include hypertension, hyperlipidemia, and obesity. Clearly, it is of vital importance to address a patient's weight, BP, LDL-C, HDL-C, and triglycerides.

Importance of glycemic control

Issues of glycemic control dictate future treatment and outcomes for every patient with diabetes.

An FG level greater than 140 mg/dL (7.8 retool/L) increases the risk for complications such as diabetic retinopathy. (4) Strict glycemic control reduces risk for microvascular (retinopathy, nephropathy, and neuropathy) and macrovascular (myocardial infarction [MI] and stroke) complications. (5,6)

Current American Diabetes Association (ADA) recommendations (TABLE 1) for glycemic control feature an AIC goal of less than 7% for patients in general and an A1C as close to normal (less than 6%) for the individual patient. (7) In the United Kingdom Prospective Diabetes Study (UKPDS), each 1% reduction in AIC level was associated with a decreased risk of 37% for microvascular disease, 14 % for MI, 21% for diabetes-related deaths, and 14% for all-cause mortality. (6) The current and growing impact of type 2 DM in the United States is summarized in TABLE 2.

Glycemic control: A long-term challenge

Lifestyle modification remains the mainstay of diabetes treatment and prevention, although diet and exercise alone often do not succeed long-term. The UKPDS showed that, despite an intensive 3-month dietary program, excellent glycemic control (FG, [less than or equal to] 108 mg/dL) was achieved by only 16% of participants. (8)

Additional interventions will likely be required over time; normoglycemia may be achievable only with early use of pharmacologic agents. The ADA recommends initiating treatment with lifestyle management and metformin. (7) The American Association of Clinical Endocrinologists (AACE) recommends lifestyle management and combination pharmacologic treatment when a patient has an AIC level of 7% to 8%. (3)

Even at an early stage, the progressive nature of…