New 2012 ADA/EASD Hyperglycemia Management Guidelines

by Ann Valtez, MD

QUESTION: Dear sir/maam:

What is the new ADA Guidelines 2012? Thanks!

Yours,
Ann Valdez, MD


ANSWER: Hi Dr.Ann,

For this year (2012), the recommendations of the American Diabetes Association (ADA) are released in collaboration with the European Association of the Study of Diabetes (EASD).

The emphasis is put in the “patient-specific treatment of hyperglycemia in type 2 Diabetics” as there are many factors that complicate the management of type 2 diabetes, such as the wide variety and amounts of medicines, their potential adverse effects, and doubts on the effectiveness of intensive glycemic control on macrovascular complications.

Therefore, 7% is the new goal of HbA1c that should generally consider. However, as for the last guidelines, different patients should set their individual goal.

For example, higher goal should be set for the patients with advanced cardiovascular disease, reduced life expectancy, and multiple medical problems. In contrary, lower goal is set for the newly diagnosed patients who are also very motivated.

Multiple drug therapy is also encouraged while treating diabetics, like adding dipeptidyl peptidase-4 (DPP4) to the existing diabetic therapy.

In continuity to the last guidelines, doctors are recommended to treat their diabetic patients according to their individual needs rather then following defined prescript algorithms.

Moreover, patient tolerances, preferences, age, disease course, comorbid conditions, weight, race/ethnicity, sex and/or lifestyle have to be considered too (i.e. a patient-centered-management).

The very first start has to be with metformin and a follow-up of 3 months. If the goal is not set, the changes in therapy should be according to the patient specific factors.

Let’s say, we want the patient to start injection therapy; but the patient does not collaborate. Therefore, another therapy should be considered.

In addition, an important emphasis is put on the education of each diabetic individually or in groups; where dietary intervention, a good weight management and the crucial role of enhanced physical should be highlighted.

The following are some Key Points of the new ADA/EASD recommendations for 2012:

- Specific patients should have individualized glycemic targets and treatments to lower glucose according to their specific characteristics.

- Each type 2 diabetes treatment program is based on diet, exercise and education.

- Where there is no contraindication, Metformin is the first-line drug of choice.

- With regards to other hypoglycemiants, data are still

limited. A combination therapy with 1 to 2 additional oral or injectable agents has to be considered when obtaining as less side effects as possible.

- Ultimately, and only ultimately, insulin monotherapy of in combination with other hypoglycemiants is needed to maintain glycemic control.

- Patient participation in all treatment decisions is highly encouraged, addressing their preferences, needs, and values.

- Reducing cardiovascular risk should be the major treatment goal.

You can have the full article reported at the online edition of Diabetes Care and in Diabetologia on April 19th.

All the best!

Dr.Alba



QUESTION: Dear Doctor,

What is dipeptidyl peptidase-4 (DPP4)and which are the branded products which contain it?

With Regards

V.S.Prasad


ANSWER: Hi Prasad,

Dipeptidyl peptidase-4 (DPP4) inhibitors is a new group of diabetes medications. Dipeptidyl peptidase-4 is an enzyme encoded by the DPP4 genes and plays an important role in degradation of incretin.

Incretin, on the other hand, are those hormones of the gastro-intestinal tract that enhance the secretion of insulin from pancreas after eating before sugar is elevated in the bloodstream.

As you can see, when the DPP4-inhibitors inhibits this enzyme, they indirectly inhibit the degradation of incretin; leading to increased incretin; higher insulin levels and lower blood sugar levels.

In other words, fasting and post-prandial glucose levels are reduced, resulting in a good control of diabetes.

Although it sounds so perfect for diabetics; however, the use of such drugs have been shown to be related to increased infection risk and/or other immune problems.

This is because incretin is a kind of protein residing in many other body cells, including those of immune system. When DPP4-inhibitors are used, the degradation of incretin in all body sites is inhibited.

You can imagine the consequences by yourself!

Next, with regards to the brands available in the market, the most common DPP4-inhibitors used include: sitagliptin, vildagliptin, and saxagliptin.

At the end, all this info is not to confound you; but to make you realize the importance of taking the drugs only when your doctor has prescribed it and not on your own to avoid undesiderable side effects.

In addition, I want to emphasize the importance of simple natural steps to beat diabetes instead of using the chemicals.

However, each natural step needs determination and a strong willing for related success!

Hope it helped!

Dr.Alba