Activity 6: Next Steps for Patients with Sub-Optimal Glycemic Control

Recommendation #1: Lowering A1C to below or around 7% has been shown to reduce microvascular complications of diabetes and, if implemented soon after the diagnosis of diabetes, is associated with long-term reduction in macrovascular disease. Therefore, a reasonable A1C goal for many nonpregnant adults is less than 7%.  
Source: Standards of Medical Care in Diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-63. 
Website: http://care.diabetesjournals.org/content/35/Supplement_1/S11.full
Strength of Evidence: B 

Recommendation #2: Providers might reasonably suggest more stringent A1C goals (such as less than 6.5%) for selected individual patients, if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Such patients might include those with short duration of diabetes, long life expectancy, and no significant cardiovascular disease.  
Source: Standards of Medical Care in Diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-63. 
Website: http://care.diabetesjournals.org/content/35/Supplement_1/S11.full
Strength of Evidence: C

Recommendation #3: Less stringent A1C goals (such as less than 8%) may be appropriate for  patients with a history of severe hypoglycemia, limited life expectancy, advanced micro- or macrovascular complications, or extensive comorbid conditions, and those with long-standing diabetes in whom the general goal is difficult to attain.
Source: Standards of Medical Care in Diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-63. 
Website: http://care.diabetesjournals.org/content/35/Supplement_1/S11.full
Strength of Evidence: B

Recommendation #4: At the time of type 2 diabetes diagnosis, initiate metformin therapy along with lifestyle interventions, unless metformin is contraindicated.
Source: Standards of Medical Care in Diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-63. 
Website: http://care.diabetesjournals.org/content/35/Supplement_1/S11.full
Strength of Evidence: A

Recommendation #5: If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3 to 6 months, add a second oral agent, a GLP-1 receptor agonist, or insulin.
Source: Standards of Medical Care in Diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-63. 
Website: http://care.diabetesjournals.org/content/35/Supplement_1/S11.full
Strength of Evidence: E

Recommendation #6: In patients newly diagnosed with type 2 diabetes who have markedly symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents, from the outset.
Source: Standards of Medical Care in Diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-63. 
Website: http://care.diabetesjournals.org/content/35/Supplement_1/S11.full
Strength of Evidence: E

Recommendation #7: Consider aspirin therapy (75 mg/day to 162 mg/day) as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk greater than 10%). This includes most men older than 50 years of age or women older than 60 years of age who have at least one additional major risk factor. 
Source: Standards of Medical Care in Diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-63. 
Website: http://care.diabetesjournals.org/content/35/Supplement_1/S11.full
Strength of Evidence: C

Recommendation #8: Aspirin should not be recommended for cardiovascular disease (CVD) prevention for adults with diabetes at low CVD risk (10-year CVD risk less than 5%, such as in men younger than 50 years of age and women younger than 60 years of age with no major additional CVD risk factors), since the potential adverse effects from bleeding likely offset the potential benefits.
Source: Standards of Medical Care in Diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-63. 
Website: http://care.diabetesjournals.org/content/35/Supplement_1/S11.full
Strength of Evidence: C

Download PDF of EB Recs

Presentation Slides for Next Steps for Patients with Sub-Optimal Glycemic Control

American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-63.

Heaf JG, van Biesen W. Metformin and chronic renal impairment: a story of choices and ugly ducklings. Clin Diabetes 2011;29:97-101.

Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577-89.

Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2012 [In Press].

Kuritzky L. Managing type 2 diabetes in the primary care setting: beyond glucocentricity. Am J Med Sci 2010;340:133-43.

Piccinni C, Motola D, Marchesini G, Poluzzi E. Assessing the association of pioglitazone use and bladder cancer through drug adverse event reporting. Diabetes Care 2011;34:1369-71.

Qaseem A, Humphrey LL, Sweet DE, Starkey M, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2012;156:218-31.

Reid T. Choosing GLP-1 receptor agonists or DPP-4 inhibitors: weighing the clinical trial evidence. Clin Diabetes 2012;30:3-12.

Reinstatler L, Qi YP, Williamson RP, Garn JV, Oakley GP Jr. Association of biochemical B12 deficiency with metformin therapy and vitamin B12 supplements: the National Health and Nutrition Examination Survey, 1999-2006. Diabetes Care 2012;35:327-33.

Ruiter R, Visser LE, van Herk-Sukel MP, Coeberg JW, Haak HR, Geelhoed-Duijvestijn PH, et al. Lower risk of cancer in patients on metformin in comparison with those on sulfonylurea derivatives: results from a large population-based follow-up study. Diabetes Care 2012;35:119-24.

Vilsbøll T, Christensen M, Junker AE, Knop FK, Gluud LL. Effects of glucagon-like peptide-1 receptor agonists on weight loss: systematic review and meta-analyses of randomised controlled trails. BMJ 2012;344:d7771.

Summary of Glycemic Recommendations for Many Nonpregnant Adults with Diabetes. (Table 9 from American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-63.): http://care.diabetesjournals.org/content/35/Supplement_1/S11/T9.expansion.html

Noninsulin Therapies for Hyperglycemia in Type 2 Diabetes: Properties of Selected Glucose-lowering Drugs that may Guide Individualization of Therapy. (Table 10 from American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-63.): http://care.diabetesjournals.org/content/35/Supplement_1/S11/T10.expansion.html

 

 

 

 

Board ReviewSAMs PrepAAFP Live!

Latest Podcasts
 
Stay Current
If not registered enter your email