Activity 5: Intensifying Insulin Therapy in Type 2 Diabetes: Strategies for Family Medicine

Practice recommendations discussed in this program are from the following sources:

American Diabetes Association

Source: American Diabetes Association. Standards of Medical Care in Diabetes—2010. Diabetes Care 2010;33(Suppl 1):S11-S61.
Website: http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.pdf+html
Strength of Evidence: The strength of evidence is indicated following each recommendation. See table below for description of evidence levels.

Self-Monitoring of Blood Glucose (SMBG)

Recommendation #1:

  • SMBG should be carried out three or more times daily for patients using multiple insulin injections or insulin pump therapy. (A)
  • To achieve postprandial glucose targets, postprandial SMBG may be appropriate. (E)
  • When prescribing SMBG, ensure that patients receive initial instruction in, and routine follow-up evaluation of, SMBG technique and using data to adjust therapy. (E)

Glycemic Goal

Recommendation #2:

  • Lowering A1C to below or around 7% has been shown to reduce microvascular and neuropathic complications of type 1 and type 2 diabetes. Therefore, for microvascular disease prevention, the A1C goal for nonpregnant adults in general is 7%. (A)
  • Less-stringent A1C goals than the general goal of <7% may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, and extensive comorbid conditions, and those with longstanding diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents, including insulin. (C)

Diabetes Education

Recommendation #3: People with diabetes should receive diabetes self-management education according to national standards when their diabetes is diagnosed, and as needed thereafter. (B)

Medical Nutrition Therapy

Recommendation #4: Individuals with diabetes should receive individualized medical nutrition therapy (MNT) as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with components of diabetes MNT. (A)

Hypoglycemia

Recommendation #5: Glucose (15 g-20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. If, after 15 minutes, SMBG shows continued hypoglycemia, treatment should be repeated. (E)

Definitions of the ADA's Level of Evidence

Level of evidence

Description

A

Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including:

• Evidence from a well-conducted multicenter trial
• Evidence from a meta-analysis that incorporated quality ratings in the analysis

Compelling nonexperimental evidence, i.e., the "all or none" rule developed by the Centre for Evidence-Based Medicine at Oxford

Supportive evidence from well-conducted randomized controlled trials that are adequately powered, including:

• Evidence from a well-conducted trial at one or more institutions
• Evidence from a meta-analysis that incorporated quality ratings in the analysis

B

Supportive evidence from well-conducted cohort studies, including:

• Evidence from a well-conducted prospective cohort study or registry
• Evidence from a well-conducted meta-analysis of cohort studies

Supportive evidence from a well-conducted case-control study

C

Supportive evidence from poorly controlled or uncontrolled studies, including:

• Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results
• Evidence from observational studies with high potential for bias (such as case series with comparison to historical controls)
• Evidence from case series or case reports

Conflicting evidence with the weight of evidence supporting the recommendation

E

Expert consensus or clinical experience

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