Impact of data from recent clinical trials on strategies for treating patients with type 2 diabetes mellitus

Abstract

Type 2 diabetes is associated with increased risk for the development of cardiovascular disease (CVD) secondary to hyperglycemia's toxicity to blood vessels. The escalating incidence of CVD among patients with type 2 diabetes has prompted research into how lowering glycated hemoglobin (HbA(1c)) may improve CVD-related morbidity and mortality. Data from recent studies have shown that some patients with type 2 diabetes actually have increased mortality after achieving the lowest possible HbA(1c) using intensive antidiabetes treatment. Multiple factors, such as baseline HbA(1c), duration of diabetes, pancreatic beta-cell decline, presence of overweight/obesity, and the pharmacologic durability of antidiabetes medications influence diabetes treatment plans and therapeutic results. Hypertension and dyslipidemia are common comorbidities in patients with type 2 diabetes, which impact the risk of CVD independently of glycemic control. Consideration of all of these risk factors provides the best option for reducing morbidity and mortality in patients with type 2 diabetes. Based on the results of recent trials, the appropriate use of current antidiabetes therapies can optimize glycemic control, but use of intensive glucose-lowering therapy will need to be tailored to individual patient needs and risks.

Keywords: HbA1c; cardiovascular disease; diabetes treatment; glucose control; incretin-based therapies; type 2 diabetes.

Figure 1

ADA/EASD consensus guidelines treatment algorithm for patients with type 2 diabetes. Reinforce lifestyle interventions at every visit; check HbA_1c every three months until HbA_1c is <7% and then at least every six months. The interventions should be changed if HbA_1c is ≥7%. Copyright © 2009. Adapted with permission from Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32(1):193–203. Notes: ^aSulfonylureas other than glyburide or chlorpropamide. ^bInsufficient clinical use to be confident regarding safety. Abbreviations: ADA, American Diabetes Association; CHF, congestive heart failure; EASD, European Association for the Study of Diabetes; GLP-1, glucagon-like peptide-1.