Personalized therapy algorithms for type 2 diabetes: a phenotype-based approach

Abstract

Type 2 diabetes is a progressive disease with a complex and multifactorial pathophysiology. Patients with type 2 diabetes show a variety of clinical features, including different "phenotypes" of hyperglycemia (eg, fasting/preprandial or postprandial). Thus, the best treatment choice is sometimes difficult to make, and treatment initiation or optimization is postponed. This situation may explain why, despite the existing complex therapeutic armamentarium and guidelines for the treatment of type 2 diabetes, a significant proportion of patients do not have good metabolic control and at risk of developing the late complications of diabetes. The Italian Association of Medical Diabetologists has developed an innovative personalized algorithm for the treatment of type 2 diabetes, which is available online. According to the main features shown by the patient, six algorithms are proposed, according to glycated hemoglobin (HbA1c, ≥9% or ≤9%), body mass index (≤30 kg/m(2) or ≥30 kg/m(2)), occupational risk potentially related to hypoglycemia, chronic renal failure, and frail elderly status. Through self-monitoring of blood glucose, patients are phenotyped according to the occurrence of fasting/preprandial or postprandial hyperglycemia. In each of these six algorithms, the gradual choice of treatment is related to the identified phenotype. With one exception, these algorithms contain a stepwise approach for patients with type 2 diabetes who are metformin-intolerant. The glycemic targets (HbA1c, fasting/preprandial and postprandial glycemia) are also personalized. This accessible and easy to use algorithm may help physicians to choose a personalized treatment plan for each patient and to optimize it in a timely manner, thereby lessening clinical inertia.

Keywords: Italian Association of Medical Diabetologists; Italian algorithm; personalized treatment; treatment guidelines; type 2 diabetes.

Figure 1

HbA_1c target has been individualized based on the age of the patient and on the presence of macro-vascular diabetes complications/co-morbidities. Notes: *Carefully evaluate (at presentation and over the course of time) glomerular filtration rate (GFR), potential hypoglycemia risks (with particular care in the use of sulfonylureas or glinides), nutritional status, and presence of comorbidities/frailty. **The HbA_1c target values proposed are intended as safe objectives, limiting the risk of hypoglycemia. Abbreviation: HbA_1c, glycated hemoglobin.

Figure 2

The Italian algorithm. Notes: The Italian algorithm takes into account some individual variables/main features: initial value of HbA_1c; BMI, <30 kg/m² and ≥30 kg/m²; professions associated with hypoglycemia risk such as work at high altitude, pilots, drivers, crane machinists, platform workers, etc; presence of chronic renal failure; frailty of elderly T2D patients. Copyright © 2013 AMD. Reproduced with permission from http://www.aemmedi.it/algoritmi_en_2013/algoritmi.html. Abbreviations: AMD, Associazione Medici Diabetologi (Italy); BMI, body mass index; CRF, chronic renal failure; HbA_1c, glycated hemoglobin.