Commentary: The new ADA Guidelines for Type 2 Diabetes Mellitus

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On April 19, 2012 The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) issued a joint position statement. These new guidelines differ from the prior guidelines published in 2006 by Nathan and co-workers in that they emphasize patient-specific treatment of hyperglycemia in persons with type 2 diabetes.

There are a number of reasons for the new guidelines. Perhaps the most important reason is that there is now greater available pharmacotherapy and more information about potential adverse effects. But also new uncertainties concerning the effects of intensive glycemic control on macrovascular complications have emerged following the publication of ACCORD (as well as other studies).

The new elements of the new guidelines are:

1. The ADA has set the HbA1c goal at 7% in general, but with some individualization (ACCORD).  There is a higher HbA1C for patients with advanced cardiovascular disease, reduced life expectancy, and multiple medical problems and a lower HbA1C for patients with newly diagnosed T2D and the “very motivated”

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2. Recognition that multiple agents needed:  e.g., the dipeptidyl peptidase-4 (DPP4) inhibitors available since the last hyperglycemia guideline was published.

3. The ADA is advocating that clinicians avoid clearly defined algorithms - less prescriptive and more patient-centered.  Rather, the ADA says that recommendations ought to be tailored to individual patient needs, preferences, and tolerances and should be based on differences in age and disease course. Other factors affecting individualized treatment plans include specific symptoms, comorbid conditions, weight, race/ethnicity, sex, and lifestyle.

4.  The mainstay of any type 2 diabetes treatment program is still diet, exercise, and education. Metformin is the preferred first-line drug, in the absence of contraindications. Data are limited regarding use of agents other than metformin., however the ADA recommends a layered approach (see Figure). A reasonable approach is combination therapy with 1 to 2 additional oral or injectable agents, with the goal of minimizing side effects to the extent possible.

5. To maintain glycemic control, the ADA says, many patients will ultimately need insulin monotherapy or in combination with other medications.