Translating Guidelines into Primary Care of Patients With Type 2 Diabetes
Translating Guidelines into Primary Care of Patients With Type 2 Diabetes
Optimal glycemic control is fundamental to diabetes management. New diabetes guidelines suggest that recommended glycated hemoglobin (A1C) targets for Type 2 diabetes can be, for most patients, achieved through a stringent, multi-pronged, multi-disciplined approach comprising early and focused intervention, regular monitoring, timely changes to medication, early use of combination therapy, early use of insulin, and patient empowerment through education. Using examples from real-life patient care, the implementation of these guidelines is reviewed from the perspective of the advanced practice nurse.
According to the American College of Endocrinology (ACE) and American Association of Clinical Endocrinologists (AACE), diabetes practitioners must do more to ensure that their patients with Type 2 diabetes (T2DM) achieve glycemic targets.
One reason for this rallying cry is the alarming increase in the number of pre-diabetes (where blood sugar levels are higher than normal, but not yet high enough to be diagnosed as diabetes) and T2DM cases in the US. A recent estimation puts the number of people in the United States with pre-diabetes at 54 million, while those with diabetes number 23.6 million, of whom 90% to 95% have T2DM. Another reason is the current failure of some 63% of patients with diabetes to achieve target glycemic levels (glycated hemoglobin [A1C] ≤ 7%). This failure is associated with the progressive development of diabetic complications, such as cardiovascular disease, nephropathy, retinopathy, and neuropathy, which in the short term reduce quality of life, but in the long term are associated with serious complications or premature death.
Specialist (ACE/AACE) and diabetes (American Diabetes Association [ADA]/European Association for the Study of Diabetes [EASD]) societies have already taken steps to change this alarming scenario. Although glycemic targets had been set for some years, clear guidelines on how best to attain them had not been developed, in part because of the lack of therapeutic options. However, in 2005, ACE/AACE guidelines derived from a consensus conference were developed with the aim of more effectively implementing glycemic goals. To simplify their message and improve treatment in real-life clinical settings, representatives of ACE and AACE met again to create the "Treat-To-Target Road Map." Figure 1, Figure 2 present the Road Map recommendations for those nave to therapy and for treated patients. Within the same time period, a treatment algorithm for the management of hyperglycemia in adults with T2DM was developed by ADA/EASD to aid selection of the most appropriate interventions. This algorithm has been incorporated into the 2008 annual update of the ADA "Standards of Medical Care in Diabetes."
(Enlarge Image)
Figure 1.
ACE/AACE Road Map for treatment-nave patients. A1C = glycated hemoglobin; AGI = α-glucosidase inhibitor; DPP-4 = dipeptidyl peptidase-4; FPG = fasting plasma glucose; PPG = postprandial glucose; Rx = treatment; SU = sulfonylurea; TZD = thiazolidinedione. Reproduced with permission.
(Enlarge Image)
Figure 2.
ACE/AACE Road Map for treated patients. A1C = glycated hemoglobin; AGI = α-glucosidase inhibitor; DPP-4 = dipeptidyl peptidase-4; FPG = fasting plasma glucose; PPG = postprandial glucose; Rx = treatment; SU = sulfonylurea; TZD = thiazolidinedione. Reproduced with permission.
This article presents the key messages issuing from current guidelines on diabetes care and illustrates ways in which nurse practitioners can use these messages to improve diabetic management in the community.
Abstract and Introduction
Abstract
Optimal glycemic control is fundamental to diabetes management. New diabetes guidelines suggest that recommended glycated hemoglobin (A1C) targets for Type 2 diabetes can be, for most patients, achieved through a stringent, multi-pronged, multi-disciplined approach comprising early and focused intervention, regular monitoring, timely changes to medication, early use of combination therapy, early use of insulin, and patient empowerment through education. Using examples from real-life patient care, the implementation of these guidelines is reviewed from the perspective of the advanced practice nurse.
Introduction
According to the American College of Endocrinology (ACE) and American Association of Clinical Endocrinologists (AACE), diabetes practitioners must do more to ensure that their patients with Type 2 diabetes (T2DM) achieve glycemic targets.
One reason for this rallying cry is the alarming increase in the number of pre-diabetes (where blood sugar levels are higher than normal, but not yet high enough to be diagnosed as diabetes) and T2DM cases in the US. A recent estimation puts the number of people in the United States with pre-diabetes at 54 million, while those with diabetes number 23.6 million, of whom 90% to 95% have T2DM. Another reason is the current failure of some 63% of patients with diabetes to achieve target glycemic levels (glycated hemoglobin [A1C] ≤ 7%). This failure is associated with the progressive development of diabetic complications, such as cardiovascular disease, nephropathy, retinopathy, and neuropathy, which in the short term reduce quality of life, but in the long term are associated with serious complications or premature death.
Specialist (ACE/AACE) and diabetes (American Diabetes Association [ADA]/European Association for the Study of Diabetes [EASD]) societies have already taken steps to change this alarming scenario. Although glycemic targets had been set for some years, clear guidelines on how best to attain them had not been developed, in part because of the lack of therapeutic options. However, in 2005, ACE/AACE guidelines derived from a consensus conference were developed with the aim of more effectively implementing glycemic goals. To simplify their message and improve treatment in real-life clinical settings, representatives of ACE and AACE met again to create the "Treat-To-Target Road Map." Figure 1, Figure 2 present the Road Map recommendations for those nave to therapy and for treated patients. Within the same time period, a treatment algorithm for the management of hyperglycemia in adults with T2DM was developed by ADA/EASD to aid selection of the most appropriate interventions. This algorithm has been incorporated into the 2008 annual update of the ADA "Standards of Medical Care in Diabetes."
(Enlarge Image)
Figure 1.
ACE/AACE Road Map for treatment-nave patients. A1C = glycated hemoglobin; AGI = α-glucosidase inhibitor; DPP-4 = dipeptidyl peptidase-4; FPG = fasting plasma glucose; PPG = postprandial glucose; Rx = treatment; SU = sulfonylurea; TZD = thiazolidinedione. Reproduced with permission.
(Enlarge Image)
Figure 2.
ACE/AACE Road Map for treated patients. A1C = glycated hemoglobin; AGI = α-glucosidase inhibitor; DPP-4 = dipeptidyl peptidase-4; FPG = fasting plasma glucose; PPG = postprandial glucose; Rx = treatment; SU = sulfonylurea; TZD = thiazolidinedione. Reproduced with permission.
This article presents the key messages issuing from current guidelines on diabetes care and illustrates ways in which nurse practitioners can use these messages to improve diabetic management in the community.
