Optimum Care in Type 2 Diabetes:
Does One Size Fit All?
James LaSalle
on behalf of the
Global Partnership for Effective Diabetes Management
This slideset was developed in 2009 with support from GlaxoSmithKline
Need to individualize patient care
"Good glycaemic control continues to have an
essential role in type 2 diabetes management...
However, having reviewed the evidence, we recognise
that individualising targets and/or treatment according
to patient type is paramount.
For example, while early intervention is preferred
wherever appropriate, certain high risk groups may not
respond to overly intensive glucose-lowering regimens
such as that utilised in ACCORD."
Del Prato S, et al. Int J Clin Pract 2009; in press.
Patient groups requiring special
consideration
• Newly diagnosed individuals with
type 2 diabetes, but no
complications
– Overweight or obese adults
– Lean adults
• Individuals with a history of poor
glycemic control
– No complications
– History of CVD
• Individuals at risk of hypoglycemia
Del Prato S, et al. Int J Clin Pract 2009; in press.
Case study: Newly-diagnosed adults, no
complications, overweight/obese






HbA1c > 6.5%
BMI > 25 kg/m2
Typically > 30 years of age
Mild symptoms or asymptomatic
Diagnosis before emergence of complications
No associated comorbidities e.g. hypertension,
dyslipidemia
Del Prato S, et al. Int J Clin Pract 2009; in press.
Stepwise approach: delays control and
leaves patients at risk of complications
Diet and
exercise
OAD
monotherapy
OAD
monotherapy
uptitration
OAD
combination
OAD +
basal insulin
OAD +
multiple daily
insulin injections
10
HbA1c (%)1
9
Mean
8
7
6
OAD = oral antidiabetic
Duration of diabetes
1. Adapted from Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.
2. Stratton IM, et al. BMJ 2000; 321:405–412.
Copyright 2005 Blackwell Publishing Ltd. Reproduced with permission of Blackwell Publishing Ltd.
Early, intensive intervention: reach glycemic
goals and reduce the risk of complications
10
Diet and
exercise
OAD
monotherapy
HbA1c (%)1
9
8
OAD
combination
OAD
uptitration
OAD +
basal insulin
OAD + multiple
daily insulin
injections
Mean
7
6
OAD = oral antidiabetic
Duration of diabetes
1. Adapted from Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.
2. Stratton IM, et al. BMJ 2000; 321:405–412.
Copyright 2005 Blackwell Publishing Ltd. Reproduced with permission of Blackwell Publishing Ltd.
Newly diagnosed adults, no
complications, overweight/obese
Practical guidance: glycemic targets
GOAL: Bottom of target range (HbA1c 6.5–7%), even in patients with
modest hyperglycemia (HbA1c < 7.5%)
HOW: Aim for HbA1c as close to normal as can safely be achieved
without causing hypoglycemia or marked weight gain
If HbA1c < 7.5%, consider agents not associated with
hypoglycemia that address the underlying pathophysiology
of diabetes
Del Prato S, et al. Int J Clin Pract 2009; in press.
Newly diagnosed adults, no
complications, overweight/obese
Practical guidance: other considerations
• As for all people with type 2 diabetes, diet and
exercise should be continually reinforced
• Overweight and obese patients are at increased risk
of CVD, pay particular attention to managing
all CV risk factors
Glycemic control
=
Lipid-lowering
=
Antihypertensives
Del Prato S, et al. Int J Clin Pract 2009; in press.
Case study: newly diagnosed adults,
no complications, lean






HbA1c > 6.5%
BMI < 25 kg/m2
Typically > 30 years of age
Mild symptoms or asymptomatic
Diagnosis before emergence of complications
No associated comorbidities, e.g. hypertension,
dyslipidemia
Del Prato S, et al. Int J Clin Pract 2009; in press.
Lean patients may have a greater degree
of -cell dysfunction
• Most individuals with type 2 diabetes are overweight or
obese but this varies across the world
South-East Asia*
< 40% of T2D are obese
North America
almost 90% of
T2D are obese
• In lean patients, -cell dysfunction is often more marked
compared with overweight/obese individuals
– Particularly in some non-western populations
– LADA may also be more prevalent in lean patients
Brunetti P. Int J Clin Pract 2007; 61:3–9.
Newly diagnosed adults, no
complications, lean
Practical guidance: glycemic targets
GOAL: Bottom of target range (HbA1c 6.5–7%), even in patients with
modest hyperglycemia (HbA1c < 7.5%)
HOW: Aim for HbA1c as close to normal as can safely be achieved
without causing hypoglycemia or marked weight gain
Del Prato S, et al. Int J Clin Pract 2009; in press.
Newly diagnosed adults, no
complications, lean
Practical guidance: other considerations
• Increased likelihood of β-cell dysfunction, therefore early therapy
should include agents that support β-cell function
• Despite lower CV risk, lean individuals should still
-cell
be educated about maintaining a healthy
dysfunction
lifestyle to prevent weight gain

• Since LADA may be present, consider
testing for autoantibodies, where possible
Del Prato S, et al. Int J Clin Pract 2009; in press.
Case study: history of inadequate
glycemic control, no complications

Likely to be older than newly diagnosed individuals

No complications and a longer duration of diabetes with
inadequate glycemic control (HbA1c > 7.5%) ≥ 1 year

No associated comorbidities, e.g. hypertension,
dyslipidemia
Del Prato S, et al. Int J Clin Pract 2009; in press.
Level of care in patients with type 2
diabetes and sustained hyperglycemia
Proportion of patients receiving
appropriate care
1.0
0.9
After 2 years,
0.8
11% of patients had still not
received appropriate care*
0.7
0.6
After 12 months,
25% of patients had not
0.5
received appropriate care*
0.4
0.3
After 6 months,
0.2
41% of patients had not
received appropriate care*
0.1
0
0
10
20
30
40
50
60
Months of sustained hyperglycemia
*Appropriate care defined as medication intensification or HbA1c test result ≤ 7%.
Lafata JE, et al. Diabetes Care 2009; 32:1447–1452.
Copyright 2009 American Diabetes Association. Reprinted with permission from The American Diabetes Association.
History of inadequate glycemic control,
no complications
Practical guidance: glycemic targets
GOAL: Target near-normal HbA1c
HOW: Aim for a more gradual reduction in HbA1c versus newly
diagnosed individuals
Reassess potential reasons for inadequate glycemic control, e.g.
• overly conservative management, e.g. delay in introducing
combination therapy
• inadequate adherence to antidiabetic regimens
• inappropriate choice of agents (e.g. agents that do not address
the underlying pathophysiology)
Del Prato S, et al. Int J Clin Pract 2009; in press.
Challenges in increasing adherence
62% took tablets correctly in
relation to food
20% regularly forgot to take
Patient adherence
to therapy
their tablets
5% omitted tablets if their blood
glucose was too high
2% omitted tablets if their blood
glucose was too low
Browne DL, et al. Diabet Med 2000; 17:528–531.
Challenges in improving patient
understanding
35% recalled receiving advice
about their medication
15% knew the mechanism of
Patient knowledge
of oral antidiabetic
agents
action of their therapy
10% taking sulfonylureas knew
that they could cause hypoglycemia
20% taking metformin knew it
could cause gastrointestinal
side effects
Browne DL, et al. Diabet Med 2000; 17:528–531.
History of inadequate glycemic control,
no complications
Practical guidance: other considerations
• Implement structured educational programs to motivate individuals
with type 2 diabetes to assume a more active role in managing
their condition
“I don’t need to take my tablets
– I don’t feel ill”
“Complications only occur
in patients who take insulin”
Del Prato S, et al. Int J Clin Pract 2009; in press.
Case study: history of inadequate glycemic
control and cardiovascular disease

Known history of CVD

Likely to have large pill burden and restrictions on
choice of therapy due to comorbidities
Del Prato S, et al. Int J Clin Pract 2009; in press.
History of inadequate glycemic control
and cardiovascular disease
Practical guidance: glycemic targets
GOAL: Guidance as for patients with a history of inadequate glycemic
control but no complications, i.e. target near-normal HbA1c
HOW: Take particular care to avoid hypoglycemia
Adopt less stringent glycemic targets and aim for a more
gradual reduction in HbA1c
Del Prato S, et al. Int J Clin Pract 2009; in press.
History of inadequate glycemic control
and cardiovascular disease
Practical guidance: other considerations
• CV risk management should be intensified in
these individuals
• Be vigilant for contraindications and other limitations
concerning choice of agents and possible
drug interactions
Del Prato S, et al. Int J Clin Pract 2009; in press.
Case study: individuals at risk
of hypoglycemia
 Previous symptoms of hypoglycemia
 Particularly wide daily glucose fluctuations
 Individuals such as the elderly who often
have impaired creatinine clearance, and
irregular lifestyles/eating patterns increasing
susceptibility to hypoglycemia
– Especially when taking hypoglycemic
agents such as insulin and sulfonylureas
Del Prato S, et al. Int J Clin Pract 2009; in press.
Increased risk of hypoglycemia with
intensive glycemic control: ACCORD
Hypoglycemia (%)
20
*
15
10
16.2%
*
Intensive
10.5%
Standard
5
5.1%
3.5%
0
Requiring
medical
assistance
Requiring any
assistance
*P < 0.001
Gerstein HC, et al. N Engl J Med 2008; 358:2545–2559.
Individuals at risk of hypoglycemia
Practical guidance: glycemic targets
WHAT: Targets should be individualized according to the risk of
hypoglycemia, e.g.
• history of severe or frequent hypoglycemia
• kidney function
• age of patient
• previous CV events
Del Prato S, et al. Int J Clin Pract 2009; in press.
Individuals at risk of hypoglycemia
Practical guidance: other considerations
• Educate patients on being alert to possible hypoglycemia, to
increase awareness and responsiveness to symptoms
of hypoglycemia
• Counseling particularly vulnerable patients such as the
elderly on increased risk of hypoglycemia with irregular
lifestyles/eating patterns and encourage compliance
to prescribed regimens
• Emphasize the importance of regular
self-monitoring of glucose where appropriate
Del Prato S, et al. Int J Clin Pract 2009; in press.
Summary: one size does not fit all
• Good glycemic control, including early
intervention, remains the cornerstone of
diabetes care
• However, strategies to achieve glycemic targets
should always ensure patient safety
• Treatment should be individualized to the
patient
Del Prato S, et al. Int J Clin Pract 2009; in press.