Long-term glycaemic control in Type 2 diabetes: a priority but not reality

5^th July, 2006 – GPs believe that sustaining glycaemic control over time in Type 2 diabetes is more important than the current clinical aim of simply lowering blood glucose (HbA1c) to target levels, according to a new survey of 206 GPs published today.¹   Achieving prolonged, sustained glycaemic control was rated the most important treatment goal in the successful management of Type 2 diabetes, prioritised over other key aims including controlling blood pressure, cholesterol levels, and body mass index.¹ It is widely believed that achieving sustained glycaemic control can reduce long-term complications² and therefore delay disease progression in Type 2 diabetes over time.

Although achieving sustained glycaemic control is clearly a priority for GPs, the same survey has demonstrated that frequent monitoring of glycaemic levels is not the reality in practice.  It is widely accepted that once a target HbA1c threshold had been exceeded, HbA1c is likely to continue to rise if treatment remains unchanged. ³  Almost half of GPs stated they would consider introducing alternative therapy after only three months if a patient’s HbA1c levels began to rise, but 78% of GPs stated that HbA1c levels are realistically reviewed no more than every six to twelve months – making it impossible for this crucial review and re-evaluation of therapy.¹ 

This disparity has potentially serious and long-term consequences for patients, and huge costs to the NHS.  Type 2 diabetes is regarded as a progressive disease, and those people experiencing prolonged, poor glycaemic control as a result of the condition are at increased risk of angina, heart attacks and strokes, all leading to premature death and contributing heavily to the cost of diabetes care.⁴   The NHS spends approximately £600,000 an hour treating diabetes, ⁵ the majority of which goes towards paying for the associated complications of the disease. ⁶  

Dr Eugene Hughes, Chair of Primary Care Diabetes EUROPE comments: “Tightly maintained glycaemic control is widely believed to reduce and even prevent complications associated with Type 2 diabetes and delay disease progression over time; indeed glycaemic burden - the time when the patient is above target HbA1c - has been linked to increased risk of microvascular complications.  Until glycaemic control becomes better maintained over the long-term, the cost and prevalence of Type 2 diabetes will only continue to rise.”

Even though lifestyle modifications are beneficial in the management of Type 2 diabetes, clinical studies have shown that adhering to dietary changes alone is rarely sufficient in the long-term and almost all patients will eventually require pharmacotherapy in addition to lifestyle modifications to control their glucose levels. ⁷    Furthermore, the majority of patients need multiple therapies to attain these glycaemic target levels in the longer term. ⁸  

Dr Hughes continued: “Healthcare professionals are already helping patients achieve glycaemic targets, but more could be done to ensure that those with Type 2 diabetes are getting as near to the recommended targets as possible and importantly, staying there for as long as possible.  Regular review is essential to limiting long-term risk and disease progression. If targets are not achieved or sustained at low levels with current treatment, another therapy can be introduced."

Two thirds of people with Type 2 diabetes in the UK are above recommended clinical targets. ⁹   Furthermore, findings from an audit presented at the Diabetes UK Annual Conference in March showed average HbA1c levels were 7.84%, 7.44% and 7.86% in England , Wales , and Scotland respectively. ¹⁰   There are a number of guidelines available on recommended blood glucose levels but it is generally accepted that target HbA1c levels should be 6.5% for each patient with Type 2 diabetes.¹¹ One of the key indicators of the General Medical Services (GMS) contract is the percentage of patients with an HbA1c level of <7.5% in the last 15 months.¹²

For further information, please contact Emily Brooks or Andrea Petruzella at Virgo HEALTH PR on 0844 583 8900 or

emily.brooks@virgohealthpr.com / andrea.petruzella@virgohealthpr.com

About Type 2 diabetes

Over 100,000 people are diagnosed with Type 2 diabetes each year in the UK – approximately one person every five minutes. ¹³  Type 2 diabetes is the fourth leading cause of death in most developed countries. ¹⁴ 

Type 2 diabetes is a complex and currently incurable condition in which the body is unable to properly process glucose (sugar) levels in the blood due to a combination of genetic and environmental factors, particularly lack of physical activity and obesity. This leads to insulin resistance, a failure by the body to use its own insulin properly, which then results in the onset of beta cell dysfunction and a loss of blood glucose control.⁴

About the survey

The survey, conducted by TNS Healthcare, involved 204 interviews with GPs via the GP omnibus service. Fieldwork for the survey was conducted between 18th - 22nd May 2006. 

The survey was sponsored by an educational grant from GlaxoSmithKline, one of the world's leading research-based pharmaceutical and health care companies, committed to improving the quality of human life by enabling people to do more, feel better and live longer. 

GlaxoSmithKline market Avandamet (rosiglitazone/metformin), which is indicated in the treatment of Type 2 diabetes patients, particularly overweight patients, who are unable to achieve sufficient glycaemic control at their maximally tolerated dose of oral metformin alone.

¹ TNS Healthcare, Survey of 204 GPs, conducted May 2006

² UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352: 837-853.

³ Brown JB et al. Diabetes Care 2004; 27: 1535–1540

⁴ Barnett A et al.  DEFINe Dossier – Diabetes: Evaluating Future Impact Now.  November 2004. (Sponsored by GlaxoSmithKline)

⁵ Diabetes UK. Fact Sheet No 3 – Diabetes: Cost and complications. London : Diabetes UK , September 2000 (last accessed 17.01.06)

⁶  Diabetes in the UK 2004. A report from Diabetes UK October 2004

⁷ Turner RC et al. JAMA 1999; 281: 2005–2012

⁸ UK Prospective Diabetes Study (UKPDS) Group 49. JAMA 1999; 281: 2005–2012

⁹ Ambery PD et al.  Are we still missing the goal with respect to glycaemic targets in 2004.  Diabetic Medicine 2005; 22 (Suppl 2):86. P120

¹⁰ Savage M et al. Audit data presented at Diabetes Annual Conference, March 2006

¹¹ Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Prepared by British Cardiac Society, Diabetes UK , HEART UK , Primary Care Cardiovascular Society, The Stroke Association. Heart (2005) 91 (Suppl 5): v1-v52)

^12. Quality and Outcomes Framework Guidance (updated August 2004) (http://www.dh.gov.uk/assetRoot/04/08/86/93/04088693.pdf). Last accessed May 2006

¹³ International Diabetes Federation, Global Guidelines for the management of Type 2 diabetes.

¹⁴ Pagano E et al. Costs of diabetes. A methodological analysis of the literature. Pharmacoeconomics 1999; 15 (6): 583-595

Sustained Glycaemic Control Backgrounder

What is glycaemic control?

Good glycaemic control refers to keeping blood glucose levels at recommended target levels for as long as possible and is one of the main aims of treatment in the management of Type 2 diabetes. Evidence suggests that many of the long-term complications of diabetes, especially the microvascular complications, result from many years of elevated levels of glucose in the blood (hyperglycemia).  It is widely believed that such long-term complications associated with diabetes could be avoided altogether with earlier diagnosis, tightly controlled and sustained blood glucose levels and other effective treatment.[i] 

How is glycaemic control assessed?

The glycosylated haemoglobin, or HbA1c test, is a test for people diagnosed with Type 2 diabetes and is used to assess how well their Type 2 diabetes is being managed.  By reflecting the average blood glucose over the past 3 months, the HbA1c test provides a good measurement of long-term blood glucose control.

Why is glycaemic control important?

o        Impact on society

Almost 2 million people in the UK today have diagnosed Type 2 diabetes while at least a million more – ‘the missing million’ – are thought to have diabetes but do not know it.[ii] The NHS spends approximately £600,000 per hour on treating diabetes and its complications.⁵   Diabetes is associated with serious chronic ill health, disability and premature mortality. Long-term complications such as blindness, kidney disease, amputations, heart disease, and strokes contribute the most to the cost of diabetes care.⁵

o        Impact on the individual

More than 50% of patients with Type 2 diabetes already have complications at diagnosis.[iii]   Furthermore, people experiencing poor glycaemic control are at increased risk of atheroma which can cause problems such as, nephropathy (approximately 1,000 people in the UK go onto dialysis each year because of their diabetes); retinopathy (diabetes is the leading cause of blindness in people of working age in the UK); amputation (in the UK, diabetes is the most common cause of non-traumatic amputation) and impotence as well as angina, heart attacks, and strokes.[iv]  Due to these associated risks, it is estimated that a person with Type 2 diabetes will die 10 years prematurely.[v] 

The importance of achieving glycaemic control has been clearly demonstrated in the United Kingdom Prospective Diabetes Study (UKPDS). The UKPDS showed that tight glycaemic control was associated with significantly lower risk of a wide spectrum of endpoints.1 Tight glycaemic control can reduce the risk of heart disease by 56%, stroke by 46%, kidney disease by 33% and eye disease by 33%,5 and can reduce the risk of cardiovascular complications by as much as a third.^[vi] 

The majority of people with Type 2 diabetes currently fail to achieve long-term glycaemic control meaning they experience glycaemic burden. Glycaemic burden refers to the time when a patient is above target HbA1c levels and has been shown to place the patient at significant risk of microvascular complications.^[vii]

Current Guidelines

There are a number of guidelines available on recommended blood glucose levels but it is generally accepted that target HbA1c levels should be set between 6.5 and 7.5% for each patient with Type 2 diabetes.

o        The National Institute for Health and Clinical Excellence (NICE) recommends a blood glucose level of between 6.5-7.5%.[viii] 

o        18% of the clinical points available in the General Medical Services (GMS) contract are diabetes-focused.  The contract requires annual monitoring of HbA1c levels with one of the key indicators being the percentage of patients with an HbA1c level of <7.5% in the last 15 months.[ix]

o        The Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice state that the optimal target for blood glucose levels is an HbA1c level of 6.5%.[x]

o        The International Diabetes Federation, which produced the first ever evidence-based Global Guideline for Type 2 diabetes in 2004, recommends maintaining blood glucose levels below 6.5%.[xi]

Achieving sustained glycaemic control

It is widely believed that achieving sustained glycaemic control can reduce long-term complications[xii] and therefore delay disease progression in Type 2 diabetes over time.

A recent study has shown that once a target HbA1c threshold had been exceeded the likelihood of HbA1c further deteriorating increases if treatment remains unchanged.[xiii] 

It is often the case that clinicians wait until HbA1c is well above the desired target level before attempting combination therapy, resulting in increased glycaemic burden for the patient.

Even though lifestyle modifications are always beneficial in the management of Type 2 diabetes, clinical studies have shown that adhering to dietary changes alone is rarely sufficient in the long term – almost all patients will eventually require pharmacotherapy to control their glucose levels.[xiv]  Furthermore, the majority of patients need multiple therapies to attain these glycaemic target levels in the longer term.[xv]

It is well established that the implementation of intensive therapy in diabetes as early as is safely possible, and the maintenance of such therapy for as long as possible, with the resulting prolonged period of nearly normal blood glucose levels, will result in an even greater reduction in the risk of complications.[xvi]

Regular review is essential to achieve the HbA1c target and provide patients with optimal Type 2 diabetes treatment. If targets are not achieved and sustained, another therapy can be introduced. Diet changes and physical exercise should be maintained throughout the treatment period.