International diabetes experts launch first global recommendations for effective management of type 2 diabetes

“10 Practical Steps” aim to help physicians and patients reach treatment goals

London , UK , 11 October, 2005 – In the face of an emerging worldwide epidemic of type 2 diabetes, the Global Partnership for Effective Diabetes Management today launched the first global recommendations designed to help physicians overcome common barriers to achieving recommended treatment goals for diabetes management.  Despite increasingly stringent clinical practice guidelines, more than 60 percent of those with type 2 diabetes currently have glucose levels above the recommended targets (HbA_1c less than 6.5 percent), putting them at increased risk for serious complications such as cardiovascular disease – the leading cause of diabetes-related death.^1,2

The Global Partnership for Effective Diabetes Management, a multidisciplinary task force of internationally respected diabetes experts from leading institutions and diabetes organisations worldwide, recognised that current treatment strategies were not sufficient to get patients to achieve glucose goals.  Their global call to action, including “10 Practical Steps to Better Glucose Control”, is published in the November issue of the International Journal of Clinical Practice.  The publication supports appeals from the International Diabetes Federation and the American Association of Clinical Endocrinologists, who call for physicians to partner with patients to achieve a treatment goal of HbA_1c 6.5 percent or less.^3,4

“Because of the progressive nature of type 2 diabetes, the longer patients remain uncontrolled, the more extensive the diabetes-related damage such as blindness and kidney failure, and the harder it is to keep glucose levels in check.  With the vast majority of people with type 2 diabetes not at recommended treatment goals, the stakes are high,” said Professor Stefano Del Prato, chair of the Global Partnership for Effective Diabetes Management and professor of endocrinology and metabolism and chief of the Section of Diabetes, both at the University of Pisa .  “However it isn’t easy to get patients to currently recommended treatment glucose targets and physicians need practical guidance.  Our “10 Practical Steps” were specifically developed to address the current gap between treatment guidelines and therapeutic practice.  Given the escalating global epidemic of type 2 diabetes, a sense of urgency and proactive management strategies are required to get more patients to recommended goals.”

Move from reactive, stepwise approach to proactive strategy
Most physicians rely on a “stepwise approach” to control blood glucose levels in people with type 2 diabetes that begins with diet and exercise, followed by treatment with a single oral anti-diabetic drug, where the dose is often slowly increased to maximal effect, and then to combination drug therapy, if necessary.⁵  With the stepwise approach, it can take up to 21 months for patients who are not at glucose goal to move from single therapy to combination therapy.⁶  However, earlier use of a combination of drugs with complementary actions has been shown to be effective in getting patients to target glucose levels, reducing complications and delaying disease progression.^7,8

The Global Partnership advocates a proactive approach to the management of type 2 diabetes, calling for earlier use of combination therapy, in parallel with diet and exercise reinforcement.  The recommendations provide specific action points for when changes in treatment strategy should be considered, for example, newly diagnosed patients should be treated intensively so as to achieve target HbA_1c less than 6.5 percent within 6 months of diagnosis, and for currently diagnosed patients who are not at target HbA_1c less than 6.5 percent within 3 months, combination therapy should be considered.

Numbers too big to ignore
The fourth or fifth leading cause of death in most developed countries, diabetes has reached epidemic proportions in many developing and newly industrialised nations.²  Complications from diabetes, such as coronary artery and peripheral vascular disease, stroke, diabetic neuropathy, amputations, renal failure and blindness are resulting in increasing disability, reduced life expectancy and enormous health costs for virtually every society.⁹  The total cost of diabetes is €29 billion in Europe⁹ and $132 billion in the US,¹⁰ and complications are the single factor with the largest impact on cost (75 percent of people with diabetes die of cardiovascular disease¹¹).⁹

“The trend of escalating diabetes prevalence will no doubt lead to an immense financial burden in many countries unless urgent action is taken to prevent both diabetes and its complications,” said Professor Del Prato.

Despite widespread publication of new glucose guidelines calling for lower treatment targets, several large scale studies have shown that current management of glycaemia is falling significantly short of recommended treatment goals.  In fact, there was little improvement in the proportion of patients achieving good glucose control in the US National Health and Nutrition Examination Survey (NHANES) III (1998 and 1994) and the NHANES 1999–2000.¹²  In NHANES and the CODE 2 Europe study, only 37% and 31% of patients respectively achieved glucose control.^1,12

Practical advice to help patients get to goal
The Global Partnership developed their “10 Practical Steps” – as well as a companion piece that outlines supporting evidence – as part of the Control to Goal programme, an integrated diabetes education and support initiative for healthcare professionals that addresses the roadblocks to effective diabetes management.  The recommendations of the Global Partnership focus on the following four areas:

Achieving good glucose control

1.      Aim for good glycaemic control, defined as HbA_1c < 6.5 percent*

2.      Monitor HbA_1c every three months in addition to regular glucose self-monitoring

3.      Aggressively manage hyperglycaemia, dyslipidaemia and hypertension with the same intensity to obtain the best patient outcome

4.      Refer all newly diagnosed patients to a unit specialising in diabetes care where possible

Targeting the underlying pathophysiology of type 2 diabetes

5.      Address the underlying pathophysiology, including treatment of insulin resistance

Earlier and intensive treatment with combination therapies

6.      Treat patients intensively so as to achieve target HbA_1c < 6.5 percent* within 6 months of diagnosis

7.      After 3 months, if patients are not at target HbA_1c < 6.5 percent*, consider combination therapy

8.      Initiate combination therapy or insulin immediately for all patients with HbA_1c

= 9 percent at diagnosis

9.      Use combinations of oral antidiabetic agents with complementary mechanisms of action

Using a multidisciplinary team

10.  Implement a multi- and interdisciplinary team approach to diabetes management to encourage patient education and self care and share responsibility for patients achieving glucose goals

*Or fasting/pre-prandial glucose <110 mg/dl (6.0 mmol/l) where assessment of HbA_1c is not possible

“We hope that people will act – as quickly as possible – to incorporate the proactive approach to patient management reflected in these recommendations into clinical practice.  With a renewed sense of urgency and focus, we can reduce the risk of diabetes-related complications, improve patient quality of life and, possibly, exert a more effective control on growing diabetes-related costs,” said Professor Del Prato.

Getting to goal: A patient’s perspective
Five time Olympic champion, Sir Steve Redgrave CBE, attended the launch of the 10 Practical Steps at Diabeticare at Hillingdon Hospital to illustrate the difference that achieving good glycaemic control can make on daily life.

‘Diabetes does not have to be an obstacle to achieving your personal goals,’ Sir Steve Redgrave explained. ‘Since being diagnosed with type 2 diabetes – and throughout extensive training and competition – I worked closely with my healthcare teams to reach and maintain my glucose targets.  Controlling my glucose allowed me to focus on winning.’

Sir Steve Redgrave’s doctor, Dr. Ian Gallen, endocrinologist and lead for diabetes at Wycombe Hospital in England , said, ‘Keeping in excellent health is of paramount importance to any athlete, but in Steve’s case it required closer attention.

His diagnosis of type 2 diabetes prior to the Sydney Olympics meant we had to work together very closely to return his performance to pre-diagnosis level of excellence. This successful early intervention with intensive treatment can be applied to the management of all people with diabetes, and I welcome recommendations that reflect this. As for results, Steve’s record speaks for itself.’

About the Global Partnership and Control to Goal Programme
The Global Partnership for Effective Diabetes Management, sponsored by GlaxoSmithKline, was launched in 2004 with the objective of providing guidance to facilitate improved treatment outcomes for people with type 2 diabetes. The Global Partnership published its recommendations in the IJCP as part of the Control to Goal programme.  The Control to Goal programme addresses barriers to effective diabetes management and provides support to healthcare professionals to help them increase the proportion of individuals achieving recommended glucose goals.

# # #

Notes

·         The full report and recommendations will appear in ‘Improving Glucose Management: ten steps to get more patients with type 2 to glucose goal. Recommendations from the Global Partnership for Effective Diabetes Management,’ Del Prato S, Felton A, Munro N, Nesto R, Zimmet P and Zinman B, on behalf of the Global Partnership for Effective Diabetes Management.  Int J Clin Pract, November 2005, 59:1345-1355.

·         The HbA_1c test measures how well a person’s glucose levels are being controlled over time, providing a picture of a patient’s long-term diabetes management.  Specifically, HbA_1c, measures the percentage of the haemoglobin (Hb) molecules in red blood cells chemically linked to glucose.¹³  The percent is higher if more glucose is in a patient’s blood.  HbA_1c is normal if it is 6 percent or less.¹⁴

·         For information about Control to Goal, the 10 recommendations, the Global Partnership or type 2 diabetes, please refer to www.diabetespressoffice.com for:

o       10 Practical Steps

o       Facts about Control to Goal

o       Facts about the Global Partnership for Effective Diabetes Management

o       Facts about type 2 diabetes

References

1.        Liebl A, Mata M & Eschwege E. Evaluation of risk factors for development of complications in type II diabetes in Europe . Diabetologia 2002; 45:S23–S28.

2.        International Diabetes Federation. Diabetes Atlas, 2nd edn 2003; Brussels : International Diabetes Federation.

3.        International Diabetes Federation. Global Guideline for Type 2 Diabetes, 2005; Brussels : International Diabetes Federation.

4.        American Association of Clinical Endocrinologists. Medical guidelines for the management of diabetes mellitus: the AACE system of intensive diabetes self-management – 2002 update. Endocr Pract 2002; 8 (Supplement 1):40–82.

5.        Campbell IW. Need for intensive, early glycaemic control in patients with type 2 diabetes. Br J Cardiol 2000; 7:625–631.

6.        Brown JB & Nichols GA. Glycemic burden of oral agent failure in type 2 diabetes. Diabetes 2003; 52 (Supplement 1):A61–A62.

7.        Garber AJ, Larsen J, Schneider SH, et al. Simultaneous glyburide/metformin therapy is superior to component monotherapy as an initial pharmacological treatment for type 2 diabetes. Diabetes Obes Metab 2002; 4:201–208.

8.        Garber AJ, Donovan DS, Jr., Dandona P, et al. Efficacy of glyburide/metformin tablets compared with initial monotherapy in type 2 diabetes. J Clin Endocrinol Metab 2003; 88:3598–3604.

9.        Jonsson B. Revealing the cost of type II diabetes in Europe . Diabetologia 2002; 45:S5–12.

10.     American Diabetes Association. Economic costs of diabetes in the U.S. in 2002. Diabetes Care 2003; 26:917–932.

11.     Gray RP & Yudkin JS. Chapter 57. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes, 1997;  Edited by JC Pickup & G Williams. Oxford : Blackwell Sciences Ltd.

12.     Saydah SH, Fradkin J & Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA 2004; 291:335–342.

13.     Bell JI & Hockaday TDR. Diabetes mellitus. In Oxford Textbook of Medicine, vol. 2 1996; pp. 1448–1504. Edited by DJ Wetherall, JGG Ledingham & DA Warrell. Oxford : Oxford University Press.

14.     Canadian Diabetes Association. Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada . Can J Diabetes 2003; 27 (Supplement 2):S1–S152.

(16/10/05)