1. 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

2. 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.

3. 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.

4. 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.

5. OAD monotherapy uptitration OAD + multiple daily insulin injections
Stepwise approach: delays control and leaves patients at risk of complications
OAD monotherapy uptitration
OAD + multiple daily insulin injections
Diet and
exercise
OAD
monotherapy
OAD
combination
OAD + basal insulin 10
Complications2 9
Mean
HbA1c (%)1 8 7 6
Duration of diabetes
OAD = oral antidiabetic
1. Adapted from Del Prato S, et al. Int J Clin Pract 2005; 59:1345– Stratton IM, et al. BMJ 2000; 321:405–412.
Copyright 2005 Blackwell Publishing Ltd. Reproduced with permission of Blackwell Publishing Ltd.

6. OAD + multiple daily insulin injections
Early, intensive intervention: reach glycemic goals and reduce the risk of complications
Diet and
exercise 10
OAD
monotherapy 9
OAD + multiple daily insulin injections
OAD
combination
OAD
uptitration
OAD + basal insulin
HbA1c (%)1 8
Complications2
Mean 7 6
Duration of diabetes
OAD = oral antidiabetic
1. Adapted from Del Prato S, et al. Int J Clin Pract 2005; 59:1345– Stratton IM, et al. BMJ 2000; 321:405–412.
Copyright 2005 Blackwell Publishing Ltd. Reproduced with permission of Blackwell Publishing Ltd.

7. 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.

8. 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
FPG
SBP TC
DBP
TGs = =
Glycemic control
Lipid-lowering
Antihypertensives
HbA1c
HDL
LDL
ABPM
Del Prato S, et al. Int J Clin Pract 2009; in press.

9. 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.

10. 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.

11. 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.

12. 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 be educated about maintaining a healthy lifestyle to prevent weight gain
Since LADA may be present, consider testing for autoantibodies, where possible
-cell
dysfunction 
Del Prato S, et al. Int J Clin Pract 2009; in press.

13. 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.

14. Level of care in patients with type 2 diabetes and sustained hyperglycemia
1.0
0.9
After 2 years, 11% of patients had still not received appropriate care*
0.8
0.7
After 12 months, 25% of patients had not received appropriate care*
0.6
Proportion of patients receiving appropriate care
After 6 months, 41% of patients had not received appropriate care*
0.5
0.4
0.3
0.2
0.1 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.

15. 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.

16. Challenges in increasing adherence
62% took tablets correctly in relation to food
20% regularly forgot to take their tablets
5% omitted tablets if their blood glucose was too high
2% omitted tablets if their blood glucose was too low
Patient adherence to therapy
Browne DL, et al. Diabet Med 2000; 17:528–531.

17. Challenges in improving patient understanding
35% recalled receiving advice about their medication
15% knew the mechanism of action of their therapy
10% taking sulfonylureas knew that they could cause hypoglycemia
20% taking metformin knew it could cause gastrointestinal side effects
Patient knowledge of oral antidiabetic agents
Browne DL, et al. Diabet Med 2000; 17:528–531.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. Increased risk of hypoglycemia with intensive glycemic control: ACCORD20 * 15
16.2% *
Hypoglycemia (%)
Intensive 10
10.5%
Standard 5
5.1%
3.5%
Requiring
Requiring any
medical
assistance
assistance
*P < 0.001
Gerstein HC, et al. N Engl J Med 2008; 358:2545–2559.

24. 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.

25. 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.

26. 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.