Most individuals with diabetes are cared for by their primary care provider rather than the endocrinologist. According to this committee, whose members were appointed by the ADA, the European Association for the Study of Diabetes (EASD), and the International Diabetes Federation, a diagnosis of diabetes should be made when HbA1c levels are 6.5% or higher. If the patient cannot tolerate the drug at any dose, other options should be considered, such as a sulfonylurea, basal insulin, glucagon-like peptide-1 (GLP-1) mimetic, or a dipeptidyl peptidase-4 (DPP-4) inhibitor, which can improve both postprandial blood glucose and fasting blood glucose. Glucagon-like peptide-1 mimetics can also cause nausea, but patients who experience nausea with metformin will not necessarily experience nausea with GLP-1 mimetics.
Tier 1 treatment continues lifestyle adjustments and metformin and adds a sulfonylurea or basal insulin if not at goal. Tier 2 also continues lifestyle changes and metformin therapy, but it adds a GLP-1 agonist or a thiazolidinedione as add-on therapy (Figure 1). The initiation of therapy with metformin is recommended unless the patient cannot tolerate the agent because of gastrointestinal problems.
Based on the growing national and global prevalence of diabetes, it is essential that physicians screen patients for diabetes and identify individuals at risk for diabetes.
Approximately $1 of every $5 in healthcare spending is used for someone with diagnosed diabetes.
In 1995, the prevalence of diabetes in adults worldwide was approximately 135 million.4 The global prevalence of diabetes in adults aged 20 years and older in 2000 was estimated to be 171 million. Therefore, it is critical to identify diabetes early and to treat intensively with treatment guidelines in mind. The ADA recommends that the test be performed in a laboratory using a method that is certified by the National Glycohemoglobin Standardization Program and standardized to the Diabetes Control and Complications Trial assay.
The recommendation is that all patients be treated with metformin and lifestyle modifications at diagnosis (Figure 1). American Diabetes Association consensus statement for the management of type 2 diabetes mellitus. However, because a GLP-1 agonist is more expensive than other treatment options for add-on therapy and is administered by injection, GLP-1 agonists may represent potential barriers for patients.
If the HbA1c goal is not achieved safely, dual therapy can be added after 2 to 3 months, and triple therapy in another 2 to 3 months if dual therapy is ineffective. American College of Endocrinology and the American Association of Clinical Endocrinologists diabetes algorithm for glycemic control.
Strategies should be developed quickly to modify lifestyle and afford these individuals therapies to reduce blood glucose levels and hopefully reduce diabetes complications. Physicians must be able to identify individuals who are at risk for diabetes and implement strategies to prevent diabetes onset.
India, followed by China and then the United States, has the highest number of individuals with diabetes (Table 1).5 Globally, diabetes prevalence is similar in men and women. It is of equal importance to identify individuals with “at risk for diabetes” and provide sufficient lifestyle modifications for these individuals.
Metformin should be initiated at 500 mg once or twice per day with meals (breakfast, dinner, or both) or 850 mg once per day.11 If gastrointestinal side effects have not occurred after 5 to 7 days, the dose can be advanced to 850 to 1000 mg twice per day (before breakfast and dinner).
Tier 1 included well-validated core therapies, such as metformin, sulfonylureas, and basal insulin, and Tier 2 included less well-validated core therapies, such as TZDs and GLP-1 agonists. Because early diagnosis is critical for reducing the complications of type 2 diabetes mellitus (T2DM), physicians must actively screen for and diagnose diabetes in their practice. Accessed June 9, 2010.2Yokoyama H, Okudaira M, Otani T, Takaike H, Miura J, Saeki A, et al.
Economic costs of diabetes in the US in 2007 [published correction appears in Diabetes Care.
International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes [published online ahead of print June 5, 2009]. Accessed June 9, 2010.12Pratley RE, Nauck M, Bailey T, Montanya E, Cuddihy R, Filetti S, et al. Liraglutide versus sitagliptin for patients with type 2 diabetes who did not have adequate glycaemic control with metformin: a 26-week, randomised, parallel-group, open-label trial. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor sitagliptin added to ongoing metformin therapy in patients with type 2 diabetes inadequately controlled with metformin alone. Accessed July 7, 2010.14Rodbard HW, Jellinger PS, Davidson JA, Einhorn D, Garber AJ, Grunberger G, et al.
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