Page 48 - The SA Journal Diabetes & Vascular Disease Volume 9 No 4 (November 2012)

190 VOLUME 9 NUMBER 4 • NOVEMBER 2012
REPORT SA JOURNAL OF DIABETES & VASCULAR DISEASE
matic viewpoint that goals must be indi-
vidualised.
The precise glycaemic target should
take into account several factors, including
the patient’s attitude and expected treat-
ment efforts, the risk potentially associated
with glycaemia and other adverse effects,
disease duration, life expectancy, other
co-morbidities, established vascular com-
plications, and the patient’s own resources
and support system (Fig. 1).
For example, some patients may feel that
the weight gain associated with a particular
diabetes therapy is unacceptable and may
want other options considered. Others may
consider risk of hypoglycaemia as something
they want their therapy to address. Patients
who are older and with multiple co-morbidi-
ties will have different issues compared with
a younger, newly diagnosed person who is
otherwise healthy.
‘ The overarching goal should be to
safely reduce blood glucose concentrations
to a range that will substantially minimise
long-term complications but always keep-
ing in mind the potential adversities with
treatment burden, particularly in the elderly
who are more often exposed to multiple
drug treatments’, says Prof Boulton.
This statement, issued by the two lead-
ing academic associations in diabetes
research, points out that there is a need for
numerous studies in specific subgroups of
people of different ages and with different
stages of diabetes, in order to assess the
various possible combinations of glucose-
lowering therapies. Other key points from
the new guidelines:
Diet, exercise and education remain •
the foundation of any type 2 diabetes
treatment programme.
Unless there are prevalent contraindi- •
cations, metformin is the optimal first-
line drug.
After metformin, there are limited •
data to guide treatment. Combination
therapy with an additional one or two
oral or injectable agents is reasonable,
aiming to minimise side effects where
possible.
Ultimately, many patients will require •
insulin therapy alone or in combination
with other agents to maintain glucose
control.
Comprehensive cardiovascular risk reduc- •
tion must be a major focus of therapy.
1. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M,
Ferrannini E, et al . Management of hyperglycaemia
in type 2 diabetes: a patient-centred approach.
Position statement of the American Diabetes
Association (ADA) and the European Association
for the Study of Diabetes (EASD). Diabetologia
2012. DOI: 1007/s00125-012-2534-0.
South African expert comments on
the new EASD/ADA guideline
Dr Larry Distiller
The recently published EASD guidelines for
type 2 diabetes incorporate three new prin-
ciples, which may be considered by some to
be revolutionary when compared to previ-
ous international position statements. Over
the past few years it has become apparent
that it is not scientifically justified to set one
single HbA 1c target for everyone with type
2 diabetes; be it ≤ 7.0% or ≤ 6.5%.
Clinical trials over the past few years,
such as the ACCORD and VADT trials,
have not shown any advantage in induc-
ing tight control in long-standing, high-risk
patients with vascular disease, and in fact
the fear and danger of possible hypogly-
caemia outweigh the advantages of exces-
sively tight glycaemic control. On the other
hand, based largely on the extension of the
UKPDS, it appears that tight glycaemic con-
trol is in fact worth striving for in younger,
newly diagnosed and otherwise healthy
type 2 diabetes patients.
The trend towards individualised targets
is set out clearly in the ADA/EASD position
statement, which indicates graphically the
factors that need to be considered before
deciding on an HbA1 c target for any individ-
ual patient. The SEMDSA guidelines follow
the same principle. The concept of ‘one
size fits all’ no longer applies.
The second major principle that becomes
apparent in this position statement is the
need to discuss therapeutic options with
the patient and for joint patient–doctor
decisions to be made. The days of dictat-
ing treatments to our patients are past.
We need to be mindful that the care we
provide to our patients is respectful of indi-
vidual patient preferences and responds to
their specific needs and values. This may
require much more intensive patient edu-
cation so that they are empowered to help
in the decision-making process.
Thirdly, the treatment algorithm is far
less dictatorial than in the past. Essentially,
any and all treatments can be used in any
order, depending on clinical needs, finan-
cial concerns and patient choice. This, for
the first time, acknowledges that the treat-
ment of diabetes is highly individualised
and that it is more important to achieve
target glycaemic levels. It matters less how
you get there.
The new ADA/EASD guidelines offer a
unique freedom for decision making and
patient–doctor collaboration seldom rec-
ommended in previous guidelines and
mirrors the philosophy inherent in the pub-
lished SEMDSA guidelines.
New analysis shows liraglutide is
more effective when used early in
the management of type 2 diabetes
A new retrospective analysis shows that
patients with a baseline HbA1c level < 8.5%,
a shorter duration of diabetes (< 4.9 years)
and previous treatment with a single anti-
diabetic medicine or diet modification were
most likely to achieve an HbA1 c < 7%, with
no weight gain and no hypoglycaemia over
26 weeks of treatment with liraglutide 1.8
mg.1 The study analysed data pooled from
seven phase 3 clinical trials.
‘ We know from clinical practice that
liraglutide is highly effective at controlling
blood sugar levels, with the added ben-
efit of weight loss’, said Dr Vanita Aroda,
physician investigator from MedStar Health
Research Institute, Hyattsville, USA. ‘These
new results show an increased likelihood of
achieving target glycaemic control (HbA1c
< 7%) with no weight gain and no hypogly-
caemia when liraglutide is used earlier in
the management of type 2 diabetes.’
This new study retrospectively analysed
clinical trial data, which included 1 530
patients with type 2 diabetes, using recur-
sive partitioning analyses to identify factors
that predict greatest therapeutic benefit
in response to treatment with liraglutide.
Responders in the study were defined as
those patients achieving a composite end-
point of HbA1c < 7%, with no weight gain
and no hypoglycaemia over 26 weeks.1
1. Ratner R, et al. Identifying predictors of response
to liraglutide in type 2 diabetes using recursive par-
titioning analysis. Presented at the 48th European
Association for the Study of Diabetes (EASD) annual
meeting, Berlin, Germany, 1–5 October 2012.
Linagliptin is effective and well
tolerated for patients with type 2
diabetes with different background
therapies
A large phase 3 study and three pooled
analyses of phase 3 data show that lina-
gliptin is effective and well tolerated for
patients with type 2 diabetes (T2D), includ-