Diabetes

Reviews/Consensus Reports/ADA Statements
P O S I T I O N S T A T E M E N T

Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach
Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)
SILVIO E. INZUCCHI, MD1 RICHARD M. BERGENSTAL, MD2 JOHN B. BUSE, MD, PHD3 MICHAELA DIAMANT, MD, PHD4 ELE FERRANNINI,MD5 MICHAEL NAUCK, MD6 ANNE L. PETERS, MD7 APOSTOLOS TSAPAS, MD, PHD8 RICHARD WENDER, MD9 DAVID R. MATTHEWS, MD, DPHIL10,11,12 treatment, and smoking cessation) is likely to have even greater benefits. These recommendations should be considered within the context of the needs, preferences, and tolerances of each patient; individualization of treatment is the cornerstone of success. Ourrecommendations are less prescriptive than and not as algorithmic as prior guidelines. This follows from the general lack of comparativeeffectiveness research in this area. Our intent is therefore to encourage an appreciation of the variable and progressive nature of type 2 diabetes, the specific role of each drug, the patient and disease factors that drive clinical decision making (20–23), and the constraintsimposed by age and comorbidity (4,6). The implementation of these guidelines will require thoughtful clinicians to integrate current evidence with other constraints and imperatives in the context of patient-specific factors. PATIENT-CENTERED APPROACHdEvidence-based advice depends on the existence of primary source evidence. This emerges only from clinical trial results in highly selected patients,using limited strategies. It does not address the range of choices available, or the order of use of additional therapies. Even if such evidence were available, the data would show median responses and not address the vital question of who responded to which therapy and why (24). Patient-centered care is defined as an approach to “providing care that is respectful of and responsive to individualpatient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (25). This should be the organizing principle underlying health care for individuals with any chronic disease, but given our uncertainties in terms of choice or sequence of therapy, it is particularly appropriate in type 2 diabetes. Ultimately, it is patients who make the final decisions regardingtheir lifestyle choices and, to some degree, the pharmaceutical interventions they use; their implementation occurs in the context of the patients’ real lives and
care.diabetesjournals.org

G

lycemic management in type 2 diabetes mellitus has become increasingly complex and, to some extent, controversial, with a widening array of pharmacological agents now available (1–5), mounting concernsabout their potential adverse effects and new uncertainties regarding the benefits of intensive glycemic control on macrovascular complications (6–9). Many clinicians are therefore perplexed as to the optimal strategies for their patients. As a consequence, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a joint task force to examine theevidence and develop recommendations for antihyperglycemic therapy in nonpregnant adults with type 2 diabetes. Several guideline documents have been developed by members of these two organizations (10) and by other societies and federations (2,11–15). However, an update was

deemed necessary because of contemporary information on the benefits/risks of glycemic control, recent evidence concerningefficacy and safety of several new drug classes (16,17), the withdrawal/restriction of others, and increasing calls for a move toward more patient-centered care (18,19). This statement has been written incorporating the best available evidence and, where solid support does not exist, using the experience and insight of the writing group, incorporating an extensive review by additional experts...