ADA/EASD Algorithm for Type 2 Diabetes
In August 2006, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) published a joint consensus statement on glucose management in type 2 diabetes. The statement includes a new treatment algorithm for doctors and nurses, which emphasizes four main points:
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Achieving and maintaining normal glycemic levels
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Initiating therapy with lifestyle intervention and metformin therapy
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Rapid addition of more medications for patients over glycemic target
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Early initiation of insulin therapy when needed
The statement focuses on A1c as the measure of glycemic control. While A1c is certainly the gold standard for monitoring therapy, we couldn't help but wonder whether glycemic variability will be used in the future. Certainly, the algorithm is forward-looking to recommend immediate therapy at diagnosis for type 2 patients — metformin is the standard therapy recommended, probably because it is relatively inexpensive and there are many years of demonstrated safety. If patients do not meet the A1c <7% goal on metformin alone, a second oral drug should quickly be added, either a sulfonylurea or a thiazolidinedione (TZD). Rather than suggesting the addition of a third oral drug for patients who are still not at goal, the algorithm recommends insulin therapy. Insulin can be effectively used with an insulin sensitizer such as metformin or a TZD. Although many new drugs have recently become available for type 2 diabetes, the algorithm only recommends metformin, sulfonylureas, TZDs, and insulin, citing issues with cost, efficacy, and lack of data for all other drugs. It is true that Byetta and Symlin had been on the market for less than two years when this statement was drafted, but both doctors and patients have found these drugs so helpful that we believe it would have been useful to include them anyway as alternatives. The oft-changing environment reflects the extent to which the therapeutic landscape is changing so rapidly. Since this statement was published, yet another new class of drugs has entered the market, in the form of Merck's sitagliptin (Januvia), the first DPP-4 inhibitor.
The bottom line: The ADA/EASD recommends that doctors make faster and more aggressive therapy adjustments to help type 2 patients meet and maintain A1c goals. Earlier initiation of insulin therapy is advised. Their therapy algorithm does not recommend use of the new incretin class of drugs, but we tend to think that looking forward, Byetta as well as Symlin will become an increasingly important part of the treatment of type 2 diabetes.
(Nathan D. M. et al. "Management of hyperglycaemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy." Diabetes Care. Aug 2006. 29(8):1963-1972.)
