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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Striving for Balance: The Importance of Optimal Glucose Control in Type 2 Diabetes


GOAL
The goal of this activity is to provide practicing clinicians with current information regarding the treatment of patients with type 2 diabetes.

TARGET AUDIENCE
This activity is designed for endocrinologists and primary care physicians who treat patients with type 2 diabetes. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Apply currently available treatment strategies for reaching and maintaining A1c target goals in patients with diabetes.
  • Explain the importance of balancing postprandial and fasting glucose levels in maintaining tight glycemic control and preventing comorbid conditions.
  • Employ combination drug regimens effectively to optimize the treatment of patients with type 2 diabetes.
  • Predict and prevent adverse drug reactions such as hypoglycemia, cardiovascular complications, and fluid retention whether using a monotherapy or combination drug regimen.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1 category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity: 1 hour.

Release date: February 15, 2003. Expiration date: February 15, 2005.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an unrestricted educational grant from Aventis Pharmaceuticals Inc.

Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.

Full Disclosure Policy Affecting CME Activities:
As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. Faculty Advisors and Participating Faculty reported the following:

PROGRAM DIRECTORS

    Simeon Margolis, MD, PhD
    Professor of Endocrinology
    Professor of Biological Chemistry
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Margolis reports having no financial or advisory relationships with any corporate organization.

    Christopher D. Saudek, MD
    Professor of Endocrinology
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Saudek reports having no financial or advisory relationships with any corporate organization.

PARTICIPATING FACULTY

    Lawrence Blonde, MD
    Director
    Ochsner Diabetes Clinical Research Unit, Section on Endocrinology, Diabetes and Metabolism, and Associate Residency Program Director in the Department of Internal Medicine at the Ochsner Clinic Foundation.
    New Orleans, Louisiana
    • Dr Blonde reports receiving grant and/or research support from Amilyn Pharmaceuticals, Aventis, Bayer, Becton Dickinson, Bristol-Meyers Squibb, GlaxoSmithKline, Eli Lilly and Company, EMD Pharmaceuticals, MedicaLogic, Medscape, Merck and Company, Novo-Nordisk, Novartis Corporation, Parke-Davis, Pfizer Inc, and Proctor & Gamble; and serving as a consultant to and/or receiving honoraria from Amilyn Pharmaceuticals, Aventis, Bayer, Becton Dickinson, Bristol-Meyers Squibb, GlaxoSmithKline, Eli Lilly and Company, EMD Pharmaceuticals, MedicaLogic, Medscape, Merck and Company, Nobex, Novo-Nordisk, Novartis Corporation, Parke-Davis, and Pfizer Inc.

    Richard Hellman, MD, FACP, FACE
    Clinical Professor of Endocrinology
    University of Missouri/Kansas City School of Medicine
    Kansas City, Missouri
    • Dr Hellman reports having no financial or advisory relationships with any corporate organization.

    John A. Seibel, MD, FACP, MACE
    Director, New Mexico Endocrine Center
    Albuquerque, New Mexico
    • Dr Seibel reports serving as a consultant to Aventis Pharmaceuticals Inc, Merck & Co, Inc, and Solvay Pharmaceuticals.

Notice:
In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Striving for Balance: The Importance of Optimal Glucose Control in Type 2 Diabetes
Christopher D. Saudek, MD,* and Simeon Margolis, MD, PhD†

This issue of Advanced Studies in Medicine focuses on postprandial glucose control as presented at the 11th Annual Meeting & Clinical Congress of the American Association of Clinical Endocrinologists (AACE) held in Chicago, Illinois, May 2002.

Highlights from an interactive symposium titled Balancing the Intricacies of Attaining Treatment Goals in Type 2 Diabetes: Controlling Postprandial Glucose, as well as New Clinical Diabetes Pearls, are featured. Two speakers, Lawrence Blonde, MD, director of the Ochsner Diabetes Clinical Research Unit in the Section of Endocrinology, Diabetes, and Metabolism, and John A. Seibel, MD, director of the New Mexico Endocrine Center, participated in the symposium, each presenting case studies related to postprandial glucose control. Attendees were requested to use keypads to make diagnoses and treatment recommendations. The Pearls, in a newly devised format by Richard Hellman, MD, were selected case studies on new diagnostic or therapeutic findings chosen to encourage and stimulate discussion and participation among attendees.

Background
Most patients with diabetes are not meeting the goal for glycemic control. In an unpublished trial in Texas, the mean glycosylated hemoglobin (A1c) level among patients who were being screened for a clinical trial of glyburide or metformin was 9% (Texas Department of Health, unpublished data, 2001). In nearly 20% of the patients, the level was greater than 11%. Many people are not being tested for A1c levels or for other risk factors for the complications of diabetes. In the same trial in Texas, only 68% of the patients had their A1c levels tested as frequently as recommended. Of these patients, nearly 56% had A1c levels greater than 8%.

Three major studies—the Diabetes Control and Complications Trial, the Kumamoto Study, and the United Kingdom Prospective Diabetes Study—have documented that for every 1.0% reduction in A1c level, there is a significant decrease in the microvascular complications of diabetes.1-3 The case for more aggressive guidelines to control diabetes could not be made more strongly.

The American College of Endocrinology (ACE) has provided new guidelines for glycemic control of type 2 diabetes to lower the risk of complications. In the last 10 years, there have been no guidelines for postprandial blood sugars, even though most people spend several hours a day in a postprandial state. After lengthy discussions, it was determined that the postprandial glucose level at 2 hours should be less than 140 mg/dL.

The ACE also recommends screening at an earlier age. Type 2 diabetes is now occurring more commonly in children and in adolescents. Between 1990 and 1998, the prevalence of type 2 diabetes increased by 76% in adults aged 30 to 39 years.4 The ACE now recommends screening in high-risk populations at any age and in adults aged 30 and older.

The Centers for Disease Control's Behavioral Risk Factor Surveillance System has shown an increasing shift and trend toward a higher prevalence of obesity throughout the United States—an increase of 60% among adults alone.5,6 The 33% increase in the past decade in the prevalence of diabetes among adults has been attributed to increases in obesity. The prevalence rate of diabetes within the total population of the United States is now greater than 7%.5 Certainly better diagnosis accounts for some of this increase; however, the epidemic of obesity among children, teens, and adults puts many more people at risk for diabetes. Early screening among adults, comprehensive standards, and aggressive treatment are critical for preventing complications associated with diabetes. The most successful strategy includes making an early diagnosis, providing more aggressive and early interventions, and offering additional therapies. Remaining with a single medication for too long is no longer acceptable.

Guidelines: Steps to Optimal Diabetes Management
The AACE and the ACE recommend treating type 2 diabetes as aggressively as type 1 diabetes.7 The goal is to prevent acute and chronic complications associated with diabetes. Managing patients with diabetes requires balancing treatment and patient goals with lifestyle. Pharmacologic management should reflect this approach and attempt to balance fasting and postprandial glucose levels. Recommendations for diabetes management addressed in the ACE and the AACE guidelines include the following:

  • Early screening and intervention are essential to improve patient outcomes. The American Diabetes Association recommends screening patients aged 45 years or older who have significant risk factors.8 Screening for high-risk patients is recommended as early as age 30.
    a. Risk factors include a family history of diabetes, cardiovascular disease, obesity, sedentary lifestyle, impaired glucose tolerance or impaired fasting glucose, delivering a baby weighing more than 9 pounds (4 kg), polycystic ovary syndrome, and race (Latin American, African American, Asian American, Native American, or Pacific Islander).
    b. Diagnostic criteria in nonpregnant adults includes symptoms of diabetes associated with a random plasma glucose concentration of 200 mg/dL or more, fasting plasma glucose (FPG) of 126 mg/dL or more, and a 2-hour blood glucose greater than 200 mg/dL during an oral glucose tolerance test (OGTT).
    c. It was also recommended that clinicians use only the FPG, but that the OGTT should also be used to identify high-risk groups and to determine the degree of a patient's glucose intolerance.9
  • The severity of diabetes should be assessed as early as possible along with a thorough physical evaluation to identify coexisting conditions. All comorbid conditions should be aggressively treated.
  • Patients must understand the importance of lifestyle modification, including exercise, nutritional therapy, and smoking cessation, as well as regular self-monitoring of glucose levels.
  • Pharmacologic treatment should be reassessed semiannually. Monotherapy or combination therapy requires direction and monitoring by a physician, because of the complexity of treatment regimens for patients with type 2 diabetes.7
  • A1c levels must be maintained at 6.5% or less. In addition, A1c measurements should be performed at least twice yearly in patients who are at target and at least quarterly in patients who are above target or who are undergoing a change in therapy, or both.4
  • Blood glucose levels should be maintained as follows: A1c of 6.5% or less; preprandial glucose of 100 mg/dL or less; and postprandial glucose of 140 mg/dL or less. Fasting plasma glucose levels greater than 100 mg/dL have been associated with an increased risk of retinopathy and cardiovascular complications.4 Results from the Diabetes Epidemiology: Collaborative Analysis of Diagnostic Criteria in Europe (DECODE) study indicated that postprandial plasma glucose is the most robust determinant of all-cause mortality.10

REFERENCES

1. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993; 329:977-986.
2. Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract. 1995;28(2):103-117.
3. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837-853.
4. Consensus Development Conference Panel. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002; 8(suppl 1):5-11.
5. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001;286(10):1195-1200.
6. Centers for Disease Control and Prevention. Facts about diabetes. Available at: http://www.cdc.gov/od/oc/ media/pressrel/r2K1027a.htm. Accessed January 18, 2001.
7. American Association of Clinical Endocrinologists and the American College of Endocrinology-2002. The American Association of Clinical Endocrinologists medical guidelines for the management of diabetes mellitus: the AACE system of intensive diabetes self-management-2002 update. Endocr Pract. 2002;8(suppl 1):41-82.
8. American Diabetes Association. Clinical practice recommendations. Diabetes Care. 2001;24:S21-S24.
9. Hellman R. Screening and diagnostic testing for diabetes and related conditions. Endocr Pract. 2002;8(suppl 1):
41-82.
10. Zinman B. Postprandial plasma glucose control. Endocr Pract.2002;8(suppl 1):35-36.

*Professor of Medicine, Department of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Professor of Medicine, Professor of Biological Chemistry, Department of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.