Practice Recommendations
- Patients should be screened for diabetes at age 45 years—earlier if they are overweight and have at least 1 other risk factor.
- Management of type 2 diabetes requires a multifactorial approach that includes not only glycemic control but also addresses such risk factors as hypertension, dyslipidemia, renal impairment, and obesity.
- Tight glucose control (A1C <7%) may require intensive therapy with more than one antiglycemic agent. Early addition of basal insulin may be an efficient way to achieve A1C targets in some patients.
According to the latest estimates by the American Diabetes Association (ADA), more than 12.1 million persons in the United States have been diagnosed with diabetes and about 6 million remain undiagnosed.1 Type 2 diabetes, which comprises the majority (up to 95%) of all diabetes cases,2 has a profound impact on patient health and quality of life and places significant burdens on the health care system. For example, it confers a risk for myocardial infarction (MI) and cardiovascular mortality that is comparable to that for patients who have previously had an MI.3
Economically, the costs of diabetes in the United States are overwhelming: direct and indirect medical expenditures related to diabetes totaled $132 billion in 2002 and are expected to increase to $192 billion annually by 2020.1 Demographically adjusted, per-capita expenses for persons diagnosed with diabetes are more than double those of persons without diabetes.1
Clinical challenge
Type 2 diabetes poses a major challenge to primary care physicians, who are the main providers of care for about 80% of patients with this disease.4 Patients may present with a variety of complications, including neurologic, peripheral vascular, cardiovascular (eg, MI, stroke), renal, and ophthalmic disorders.1 Often, both microvascular and macrovascular complications precede the initial diagnosis of diabetes.5
Results of randomized clinical trials and population-based studies confirm that secondary preventive measures (ie, ameliorating risk factors in patients with known diabetes) and improved glycemic control can help reduce diabetes complications.3,6 A multifactorial approach that both achieves glycemic control and addresses other risk factors, such as dyslipidemia, hypertension, and microalbuminuria, has been demonstrated to be important, particularly for reducing macrovascular complications.7-9 Treatment goals for patients with type 2 diabetes include: an A1C value of <7.0%, a low-density lipoprotein cholesterol level of <100 mg/dL, and a blood pressure level of <130/80 mm Hg.10-12
The United Kingdom Prospective Diabetes Study (UKPDS 35)—in a posthoc observational substudy—suggested that there is “no threshold” for A1C lowering for any type of diabetes complication, indicating that treatment probably should aim to bring the A1C level as close to normal as possible.6 Thus, the American College of Endocrinology (ACE), for example, has set an even more aggressive A1C goal of ≤6.5%.13 Organizations such as the ADA and ACE believe that lower A1C targets not only are beneficial but that they also are achievable with currently available therapeutic agents. Ultimately, an individual patient’s comorbid conditions, life expectancy, and preferences must be considered when determining goals.14
Despite compelling outcomes data, the prevalence of diabetes remains high and clinical control remains suboptimal. The Health Plan Employer Data and Information Set, a widely used tool for measuring quality of health care, currently considers an A1C of >9.5% as “poorly controlled” disease.15 According to data from the Third National Health and Nutrition Examination Survey, 18% of patients with diabetes have an A1C of >9.5%.16 In areas where obesity is highly prevalent, such as New Orleans, the percentages are even higher, with up to 43% of obese patients treated at urban teaching hospitals in that area having A1C values of >9.5%.17 The Diabetes Quality Improvement Project, which governs 20 public and private health care organizations, found that 35% of its patients had a mean A1C of >9.5%.18 Considering that 9.5% is well above the ADA goal of <7.0%, data such as these underscore the need for more widespread diabetes screening and earlier intervention.
Identifying diabetes
The ADA recommends that screening with a fasting plasma glucose test be considered in all patients aged 45 years and older, particularly those with a body mass index of 25 kg/m2 or more.19 If the results are normal, screening should be repeated every 3 years. However, patients who are thought to be at increased risk should be considered for more frequent screening. The ADA recommendations have been endorsed by the American Academy of Pediatrics. The American Academy of Family Physicians follows the recommendations established by the US Preventive Services Task Force: screening is suggested in adults with hypertension or dyslipidemia.20