Managing Special Populations Among Patients With Type 2 Diabetes Mellitus

Jonathan G. Marquess, Pharm.D.

Disclosures

Pharmacotherapy. 2011;31(12):65S-72S. 

In This Article

Abstract and Introduction

Abstract

Glycemic goals and the therapies used to achieve them must be individualized for each patient based on several factors, one of the more important being coexisting conditions such as renal disease, liver disease, and cardiovascular disease. The potential to lower hemoglobin A1c and the possible long-term benefits of diabetes treatments must be balanced with safety issues, adverse effects, tolerability, ease of use, long-term adherence, and expense. The American Association of Clinical Endocrinologists and the American Diabetes Association have addressed these concerns by developing treatment guidelines to maximize efficacy and safety in the majority of patients with type 2 diabetes. Other organizations, including the American Medical Directors Association and the American Geriatric Society, have also published guidelines for diabetes management for patients in long-term care facilities. This review discusses the safety profiles of antidiabetic drugs, and the special treatment needs with respect to these drugs for patients with diabetes and comorbidities such as renal disease, liver disease, and cardiovascular disease.

Introduction

Type 2 diabetes mellitus is a progressive disease characterized by worsening hyperglycemia associated with β-cell failure. The disease requires ongoing medical care, and therapeutic regimens must be modified over time to continuously meet treatment goals.[1] Glycemic goals and the therapies used to achieve them must be individualized for each patient based on several factors, one of the more important being concomitant medical conditions such as renal disease, liver disease, and cardiovascular disease.[2] In addition, history of hyperglycemia, previous antidiabetic therapy, adverse reactions, concomitant drugs, duration of diabetes, life expectancy, cognitive and physical functioning, age, adherence to treatment, and the patient's motivation must be considered when determining treatment regimens.[3]

The potential to lower hemoglobin A1c (A1C) and the possible long-term benefits of antidiabetic treatments must be balanced with safety issues, tolerability, ease of use, long-term adherence, and drug expense.[1] The American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) have addressed these concerns by developing guidelines to maximize the efficacy and safety of treatment for the majority of patients with type 2 diabetes.[2,4] The guidelines provide recommendations for screening, diagnosis, and therapy for type 2 diabetes. Clinicians should use these recommendations to develop treatment regimens individualized to each patient's needs. Additional guidelines from the American Medical Directors Association and the American Geriatric Society address the management of diabetes for patients in long-term care facilities.[5,6]

The AACE also published a consensus statement that emphasizes the safety and efficacy of antidiabetic drugs over their costs,[3] as the expense of the drugs is only a small portion of the total cost of diabetes care. Instead, the focus is placed on the avoidance of hypoglycemia and weight gain by using lifestyle modifications, diabetes education, dietary consultation, self-monitoring of blood glucose levels, and concomitant drug therapy. In the ADA guidelines, the recommended approach for treating hyperglycemia in individuals with type 2 diabetes includes intervention with metformin and lifestyle changes after diagnosis.[2] Therapy should be continued and augmented with other treatments, such as insulin, if necessary, to achieve and maintain glycemic control.

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