The VA/DoD Clinical Practice Guidelines for the Management of Diabetes Mellitus issued in 2010 aligns closely with the new ADA position statement regarding glycemic control. The VA/DoD Guidelines support a HbA1c target of less than 7% for younger patients with uncomplicated diabetes and a goal of less than 8% for those who have had the disease more than 10 years, have comorbid conditions and require a combination of medications including insulin to manage the hyperglycemia. The VA/DoD guidelines recommend a range of 8%-9%, although it says that aggressive glucose management is unlikely to benefit patients with advanced microvascular complications or major comorbid illness or a life expectancy of less than five years.

Since 2006, ADA guidelines have provided an algorithm for selection of drug therapies for management of hyperglycemia, but the 2012 statement moves away from a rigidly prescriptive approach toward one that focuses not only on the patients’ pathophysiology and preferences but also on the risk/benefit profile of specific therapeutic agents.

As a result of the approval of new drugs, heightened awareness of side effects and growing uncertainty about the impact of intensive glycemic control on macrovascular complications, “glycemic management in type 2 diabetes mellitus has become increasingly complex and, to some extent, controversial,” the position statement authors note.

“The wide range of pharmacological choices, along with conflicting data about some of those choices and differences in how patients respond to medications, makes it difficult to prescribe a single-treatment regimen based on an algorithm that is designed to work for everyone,” said Vivian Fonseca, MD, president, Medicine & Science of the ADA.

The more flexible guidance also reflects the realities of treatment-adherence factors: price, side effects, patient attitudes and convenience.

“For the first time, the guidelines address a patient’s willingness to be motivated and adherent, as well as their disease state,” said Morello. “They are far more patient-centric.”

As with previous recommendations, the latest consensus statement recommends all patients receive diabetes education with a focus on weight reduction and increased physical activity. For cost and efficacy reasons, metformin remains the preferred first-line drug for most patients. After that, the course of treatment could vary widely.

Unless metformin is contraindicated, the ADA guidelines state that newly diagnosed patients with HbA1c:

• Below 7.5% who are also highly motivated could be encouraged to implement lifestyle changes for three to six months to try to reach target levels prior to initiating pharmacotherapy, generally with metformin.

• Below 9.0% (or lower, if unmotivated to follow diet and exercise recommendations) should immediately start on metformin, in most cases.

• Above 9% should be started on two noninsulin agents or insulin.

• Between 10% and 12% should be seriously considered for insulin therapy from the outset.