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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe International Diabetes Federation estimates that up to 1 adult in 10 will have diabetes by 2030 [International Diabetes Federation. \u003Cem\u003EIDF Diabetes Atlas\u003C\/em\u003E. 5th ed. 2009]. To better handle this impending crisis, the latest American Diabetes Association and European Association for the Study of Diabetes guidelines present a new perspective on the management of hyperglycemia in type 2 diabetes (T2DM) [Inzucchi SE et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2012; Inzucchi SE et al. \u003Cem\u003EDiabetologia\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EHyperglycemia\/Hypoglycemia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENursing Diabetes \u0026amp; Endocrinology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes Mellitus\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThe International Diabetes Federation estimates that up to 1 adult in 10 will have diabetes by 2030 [International Diabetes Federation. \u003Cem\u003EIDF Diabetes Atlas.\u003C\/em\u003E 5th ed. 2009]. To better handle this impending crisis, the latest American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) guidelines present a new perspective on the management of hyperglycemia in type 2 diabetes (T2DM) [Inzucchi SE et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2012; Inzucchi SE et al. \u003Cem\u003EDiabetologia\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EDavid R. Matthews, MD, DPhil, The Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom, discussed the individualization of treatment, including the need for the new guidelines, their development, and the likely effect on the treatment of hyperglycemia.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe two organizations issued the joint statement for many reasons, including an increasing number and variety of agents, trial data that challenges the simplistic view of \u201cthe lower the better\u201d approach to glycemic control, concerns about the safety of some medications, an algorithmic management approach that few physicians use in practice, concerns by some purchasers of health care and advisory bodies about a \u201cone size fits all\u201d treatment strategy, and increasing discourse about patient-centered medicine.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EMore than other previously reported guidelines, the 2012 ADA\/EASD position statement clearly states that one size does \u003Cem\u003Enot\u003C\/em\u003E fit all [Cefalu WT. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2012]. For the first time, the guidelines also stress patient preferences in the treatment process, an approach that takes into account patient attitudes, risks of therapy, disease duration, life expectancy, comorbidities, the presence of complications, and available resource and support systems (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/9\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022The Elements of Decision Making Used to Determine Appropriate Efforts to Achieve Glycemic Targets.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-282252093\u0022 data-figure-caption=\u0022The Elements of Decision Making Used to Determine Appropriate Efforts to Achieve Glycemic Targets.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/9\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/9\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/9\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13082\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EThe Elements of Decision Making Used to Determine Appropriate Efforts to Achieve Glycemic Targets.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced from Inzucchi SE et al. Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach. \u003Cem\u003EDiabetes Care\u003C\/em\u003E Jun 2012;35(10):1364\u20131379, with permission from the American Diabetes Association.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003EProf. Matthews explained the importance of striving for patient centrality, noting that patient involvement is much more crucial in chronic versus acute disease due to the priority for self-care. He stressed that it improves compliance and is more cost effective.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EMaking a Difference\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EDespite its departure from the more traditional, algorithm-based guideline, there are no guarantees that the new position statement will do anything more than generate a wide range of opinions and emotions among those in the medical community [Cefalu WT. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2012]. Amanda Adler, MD, PhD, Institute of Metabolic Sciences, Cambridge, United Kingdom, discussed the guidelines\u0027 strengths, areas for future improvement, whether they will make a clinical difference, and what is next.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EAmong the position statement\u0027s strong points, Prof. Adler noted the enormous amount of work that went into creating it\u2014more than 45 revisions between 2010 and 2012 [Cefalu WT. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2012]\u2014and described its recommendations as thoughtful and sensible. She agreed with the need for quality-of-life research and trials that deliver meaningful data on meaningful outcomes, and acknowledged the challenge of offering therapies to patients with multiple morbidities.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EProf. Adler said that many factors\u2014pro and con\u2014will determine whether the guidelines affect actual practice. On the con side, there is a lack of evidence that a patient-centered approach leads to better health, the fact that the ADA already calls for \u0026lt;7.0% HbA1C in most (but not all) patients, and the fact that the recommendations differ from others that people might prefer.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EThe new guidelines stand the greatest chance of promoting change if they inspire further research, and are understood, read, discussed, and disseminated; included in quality-improvement activities; easy to remember; applied where clinicians lack the latest information; and developed by influential, successful people who are widely admired.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EAccording to Prof. Adler, the next round of guidance needs to be more inclusive, transparent, and evidence-based. In the interim, the goals of the ADA\/EASD guidelines are to inspire clinicians to think about and choose treatment targets and strategies that best serve their patients. \u201cAspiring to this is unquestionably good,\u201d she said.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EThe Changing Role of Drugs\u003C\/h2\u003E\n         \u003Cp id=\u0022p-13\u0022\u003ESilvio E. Inzucchi, MD, Yale University, New Haven, Connecticut, USA, discussed the role of drugs in the management of hyperglycemia and related questions addressed in the new guidelines. He focused on the best drug to initiate therapy, the next steps if glucose is inadequately controlled, whether there is an optimal sequence of medications, when insulin should be used, and what patient features should guide therapy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EThe burden of treatment for many people with complex chronic comorbidities must be acknowledged in the development of any treatment program; the clinician must weigh the benefits and risks of each therapy, especially in older patients who are managing multiple clinical conditions. Prioritizing from the patient\u0027s perspective is important [May C et al. \u003Cem\u003EBMJ\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EGiven the increase in the number of medications for T2DM, clinicians and patients need information about their effectiveness and safety to make informed choices [Bennett WL et al. \u003Cem\u003EAnn Intern Med\u003C\/em\u003E 2011]. Dr. Inzucchi explained that each drug class has a unique mechanism of action and lowers blood glucose to about the same extent. Many drugs have additional benefits, but their long-term effects are unknown. Moreover, there are major differences in side effects and costs (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13086\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13086\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13086\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-16\u0022 class=\u0022first-child\u0022\u003EProperties of Anti-hyperglycemic Agents.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EAccording to Dr. Inzucchi, glycemic targets and blood glucose-lowering therapies must be individualized. Diet, exercise, and education are the foundation of any T2DM therapy program. Unless contraindicated, metformin is the optimal first-line drug; however, more data are limited. Nonetheless, combination therapy with 1 to 2 other oral\/injectable agents that minimize side effects is reasonable. Ultimately, many patients will require insulin therapy alone or in combination with other agents to maintain blood glucose (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/9\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Antihyperglycemic Therapy.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-282252093\u0022 data-figure-caption=\u0022Antihyperglycemic Therapy.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/9\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/9\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/9\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13084\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-19\u0022 class=\u0022first-child\u0022\u003EAntihyperglycemic Therapy.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Inzucchi SE et al. Management of Hyperglycemiain Type 2 Diabetes: A Patient-Centered Approach. \u003Cem\u003EDiabetes Care\u003C\/em\u003E Jun 2012;35(10):1364\u20131379, with permission from the American Diabetes Association.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EEarlier guidelines focused drug treatment choices mainly on HbA1C levels after lifestyle modification [Robard H et al. \u003Cem\u003EEndocr Pract\u003C\/em\u003E 2009]. For example, Nathan et al. [\u003Cem\u003EDiabetes Care\u003C\/em\u003E 2008] recommended that clinicians check HbA1C levels every 3 months until \u0026lt;7.0%, then at least every 6 months thereafter, with new drug interventions whenever HbA1C levels reach \u22657.0%.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EThe new ADA\/EASD guidelines shift the focus on medication choices from HbA1C levels alone and add patient-centered considerations. Dr. Inzucchi emphasized the need to make all treatment decisions in conjunction with patients (with a focus on their preferences, needs, and values) and stressed that comprehensive cardiovascular risk reduction should be a major focus of therapy.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/16\/9.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzn8hp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzn8hp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzn8hp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}