• Diabetes Mellitus
• Cardiometabolic Disorder

As new data emerge and diabetes treatment strategies are modified, the priorities that are associated with diabetes management tend to shift. Clinicians are beginning to take a fresh look at diabetes care goals and are considering personalized approaches versus the standardized care methods. Cardiometabolic risk assessment has become a key component to these new management strategies. Many of these risk factors can be alleviated with lifestyle modification and diet adjustments. Over the past decade, trial data have broadened our understanding of cardiometabolic risk as it applies to diabetes and other health issues. For this reason, a new focus on cardiometabolic risk and prevention is emerging.

According to ADA standards of care in diabetes, the target HbA1C for adult patients with type 1 and type 2 diabetes mellitus should be <7.0% for macrovascular risk reduction [ADA Standards of Care. Diabetes Care 2010]. Craig Williams, PharmD, Oregon Health & Science University School of Medicine, Portland, OR, discussed the current clinical goals for cardiometabolic risk reduction, based on trial data. Cardiometabolic risk reduction involves HbA1C levels, blood pressure (BP), low-density lipoprotein (LDL) cholesterol, and, potentially, aspirin therapy. Current recommended clinical goals are shown in the table below (Table 1). The American Diabetes Association, American Heart Association, and American College of Cardiology guidelines concur with these recommendations and have updated their protocols accordingly. Some data suggest that more aggressive targets are not warranted for CVD reduction [The ACCORD Study Group. N Engl J Med 2010].

The issue of standardized versus personalized diabetes care goals has been a point of contention among diabetologists and primary care physicians alike, and how to best personalize treatment parameters, such as HbA1C, BP, and lipids, remains unclear. Patrick J. O'Connor, MD, HealthPartners Research Foundation, Minneapolis, MN, discussed potential challenges and advantages that are associated with the personalized treatment approach. Standardized guidelines focus on maximizing the percentage of patients who reach evidence-based goals, while personalized guidelines emphasize clinical interventions that best minimize personal or population macrovascular and microvascular complication risks.

Standardized care goals that are derived strictly from evidence-based medicine are not without their flaws, as Dr. O'Connor pointed out. Randomized clinical trial data are often based on patients who differ from the real world in relation to severity of illness, adherence, or access to clinical care.

Standardized care goals that are derived from observational studies may not accurately determine optimal ranges of A1C, BP, and lipids. For example, epidemiological data suggest that any A1C level over normal increases risks of macrovascular complications, but recent clinical trials have not shown reduced cardiovascular mortality when patients with elevated A1C are aggressively treated to normal A1C. In the world of clinical intervention, more is not always better. Beyond a certain point, aggressive treatment may not have a favorable impact on outcomes. In certain circumstances, patients may benefit from more moderate goals.

Prioritization of treatment strategies that are based on individual absolute risk and benefit may be the preferred method moving forward. Such an approach is based on an obvious fact—not all evidence-based care recommendations have equal benefit to a given patient at a given time. The goal of prioritized care is to identify which clinical interventions have the most benefit while taking into account patient preference.

Adoption of a prioritized approach to care may reduce polypharmacy and the cost of care while maintaining or improving good clinical outcomes. However, such an approach will require modification of accountability measures to focus more on risk reduction rather than achievement of specific standardized goals in the clinical “silos” of glucose, BP, or lipid control, for example.

In order to streamline this personalized approach, electronic tools may facilitate tailored decision-making. Richard W. Grant, MD, Massachusetts General Hospital, Boston, MA, discussed personalized diabetes care in the setting of electronic software. The algorithms within such software could be tailored to the individual patient's preferences and could reflect the philosophy of the clinician. Health IT tools have the potential to foster patient-physician collaboration through online web portals and allow implementation of personalized decision-making algorithms without adding to the treatment burden. Additionally, fast-track tools may generate letters and treatment recommendations between visits at the clinician's discretion, keeping the lines of communication open throughout the duration of treatment. In a study by Grant and colleagues that evaluated the effect of the personalized approach using electronic health record software in diabetic patients, patients took an active role in their diabetes management, and a diabetes care plan was developed based on their individual risks and needs. Those in the intervention arm demonstrated an increase in active medication management compared with control (p<0.001) [Grant RW et al. Arch Int Med 2008]. The use of electronic tools may assist clinicians in the transition from standardized to personalized care.

Cardiometabolic risk assessment is becoming an integral part of diabetes care strategies. Clinicians are beginning to modify their methods of treatment, based on risk profiles. The medical community has become more aware of the impact of lifestyle and other factors on diabetic management. New treatment strategies, such as personalized goals and care plans, are on the horizon and may influence the global problem of obesity and cardiometabolic syndrome.

• © 2010 MD Conference Express