Successful management of diabetes is possibly one of the biggest challenges faced by the medical fraternity & patients alike.

A newly diagnosed patient with type 2 diabetes, is put on metformin and advised lifestyle modification. If this approach does not meet with success, an algorithmic list of medications is introduced in sequential order to achieve glycemic targets.

However, it must be remembered that diabetes is not a standalone disease but forms a part of the much bigger problem of cardiovascular disease. Therefore, defining any therapeutic target requires that along with glycemic control other risk factors like weight, lipids, blood pressure etc. must also be managed.

The past decade has furthered our understanding of diabetic etiologies & their underlying pathophysiological mechanisms. As it becomes clearer that not all patients will share common pathologies (and most certainly will not share common preferences & values), the usual step-up approach towards medication has begun to appear outdated.

Newer drugs are being developed to target underlying pathophysiological differences – thiazolidinediones help in reducing peripheral insulin resistance, gliptins and incretin mimetics restore gut endocrine mechanisms etc. These newer therapies do not increase CV risk or contribute to weight gain.

The trend now is towards individualizing the management of diabetes by not following an algorithmic approach.

In 2012, the American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) issued consensus recommendations citing individualization of treatment to be the cornerstone of therapeutic success. Clinicians have now begun weighing current evidence of disease along with other constraints – the variable nature of diabetes, specific role of each drug, patient variables of age, ethnicity, co-morbidities etc. before designing a treatment regimen for a patient.

Such a structured personalized approach has been the focus of some patient registries and has shown reduction in risk of myocardial infarction (MI) and diabetes-related end points.

 The increasing role of increasing patient awareness & engagement is also expected to help – home-based testing, smartphone apps that collect, store & analyze patient data – will all contribute to the success of individualized management strategies.

As Dr Matt Petersen, MD of the American Diabetes Association says, “Anything that works for a particular patient is the way to go.”

Dr Vikram Vora is a senior consultant for healthcare communication, corporate medical services and clinical research. He is based in Mumbai and can be reached at drvikramvora@gmail.com

References:

  1. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012 Jun; 35(6):1364-79
  2. Journal of Lancaster General Hospital, Summer 2015 – Vol. 10, No. 2
  3. Structured personal care of type 2 diabetes: a 19 year follow-up of the study Diabetes Care in General Practice (DCGP). 2013 Jun; 56(6):1243-53.