Are diabetes management guidelines applicable in ‘real life’?

Abstract

BackgroundThe American Diabetes Association (ADA) has published several diabetes treatment algorithms, but none have been tested in real-life settings. The aim of this study is to analyze the feasibility of achieving and/or maintaining HbA1c levels <7.0% using current diabetes treatment guidelines and the resources available in the public health care system of Brazil.MethodsA one-year, single-arm interventional study was conducted with type 2 diabetes patients in a primary care unit. Intervention consisted of intensification of lifestyle changes and sequential prescription of drugs based on ADA guidelines using the medications available through the publicly funded Unified Health System (Sistema Único de Saúde, SUS).ResultsNinety patients (age: 62.7±10.4 years; diabetes duration: 8.2±9.1 years) completed the trial. During the intervention period, increases were observed in number of oral antidiabetic agent (OAD) classes per patient (1.50±0.74 vs. 1.67±0.7; p=0.015), OAD pills per patient (2.64±1.89 vs. 3.33±2.23 pills/patient; p <0.001), insulin dosage (0.20±0.29 vs.0.50±0.36 UI/kg/day; p=0.008) and number of patients on insulin (19 [21%] vs. 31 [34%]; p<0.01), but no improvement in HbA1c (7.2±1.6% vs. 7.3±1.5%; p=0.453) or frequency of patients on target, defined as HbA1c <7% (53.3% vs. 48.9%; p=0.655). Patients with baseline HbA1c <7% had a small increase in HbA1c during the trial (6.3±0.4 vs. 6.7±0.9%; p=0.002). No such change was observed in those with baseline HbA1c ≥7%.ConclusionsIn this group of patients with a mean baseline HbA1c of 7.2%, implementation of 2006/2009 ADA/EASD guidelines led to achievement of the therapeutic goal of HbA1c <7% in a small proportion of patients.

Multifactorial intervention for diabetes control among older users of insulin

“…A study performed in basic health care 15 with monthly adjustments in the treatment of diabetes, including SMBG, did not find any improvement in glycemic control in any patient. No improvement in glycemic control was observed even when these authors considered only patients with HbA1c greater than 7% at baseline (mean 8.6% [SE = 1.5%]).…”

Improving quality of diabetes care by integrating psychological and social care for poorly controlled diabetes

“…26 The improvements in glycemic control achieved by 3DFD were three times greater than new antidiabetic agents recently introduced onto the market. 27 This improvement is particularly promising considering the longstanding difficulties the patients have had with self-management. 28 The improvement in nonattendance rates from 27.5% to 21% demonstrates that the quality improvement project led to a move towards the national average (12%).…”

Self-Monitoring of Blood Glucose as an Integral Part in the Management of People with Type 2 Diabetes Mellitus

“…Another issue to consider is the number of capillary BG measurements needed to improve glycemic control. A regional study showed that the use of a restricted structured scheme of SMBG (fasting, 3 times a week) did not improve control in people with T2DM not treated with insulin, suggesting that a more intensive anti-diabetic approach would be necessary to obtain better results [ 65 ].…”