Type 2 diabetes is a progressive disease. This progression is characterised by continuing decline in beta-cell mass and function added to worsening insulin resistance.1 This means that most patients require intensified therapy over time to maintain glycaemic control.1
The consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes recommends that treatment be intensified if HbA1c is persistently ≥7%.5 The International Diabetes Federation Global Guideline for Type 2 Diabetes advises intensification if HbA1c is persistently ≥6.5%.6
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Treatment algorithm for type 2 diabetes5
*These interventions represent the best established and most effective and cost-effective therapeutic strategy for achieving target glycaemic goals, as derived from clinical trials and clinical judgment and published in a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes.
†Sulphonylureas other than glibenclamide (glyburide) or chlorpropamide
‡Insufficient clinical use to be confident regarding safety
Adapted from Nathan DM et al., 2009.5
Note: Guidelines also support the use of premix insulin as a starting insulin, in some cases.6
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Current therapies improve glycaemic control but largely fail to address the underlying decline in beta-cell function. And, as beta-cell function continues to decline, some of these therapies become less effective.1 Developing therapies that can preserve or improve beta-cell function is therefore a key goal.
Other key aspects of progression are development of worsening metabolic abnormalities and the increasing risk of microvascular and macrovascular complications.1
Patient perceptions of disease progression
Intensifying diabetes therapy may be interpreted by patients as a failure of their previous treatment or as a personal failure to follow lifestyle recommendations adequately. This unwarranted feeling of failure occurs more often when patients have to move on to insulin use. In fact, the need to intensify therapy is not a failure of treatment but rather a reflection of the progressive course of type 2 diabetes.2,3,4
A practical guidance to help address the challenges of insulin management throughout the diabetes continuum is available.
In the multinational Diabetes Attitudes, Wishes and Needs (DAWN) survey, almost 55 percent of patients interpreted starting insulin therapy as meaning that they had not succeeded with their previous treatment regimen.2,3 Patients who are reluctant to start insulin or other injectable therapies can benefit from counselling and education programmes such as those that have been developed within the DAWN programme.3
References
1Fonseca VA. Defining and characterising progression of type 2 diabetes. Br J Diab Vasc Dis 2008; 8: S3.
2Korytkowski M. When oral agents fail: practical barriers to starting insulin. Int J Obes Relat Metab Disord. 2002; 26(Suppl 3): S18-S24.
3Skovlund SE, Peyrot M, for the Diabetes Attitudes, Wishes, and Needs (DAWN) International Advisory Panel. The Diabetes Attitudes, Wishes, and Needs (DAWN) Program: a new approach to improving outcomes of diabetes care. Diabetes Spectr. 2005; 18: 136-142.
4Peyrot M, Rubin RR, Lauritzen T et al., Resistance to insulin therapy among patients and providers. Results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) Study. Diabetes Care 2005; 28: 2673-2679.
5Nathan DM, Buse JB, Davidson MB et al., Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009; 32: 193-203.
6International Diabetes Federation guidelines: Global guidelines for type 2 diabetes 2005. Available at: http://www.idf.org. Accessed 21 January 2010.