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256 American Family Physician www.aafp.org/afp Volume 89, Number 4 ◆
February 15, 2014
“Lending a Hand” to Patients with Type 2
Diabetes: A Simple Way to Communicate
Treatment Goals
DEBORAH R. ERLICH, MD, MMedEd, Tufts University
School of Medicine, Boston, Massachusetts
DAVID C. SLAWSON, MD, University of Virginia School of
Medicine, Charlottesville, Virginia
ALLEN F. SHAUGHNESSY, PharmD, MMedEd, Tufts
University School of Medicine, Boston, Massachusetts
Because sugar was historically the defining feature of
diabetes mellitus (meaning “excess urination of honey”),
treatment focused primarily on lowering blood glucose
levels until recently. However, based on high-quality
evidence from meta-analyses, glucose control should no
longer be the main focus of treatment. A new approach to
the care of adults with type 2 diabetes emphasizes proven
interventions that improve duration and quality of life.
Bolstering data from the University Group Diabetes
Program published in 1970,1
four more recent studies
have shown that intensive treatment aimed at lower-
ing blood glucose levels neither affects mortality nor
decreases complications of type 2 diabetes.2-5
In contrast,
interventions that are especially effective at extending life
in these patients include smoking cessation,6
blood pres-
sure control, and reduction of lipid levels.5
The United Kingdom Prospective Diabetes
Study also showed that treatment with met-
formin (Glucophage) decreases mortality,
regardless of its effect on blood glucose or
A1C levels.7
These findings are reflected in
new guidelines from the American Diabetes
Association and the European Association
for the Study of Diabetes.8
An easy way to illustrate this new
approach to patients is by “lending a hand”
(Figure 1).4,5,7,9-14
From thumb to little finger,
each digit on an open hand portrays one
intervention in decreasing order of benefit:
smoking cessation (thumb), blood pressure
control (index finger), metformin therapy
(middle finger), lipid reduction (ring finger),
and glycemic control (little finger).5,7,14-16
Step 1 (Thumb): Smoking Cessation
Smoking poses a greater risk of morbidity
and mortality than any other physiologic
abnormality in patients with diabetes.15
Addressing other issues without addressing smoking is
like rearranging deck chairs on the Titanic. Smoking ces-
sation is the primary goal except in patients with other
risk factors that are so poorly controlled they will cause
short-term effects (e.g., hypertensive crisis).
Step 2 (Index Finger): Blood Pressure Control
Blood pressure should be decreased to less than 140/80
mm Hg, based on evidence of fewer cardiovascular
events and lower mortality in patients with type 2 dia-
betes.2,10,16-18
Further reducing the systolic blood pres-
sure to 120 mm Hg confers no additional benefit and
may increase the risk of adverse effects, such as syncope,
arrhythmia, and renal failure.18
A thiazide diuretic or
angiotensin-converting enzyme inhibitor should be the
initial choice for pharmacotherapy.16,19
Step 3 (Middle Finger): Metformin Therapy
Metformin therapy delays premature mortality indepen-
dent of its effect on glucose levels, and should be prescribed
for overweight patients with type 2 diabetes unless contra-
indicated.7,20
Lactic acidosis, once associated with phenfor-
min use, is not a risk with metformin, and it is even safe in
patients with moderate renal dysfunction (i.e., glomerular
filtration rate of 30 to 59 mL per minute per 1.73 m2
).21
Editorials
Figure 1. Approach to management of type 2 diabetes mellitus.
Each digit from thumb to little finger represents an intervention, in
decreasing order of benefit. (NNT = number needed to treat.)
Information from references 4, 5, 7, and 9 through 14.
Smoking cessation
Decreases mortality
(NNT=11 over 10 years)9
Blood pressure control
Decreases mortality
(NNT=15 over 10 years)10
Decreases complications
(NNT=6 over 10 years)10
Metformin therapy
Decreases mortality
(NNT=15 over 10 years)7
Decreases complications
(NNT=10 over 10 years)7,11
Lipid reduction
Decreases cardiac
events (NNT=10 to
15 over 10 years)5
Extends life by 3 years
for men12
and by
2 years for women13
Glycemic control
No effect on
mortality4,5
or
clinically relevant
complications14
▲
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Editorials
258 American Family Physician www.aafp.org/afp Volume 89, Number 4 ◆
February 15, 2014
Step 4 (Ring Finger): Lipid Reduction
Lipid reduction decreases cardiovascular mortality in
adults with type 2 diabetes.13,22
Lowering cholesterol lev-
els, preferably with statin therapy and lifestyle changes,
extends life by 3.0 to 3.4 years in men12
and by 1.6 to
2.4 years in women.13
Step 5 (Little Finger): Glycemic Control
Despite the current focus on A1C as an indicator of qual-
ity of care, lowering glucose levels to the nondiabetic
normal range does not significantly affect mortality com-
pared with conventional glycemic control,4
and it does
not reduce the risk of macrovascular complications from
myocardial infarction or stroke.3,14
Glycemic reduction
increases the risk of hypoglycemia and its complications,2
and can actually increase mortality if A1C is lowered con-
sistently below 7.5%.23
Recently revised guidelines from the American Dia-
betes Association and the European Association for the
Study of Diabetes propose less stringent goals (e.g., A1C
less than 8%) for most patients with diabetes who have
comorbidities.8,20
A fasting blood glucose level of less
than 200 mg per dL (11.1 mmol per L) is reasonable in
these patients.8,20
A management plan should center on
controlling hyperglycemic symptoms in concert with
individual patient preferences.
Physicians should not let well-intentioned but mis-
guided concern for glucose levels distract them from
attending to other interventions that more profoundly
affect mortality: smoking cessation, blood pressure
control, metformin therapy, and lipid reduction. This
approach requires a shift in the thinking of patients and
physicians. Patients with type 2 diabetes who currently
focus first on glycemic control will need to “reverse the
hand” to improve the duration and quality of life.
Address correspondence to Deborah R. Erlich, MD, MMedEd, at
drerlich@gmail.com. Reprints are not available from the authors.
Author disclosure: No relevant financial affiliations.
REFERENCES
1. Meinert CL, Knatterud GL, Prout TE, Klimt CR. A study of the effects
of hypoglycemic agents on vascular complications in patients with
adult-onset diabetes. II. Mortality results. Diabetes. 1970;19(suppl):
789-830.
2. Patel A, MacMahon S, Chalmers J, et al.; ADVANCE Collaborative
Group. Intensive blood glucose control and vascular outcomes in
patients with type 2 diabetes. N Engl J Med. 2008;358(24):2560-2572.
3. Boussageon R, Bejan-Angoulvant T, Saadatian-Elahi M, et al. Effect of
intensive glucose lowering treatment on all cause mortality, cardiovas-
cular death, and microvascular events in type 2 diabetes: meta-analysis
of randomised controlled trials. BMJ. 2011;343:d4169.
4. Hemmingsen B, Lund SS, Gluud C, et al. Targeting intensive glycaemic
control versus targeting conventional glycaemic control for type 2 dia-
betes mellitus. Cochrane Database Syst Rev. 2011;(6):CD008143.
5. Huang ES, Meigs JB, Singer DE. The effect of interventions to prevent
cardiovascular disease in patients with type 2 diabetes mellitus. Am J
Med. 2001;111(8):633-642.
6. Yusuf S, Hawken S, Ounpuu S, et al.; INTERHEART Study Investigators.
Effect of potentially modifiable risk factors associated with myocardial
infarction in 52 countries (the INTERHEART study): case-control study.
Lancet. 2004;364(9438):937-952.
7. UK Prospective Diabetes Study Group. Effect of intensive blood-glucose
control with metformin on complications in overweight patients with
type 2 diabetes (UKPDS 34) [published correction appears in Lancet.
1998;352(9139):1558]. Lancet. 1998;352(9131):854-865.
8. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglyce-
mia in type 2 diabetes: a patient-centered approach: position statement
of the American Diabetes Association (ADA) and the European Associa-
tion for the Study of Diabetes (EASD) [published correction appears in
Diabetes Care. 2013;36(2):490]. Diabetes Care. 2012;35(6):1364-1379.
9. Hughes JR. A quantitative estimate of the clinical significance of treat-
ing tobacco dependence. Am J Prev Med. 2010;39(3):285-286.
10. UK Prospective Diabetes Study Group. Tight blood pressure control
and risk of macrovascular and microvascular complications in type 2
diabetes: UKPDS 38 [published correction appears in BMJ. 1999;318
(7175):29]. BMJ. 1998;317(7160):703-713.
11. Srinivasan B, Taub N, Khunti K, Davies M. Diabetes: glycaemic control in
type 2. Clin Evid (Online). 2008. http://www.clinicalevidence.bmj.com/x/
pdf/clinical-evidence/en-gb/systematic-review-archive/2008-03-0609.
pdf(subscription required). Accessed September 11, 2013.
12. Grover SA, Coupal L, Zowall H, Weiss TW, Alexander CM. Evaluating
the benefits of treating dyslipidemia: the importance of diabetes as a
risk factor. Am J Med. 2003;115(2):122-128.
13. O’Connor NR. Diabetes mellitus (type 2). Essential Evidence Plus.
http://www.essentialevidenceplus.com/content/eee/127 (subscription
required). Accessed August 26, 2012.
14. UK Prospective Diabetes Study Group. Intensive blood-glucose control
with sulphonylureas or insulin compared with conventional treatment
and risk of complications in patients with type 2 diabetes (UKPDS 33)
[published correction appears in Lancet. 1999;354(9178):602]. Lancet.
1998;352(9131):837-853.
15. Centers for Disease Control and Prevention. Adult cigarette smoking
in the United States: current estimate. http://www.cdc.gov/tobacco/
data_statistics/fact_sheets/adult_data/cig_smoking. Accessed August
26, 2012.
16. Vijan S, Hayward RA. Treatment of hypertension in type 2 diabetes
mellitus: blood pressure goals, choice of agents, and setting priorities
in diabetes care. Ann Intern Med. 2003;138(7):593-602.
17. Sibal L, Home PD. Management of type 2 diabetes: NICE guidelines.
Clin Med. 2009;9(4):353-357.
18. Cushman WC, Evans GW, Byington RP, et al.; ACCORD Study Group.
Effects of intensive blood-pressure control in type 2 diabetes mellitus.
N Engl J Med. 2010;362(17):1575-1585.
19. Chobanian AV, Bakris GL, Black HR, et al.; Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pres-
sure; National Heart, Lung, and Blood Institute; National High Blood
Pressure Education Program Coordinating Committee. Seventh report
of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure. Hypertension. 2003;42(6):
1206-1252.
20. American Diabetes Association. Standards of medical care in diabe-
tes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.
21. Salpeter SR, Greyber E, Pasternak GA, Salpeter EE. Risk of fatal and
nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus.
Cochrane Database Syst Rev. 2010;(4):CD002967.
22. Ginsberg HN, Elam MB, Lovato LC, et al.; ACCORD Study Group. Effects
of combination lipid therapy in type 2 diabetes mellitus [published cor-
rection appears in N Engl J Med. 2010;362(18):1748]. N Engl J Med.
2010;362(17):1563-1574.
23. Currie CJ, Peters JR, Tynan A, et al. Survival as a function of HbA(1c)
in people with type 2 diabetes: a retrospective cohort study. Lancet.
2010;375(9713):481-489. ■

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“Échale una mano” al paciente con Diabetes tipo 2: Una sencilla manera de comunicar los objetivos del tratamiento

  • 1. 256 American Family Physician www.aafp.org/afp Volume 89, Number 4 ◆ February 15, 2014 “Lending a Hand” to Patients with Type 2 Diabetes: A Simple Way to Communicate Treatment Goals DEBORAH R. ERLICH, MD, MMedEd, Tufts University School of Medicine, Boston, Massachusetts DAVID C. SLAWSON, MD, University of Virginia School of Medicine, Charlottesville, Virginia ALLEN F. SHAUGHNESSY, PharmD, MMedEd, Tufts University School of Medicine, Boston, Massachusetts Because sugar was historically the defining feature of diabetes mellitus (meaning “excess urination of honey”), treatment focused primarily on lowering blood glucose levels until recently. However, based on high-quality evidence from meta-analyses, glucose control should no longer be the main focus of treatment. A new approach to the care of adults with type 2 diabetes emphasizes proven interventions that improve duration and quality of life. Bolstering data from the University Group Diabetes Program published in 1970,1 four more recent studies have shown that intensive treatment aimed at lower- ing blood glucose levels neither affects mortality nor decreases complications of type 2 diabetes.2-5 In contrast, interventions that are especially effective at extending life in these patients include smoking cessation,6 blood pres- sure control, and reduction of lipid levels.5 The United Kingdom Prospective Diabetes Study also showed that treatment with met- formin (Glucophage) decreases mortality, regardless of its effect on blood glucose or A1C levels.7 These findings are reflected in new guidelines from the American Diabetes Association and the European Association for the Study of Diabetes.8 An easy way to illustrate this new approach to patients is by “lending a hand” (Figure 1).4,5,7,9-14 From thumb to little finger, each digit on an open hand portrays one intervention in decreasing order of benefit: smoking cessation (thumb), blood pressure control (index finger), metformin therapy (middle finger), lipid reduction (ring finger), and glycemic control (little finger).5,7,14-16 Step 1 (Thumb): Smoking Cessation Smoking poses a greater risk of morbidity and mortality than any other physiologic abnormality in patients with diabetes.15 Addressing other issues without addressing smoking is like rearranging deck chairs on the Titanic. Smoking ces- sation is the primary goal except in patients with other risk factors that are so poorly controlled they will cause short-term effects (e.g., hypertensive crisis). Step 2 (Index Finger): Blood Pressure Control Blood pressure should be decreased to less than 140/80 mm Hg, based on evidence of fewer cardiovascular events and lower mortality in patients with type 2 dia- betes.2,10,16-18 Further reducing the systolic blood pres- sure to 120 mm Hg confers no additional benefit and may increase the risk of adverse effects, such as syncope, arrhythmia, and renal failure.18 A thiazide diuretic or angiotensin-converting enzyme inhibitor should be the initial choice for pharmacotherapy.16,19 Step 3 (Middle Finger): Metformin Therapy Metformin therapy delays premature mortality indepen- dent of its effect on glucose levels, and should be prescribed for overweight patients with type 2 diabetes unless contra- indicated.7,20 Lactic acidosis, once associated with phenfor- min use, is not a risk with metformin, and it is even safe in patients with moderate renal dysfunction (i.e., glomerular filtration rate of 30 to 59 mL per minute per 1.73 m2 ).21 Editorials Figure 1. Approach to management of type 2 diabetes mellitus. Each digit from thumb to little finger represents an intervention, in decreasing order of benefit. (NNT = number needed to treat.) Information from references 4, 5, 7, and 9 through 14. Smoking cessation Decreases mortality (NNT=11 over 10 years)9 Blood pressure control Decreases mortality (NNT=15 over 10 years)10 Decreases complications (NNT=6 over 10 years)10 Metformin therapy Decreases mortality (NNT=15 over 10 years)7 Decreases complications (NNT=10 over 10 years)7,11 Lipid reduction Decreases cardiac events (NNT=10 to 15 over 10 years)5 Extends life by 3 years for men12 and by 2 years for women13 Glycemic control No effect on mortality4,5 or clinically relevant complications14 ▲ Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2014 American Academy of Family Physicians. For the private, non- commercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
  • 2. Editorials 258 American Family Physician www.aafp.org/afp Volume 89, Number 4 ◆ February 15, 2014 Step 4 (Ring Finger): Lipid Reduction Lipid reduction decreases cardiovascular mortality in adults with type 2 diabetes.13,22 Lowering cholesterol lev- els, preferably with statin therapy and lifestyle changes, extends life by 3.0 to 3.4 years in men12 and by 1.6 to 2.4 years in women.13 Step 5 (Little Finger): Glycemic Control Despite the current focus on A1C as an indicator of qual- ity of care, lowering glucose levels to the nondiabetic normal range does not significantly affect mortality com- pared with conventional glycemic control,4 and it does not reduce the risk of macrovascular complications from myocardial infarction or stroke.3,14 Glycemic reduction increases the risk of hypoglycemia and its complications,2 and can actually increase mortality if A1C is lowered con- sistently below 7.5%.23 Recently revised guidelines from the American Dia- betes Association and the European Association for the Study of Diabetes propose less stringent goals (e.g., A1C less than 8%) for most patients with diabetes who have comorbidities.8,20 A fasting blood glucose level of less than 200 mg per dL (11.1 mmol per L) is reasonable in these patients.8,20 A management plan should center on controlling hyperglycemic symptoms in concert with individual patient preferences. Physicians should not let well-intentioned but mis- guided concern for glucose levels distract them from attending to other interventions that more profoundly affect mortality: smoking cessation, blood pressure control, metformin therapy, and lipid reduction. This approach requires a shift in the thinking of patients and physicians. Patients with type 2 diabetes who currently focus first on glycemic control will need to “reverse the hand” to improve the duration and quality of life. Address correspondence to Deborah R. Erlich, MD, MMedEd, at drerlich@gmail.com. Reprints are not available from the authors. Author disclosure: No relevant financial affiliations. REFERENCES 1. Meinert CL, Knatterud GL, Prout TE, Klimt CR. A study of the effects of hypoglycemic agents on vascular complications in patients with adult-onset diabetes. II. Mortality results. Diabetes. 1970;19(suppl): 789-830. 2. Patel A, MacMahon S, Chalmers J, et al.; ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358(24):2560-2572. 3. Boussageon R, Bejan-Angoulvant T, Saadatian-Elahi M, et al. Effect of intensive glucose lowering treatment on all cause mortality, cardiovas- cular death, and microvascular events in type 2 diabetes: meta-analysis of randomised controlled trials. BMJ. 2011;343:d4169. 4. Hemmingsen B, Lund SS, Gluud C, et al. Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 dia- betes mellitus. Cochrane Database Syst Rev. 2011;(6):CD008143. 5. Huang ES, Meigs JB, Singer DE. The effect of interventions to prevent cardiovascular disease in patients with type 2 diabetes mellitus. Am J Med. 2001;111(8):633-642. 6. Yusuf S, Hawken S, Ounpuu S, et al.; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937-952. 7. UK Prospective Diabetes Study Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34) [published correction appears in Lancet. 1998;352(9139):1558]. Lancet. 1998;352(9131):854-865. 8. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglyce- mia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Associa- tion for the Study of Diabetes (EASD) [published correction appears in Diabetes Care. 2013;36(2):490]. Diabetes Care. 2012;35(6):1364-1379. 9. Hughes JR. A quantitative estimate of the clinical significance of treat- ing tobacco dependence. Am J Prev Med. 2010;39(3):285-286. 10. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38 [published correction appears in BMJ. 1999;318 (7175):29]. BMJ. 1998;317(7160):703-713. 11. Srinivasan B, Taub N, Khunti K, Davies M. Diabetes: glycaemic control in type 2. Clin Evid (Online). 2008. http://www.clinicalevidence.bmj.com/x/ pdf/clinical-evidence/en-gb/systematic-review-archive/2008-03-0609. pdf(subscription required). Accessed September 11, 2013. 12. Grover SA, Coupal L, Zowall H, Weiss TW, Alexander CM. Evaluating the benefits of treating dyslipidemia: the importance of diabetes as a risk factor. Am J Med. 2003;115(2):122-128. 13. O’Connor NR. Diabetes mellitus (type 2). Essential Evidence Plus. http://www.essentialevidenceplus.com/content/eee/127 (subscription required). Accessed August 26, 2012. 14. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33) [published correction appears in Lancet. 1999;354(9178):602]. Lancet. 1998;352(9131):837-853. 15. Centers for Disease Control and Prevention. Adult cigarette smoking in the United States: current estimate. http://www.cdc.gov/tobacco/ data_statistics/fact_sheets/adult_data/cig_smoking. Accessed August 26, 2012. 16. Vijan S, Hayward RA. Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Intern Med. 2003;138(7):593-602. 17. Sibal L, Home PD. Management of type 2 diabetes: NICE guidelines. Clin Med. 2009;9(4):353-357. 18. Cushman WC, Evans GW, Byington RP, et al.; ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1575-1585. 19. Chobanian AV, Bakris GL, Black HR, et al.; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pres- sure; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6): 1206-1252. 20. American Diabetes Association. Standards of medical care in diabe- tes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63. 21. Salpeter SR, Greyber E, Pasternak GA, Salpeter EE. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database Syst Rev. 2010;(4):CD002967. 22. Ginsberg HN, Elam MB, Lovato LC, et al.; ACCORD Study Group. Effects of combination lipid therapy in type 2 diabetes mellitus [published cor- rection appears in N Engl J Med. 2010;362(18):1748]. N Engl J Med. 2010;362(17):1563-1574. 23. Currie CJ, Peters JR, Tynan A, et al. Survival as a function of HbA(1c) in people with type 2 diabetes: a retrospective cohort study. Lancet. 2010;375(9713):481-489. ■