Endocrinology Groups Update Algorithm on Type 2 Diabetes Management — Physician’s First Watch

Medical News |
January 14, 2016

Endocrinology Groups Update Algorithm on Type 2 Diabetes Management

By the Editors

The American Association of Clinical Endocrinologists and the American College of Endocrinology have updated their 2013 algorithm for managing patients with type 2 diabetes. Available free of charge at the link below, the new algorithm advocates for glycemic control, offers recommendations for blood pressure and lipid targets, and emphasizes obesity and prediabetes as risk factors for diabetes and related complications.

In addition, the document includes a new section on lifestyle optimization (emphasizing diet, exercise, adequate sleep, smoking cessation, and behavioral support) as an adjunct to medical therapy, and it reviews all classes of FDA-approved obesity, antihyperglycemic, lipid-lowering, and antihypertensive medications.

Reader Comments (3)

Padmavathy Menon Physician, Endocrinology, Jupiter Hospital, ex professor & head Endocrinology, SGS Medical colle

I would like it as near normal as possible in young without hypo and in elderly 140 - 200 mg /day may be acceptable.
Guidelines do not advise to reduce the dose of OADs or insulin when the control is being achieved - they are also not asked for increased hunger, a pointed question which is the first sign when on SU. I believe par of "hypo" is lack of insight of the managing physician - hence do not control strictly in young subjects is not acceptable. The principle of smallest dose required to control is very often forgotten by busy physicians


Just suppose, for the sake of argument, that all studies except DCCT and UKPDS 34 support the view that tight glycemic control really does not work and except for treatment with diet or metformin has iatrogenic mortality that exceeds any minimal or no benefit by driving the blood sugar to low normal levels.

This report does not discuss the large body contradictory studies and opinions.

Take out the DCCT study (too small outcome cell numbers)
and the UKPDS 34 (odd and unscientific presentation of data)
and all that is left is 30 years of near religious ideological fervor
that today, I believe, is responsible for morbidity and mortality from the overuse of drugs to lower glucose lab values to levels not supported by any study. This is especially true for use at all of insulin preparations in Type 2 diabetes and overdosing of insulin in Type 1.

Hypoglycemia is always iatrogenic and it occurred in the DCCT trial at a very significant level, more significantly that any of the minor outcomes (the "prime objective" CV mortality, was not impacted). Next to hypoxia, hypoglycemia is the biggest threat to the physiology of the human organism. Hypoglycemia has been "down regulated" as a hindrance to "glycemic control". This is harmful bias not science.

Perhaps the committees need to more thoroughly review of the diabetes literature beginning in 1901 with the Johns Hopkins pathologist Eugene Opie, through Dolger, Siperstein, Shields Warren, Montori, Currie, Cryer, all of the Michael Somogyi papers, Heller, and Ditzel.

The studies on the mitogenic and other negative effects of suprapharmacological administration of human insulin need to be presented, e.g., the effects of insulin on VEGF upregulation and the impact on retinal disease.

The committees might review all of major studies (NICE SUGAR, Veterns, Digami, ACCORD, AHEAD, CHIP, ADVANCE, the University Study, and ORIGIN. Maybe it is time for a meta-analysis?

It is time to replicate the DCCT, which has never been done.

It is time to actually perform the boring but important task of developing actual norms for the lab studies used to diagnosis the disease as the Fajans and Conn (1956) values used today were never formed.

As a practicing physician I am holding off on following these guidelines until the large body of literature with an alternate hypothesis to tight glycemic control is tested.

Thomas F. Kline MD. PhD
Raleigh, NC

Tracy Kolenchuk Other, Other, Healthicine.org

What would the world be like if the goal was to cure Type 2 Diabetes instead of managing it?

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