Type 2 Diabetes: Treat to Target

Funnell MM, Kruger DF. Nurse Pract. 2004;29:11-15, 19-25.

Achieving and maintaining glycemic control is the guiding principle of care in diabetes. Improved glycemic control significantly reduces the risk of developing diabetes-related microvascular and macrovascular complications, as demonstrated in numerous studies, including the landmark Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS). Current treatment targets for adults with diabetes, as recommended by the American Diabetes Association (ADA), are A1C≤7% and preprandial plasma glucose 90–130 mg/dL.

Pharmacologic treatment options for type 2 diabetes include oral agents agents (such as sulfonylureas, thiazolidinediones, α-glucosidase inhibitors, biguanides, and meglitinides), insulin, and insulin analogs. Type 2 diabetes is a progressive disease, and treatment needs to be regularly assessed to ensure glycemic control is maintained. Choice of treatment is dependent on a number of factors: patient history, patient preference, current glycemic control, and the appropriateness of available treatment in terms of mechanism of action and side effects. In newly diagnosed type 2 diabetes, glycemic control can often be achieved by improvements in diet and increased exercise. As diabetes progresses, pharmacological intervention is often required to meet treatment goals and may necessitate monotherapy with an oral agent, combination therapy with oral agents, and ultimately, insulin therapy.

Insulin therapy may be required in patients unable to maintain glycemic control with one or more oral agents (FPG levels >280 mg/dL or A1C>7%). Basal insulin therapy is often introduced first and should be initiated in a step-wise manner to decrease the risk of hypoglycemia. Most patients will eventually require basal and bolus insulin, and there are several different types of insulin formulations that differ in terms of onset, peak, and duration of action.

The commencement of insulin therapy is often difficult for patients. It is important that health professionals are aware of strategies to help patients, which is of particular relevance to nurse practitioners because of the central role they play in helping patients start insulin therapy. Such difficulties can be allayed when diabetes is first diagnosed, by explaining to patients that diabetes is a progressive disease and that treatment may eventually require insulin. Such difficulties can also be addressed through patient education, which should encompass both self-management and nutrition and can assist patients in the day-to-day management of diabetes.

The treatment of type 2 diabetes therefore requires consideration not only in terms of treatment goals and therapeutic options, but also in terms of psychosocial aspects of care, which can directly affect a patient’s ability to manage their condition on a day-to-day basis.