NPCC Treatment Guidelines for the Management of Type 2 Diabetes
NPCC Treatment Guidelines for the Management of Type 2 Diabetes
As health care professionals, we are sensitive to the fact that diabetes and its complications are significant and preventable sources of morbidity and mortality. The burden of type 2 diabetes mellitus is substantial, diminishing the physical and economic well-being of those affected. In the United States, an estimated 15.7 million people are afflicted with diabetes, most of whom (90-95%) have type 2 diabetes mellitus. Alarmingly, approximately one-third (5.4 million) of these people do not know they are ill and at risk for serious complications. Each year more than 798,000 Americans are newly diagnosed with diabetes, amounting to a doubling of prevalence rates over the past 2 decades, and these numbers continue to rise. Type 2 diabetes mellitus affects all age groups; the prevalence of the disease among children, adolescents, and young adults is increasing at a precipitous rate.
Type 2 diabetes mellitus is an insidious disease that may emerge and progress silently for years before it is detected, all the while supporting a metabolic environment that fosters long-term microvascular and macrovascular complications. In fact, results of the United Kingdom Prospective Diabetes Study (UKPDS) showed that about 50% of patients presented with complications of diabetes at diagnosis. Diabetes is the leading cause of blindness in patients aged 20-74 years and is associated with as many as 24,000 new cases of blindness each year. Diabetes is also the leading cause of end-stage renal disease, and approximately 60-70% of patients with diabetes develop some degree of neuropathy, including erectile dysfunction.
In addition, 60-70% of all diabetes-related deaths are attributable to the macrovascular manifestations of the disease. Diabetic vascular disease is responsible for a 2- to 4-fold increase in the incidence of coronary heart disease (CHD) and stroke and a 2- to 8-fold increase in the risk for heart failure. Compared with individuals without diabetes, patients with diabetes have a 15- to 40-fold increased risk for lower extremity amputations, accounting for more than 67,000 amputations annually.
Type 2 diabetes mellitus has significant economic consequences as well. In the United States, total direct and indirect costs attributable to diabetes were $98 billion in 1997. This figure includes lost earnings from premature mortality ($17 billion) and disability ($37.1 billion). In a study conducted in 1994 at Kaiser Permanente of Northern California in which the annual costs of medical care were calculated for approximately 85,000 plan members with diabetes and a matched cohort of control subjects without diabetes, the mean per capita medical costs were found to be 2.4 times higher among the patients with diabetes compared with the control subjects.
Poor glycemic control in patients with diabetes also has been correlated directly with increased overall health care costs, largely due to the high expense of managing preventable long-term complications. However, recent reports suggest that the additional medical and pharmacologic costs associated with intensified glycemic control may be offset quickly by other reductions in the utilization of health care. In a large retrospective cohort study, average annual cost savings of $685-$950/patient were realized in health maintenance organizations in just 1-2 years among adult patients with diabetes who sustained a reduction in hemoglobin A1c (HbA1c) of at least 1%. These cost savings were statistically significant only among improved patients with the highest baseline HbA1c values, but measures of health care utilization were consistently lower among the entire group of patients with improved glycemic control.
Although the correlations between hyper-glycemia and long-term complications, decreased quality of life, and increased health care costs are well established -- and the benefits of intensive control are widely known -- the current state of glycemic control remains unsatisfactory. Many patients who are diagnosed with diabetes and who seek treatment do not reach current glycemic goals defined by the American Diabetes Association (ADA) ( Table 1 ). In addition, most patients do not regularly receive all of the recommended services essential for optimal care including, but not limited to, patient education, nutritional counseling, foot examinations, routine measurement of HbA1c, blood pressure screening, ophthalmologic examinations, and cholesterol screening. Even when patients do receive all recommended evaluations, compliance with prescribed therapies is often substandard.
The poor state of glycemic control among patients with type 2 diabetes mellitus necessitates reconsideration of the current treatment paradigm. A compelling and growing body of evidence supports more aggressive, comprehensive management of patients with type 2 diabetes mellitus. Pharmacists are uniquely situated to enhance the state of care effectively for patients with type 2 diabetes mellitus. As medical professionals positioned at the forefront of patient care, it is the pharmacist's obligation to actively seek and judiciously implement the highest standards of care. Pharmacists inherently are aware of the relationship between the specialized and sophisticated body of knowledge they possess and the practical applications necessary to improve the well-being of patients. The multifaceted and dynamic nature of this profession demands the relentless pursuit and utility of the latest data, innovative applications, and evolving practices. Nowhere is this need more apparent than in the treatment of type 2 diabetes mellitus.
Introduction
As health care professionals, we are sensitive to the fact that diabetes and its complications are significant and preventable sources of morbidity and mortality. The burden of type 2 diabetes mellitus is substantial, diminishing the physical and economic well-being of those affected. In the United States, an estimated 15.7 million people are afflicted with diabetes, most of whom (90-95%) have type 2 diabetes mellitus. Alarmingly, approximately one-third (5.4 million) of these people do not know they are ill and at risk for serious complications. Each year more than 798,000 Americans are newly diagnosed with diabetes, amounting to a doubling of prevalence rates over the past 2 decades, and these numbers continue to rise. Type 2 diabetes mellitus affects all age groups; the prevalence of the disease among children, adolescents, and young adults is increasing at a precipitous rate.
Type 2 diabetes mellitus is an insidious disease that may emerge and progress silently for years before it is detected, all the while supporting a metabolic environment that fosters long-term microvascular and macrovascular complications. In fact, results of the United Kingdom Prospective Diabetes Study (UKPDS) showed that about 50% of patients presented with complications of diabetes at diagnosis. Diabetes is the leading cause of blindness in patients aged 20-74 years and is associated with as many as 24,000 new cases of blindness each year. Diabetes is also the leading cause of end-stage renal disease, and approximately 60-70% of patients with diabetes develop some degree of neuropathy, including erectile dysfunction.
In addition, 60-70% of all diabetes-related deaths are attributable to the macrovascular manifestations of the disease. Diabetic vascular disease is responsible for a 2- to 4-fold increase in the incidence of coronary heart disease (CHD) and stroke and a 2- to 8-fold increase in the risk for heart failure. Compared with individuals without diabetes, patients with diabetes have a 15- to 40-fold increased risk for lower extremity amputations, accounting for more than 67,000 amputations annually.
Type 2 diabetes mellitus has significant economic consequences as well. In the United States, total direct and indirect costs attributable to diabetes were $98 billion in 1997. This figure includes lost earnings from premature mortality ($17 billion) and disability ($37.1 billion). In a study conducted in 1994 at Kaiser Permanente of Northern California in which the annual costs of medical care were calculated for approximately 85,000 plan members with diabetes and a matched cohort of control subjects without diabetes, the mean per capita medical costs were found to be 2.4 times higher among the patients with diabetes compared with the control subjects.
Poor glycemic control in patients with diabetes also has been correlated directly with increased overall health care costs, largely due to the high expense of managing preventable long-term complications. However, recent reports suggest that the additional medical and pharmacologic costs associated with intensified glycemic control may be offset quickly by other reductions in the utilization of health care. In a large retrospective cohort study, average annual cost savings of $685-$950/patient were realized in health maintenance organizations in just 1-2 years among adult patients with diabetes who sustained a reduction in hemoglobin A1c (HbA1c) of at least 1%. These cost savings were statistically significant only among improved patients with the highest baseline HbA1c values, but measures of health care utilization were consistently lower among the entire group of patients with improved glycemic control.
Although the correlations between hyper-glycemia and long-term complications, decreased quality of life, and increased health care costs are well established -- and the benefits of intensive control are widely known -- the current state of glycemic control remains unsatisfactory. Many patients who are diagnosed with diabetes and who seek treatment do not reach current glycemic goals defined by the American Diabetes Association (ADA) ( Table 1 ). In addition, most patients do not regularly receive all of the recommended services essential for optimal care including, but not limited to, patient education, nutritional counseling, foot examinations, routine measurement of HbA1c, blood pressure screening, ophthalmologic examinations, and cholesterol screening. Even when patients do receive all recommended evaluations, compliance with prescribed therapies is often substandard.
The poor state of glycemic control among patients with type 2 diabetes mellitus necessitates reconsideration of the current treatment paradigm. A compelling and growing body of evidence supports more aggressive, comprehensive management of patients with type 2 diabetes mellitus. Pharmacists are uniquely situated to enhance the state of care effectively for patients with type 2 diabetes mellitus. As medical professionals positioned at the forefront of patient care, it is the pharmacist's obligation to actively seek and judiciously implement the highest standards of care. Pharmacists inherently are aware of the relationship between the specialized and sophisticated body of knowledge they possess and the practical applications necessary to improve the well-being of patients. The multifaceted and dynamic nature of this profession demands the relentless pursuit and utility of the latest data, innovative applications, and evolving practices. Nowhere is this need more apparent than in the treatment of type 2 diabetes mellitus.
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