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Feature Article

Type 2 diabetes: tailoring a treatment approach

Kharis Burns, N. Wah Cheung
OPEN ACCESS

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Abstract

The past decade has seen major advances in therapies for type 2 diabetes, leading to a wide array of treatment options. Management should involve a patient-centred approach with individualised glycaemic targets and selection of medications based on comorbidities, cost and patient preference.

Key Points

  • Early and optimal glycaemic control in patients with type 2 diabetes is imperative for reducing microvascular and potentially macrovascular complications.
  • Glycated haemoglobin (HbA1c) remains the key focus of glycaemic management although targets should be individualised based on age, comorbidities and life expectancy.
  • There is a vast array of therapies available and treatment algorithms provided by the Australian Diabetes Society offer guidance on treatment selection.
  • Treatment choice should be guided by patient comorbidities, adverse effect profile, acceptability of the method of administration and cost (PBS subsidy).
  • Metformin remains first-line treatment unless contraindicated. Insulin may be considered at any stage, particularly where control is poor (HbA1c above 75 mmol/mol [9%]).
  • Patients with pre-existing cardiovascular disease can be safely managed with new agents, including some DPP4-inhibitors, GLP-1 receptor agonists and SGLT-2 inhibitors, and some therapies may offer cardiovascular mortality benefit.

    Picture credit: Fertnig/iStockphoto.com
    Model used for illustrative purposes only

Type 2 diabetes represents a significant challenge to public health in Australia. With the emergence of the obesity epidemic there has been a steady increase in the prevalence of type 2 diabetes and it has been forecast that between 2000 and 2050 the number of cases in Australia will increase by more than threefold.1 Furthermore, type 2 diabetes is becoming increasingly common in younger patients, and now accounts for 31% of new diagnoses of diabetes in young adults aged 15 to 19 years.2 Research has shown that in 2000, the total estimated annual healthcare cost attributed directly to type 2 diabetes was over $630 million.1

The rapid rise in new diagnoses demands clinicians are well educated in the management of this condition. Additionally, potential micro- and macrovascular complications reinforce the need for early control, not only to improve health outcomes for individual patients, but also to mitigate the impact of the disease burden on the Australian economy.

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HbA1c targets and individualising goals

Glycaemic control remains the principal focus of diabetes management, with glycated haemoglobin (HbA1c) targets dictating most treatment decisions. It is well established that control of blood glucose levels is associated with reductions in the rates of microvascular complications and possibly also the macrovascular complications of myocardial infarction (MI), stroke and all-cause mortality.

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Several seminal trials have emerged over the past 25 years that have informed clinicians about the ideal targets for HbA1c. It is now accepted that the targets should be individualised based on factors including age, other comorbidities and life expectancy.

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Dr Burns is a Consultant Endocrinologist in the Department of Diabetes and Endocrinology at Westmead Hospital, Sydney; and Clinical Associate Lecturer at Sydney Medical School, The University of Sydney. Professor Cheung is an Endocrinologist and Director of the Department of Diabetes and Endocrinology at Westmead Hospital, Sydney; and Clinical Professor at Sydney Medical School, The University of Sydney, Sydney, NSW.