American Diabetes Association–European Association for the Study of Diabetes Position Statement: Due Diligence Was Conducted

A lmost everyone has heard the saying, “If you want to keep a friend, never talk about religion or politics.” In regard to the specific management of type 2 diabetes, we can alter this phrase somewhat and suggest, “If you want to keep a colleague, never talk about diabetes guidelines!” Most providers of diabetes care will readily admit that a forum for intense debate revolves around the issue of what is the best approach to manage individuals with diabetes. A provider can justify his decision for treatment based solely on a wide range of management strategies available in the literature. For example, if you really care to do the exercise by searching on PubMed, you will note that the search term “diabetes management”will result in .24,000 citations. The use of “diabetes guidelines” or “diabetes algorithm” as search terms will yield .8,900 and 3,100 citations, respectively. In addition to the debate based on publications, this topic also evokes considerable emotion. With the release of the latest statement on the management of hyperglycemia in type 2 diabetes, the debate will continue unabated. Specifically, this issue of Diabetes Care reports on the position statement from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Titled “Management of Hyperglycemia inType2Diabetes:APatientCentered Approach,” this effort results from a joint request of the ADA and EASD executive committees and represents the final product of years of work (1). As it has been the case when prior guidelines have been published, not only from these two organizations but also from other societies and federations, this position statement will generate considerable interest, heateddebate, and published commentaries, editorials, and letters on the strengths and weaknesses of the approach. In regard to the message delivered from previously published guidelines, there are providers who strongly feel that given the overall scope of the diabetes burden worldwide and the fact that data continue to state inadequate glycemic control today, an algorithm-based approach should not only be emphasized but also justified. Additional justification for this approach is that it provides a consistent management plan and serves an important purpose to guide providers who may not be as versed in diabetes management. Given the fact that most diabetic patients are not seen in specialized centers, the argument is made that an algorithm-based approach may provide the most feasible management plan that can be applied to the greatest number of subjects. A more defined prescriptive approach is also supported by those who feel that we should reserve the newer therapies only after the traditional agents have failed. In support of this position, the available cost-effectiveness data are cited (although, admittedly, we have very little to date). In addition, the cost of the medication and expense involved in monitoring may be provided as compelling reasons for choosing the specific management approach. On the opposite end of this argument, there is the camp of providers who feel strongly that somuch data has accumulated on the pathophysiology of type 2 diabetes that a specific pharmaceutical approach is warranted in that direction. In reality, however, the majority of providers seem to fall squarely between the two management approaches described above. Basing their decision on a number of important factors, they would suggest the use of all agents. This latter approach essentially selects a particular therapy after carefully considering all relevant factors (e.g., comorbidities, disease duration, resources, etc.) that contribute to the ultimate success or failure of the therapy. The approach to consider all factors and individualize therapy is the approach taken in the ADA-EASD position statement. In this regard, the position statement definitely achieves its objectives. The most attractive aspect of the new position statement is that, more than any other previously reported guidelines to date, it clearly emphasizes that “one size does not fit all.” As stated, the recommendations were “less prescriptive than and not as algorithmic as prior guidelines” (1). Given the varied phenotype, genotype, stage of the patient in the natural history of the disease, and current metabolic state of the patient, we, as providers, fully understand that concept. However, if you are a provider, member of a medical care facility, or representative of a health plan andyour goal is to address glycemic control issues in your patient population based on an algorithm approach that provided guidance for every step in management, you would certainly not endorse the approach taken by the writing group. Instead, we are provided with recommendations for treatment based on a knowledge and understanding of many patient and clinical factors as required before deciding to implement an individualized treatment plan. The need to pursue “individualized” therapy was clearly accelerated from the findings of the Action to Control Cardiovascular Risk in Diabetes (ACCORD), Action inDiabetes andVascularDisease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE), and Veterans Affairs Diabetes Trial (VADT) studies when evaluating cardiovascular end points (2–4). As described, not every subject benefited from intensive glycemic management, although there were suggestions that subsets of patients did benefit. Another area emphasized in the position statement was the need to consider patient preferences in this process. As specifically stated, “Patient involvement in themedical decisionmaking constitutes one of the core principles of evidencebased medicine, which mandates the synthesis of best available evidence from the literature with the clinician’s expertise and patient’s own inclinations.” As such, I really liked the concept emphasized by Fig. 1 in the position statement, and I feel that this graph alone is an incredible teaching tool. This simple graphic provides considerable understanding of the