Changing targets in the treatment of type 2 diabetes

Background: While correction of hyperglycemia remains central to the management of type 2 diabetes, current management approaches address an integrated constellation of disorders that predispose patients to the risk of microvascular and macrovascular complications. Scope: This paper reviews glycemic control targets and associated cardiovascular disease risk management in type 2 diabetes, as recommended by the American Diabetes Association (ADA), the International Diabetes Federation (IDF), and the UK National Institute for Clinical Excellence (NICE). It is based upon MEDLINE literature searches from January 1995 to April 2006. Findings: Current guidelines recommend glycated hemoglobin (HbA(1c)) target levels of approximately 6.0-7.5%. However, European and US data suggest that HbA(1c) targets are achieved by only approximately one-third of patients with type 2 diabetes. Progression from pre-diabetic impaired glucose tolerance to type 2 diabetes has recently become a target for early intervention with pharmacological agents. The aggressive treatment of dyslipidemia towards defined target levels of triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol is recommended. The ADA and OF recommend blood pressure targets of 130/80mmHg in type 2 diabetes, and the use of aspirin for secondary cardiovascular disease prevention and primary prevention in patients at increased risk. Although inflammatory biomarkers, such as C-reactive protein, may predict type 2 diabetes risk, their role remains unclear. Conclusions: Concerted efforts are necessary to increase the proportion of patients achieving current treatment targets. Such measures must aim to educate patients and physicians, remove barriers due to health care organization and access, and improve the monitoring of cardiovascular disease risk indicators. The polypharmacy 'pill burden' may be alleviated through the use of drugs that are effective against multiple aspects of the metabolic syndrome, and by coformulation of agents with established efficacy. Conclusions: Concerted efforts are necessary to increase the proportion of patients achieving current treatment targets. Such measures must aim to educate patients and physicians, remove barriers due to health care organization and access, and improve the monitoring of cardiovascular disease risk indicators. The polypharmacy 'pill burden' may be alleviated through the use of drugs that are effective against multiple aspects of the metabolic syndrome, and by coformulation of agents with established efficacy.