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Pharmacists can now refer to a new treatment algorithm for the metabolic management of Type 2 diabetes when caring for patients. This is one new addition to the Standards of Medical Care in Diabetes-2007 from the American Diabetes Association (ADA). The clinical practice guidelines have been updated to include new information about treatment and prevention that reflects the latest research.
"The new algorithm was based on a consensus guideline published in the August 2006 Diabetes Care journal," said Holly S. Divine, Pharm.D., CGP, CDE, associate professor, Pharmacy Practice and Science Department, University of Kentucky. Although lifestyle interventions are a first step to management of Type 2 diabetes, the reality is that most people will not pursue them, which further delays reducing blood glucose levels, she explained. "Metformin is a safe, cost-effective medication that has been proven to target one of the main issues with Type 2 diabetes-the production of glucose from the liver."
This year, a table of agents used to treat distal symmetric polyneuropathy (DPN) has also been added. Although the guideline says the first step in management of patients with DPN should be to aim for stable and optimal glycemic control, most patients will require medication for painful symptoms. While many of the drugs suggested have proven efficacy in published trials, none has been officially approved for DPN.
According to Divine, it's important to realize that the agents for treating DPN do not treat the complication itself, and selection of these agents should include an evaluation of potential adverse effects, how well the patient might respond, and cost-effectiveness. "Advantages and disadvantages of these agents are based primarily on adverse-effect profiles," she said.
Candis M. Morello, Pharm.D., CDE, an assistant professor of clinical pharmacy at the University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, agrees. "Compared with anticonvulsants, tricyclics cause more sedation, constipation, and weight gain," she said. However, she also pointed out that anticonvulsants can cause dizziness, sedation, and changes in thought processes. "Overall, tricyclics are less expensive and may be worth trying first."
Finally, based on recent research, this year the ADA has added a statement suggesting that ACE inhibitors be discontinued prior to childbearing in women.