Tailoring Clinical Practice Guidelines for Patients with Type 2 DiabetesPosted September 21, 2011 by Sonal Singh, MD, MPH
Several guidelines emphasize the need to use existing therapeutic options to help patients and providers achieve various treatment goals, including target glycated hemoglobin levels to improve microvascular outcomes among patients with type 2 diabetes. 1 Blood pressure medications and lipid lowering therapy and prophylactic aspirin therapy are recommended to improve cardiovascular outcomes. Influenza and pneumococcal vaccination strategies are recommended to reduce the risk of subsequent infections. Some of these recommendations may also inform the development of national quality indicators. However, we do not know whether adherence to the full range of treatment recommendations or quality indicators translates into net improvement in patient-oriented outcomes. Despite this uncertainty, clinicians are increasingly being required to adhere to practice guidelines. However, translating this evidence from guidelines into practice is challenging.
Firstly, the bulk of the evidence that informs such guidelines are primarily derived from short-term randomized controlled trials of efficacy in a restricted patient population.2 This evidence may not reflect the reality of most patients with type 2 diabetes seen in practice such as the elderly or those with comorbidities who are typically excluded from trials. Clinicians need to tailor these recommendations to various subgroups by reconciling treatment recommendations for type 2 diabetes alongside recommendations for other diseases. For example, it remains unclear whether younger patients with new onset type 2 diabetes should have different treatment goals than older patients with well-established type 2 diabetes. The comorbidity in type 2 diabetes, such as renal failure, also affects the choice of therapy and the need to select treatment goals other than those recommended in guidelines.
Secondly, various guidelines may prioritize their focus on improving glycemic targets or specific cardiovascular outcomes reflecting the preferences of various stakeholders.However, they are usually silent on the balancing the relative priorities of different treatment goals. Patient preferences for various outcomes are often unknown, implicit or assumed to be equal. The heterogeneous nature of a multi-system disease in which patients are at an increased risk of infectious complications such as pneumonia, cancers such as bladder cancer, and fractures, moreover, makes it difficult to choose the ideal treatment option for a given patient.3-6 How to practically implement these myriad treatment guidelines with varying goals and conflicting priorities while considering treatment burden is left to the treating physician within the 15 minute office visit. However, a guideline-concordant therapeutic strategy that achieves one goal, such as reduction in microvascular complications via the thiazolidinediones, may have unintended consequence on cardiovascular outcomes, or bladder cancer, or fractures.3-6
Implementation research is needed on delivering existing effective therapies for type 2 diabetes. Clinical practice guidelines may wish to consider distilling and prioritizing practical, concise, action-oriented, and real-world treatment checklists alongside treatment recommendations. These checklists should flexibly incorporate patient preferences to achieve net improvements in patient-oriented outcomes rather than surrogates.
2. Bennett WL, Maruthur NM, Singh S, et al. Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Ann Intern Med. 2011 May 3;154(9):602-613.
3. Loke YK, Kwok CS, Singh S. Comparative cardiovascular effects of thiazolidinediones: systematic review and meta-analysis of observational studies. BMJ. 2011 Mar 17;342:d1309.
4. Singh S, Loke YK, Furberg CD. Long-term use of thiazolidinediones and the associated risk of pneumonia or lower respiratory tract infection: systematic review and meta-analysis. Thorax. 2011 May;66(5):383-388.
5. Loke YK, Singh S, Furberg CD. Long-term use of thiazolidinediones and fractures in type 2 diabetes: a meta-analysis. CMAJ. 2009 Jan 6;180(1):32-39.
6. Singh S, Loke YK, Furberg CD. Long-term risk of cardiovascular events with rosiglitazone: a meta-analysis. JAMA. 2007 Sep 12;298(10):1189-1195.