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At the beginning of this year's annual conference of the German Diabetes Society (DDG) there is a new guideline for type II diabetes patients of the European and American explosive society. For example, general strict blood sugar level targets are no longer recommended.
The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have published a new joint guideline as a draft. Accordingly, the blood sugar level should always be determined individually based on the characteristics of the diabetic (type 2). Continuous movement, lifestyle changes and diabetes training for those affected remain fundamental to the treatment. According to the guideline, the drug metformin should remain the drug of first choice if there are no medical reasons to oppose it. Alternative medication is, however, only available to a limited extent, since there is usually "limited evidence". However, the guidelines state that means of communication can be considered.
Codecision of the patient important If doctors choose drug therapy, the advantages and disadvantages of undesirable side effects should be weighed up. When controlling the metabolism, those affected will still need insulin in monotherapy or combination therapies. The patient's decision-making is of great importance so that adherence to therapy is guaranteed. Therefore, diabetics should be able to choose the therapies. The main goal remains to reduce weight and reduce cardiovascular risk (cardiovascular diseases such as heart attacks). What is new is that the specialist societies no longer give specific guidelines with strict goals for the adjustment of blood sugar.
Professor Dr. Michael Albrecht Nauck from the Diabetes Center Bad Lauterberg the innovations. The doctor said to the "Ärztezeitung": "No standardized medicine is approved that neither the prescribing doctor nor the patient tastes good". The diabetes expert himself had worked on the new guidelines. Rather, the therapy can now be tailored to the findings and needs of the patient. "It is not important that the HbA1c has no number," said Nauck. In principle, an attitude that is close to a norm is always sought, "if the patient has a long life expectancy and if the adjustment is successful with proven medication and reasonable effort." Then, for example, a glycohemoglobin value of 6.5 percent is acceptable. The general therapeutic goal generally stipulates that the value be kept below 7 to 8 percent in order to delay or avoid secondary diseases.
Treatment goals not too big for older patient groups The diabetologist warned against the newspaper that the treatment goals for older patients with cardiovascular diseases were too big. The recent study "ACCORD" showed that therapists should not try "to give one drug after another and to increase the dose to infinity." Subjects who were intensively medicated and reached a value below six percent showed a higher mortality rate of 22 percent compared to other study participants. Accordingly, high doses in older people can be contraindicated in life expectancy.
Nauck shows an example to the Ärzte-Zeitung: If a patient over 90 years old had a heart attack due to metformin therapy, the value was 8 percent, in his opinion, doctors should “avoid insulin” as far as possible, since hypoglycaemia poses a much greater risk than the increased blood sugar level. Cardiac arrhythmias or falls caused by hypoglycaemia are particularly dangerous for the patient. In addition, older people with type II diabetes are taking several drugs at the same time, which can lead to dangerous interactions. In addition, older people usually suffer from impaired kidney function. Many older people are often overwhelmed with intensive insulin therapy.
Even with athletes who dive or mountaineer, it is important to “avoid hypoglycaemia because it can easily become life-threatening in certain situations,” says Nauck. The choice of medication must be made in consultation with the patient and priorities set.
Medications that lead to obesity This procedure should also apply to products that produce weight gain. Patients often wish to lose weight. Nauck emphasizes that if patients want to get rid of their superfluous finds, exercise more and pay attention to a healthy diet, "then you should not counteract this with drugs that do the opposite."
The expert takes a critical look at the recommendations for action that have been drawn up so far for some medications in the antidiabetic class. The ADA and the EASD had "leaned very far out of the window" on some points. For example, the active ingredient sulfonylurea was recommended as a second-choice agent after metformin. However, the data published so far would not confirm such a preferred recommendation. Therefore, glitazones, DPP-4 inhibitors, GLP-1 agonists and insulin are now also listed as secondary agents in the new guidelines.
Lifestyle changes of great importance After a diagnosis of diabetes, implementing lifestyle changes should remain a high priority. Patients should be motivated to support the measures to change their life part and be encouraged to "participate" right from the start. If the blood sugar level can almost be reached at the individual target value, a period of three to six months should be set for this patient group before the doctor advises that medication should be stopped. However, if it is already apparent after the diagnosis that the patient does not see any options for changing his previous life, it may make sense to start metformin therapy right from the start, as the new guidelines state.
According to the expert, colleagues are already giving suggestions for revising the guidelines. However, Nauck can imagine that "essential elements of this patient-centered approach will be adopted". The annual meeting of the German Diabetes Society started today in Stuttgart and ends on Saturday. (sb)
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