Personalizing guidelines for diabetes management: twilight or dawn of the expert?
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OPINION
Open Access
Personalizing guidelines for diabetes management: twilight or dawn of the expert? Stavroula A Paschou1 and Richard David Leslie2*
Abstract Background: This opinion article on the management of type 2 diabetes considers the old and new format of guidelines and critical changes in the character of such guidelines. We highlight limitations of the guidelines and make recommendations for how treatment can be more personalised. Discussion: Published guidelines for the management of adult-onset non-insulin requiring diabetes have adopted a formulaic approach to patient management that can be overseen centrally and delivered by personnel with limited training. Recently, guidelines have taken a patient-centered, multiple risk-factor approach. Importantly, local funding issues are considered, but drive the final action and not the decision-making process. The nature of the disease can be determined by laboratory tests, including screening for diabetes-associated autoantibodies. The strategy remains step-up, with intensification of drug or insulin dose. As with past guidelines, there is an assumption that in each patient with type 2 diabetes, metformin is used initially, but targets and therapies then veer in different directions to create a matrix of options based on the features and responses of each individual. Factors to consider include: (A)ge, (B)ody weight, (C)omplications and co-morbidities, Diabetes (D)uration and (E) xpense, but also patient preference and patient response. Summary: Guidelines for the management of type 2 diabetes have important limitations and a patient-centered, multiple target, multiple therapy approach is proposed. Keywords: Type 2 diabetes, Guidelines, Personalised treatment, Diabetes management, Patient-centered therapy
Background Ancient Greek Hippocrates (c. 460 BC to c. 370 BC) advised physicians for patients: ‘ωφελέειν ή μη βλάπτειν’, ‘to do good or to do no harm'. Modern physicians take the Hippocratic Oath in its various forms, but remain committed to the risk-benefit ratio implicit in this statement, to the overall benefit of their patients. Diabetes is a complex disease characterized by deterioration of glycaemia and co-morbidity. In adult patients, the comorbidity is often the result of a risk factor spectrum associated with a high proportion of cases and broadly identified as the Metabolic Syndrome, with the clustering of obesity, hypertension and dyslipidemia, as well as hyperglycemia [1-5]. In contrast to disease nosology, therapies have no identity, only a mode of action, a list of side-effects and a financial cost. Today we have many drugs in our armamentarium to treat type 2 * Correspondence: [email protected] 2 Department of Diabetes, St Bartholomew’s Hospital, London EC1A 7BE, UK Full list of author information is available at the end of the article
diabetes, but many of these drugs are relatively new. So, deciding which direction to take for any given patient, even whether to use drugs at all, is akin to standing on shifting sands. That decision
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