James R. Gavin

Diagnosis and management of prediabetes in the continuum of hyperglycemia: when do the risks of diabetes begin? A consensus statement from the American College of Endocrinology and the American Association of Clinical Endocrinologists.

Alan J. Garber, MD, PhD, FACE, Yehuda Handelsman, MD, FACP, FACE, Daniel Einhorn, MD, FACP, FACE, Donald A. Bergman, MD, FACE, Zachary T. Bloomgarden, MD, FACE, Vivian Fonseca, MD, FACE, W. Timothy Garvey, MD, James R. Gavin III, MD, PhD, George Grunberger, MD, FACP, FACE, Edward S. Horton, MD, FACE, Paul S. Jellinger, MD, MACE, Kenneth L. Jones, MD, Harold Lebovitz, MD, FACE, Philip Levy, MD, MACE, Darren K. McGuire, MD, MHSc, FACC, Etie S. Moghissi, MD, FACP, FACE, and Richard W. Nesto, MD, FACC, FAHA

ACE/AACE consensus conference on the implementation of outpatient management of diabetes mellitus: consensus conference recommendations.

Among the more than 20 million Americans who have diabetes, approximately 30% of the cases are undiagnosed (1). An additional 42 million people in the United States have pre-diabetes (impaired glucose tolerance [IGT], impaired fasting glucose, or both), a condition that often leads to diabetes if it is not treated (1). The dramatic 41% increase in prevalence of diabetes during the 1990s was characterized by a shift to a younger age at onset. The prevalence of diabetes increased more than 70% in the age-group 30 to 39 years (1). The longer the duration of poorly controlled diabetes, the greater the risk for development of vascular complications, including retinopathy, end-stage kidney disease, neuropathy, and coronary artery disease. These complications are not only debilitating but also expensive. In 2002, health-care costs for diabetes in the United States surpassed

How can we implement current therapies and interventions to achieve glycemic control

132 billion (1). These costs were primarily related to the treatment and consequences of complications of diabetes (2). Several large prospective studies have shown that intensive treatment of diabetes can decrease the chronic complications associated with this disease (3-6). There seems to be no glycemic threshold for reduction of complications; the lower the hemoglobin A1c (A1C) level, the lower the rate of occurrence of diabetes-related complications (7). Advances in pharmacologic therapies and new treatment technologies can facilitate reduction of blood glucose values in patients with diabetes to near-normal and achieve glycemic goal levels recommended in current practice guidelines. Nevertheless, the management of patients with diabetes in the United States has actually worsened during the past decade (8). Data from the National Health and Nutrition Examination Survey III in 1994 showed that only 44% of patients with type 2 diabetes achieved an A1C level of less than 7% (9). By the year 2000, this proportion actually decreased to 37% (10). Recently, at an American Association of Clinical Endocrinologists (AACE) meeting, a report on the state of diabetes health showed that, in a study of 157,000 Americans in 39 states, two-thirds of the subjects with type 2 diabetes had A1C values above the American College of Endocrinology (ACE) goal for glycemic control of 6.5% or less (American College of Endocrinology/ American Association of Clinical Endocrinologists. State of Diabetes in America: Striving for Better Control. Available at: http://www.aace.com/pub/StateofDiabetes/ stateofdiabetes.php). Clearly, more aggressive and comprehensive application of these available treatment options, supported by diabetes education, is needed. On January 31, 2005, ACE and AACE convened a 2day consensus conference to review current research and address questions relevant to the treatment of diabetes. The conference brought together US and international diabetes researchers, clinical and educational experts, and ACE/AACE CONSENSUS CONFERENCE ON THE IMPLEMENTATION OF OUTPATIENT MANAGEMENT OF DIABETES MELLITUS: CONSENSUS CONFERENCE RECOMMENDATIONS

Report of the expert committee on the diagnosis and classification of diabetes mellitus

OBJECTIVE To discuss the appropriate use of oral therapies to achieve and sustain glycemic targets in patients with type 2 diabetes. METHODS The stages in the development and progression of type 2 diabetes are reviewed, and the limitations of single-drug therapy are addressed. RESULTS The development of diabetes is a staged progression; affected patients show evolution through numerous stages of glucose intolerance before clinical diabetes manifests. Beta cell function continues to deteriorate until absolute failure occurs; however, other factors, such as glucose and lipid toxicities, insulin resistance in peripheral tissues, and loss of the first-phase insulin response, further impair the bodys ability to regulate release of insulin in response to glucose. Traditional treatment algorithms often fail to address the progressive, multifaceted nature of type 2 diabetes, with its numerous related abnormalities. Combination therapy with orally administered agents can be used to manage glucose concentrations and other risk factors safely and effectively. CONCLUSION The therapeutic goal in type 2 diabetes is to achieve and maintain a physiologic profile as close to normal as possible. This outcome necessitates treatment of multiple defects with use of various combinations of orally administered agents. Clinicians should focus on effective treatment of these defects to achieve established targets.