Translating ADA/EASD Guidelines and the ACE/AACE Road Maps into Primary Care of Patients with Type 2 Diabetes

Article Outline

• Abstract
• What's New About ADA/EASD Guidelines and the ACE/AACE Road Maps?
• Self-Management, Glucose Monitoring, and Dose Adjustment as a Means of Achieving A1C Targets
  • Glucose Monitoring
  • Glycemic Control in Patients with T2DM
  • Case Study 1: The Treatment-Naïve Patient
  • Case Study 2: Routine Follow-Up of a Patient With T2DM
• Education and Resources
  • Case Study 3: Patient Education
• Conclusion
• References
• Uncited reference
• Copyright

Abstract 

Optimal glycemic control is fundamental to diabetes management. New diabetes guidelines suggest that recommended glycated hemoglobin (A1C) targets for Type 2 diabetes can be, for most patients, achieved through a stringent, multi-pronged, multi-disciplined approach comprising early and focused intervention, regular monitoring, timely changes to medication, early use of combination therapy, early use of insulin, and patient empowerment through education. Using examples from real-life patient care, the implementation of these guidelines is reviewed from the perspective of the advanced practice nurse.

Keywords:  A1C , glycemic control , management guidelines , Type 2 diabetes

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According to the American College of Endocrinology (ACE) and American Association of Clinical Endocrinologists (AACE), diabetes practitioners must do more to ensure that their patients with Type 2 diabetes (T2DM) achieve glycemic targets.¹

One reason for this rallying cry is the alarming increase in the number of pre-diabetes (where blood sugar levels are higher than normal, but not yet high enough to be diagnosed as diabetes) and T2DM cases in the US.², ³ A recent estimation puts the number of people in the United States with pre-diabetes at 54 million, while those with diabetes number 23.6 million, of whom 90% to 95% have T2DM.³ Another reason is the current failure of some 63% of patients with diabetes to achieve target glycemic levels (glycated hemoglobin [A1C] ≤ 7%).⁴ This failure is associated with the progressive development of diabetic complications, such as cardiovascular disease, nephropathy, retinopathy, and neuropathy,⁵ which in the short term reduce quality of life, but in the long term are associated with serious complications or premature death.

Specialist (ACE/AACE) and diabetes (American Diabetes Association [ADA]/European Association for the Study of Diabetes [EASD]) societies have already taken steps to change this alarming scenario. Although glycemic targets had been set for some years, clear guidelines on how best to attain them had not been developed, in part because of the lack of therapeutic options. However, in 2005, ACE/AACE guidelines derived from a consensus conference were developed with the aim of more effectively implementing glycemic goals.⁶ To simplify their message and improve treatment in real-life clinical settings, representatives of ACE and AACE met again to create the “Treat-To-Target Road Map.”¹ Figure 1, Figure 2 present the Road Map recommendations for those naïve to therapy and for treated patients. Within the same time period, a treatment algorithm for the management of hyperglycemia in adults with T2DM was developed by ADA/EASD to aid selection of the most appropriate interventions.⁸ This algorithm has been incorporated into the 2008 annual update of the ADA “Standards of Medical Care in Diabetes.”⁵

This article presents the key messages issuing from current guidelines on diabetes care and illustrates ways in which nurse practitioners can use these messages to improve diabetic management in the community.

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What's New About ADA/EASD Guidelines and the ACE/AACE Road Maps? 

The ADA/EASD guidelines⁵, ⁸ and ACE/AACE Road Maps⁶, ⁹ base their recommendations for the prevention or treatment of diabetes on data from large clinical studies,¹⁰, ¹¹, ¹², ¹³, ¹⁴ as well as other influential sources.⁶, ¹⁵, ¹⁶, ¹⁷ They differ markedly in their focus and depth (Table 1). While both provide treatment guidance from the time of diagnosis, actual approaches differ. For example, developed by endocrinologists, ACE/AACE guidelines⁶ set more aggressive target A1C levels than the ADA/EASD guidelines⁵, ⁸ (≤ 6.5% vs < 7%); they also stratify patients into treatment-naïve and treated groups. In contrast, ADA/EASD guidelines⁵, ⁸ are unstratified and more general.

Table 1. Diabetes Type 2 Treatment Guidelines: Focus and Depth

AACE = American Association of Clinical Endocrinologists, ACE American College of Endocrinology, ADA = American Diabetes Association, EASD = European Association for the Study of Diabetes, FPG = fasting plasma glucose, HDL-C = high-density-lipoprotein cholesterol, LDL-C = low-density-lipoprotein cholesterol, OAD = oral antidiabetic drug, PPG = postprandial plasma glucose.

The following points are important to optimizing T2DM treatment.

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Self-Management, Glucose Monitoring, and Dose Adjustment as a Means of Achieving A1C Targets 

As the key player in the care team, the patient must be empowered to recognize the current status of his or her diabetes and act accordingly. This can only be achieved through education about diabetes: why a specific treatment is prescribed, how it works, how treatment evolves with disease progression, and the effects of diet and exercise on blood sugar and complications (Table 2). A number of different resources are available for the patient, from easy-to-read fact sheets to toll-free telephone numbers for patients with reading difficulties; many of these resources are provided by pharmaceutical companies. A major resource is a certified diabetes educator (CDE); patients can find a certified educator by contacting the American Association of Diabetes Educators. Self-management encompasses self-monitoring of blood glucose, the frequency of which varies with treatment regimen. For patients on insulin, monitoring should be performed several times a day,⁵, ⁶, ⁸ but for patients on oral drug therapies or lifestyle modification, self-monitoring can be used as an occasional tool.⁵, ⁶, ⁸, ⁹ It should be mentioned that improved glycemic control using self-management of blood glucose (SMBG) cannot always be assumed.⁷, ³⁰ However, there are several studies that suggest that feedback and reinforcement are necessary for a positive impact.³¹, ³² Patients need to understand why they are testing, what the values mean, and how to respond to results that are not desired. SMBG can be used to empower the patient to make changes.³⁰, ³²

Table 2. Empowering Patients: What Patients Should Know

Historically, guidelines have omitted reference to postprandial glucose (PPG) targets because relevant studies were lacking.³³ Based on new data on the relative contributions of PPG and fasting glucose to A1C elevations and cardiovascular complications in patients with T2DM,⁶, ¹⁵, ¹⁶, ¹⁷ the guidelines⁵, ⁶, ⁸, ⁹ now emphasize the importance of monitoring both fasting and PPG levels.⁶ Postprandial monitoring allows agents that primarily target PPG levels (eg, rapid-acting insulin analogs, short-acting insulin secretagogues, α-glucosidase inhibitors, or incretin mimetics) to be introduced or titrated.³⁴ By targeting PPG elevations, A1C levels may be improved at a lower risk of hypoglycemia and weight gain than further lowering of fasting and pre-meal glucose levels.³⁴ The importance of regular SMBG is discussed.

Glucose Monitoring 

In the practice, glucose monitoring is encouraged and is described to patients as a method of learning how to “cheat” and “get away with it.” By checking glucose levels, patients can learn what makes their blood sugar change. The practice emphasizes that it does not matter if they have more or less food, activity, or even medication; it only matters that they get the levels that they want. By checking after eating, exercise, and medications, patients learn how to make changes that get the glucose values into the desired range.

Usually, the frequency of monitoring is negotiated. For T2DM, checking postprandially is a powerful tool that gives patients feedback on the impact of food. If the reading is higher than expected, a discussion follows about what might lower it—perhaps smaller portions, different fiber content, a change in the time it is eaten (as a dessert rather than a snack), a 25-minute walk after the meal, or a change in medication.

Patients are asked how many times they feel that they can check their blood sugar:

Glycemic Control in Patients with T2DM 

The ACE/AACE guidelines⁶ recommend acheiving glycemic targets that are associated with fewer complications (A1C ≤ 6.5%; fasting/preprandial plasma glucose, <110 mg/dL; 2-hour PPG < 140 mg/dL. Therefore, clinicians should employ rigorous and progressive measures to sustain success in a progressively worsening clinical setting.⁶, ⁹ Early treatment is an important component of this success, particularly when a combination of therapies with complementary mechanisms of action (2 or more oral antidiabetic drug [OADs], combinations of OADs and basal or premixed insulin, or OADs with incretin mimetics, such as exenatide) are used in addition to customized modification to diet and exercise regimens.⁶ While metformin is generally preferred as the first OAD used concurrently with initial lifestyle modification,⁴, ⁸ choice of additional therapy depends on the ambient A1C level and previous treatment (Figure 1, Figure 2).

Early use of insulin (especially insulin analogs) is advocated by ADA/EASD guidelines as a safer approach for individuals who present with severe symptoms and glucose values > 250 to 300 mg/dL⁵, ⁸ and as a more effective and cost-effective approach to treating patients who fail to achieve glycemic goals on a combination of 2 OADs.⁶, ⁹

Traditional barriers to early use of insulin have been broken down by the following things:

In general, weight gain is similar with insulin analogs compared with human insulins; the exception appears to be insulin detemir (a basal insulin analog), where weight gain is less compared with NPH insulin.⁴⁰ To aid timely use of insulin, the ADA/EASD have devised an algorithm for its initiation (Figure 3); although the ADA/EASD emphasizes the advantages of insulin analogs, they are not specifically mentioned in the algorithm.⁵, ⁶

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• Figure 3. 

  American Diabetes Association/European Association for the Study of Diabetes algorithm for the initiation of insulin. A1C = glycated hemoglobin; bg 5 blood glucose. Copyright © 2006 American Diabetes Association. Reprinted with permission from The American Diabetes Association.⁸

Case studies 1 and 2 illustrate the pathway of T2DM treatment in line with guideline recommendations.

Case Study 1: The Treatment-Naïve Patient 

Patient M, a 57-year-old male, was referred by his cardiologist, having undergone angioplasty 10 months previously. Although he felt well immediately after the procedure, he was now feeling very tired and feared that his heart disease had worsened. There were no indicators of new coronary disease, but laboratory analysis revealed a fasting blood sugar (FBS) level of 220 mg/dL, A1C of 8.4%, and worsening of his lipid status despite adherence to his medication regimen. Current treatments included a statin, a beta-blocker, fibrate, daily aspirin, an ACE inhibitor, and a diuretic. His vital signs and laboratory parameters were blood pressure (BP) 130/78 mmHg, pulse 88 beats/min, weight 245 lbs, BMI 38.3 kg/m², total cholesterol 212 mg/dL, low-density-lipoprotein (LDL) cholesterol 124 mg/dL, high-density-lipoprotein (HDL) cholesterol 24 mg/dL, and triglycerides 320 mg/dL.

At his first visit to our office, patient M was convinced that something was wrong. He described how he always felt hungry and had gained weight over the past month.

Patient M was diagnosed with uncontrolled T2DM, severely increased blood sugar levels, and presumed glucose toxicity. The increased hunger was likely due to perceived starvation as a consequence of metabolic decompensation; he had significant insulin resistance and insulin deficiency requiring intensive combination therapy. He was also suffering with mild-to-moderate anxiety. Although lacking an understanding of diabetes, he seemed motivated to make changes.

The following plan was devised:

After 1 month, patient M returned; his glucose log showed he had been testing 5 days per week. Blood sugar levels were lower and he felt stronger. FBS was reduced to 140 to 160 mg and postprandial levels were often < 200 mg. He reported changing his food intake and was eating less because he no longer felt as hungry, but he had gained 10 pounds. His C-peptide was 2.4 (normal limits: 0.6–1.89). If his level was below 0.5, it would indicate the absence of insulin production and support diagnosis of Type 1 diabetes. However, because his levels were clearly over 1.89, it indicates excessive insulin production. A high C-peptide together with an elevated glucose supports the diagnosis of insulin resistance with sufficient residual insulin. While diabetes control was improving, target levels were not reached either before or after meals. The weight gain was secondary to improved anabolism with lowered glucose levels. Patient M was likely to benefit from the addition of an incretin mimetic and weight loss. Hence, the ongoing management plan was to continue current medications and begin subcutaneous exenatide 5 μg twice daily, with a telephone follow-up in 1 month (to increase exenatide to 10 μg twice daily) and clinic review in 2 months.

On his return to the clinic after 2 months, patient M had lost 15 pounds, his FBS values were consistently in the range of 100 to 120 mg, and postprandial blood sugar levels rarely exceeded 160 mg. In terms of other laboratory parameters and vital signs, A1C had lowered to 7.2%, total cholesterol was 145 mg/dL, HDL cholesterol was 34 mg/dL, LDL cholesterol was 86 mg/dL, the triglyceride level was 128 mg/dL, and BP was 126/84 mmHg. Patient M reported feeling great and had begun to walk daily. Hence, at this point, diabetes control was continuing to improve, there was a reduction in overall glycemia, and, although A1C was still over target, it was thought that it may not reflect the current level of control because A1C reflects a longer time period than that taken to date. The management plan for patient M was to continue current medications, reinforce current lifestyle changes, continue patterned glucose monitoring, and review in 3 months. The patient had been educated about the progressive nature of T2DM and understood that a basal insulin analog would be the next option if glycemic goals were not achieved with this regimen.

Case Study 2: Routine Follow-Up of a Patient With T2DM 

Patient S is a 68-year-old female (BMI 24.1 kg/m²) who has had T2DM for over 10 years and has been taking a combination of metformin, pioglitazone, and glyburide. Over the past 6 months, she lost 5 pounds with the help of a structured weight management program; her A1C decreased from 8.2% to 7.2%. She tests her blood sugar twice daily, and her results reveal that her FBS is higher than her bedtime levels (she does not have a bedtime snack nor does she eat during the night). Her postprandial blood sugars are generally less than 30 mg/dL higher than her FBS. Hence, although her diabetes control has improved, she has not attained goal levels. She has inadequate overnight insulinization, is at the maximum dosing for metformin, pioglitazone, and sulfonylurea, and would probably benefit from basal insulin. The ongoing management plan therefore included: addition of a long-acting basal insulin analog (starting at 10 units at night using the pen system), education explaining the rationale of insulin use and prevention/treatment of hypoglycemia, provision of treat-to-target guidelines⁴¹ for increasing dosage weekly, continued blood sugar monitoring with a focus on FBS, and telephone follow-up in 1 week and as needed, with clinic review in 3 months.

At the next visit, patient S had increased her long-acting basal insulin to 18 units. Her FBS was now < 100 mg and always lower than bedtime (hs) readings, but she had had several instances of lowered blood sugar 3 hours after a meal. The A1C was reduced to 6.6%, and her weight had not changed. Hence, diabetes control continued to improve, being almost at the target of A1C < 6.5%, while the hypoglycemia may be related to taking the long-acting sulfonylurea. For the ongoing management plan, patient S discontinued glyburide and began repaglinide. She continued patterned glucose monitoring, lifestyle changes were reinforced, and she was encouraged to participate in a diabetes support group.

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Education and Resources 

The guidelines⁵, ⁶ emphasize the importance of patient education through programs that focus on self-management knowledge and skills and lead to behavioral changes.⁶ In particular, self-management training in a group setting is advocated because it is more successful than individualized training or didactic training in terms of patients gaining insight into their disease and its treatment.⁴² A number of studies have shown that patient education programs are associated with improvements in patients’ overall health, increased exercise, reduced hospitalizations, and lower costs.⁴³, ⁴⁴, ⁴⁵, ⁴⁶ In addition, patients have been identified as having an integral role in the Chronic Care Model, which summarizes the essential elements of a health care system that improves the quality of care in chronic diseases.⁴⁷, ⁴⁸

Case Study 3: Patient Education 

Patients M and S were encouraged to enroll in group education classes for further education in diabetes self management as well as peer support. The classes follow the principles outlined by the AADE (http://www.diabeteseducator.org/AADE7/index.shtml). Family and significant others were encouraged to attend. The classes emphasize healthy eating, increasing activity, monitoring, taking medications, problem solving, reducing risks, and healthy coping. Throughout, the focus is on patient-directed self-management, with goals set by the patient. Challenges are identified and strategies discussed, practiced, and evaluated for effectiveness in overcoming those challenges. The patients are helped to feel that they own the disease, can become an expert in their care, and can track and modify results. Any challenges raised by a patient become the subject for discussion at that visit.

For example, one patient related that he hated taking medications and doubted that they actually work. As a result, he would frequently omit his repaglinide before meals. A short discussion followed regarding the role of repaglinide on insulin release at the meal, the expected glucose changes postprandially, and the reliability of glucose monitoring. He agreed to check his blood glucose 2 hours after eating—once when he omitted his repaglinide and again after a similar meal when he did take his repaglinide. To his surprise, the blood sugar level was almost 200 mg higher when he omitted the repaglinide. The lesson addressed a number of principles—healthy eating, monitoring, taking medication, problem solving, and healthy coping. By providing the rationale and the tools, he was able to teach himself and, thereafter, rarely omitted treatment.

The office support staff is also involved in diabetes education, particularly recognition and treatment of hypoglycemia, and glucose monitoring. When vital signs are measured, a capillary sample for glucose is obtained. The medical technician asks the patient if he or she has any questions regarding the procedure, models the use of the lancet and meter, and asks the patient about the glucose result.

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Conclusion 

The key message for nurse practitioners is that early and intensive glycemic control is fundamental to diabetes management to delay or prevent serious diabetes-related complications.⁴

In this review, the cases described reveal a pathway of diabetes treatment that is advocated by the guidelines. This pathway should be communicated to patients through educational strategies (Table 2). In treatment-naïve patients who have residual β-cell function, secretagogues such as sulfonylureas or insulin sensitizers (such as metformin or thiazolidinediones) can be used to reduce glycemic levels. It is vitally important that treatment is modified as pancreatic function declines with worsening disease; insulin MUST be considered early and intensified appropriately. To reduce the risk of complications, this change to treatment should be implemented prior to loss of control of glycemic levels and should be tailored to individual patient requirements.

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References 

1. Goldfarb B . ACE and AACE Issue Treat-to-Target road map . DOC News . 2005;2:11
   • View In Article
2. Centers for Disease Control and Prevention  . National diabetes fact sheet: general information and national estimates on diabetes in the United States . Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2007; 2007
   • View In Article
3. National Institute of Diabetes and Digestive and Kidney Diseases  . National diabetes statistics fact sheet: general information and national estimates on diabetes in the United States . Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; 2007; Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ Accessed August 4, 2008.
   • View In Article
4. Saydah SH , Fradkin J , Cowie CC . Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes . JAMA . 2004;291:335–342
   • View In Article
   • CrossRef
5. American Diabetes Association  . Standards of Medical Care in Diabetes – 2008 . Diabetes Care . 2008;31(Suppl 1):S13–S54
   • View In Article
6. Lebovitz HE , Austin MM , Blonde L , et al.   ACE/AACE consensus conference on the implementation of outpatient management of diabetes mellitus: consensus conference recommendations . Endocr Pract . 2006;12(Suppl 1):6–12
   • View In Article
7. Davis WA , Bruce DG , Davis T . Is self monitoring of blood glucose appropriate for all Type 2 diabetic patients? The Fremantle diabetes study . Diabetes Care . 2006;29:1764–1770
   • View In Article
   • MEDLINE
   • CrossRef
8. Nathan DM , Buse JB , Davidson MB , et al.   Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy . Diabetes Care . 2006;29:1963–1972
   • View In Article
   • MEDLINE
   • CrossRef
9. Jellinger PS , Davidson JA , Blonde L , et al.   Road maps to achieve glycemic control in type 2 diabetes mellitus: ACE/AACE Diabetes Road Map Task Force . Endocr Pract . 2007;13:260–268
   • View In Article
   • MEDLINE
10. The United Kingdom Prospective Diabetes Study Group  . Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes . Lancet . 1998;352:837–853
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (708 KB)
    • CrossRef
11. The United Kingdom Prospective Diabetes Study Group  . Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes . Lancet . 1998;352:854–865
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (582 KB)
    • CrossRef
12. Stratton IM , Adler AI , Neil HA , et al.   Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35) . BMJ . 2000;321:405–412
    • View In Article
    • MEDLINE
    • CrossRef
13. Tuomilehto J , Lindstrom J , Eriksson JG , et al.   (Finnish Diabetes Prevention Study Group). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance . N Engl J Med . 2001;344:1343–1350
    • View In Article
    • MEDLINE
    • CrossRef
14. Knowler WC , Barratt-Connor E , Fowler SE , et al.   Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin . N Engl J Med . 2002;346:393–403
    • View In Article
    • CrossRef
15. Monnier L , Lapinski H , Colette C . Contributions of fasting and postprandial plasma glucose increments to the overall diurnal hyperglycemia of type 2 diabetic patients: variations with increasing levels of HbA(1c) . Diabetes Care . 2003;26:881–885
    • View In Article
    • MEDLINE
    • CrossRef
16. DECODE Study Group  , European Diabetes Epidemiology Group  . Is the current definition for diabetes relevant to mortality risk from all causes and cardiovascular and noncardiovascular diseases? . Diabetes Care . 2003;26:688–696
    • View In Article
    • MEDLINE
    • CrossRef
17. Esposito K , Giugliano D , Nappo F , et al.   Regression of carotid atherosclerosis by control of postprandial hyperglycemia in type 2 diabetes mellitus . Circulation . 2004;110:214–219
    • View In Article
    • CrossRef
18. Genuth S . Insights from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study on the use of intensive glycemic treatment to reduce the risk of complications of type I diabetes . Endocr Pract . 2006;12(Suppl 1):34–41
    • View In Article
19. Hanefeld M , Koehler C , Schaper F , et al.   Postprandial plasma glucose is an independent risk factor for increased carotid intima-media thickness in non-diabetic individuals . Atherosclerosis . 1999;144:229–235
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (211 KB)
    • CrossRef
20. Hanefeld M , Temelkova-Kurktschiev T . Control of post-prandial hyperglycemia – an essential part of good diabetes treatment and prevention of cardiovascular complications . Nutr Metab Cardiovasc Dis . 2002;12:98–107
    • View In Article
    • MEDLINE
21. Nathan DM , Cleary PA , Cacklund JY , et al.   Intensive diabetes treatment and cardiovascular disease in patients with type I diabetes . N Engl J Med . 2005;353:2642–2653
    • View In Article
    • CrossRef
22. Ohkubo Y , Kishikawa H , Araki E , et al.   Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomizedprospective 6-year study . Diabetes Res Clin Pract . 1995;28:103–117
    • View In Article
    • Abstract
    • Full-Text PDF (1204 KB)
    • CrossRef
23. Khaw KT , Wareham N , Luben R , et al.   Glycated haemoglobin, diabetes, and mortality in men in the Norfolk cohort of European Prospective Investigation of Cancer and Nutrition (EPIC-Norfolk) . BMJ . 2000;322:15–18
    • View In Article
    • MEDLINE
    • CrossRef
24. Nissen SE , Wolski K . Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes . N Engl J Med . 2007;356:2457–2471
    • View In Article
    • CrossRef
25. Lincoff M , Wolski K , Nicholls SJ , Nissen SE . Pioglitazone and risk of cardiovascular events in patients with Type 2 diabetes mellitus: a meta-analysis of randomized trials . JAMA . 2007;298:1180–1188
    • View In Article
    • CrossRef
26. Singh S , Loke YK , Furberg CD . Long-term risk of cardiovascular events with rosiglitazone: a meta-analysis . JAMA . 2007;298:1189–1195
    • View In Article
    • CrossRef
27. Solomon DH , Winkelmayer WC . Cardiovascular risk and the thiazolidinediones: déjà vu all over again? . JAMA . 2007;298:1216–1218
    • View In Article
    • CrossRef
28. Lago RM , Singh P , Nesto R . Congestive heart failure and cardiovascular death in patients with prediabetes and type 2 diabetes given thiazolidinediones: a meta-analysis of randomised clinical trials . Lancet . 2007;370:1129–1136
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (180 KB)
    • CrossRef
29. Home PD , Pocock SJ , Beck-Nielsen H , et al. , for the RECORD Study Group    Rosiglitazone evaluated for cardiovascular outcomes–an interim analysis . N Engl J Med . 2007;357:28–38
    • View In Article
    • CrossRef
30. Siebolds M , Gaedeke O , Schwede U . Self-monitoring of blood glucose – psychological aspects relevant to changes in HbA1c in type 2 diabetic patients treated with diet or diet plus oral antidiabetic medication . Patient Educ. Couns. . 2006;62:104–110
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (131 KB)
    • CrossRef
31. Welschen LMC , Bloemendal E , Nijpels G , et al.   Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin . Cochrane Database of Syst Rev . 2005; Issue 3. Art. No.: CD005060
    • View In Article
32. Schwedes U , Siebolds M , Mertes G . Meal-related structured self-monitoring of blood glucose: effect on diabetes control in non-insulin-treated type 2 diabetic patients . Diabetes Care . 2002;25:1928–1932
    • View In Article
    • MEDLINE
    • CrossRef
33. Rohlfing CL , Wiedmeyer HM , Little RR , et al.   Defining the relationship between plasma glucose and HbA1c: analysis of glucose profiles and HbA1c in the Diabetes Control and Complications Trial . Diabetes Care . 2002;25:275–278
    • View In Article
    • MEDLINE
    • CrossRef
34. American Diabetes Association  . Postprandial blood glucose (Consensus Statement) . Diabetes Care . 2001;24:775–778
    • View In Article
    • MEDLINE
    • CrossRef
35. Meneghini LF , Rosenberg KH , Koenen C , et al.   Insulin detemir improves glycaemic control with less hypoglycaemia and no weight gain in patients with type 2 diabetes who were insulin naïve or treated with NPH or insulin glargine: clinical practice experience from a German subgroup of the PREDICTIVE study . Diabetes Obes Metab . 2007;9:418–427
    • View In Article
    • MEDLINE
    • CrossRef
36. Hirsch IB . Type 1 diabetes mellitus and the use of flexible insulin regimens . Am Fam Physician . 1999;60:2343–2352 2355-2356.
    • View In Article
    • MEDLINE
37. Hermansen K , Fontaine P , Kukolja KK , et al.   Insulin analogues (insulin detemir and insulin aspart) versus traditional human insulins (NPH insulin and regular human insulin) in basal-bolus therapy for patients with type 1 diabetes . Diabetologia . 2004;47:622–629
    • View In Article
    • MEDLINE
    • CrossRef
38. Raslova K , Tamer SC , Clauson P , et al.   Insulin detemir results in less weight gain than NPH insulin when used in basal-bolus therapy for type 2 diabetes mellitus, and this advantage increases with baseline body mass index . Clin Drug Investig . 2007;27:279–285
    • View In Article
    • MEDLINE
    • CrossRef
39. Home P , Kurtzhals P . Insulin detemir: from concept to clinical experience . Expert Opin Pharmacother . 2006;7:325–343
    • View In Article
    • CrossRef
40. Riddle MC , Rosenstock J , Gerich J . The treat-to-target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients . Diabetes Care . 2003;26:3080–3086
    • View In Article
    • MEDLINE
    • CrossRef
41. Kulzer B , Hermanns N , Reinecker H , Haak T . Effects of self-management training in type 2 diabetes: a randomized, prospective trial . Diabet Med . 2007;24:415–423
    • View In Article
    • MEDLINE
    • CrossRef
42. Jorgens V . [Cost-benefit analysis of education programs and of treatment in type 2 diabetes] [Article in French] . Diabetes Metab . 1993;19(5 Suppl):510–513
    • View In Article
43. Strine TW , Okoro CA , Chapman DP , et al.   The impact of formal diabetes education on the preventive health practices and behaviors of persons with type 2 diabetes . Prev Med . 2005;41:79–84
    • View In Article
    • MEDLINE
    • CrossRef
44. Deakin T , McShane CE , Cade JE , Williams RD . Group based training for self-management strategies in people with type 2 diabetes mellitus . Cochrane Database Syst Rev . 2005;(2): CD003417.
    • View In Article
45. Ko SH , Song KH , Kim SR , et al.   Long-term effects of a structured intensive diabetes education programme (SIDEP) in patients with type 2 diabetes mellitus – a 4-year follow-up study . Diabet Med . 2007;24:55–62
    • View In Article
    • MEDLINE
    • CrossRef
46. Wagner EH . Chronic disease management: what will it take to improve care for chronic illness? . Eff Clin Pract . 1998;1:2–4
    • View In Article
    • MEDLINE
47. Wagner EH , Austin BT , Davis C , et al.   Improving chronic illness care: translating evidence into action . Health Aff (Millwood) . 2001;20:64–78 Gerstein HC , Yusuf S , Bosch J , et al.   Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomised controlled trial . Lancet . 2006;368:1096–1105
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (130 KB)
    • CrossRef

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Uncited reference 

35. Korytkowski M , Niskanen L , Asakura T . FlexPen: addressing issues of confidence and convenience in insulin delivery . Clin Ther . 2005;27(Suppl B):s89–S100