Program Management Approach

Management of Hyperglycemia in Type 2 Diabetes A Patient Centered Approach. Glycemic management in type 2 diabetes mellitus has become increasingly complex and, to some extent, controversial, with a widening array of pharmacological agents now available 15, mounting concerns about their potential adverse effects and new uncertainties regarding the benefits of intensive glycemic control on macrovascular complications 69. Breaking Dawn Parte 2 Streaming Nowvideo on this page. Many clinicians are therefore perplexed as to the optimal strategies for their patients. As a consequence, the American Diabetes Association ADA and the European Association for the Study of Diabetes EASD convened a joint task force to examine the evidence and develop recommendations for antihyperglycemic therapy in nonpregnant adults with type 2 diabetes. Video Copilot The Bullet Torrent Mac Game. Several guideline documents have been developed by members of these two organizations 1. However, an update was deemed necessary because of contemporary information on the benefitsrisks of glycemic control, recent evidence concerning efficacy and safety of several new drug classes 1. This statement has been written incorporating the best available evidence and, where solid support does not exist, using the experience and insight of the writing group, incorporating an extensive review by additional experts acknowledged below. The document refers to glycemic control yet this clearly needs to be pursued within a multifactorial risk reduction framework. This stems from the fact that patients with type 2 diabetes are at increased risk of cardiovascular morbidity and mortality the aggressive management of cardiovascular risk factors blood pressure and lipid therapy, antiplatelet treatment, and smoking cessation is likely to have even greater benefits. These recommendations should be considered within the context of the needs, preferences, and tolerances of each patient individualization of treatment is the cornerstone of success. Our recommendations are less prescriptive than and not as algorithmic as prior guidelines. This follows from the general lack of comparative effectiveness research in this area. Our intent is therefore to encourage an appreciation of the variable and progressive nature of type 2 diabetes, the specific role of each drug, the patient and disease factors that drive clinical decision making 2. The implementation of these guidelines will require thoughtful clinicians to integrate current evidence with other constraints and imperatives in the context of patient specific factors. BACKGROUNDEpidemiology and health care impact. This article has a correction. Please see Management of hyperglycemia in type 2 diabetes a patientcentered approach. Position Statement of the American Diabetes. Atkins low carb diet program uses a powerful lifetime approach to successful weight loss. Sign up today for our weight loss plan start a healthy future. ENERGY STAR is the simple choice for energy efficiency. For more than 20 years, EPAs ENERGY STAR program has been Americas resource for saving energy and. Details on programs, courses, and faculty of this school. Program Management Approach' title='Program Management Approach' />Program Management ApproachProgram Management ApproachNorth South University is the first private university of Bangladesh, was established in 1992. Chemical Reactivity there. Both the prevalence and incidence of type 2 diabetes are increasing worldwide, particularly in developing countries, in conjunction with increased obesity rates and westernization of lifestyle. The attendant economic burden for health care systems is skyrocketing, owing to the costs associated with treatment and diabetes complications. Type 2 diabetes remains a leading cause of cardiovascular disorders, blindness, end stage renal failure, amputations, and hospitalizations. It is also associated with increased risk of cancer, serious psychiatric illness, cognitive decline, chronic liver disease, accelerated arthritis, and other disabling or deadly conditions. Effective management strategies are of obvious importance. Relationship of glycemic control to outcomes. It is well established that the risk of microvascular and macrovascular complications is related to glycemia, as measured by Hb. A1c this remains a major focus of therapy 2. Prospective randomized trials have documented reduced rates of microvascular complications in type 2 diabetic patients treated to lower glycemic targets. In the UK Prospective Diabetes Study UKPDS 3. In the standard group, lifestyle intervention was the mainstay with pharmacological therapy used only if hyperglycemia became severe. In the more intensive treatment arm, patients were randomly assigned to either a sulfonylurea or insulin, with a subset of overweight patients randomized to metformin. The overall Hb. A1c achieved was 0. Associated with this difference in glycemic control was a reduction in the risk of microvascular complications retinopathy, nephropathy, neuropathy with intensive therapy. A trend toward reduced rates of myocardial infarction in this group did not reach statistical significance 3. By contrast, substantially fewer metformin treated patients experienced myocardial infarction, diabetes related and all cause mortality 3. Hb. A1c only 0. 6 lower than the conventional policy group. The UKPDS 1. 0 year follow up demonstrated that the relative benefit of having been in the intensive management policy group was maintained over a decade, resulting in the emergence of statistically significant benefits on cardiovascular disease CVD end points and total mortality in those initially assigned to sulfonylureainsulin, and persistence of CVD benefits with metformin 3. Hb. A1c levels between the groups converged soon after the randomized component of the trial had concluded. In 2. 00. 8, three shorter term studies Action to Control Cardiovascular Risk in Diabetes ACCORD 3. Action in Diabetes and Vascular Disease Preterax and Diamicron Modified Release Controlled Evaluation ADVANCE 3. Veterans Affairs Diabetes Trial VADT 3. ACCORD and VADT aimed for an Hb. A1c lt 6. 0 using complex combinations of oral agents and insulin. ADVANCE aimed for an Hb. A1c 6. 5 using a less intensive approach based on the sulfonylurea gliclazide. None of the trials demonstrated a statistically significant reduction in the primary combined cardiovascular end points. Indeed, in ACCORD, a 2. An explanation for this finding has remained elusive, although rates of hypoglycemia were threefold higher with intensive treatment. It remains unclear, however, if hypoglycemia was responsible for the adverse outcomes, or if other factors, such as more weight gain, or simply the greater complexity of therapy, contributed. There were suggestions in these trials that patients without overt CVD, with shorter duration of disease, and lower baseline Hb. A1c, benefited from the more intensive strategies. Modest improvements in some microvascular end points in the studies were likewise demonstrated. Finally, a meta analysis of cardiovascular outcomes in these trials suggested that every Hb. A1c reduction of 1 may be associated with a 1. Overview of the pathogenesis of type 2 diabetes. Any rise in glycemia is the net result of glucose influx exceeding glucose outflow from the plasma compartment. In the fasting state, hyperglycemia is directly related to increased hepatic glucose production. In the postprandial state, further glucose excursions result from the combination of insufficient suppression of this glucose output and defective insulin stimulation of glucose disposal in target tissues, mainly skeletal muscle. Once the renal tubular transport maximum for glucose is exceeded, glycosuria curbs, though does not prevent, further hyperglycemia. Abnormal islet cell function is a key and requisite feature of type 2 diabetes. In early disease stages, insulin production is normal or increased in absolute terms, but disproportionately low for the degree of insulin sensitivity, which is typically reduced. However, insulin kinetics, such as the ability of the pancreatic cell to release adequate hormone in phase with rising glycemia, are profoundly compromised. This functional islet incompetence is the main quantitative determinant of hyperglycemia 3.