Are diabetes management guidelines applicable in 'real life'?

Background: The American Diabetes Association (ADA) has published several diabetes treatment algorithms, but none have been tested in real-life settings. The aim of this study is to analyze the feasibility of achieving and/or maintaining HbA1c levels <7.0% using current diabetes treatment guidelines and the resources available in the public health care system of Brazil.

Methods: A one-year, single-arm interventional study was conducted with type 2 diabetes patients in a primary care unit. Intervention consisted of intensification of lifestyle changes and sequential prescription of drugs based on ADA guidelines using the medications available through the publicly funded Unified Health System (Sistema Único de Saúde, SUS).

Results: Ninety patients (age: 62.7±10.4 years; diabetes duration: 8.2±9.1 years) completed the trial. During the intervention period, increases were observed in number of oral antidiabetic agent (OAD) classes per patient (1.50±0.74 vs. 1.67±0.7; p=0.015), OAD pills per patient (2.64±1.89 vs. 3.33±2.23 pills/patient; p <0.001), insulin dosage (0.20±0.29 vs.0.50±0.36 UI/kg/day; p=0.008) and number of patients on insulin (19 [21%] vs. 31 [34%]; p<0.01), but no improvement in HbA1c (7.2±1.6% vs. 7.3±1.5%; p=0.453) or frequency of patients on target, defined as HbA1c <7% (53.3% vs. 48.9%; p=0.655). Patients with baseline HbA1c <7% had a small increase in HbA1c during the trial (6.3±0.4 vs. 6.7±0.9%; p=0.002). No such change was observed in those with baseline HbA1c ≥7%.

Conclusions: In this group of patients with a mean baseline HbA1c of 7.2%, implementation of 2006/2009 ADA/EASD guidelines led to achievement of the therapeutic goal of HbA1c <7% in a small proportion of patients.