08--spec--guzman*--463-47

Informe especial / Special report
Treatment of type 2 diabetes in Latin America:
a consensus statement by the medical
associations of 17 Latin American countries

Juan Rosas Guzmán,1 Ruy Lyra,2 Carlos A. Aguilar-Salinas,3Saulo Cavalcanti,4 Felix Escaño,5 Marcos Tambasia,6Elizabeth Duarte,7 and the ALAD Consensus Group1 Suggested citation
Guzmán JR, Lyra R, Aguilar-Salinas CA, Cavalcanti S, Escaño F, Tambasia M, et al. Treatment of type2 diabetes in Latin America: a consensus statement by the medical associations of 17 Latin Americancountries. Rev Panam Salud Publica. 2010;28(6):463–71.
ABSTRACT
Latin America faces unique challenges in the treatment of type 2 diabetes mellitus. The Aso-ciación Latinoamericana de Diabetes (Latin American Diabetes Association, ALAD) broughttogether medical associations in 17 countries in Latin America to produce a consensus state-ment regarding the treatment of type 2 diabetes. The goal of the document is to provide prac-tical recommendations that will guide clinicians through a simple decision-making process formanaging patients. The cornerstone elements for therapeutic decision making are: severity ofhyperglycemia, clinical condition of the patient (stable or with metabolic decompensation), andbody mass index. The consensus includes a section devoted specifically to patients with obe-sity. Information is presented as highly-relevant clinical questions. The algorithm is based onthe scientific recommendations of the 2006 ALAD guidelines (a document prepared using anevidence-based approach) and data from recent randomized controlled studies. Key words
Diabetes mellitus, type 2; obesity; consensus; practice guidelines as topic; Latin America.
cases, this geographic area invests limited 40%–60% of diabetes costs out-of-pocket.
financial resources in diabetes care. In- deed, diabetes prevalence in several Latin in the world, e.g., Mexico at 14.4% (1). In (2–5). The burden of disease will be even Asociación Latinoamericana de Diabetes, Celaya, the year 2000, the direct cost of diabetes Federación Panamericana de Endocrinologia, Per-nambuco, Brazil.
Sociedad Mexicana de Nutrición y Endocrinología.
México City, Mexico. Send correspondence to Carlos Alberto Aguilar-Salinas, [email protected]
com. Sociedade Brasileira de Diabetes, São Paulo, Brazil.
the total diabetes-related annual cost in Sociedad Dominicana de Endocrinología, SantoDomingo, República Dominicana. Sociedade Brasileira de Endocrinologia e Metabo- US$ 65 billion—US$ 15 billion in Mexico, ganize its health care services from a sys- Sociedad Boliviana de Endocrinología, Metabo-lismo y Nutrición, La Paz, Bolivia.
Rev Panam Salud Publica 28(6), 2010 Guzmán et al. • Latin American consensus statement for type 2 diabetes treatment CONSENSUS STRUCTURE
based on the best available clinical evi- takes into account the glycemic status of lines should be adapted to reflect the dif- on the most common clinical situations.
EDIC) studies’ findings (10), long-term ica are a result of the interactions among the area’s socioeconomic factors, its vari- cently demonstrated a “legacy effect” of according to the level of glycemic control Group 1. Patients with blood glu-
cose levels < 240 mg/dL (13.3 mmol/L), train and guide primary care physicians.
horts are lost after the end of the study Group 2. Patients with blood glu-
(10, 11). In Latin America, fasting blood CONSENSUS METHODOLOGY
sions. However, in line with other scien- tific organizations (12–14), glycosylated cose concentrations, making it easier for patients to understand the information.
ment for the treatment of type 2 diabetes pensation), and body mass index (BMI).
ically aimed at patients with obesity.
formation prior to a face-to-face meeting.
have the resources to manage such cases.
sonnel, patients, and relatives, obese pa- potential of intensive glycemic control to rent clinical evidence (18–21), an HbA1c all of the endorsing associations’ repre- tients. However, in certain situations this sentatives. The final version of the docu- low a healthy lifestyle before and during of complications and no major risk of hy- put into practice quickly by the partici- TABLE 1. Relationship between blood glucose
THE CONSENSUS STATEMENT
levels and Hemoglobin A
based on the scientific recommendationsof the 2006 ALAD guidelines—a docu- 1. What are the treatment goals for the
patient with type 2 diabetes?
Diabetes Association of the United States Rev Panam Salud Publica 28(6), 2010 Guzmán et al. • Latin American consensus statement for type 2 diabetes treatment TABLE 2. Proposed treatment goals for patients with type 2 diabetes in Latin America, 2010
review of the supporting evidence is be-yond the scope of this document.
inclusion of microalbuminuria as a treat- nually in all type 2 diabetes patients and pressure targets; the use of angiotensin- b With cardiovascular disease or at high risk (defined as the presence of one or more cardiovascular risk factors).
c currently used in diabetic care, including FIGURE 1. Latin American Diabetes Association recommendations for the management of hyperglycemia in patients with type 2 diabetes, 2010
Fasting glucose Ն 240 mg/dL
Fasting glucose Ն 126 mg/dL (7 mmol/L) to < 240 mg/dL (13.3 mmol/L) and/or HBA < 9%
(13.3 mmol/L) and/or HBA Ն 9%
Start lifestyle change (LSC) + Metformin (MET)
If MET is contraindicated, or not tolerated, consider any of the following antidiabetic medications: tiazolidinedione (TZD), DPP-4 inhibitors (DPP-4 INH), sulfonylurea (SU) (especially if body mass index ), meglitinides (especially in presence of high postprandial blood glucose), acarbose (if postprandial blood glucose is high, but fasting glucose is < 180mg/dL and/or HbA < 7.5%) LSC + Combination therapy:
LSC + Insulina
–Glargine or Determir 1–2 doses daily, usually combined with oral drugs or with 3 doses of fast-acting insulin or ultra fast analogue Add insulin:
LSC + Intensive controla
–Multiple dose: 3–4 insulin doses–Insulin pump a Handled or advised by a specialist.
Rev Panam Salud Publica 28(6), 2010 Guzmán et al. • Latin American consensus statement for type 2 diabetes treatment TABLE 3. Lifestyle recommendations to prevent and treat type 2 diabetes mellitus in Latin
America, 2010
teristics of insulin preparation and in-sulin analogues are included in Table 5. A. Education is the most important factor in the treatment of diabetes mellitus. Patients and their families should receive well-defined information to educate and empower them to make the right choices 2. How should a clinically-stable patient
B. Aerobic physical activities should be performed for at least 30 minutes, 5 days/week, according to each with type 2 diabetes with mean fasting
patient’s characteristics. Anaerobic activities could be considered as complementary.
glycemia < 240 mg/dL (13.3 mmol/L),
C. Nutritional medical therapy should be customized according to the baseline body mass index and physical and HbA < 9 % be managed?
activity level of each patient. Macronutrient content of the diet should be adjusted to 50%–60% carbohydrates; 20%–30% fat with less than 7% saturated fat; and 10%–20% protein (minimum 1 g/kg ofideal weight per day) D. Natural fiber intake should be 20–30 g/day. E. Daily salt intake should be < 5 g in patients with diabetes and < 3 g in patients with associated agnosed late. If the patient is clinically sta- ble, has few symptoms, no ketosis, fasting F. Diet should consider availability and patient preference, while minimizing the use of processed foods. G. Alcohol consumption should be discouraged. H. Tobacco should not be allowed.
mmol/L) and 240 mg/dL (13.3 mmol/L)and/or HbA treatment is the initiation of a healthylifestyle with adequate nutrition, regularexercise, and cessation of smoking, if ap-plicable. Alcohol consumption should be TABLE 4. Medications currently approved to treat type 2 diabetes, 2010
dose should be reduced in patients withan estimated glomerular filtration rate (eGFR) < 60 mL/min. The drug is con-traindicated if the eGFR is < 30 mL/min.
with alcoholism, severe chronic obstruc-tive pulmonary disease (COPD), and/ordecompensated heart, respiratory, orliver failure (26). TABLE 5. Characteristics of insulin preparations used in Latin America, 2010
case of gastrointestinal intolerance, the following options may be considered formonotherapy (27): bust clinical experience and low cost.
Rev Panam Salud Publica 28(6), 2010 Guzmán et al. • Latin American consensus statement for type 2 diabetes treatment lurea. The intervention of a diabetes spe- (b) Meglitinides: These drugs are partic- gets despite the use of three agents.
4. What should be done to manage
overweight patients not controlled
tions and long term safety (33, 34).
by monotherapy and who continue
(c) Glitazones: Insulin resistance and in- to gain weight?
is a contributing factor to not achieving analysis and individualized patient care.
3. What should be done if mono-
team, if available, for the implementation (d) Acarbose: Its main effect is on post- therapy fails?
titrated to reach its maximal effect. The lifestyle modifications. The timeframe for pend on the patient’s circumstances (39).
5. What should be done when treat-
ment goals are not achieved with an
oral combination?
35, 36). Less popular combinations (e.g., tion, indicates a significant deficit in in- sulin production. This is due to the pro- capacity that occurs in type 2 diabetes. To necessary in such patients. Initially, con- supports their use is not as strong as that insulin or a long-acting insulin analogue with oral agents. Glargine can be given at dosage should be regularly titrated based TABLE 6. Successful combination of oral anti-
hyperglycemic agents with their evidence-
based recommendation for patients with type
2 diabetes, 2010
ments depends on the patient characteris- tics and the experience of the practitioner.
Source: ALAD Guidelines (6).
period of at least 1–3 months is recom- Rev Panam Salud Publica 28(6), 2010 Guzmán et al. • Latin American consensus statement for type 2 diabetes treatment treated by a specialist. It is assumed that measures for adopting a healthy lifestyle sions during the early stages of the dis- are in place and reinforced regularly.
ease. They do this with limited resources progression to full insulinization will be necessary. Of note, the combination of in- 7. When should changes be made to
sential that practitioners aim to achieve the therapeutic regimen?
obligatory for the success of all treatment time to evaluate their maximal efficacy.
availability, patient requirements, meta- This is especially relevant if there is clin- specialist. Likewise, those requiring in- cemia. One option is a mixture of 2 types post-prandial glucose and HbA values.
aged by a diabetologist/endocrinologist. DISCUSSION
fixed-dose preparations can be used.
tured to face the challenge that diabetes lowering agent or insulin. Clinical inertia portions. Another option is 1–2 doses of is a contributing factor for not achieving treatment targets in all health systems. 8. How should patients be monitored?
both patients and the general public.
in Table 5 (40, 41). At this stage of inten- sive insulin therapy, referral of the pa- about the disease and its consequences.
tained changes in lifestyle and adherence 6. How should a clinically unstable pa-
to therapy. If these actions are not imple- tient with type 2 diabetes be managed?
toms, no weight loss or ketosis, the pre- tool for all patients with diabetes; in par- the treatment target levels (45, 46).
recommended. This can rapidly correct the metabolic state, reduce glucotoxicity, and volved in creating a diabetes care action after a 1–3 month period, patients should better therapeutic results. They can also be started on an insulin regimen (42).
glucometers and test strips is still a sig- is useful for the prompt correction of hy- feasible due to economic, logistic, and/or perglycemia and nutritional status (43).
Later, once these patients are stable and into account, however, that this index is countries share many ethnic, social, cul- America, and where it is available, cost is ered. This situation can occur especially 9. When should a diabetes specialist be
guidelines for the diagnosis, control, and consulted?
treatment of the patient with type 2 dia- betes, i.e., the “Guías ALAD de Diagnós- tico, Control y Tratamiento de la Diabetes with multiple insulin doses or an insulin Mellitus tipo 2” (6). This document was Rev Panam Salud Publica 28(6), 2010 Guzmán et al. • Latin American consensus statement for type 2 diabetes treatment Coordinators: Juan Rosas Guzman (Presi- various aspects of type 2 diabetes treat- Participant associations (represented by): glycemia as an acceptable alternative.
de Nutrición y Endocrinología (Carlos A.
cía); Sociedad Brasileira de Endocrinolo- Endocrinología Diabetes y Nutrición (Car- America is highlighted. However, los Alvayero); Asociación Guatemalteca ción (Vinicio Granados); Sociedad Ecuato- 7. Provides clinical indications and pos- Diabetes (Gustavo Frechtel); Sociedad Bo- liviana de Endocrinología, Metabolismo y Nutrición (Elizabeth Duarte); Asociación 2. Defines two clinical profiles that dif- docrinología (Mario Valdéz Laínez); So- 3. Includes special notes regarding obese sal, the quality of diabetes care depends on geographic factors. Because this consensus faced by patients and physicians in Latin America, its strategies are more feasible Endocrinología (Félix Escaño Polanco); and it is hoped that its impact will go far- ther than that of past efforts to improve di- type 2 diabetes not reaching the treatment targets. With the help of all participating institutions, we expect that this consensus crinología (Isaac Crespo Retes); and So- document will be helpful to improving the quality of diabetes care in Latin America.
5. Describes clinical traits of the avail- Acknowledgments. The authors wish
Roopa Mehta for editorial assistance.
REFERENCES
1. Villalpando S, Shamah-Levy T, Rojas R, 3. Gouvea Ferreira SR. Epidemiología de las posium sobre economía y diabetes. Available Aguilar-Salinas CA. Trends for type 2 dia- complicaciones de la diabetes mellitus. In: betes and other cardiovascular risk factors in Diabetes Mellitus, visión latinoamericana.
Mexico from 1993–2006. Salud Pública Mex.
Guzmán JR, Lyra R, Cavalcanti N, eds. Río de Janeiro, Brasil: Editora Guanabara Koogan; 5. Arredondo A, Zuniga A. Economic conse- 2. Barceló A, Aedo C, Rajpathak S, Robles S. The cost of diabetes in Latin America and the Ca- 4. Asociación Latinoamericana de Diabetes, Or- ribbean. Bull World Health Organ. 2003;81(1): ganización Panamericana de la Salud, Decla- ración de las Américas sobre la Diabetes. Sim- Rev Panam Salud Publica 28(6), 2010 Guzmán et al. • Latin American consensus statement for type 2 diabetes treatment 6. Guías ALAD de diagnóstico, dontrol y lar outcomes in patients with type 2 diabetes.
gain using triple therapy in type 2 diabetes.
tratamiento de la diabetes mellitus tipo 2.
N Engl J Med. 2008;358(24):2560–72.
Diabetes Care. 2004;27(7):1577–83.
20. Duckworth W, Abraira C, Moritz T, Reda D, 38. Pontiroli AE, Calderara A, Pacchioni M, Emanuele N, Reaven PD, et al. Glucose con- Cassisa C, Pozza G. Weight loss reverses sec- 7. Ohkubo Y, Kishikawa H, Araki E, Miyata T, trol and vascular complications in veterans ondary failure of oral hypoglycaemic agents Isami S, Motoyoshi S, et al. Intensive insulin with type 2 diabetes. N Engl J Med. 2009; in obese non-insulin-dependent diabetic pa- therapy prevents the progression of diabetic mi- tients independently of the duration of the crovascular complications in Japanese patients 21. Pogach L, Aron D. Balancing hypoglycemia disease. Diabete Metab. 1993;19(1):30–5.
with non-insulin-dependent diabetes mellitus: and glycemic control. A public health ap- 39. Bloomgarden ZT. Approaches to treatment of a randomized prospective 6-year study.
proach for insulin safety. JAMA. 2010;303(20): pre-diabetes and obesity and promising new Diabetes Res Clin Pract.1995;28(2):103–17.
approaches to type 2 diabetes. Diabetes Care.
8. United Kingdom Prospective Diabetes Study 22. Johnson JA, Majumdar SR, Simpson SH, Toth Group. Intensive blood glucose control with EL. Decreased mortality associated with the 40. Genuth S: Insulin use in NIDDM. Diabetes conventional treatment and risk of complica- lurea monotherapy in type 2 diabetes.
41. Raskin P, Allen E, Hollander P, Lewin A, tion in patients with type 2 diabetes. Lancet.
Diabetes Care. 2002;25(12):2244–8.
Gabbay RA, Hu P, Bode B, Garber. Initiating 23. Johnson JA, Simpson SH, Toth EL, Majumdar insulin therapy in type 2 diabetes. Diabetes 9. United Kingdom Prospective Diabetes Study Group. Effect of intensive blood glucose con- mortality associated with Metformin use in 42. Yki-Jarvinen H, Ryysy L, Nikkila K, Tulokas trol with Metformin on complication in over- subjects with type 2 diabetes. Diabet Med.
weight patients with type 2 diabetes. Lancet.
bedtime insulin regimens in patients with 24. Cockcroft DW, Gault MH. Prediction of type 2 diabetes mellitus. Ann Intern Med.
10. Nathan DM, Cleary PA, Backlund JY, on be- creatinine clearance from serum creatinine.
half of the Diabetes Control and Complica- 43. Schwartz S, Sievers R, Strange P, Lyness WH, tions Trial/Epidemiology of Diabetes Inter- 25. National Kidney Fundation. K/DOQI clinical ventions and complications Study Research practice guidelines for chronic kidney disease: formin versus triple oral therapy in the treat- Group. Intensive diabetes treatment and car- evaluation, classification, and stratification.
ment of type 2 diabetes after failure of two diovascular disease in patients with type 1 di- Am J Kidney Dis. 2002;39(2 suppl 1):S1–266.
oral drugs. Diabetes Care. 2003;26(8);2238–43.
abetes. N Engl J Med. 2005;353(25):2643–53.
26. Bailey CJ. Metformin: a multitasking medica- 44. Welschen LM, Bloemendal E, Nijpels G, 11. Holman RR, Paul SK, Bethel MA, Matthews tion. Diab Vasc Dis Res. 2008;5(3):56.
DR, Neil HA. 10-Year follow-up of intensive 27. Nathan DM. Initial management of glycemia LM. Self monitoring of blood glucose in pa- glucose control in type 2 diabetes. N Engl J in type 2 diabetes mellitus. N Engl J Med.
tients with type 2 diabetes who are not using insulin: a systematic review. Diabetes Care.
12. American Diabetes Association. Standards of 28. Deeg MA. Basic approach to managing hy- medical care in diabetes 2009. Diabetes Care.
perglycemia for the nonendocrinologist. Am J 45. Lopez Stewart G, Tambasia M, Rosas J. A Cardiol. 2005;96 (suppl. 1):37E–40E.
Multi-Center, Epidemiologic Survey of the 13. Rodbard HW, Jellinger PS, Davidson JA, 29. Inzucchi SE. Oral antihyperglycemic therapy Current Medical Practice of General Practi- Einhorn D, Garber AJ, Grunberger G, et al.
for type 2 diabetes. JAMA. 2002;287(3):360–72.
tioners Treating Subjets with type 2 Diabetes 30. Yki-Jarvinen H. Drug therapy: thiazolidine- Mellitus In Latin America. DEAL STUDY.
Clinical Endocrinologists/American College diones. N Engl J Med. 2004;351(11):1106–18.
of Endocrinology Consensus Panel on type 2 31. Chiasson JL, Josse RG, Gomis R, Hanefeld M, 46. Jimenez Corona A, Rojas Martinez R, Gómez- diabetes mellitus: an algorithm for glycemic Karasik A, Laakso M. Acarbose treatment and Pérez FJ, Aguilar-Salinas CA. Early onset type control. Endocr Pract. 2009;15(6):540–59.
the risk of cardiovascular disease and hyper- 2 diabetes in a Mexican, population-based, 14. Canadian Diabetes Association Clinical Prac- tension in patients with impaired glucose tol- nation-wide survey: results of the Encuesta tice Guidelines Expert Committee. Canadian Nacional de Salud y Nutrición 2006. Salud Diabetes Association 2008 clinical practice Publica Mex. 2010:52(supl1):S27–S35.
guidelines for the prevention and manage- 32. Palalau AI, Tahrani AA, Pilla MK, Barnett AH.
47. Aguilar Salinas CA, Gomez Pérez FJ. La de- ment of diabetes in Canada. Can J Diabetes.
DPPIV inhibitor in clinical practice. Postgrad claración de Acapulco. Rev Invest Clin. 2006; 15. Selvin E, Marinopoulos S, Berkenblit G, Rami 48. Nathan DM, Buse JB, Davidson MB, Ameri- T, Brancati FL, Powe NR, Golden SH. Meta- analysis: glycosylated hemoglobin and car- fects of exenatide (exendin-4) on glycemic ciation for the Study of Diabetes. Medical diovascular disease in diabetes mellitus. Ann control and weight over 30 weeks in patients with type 2 diabetes treated with metfomin diabetes: a consensus algorithm for the initia- 16. Stettler C, Allemann S, Juni P, Cull CA, and a sulfonylurea. Diabetes Care. 2005;28(5): tion and adjustment of therapy; a consensus Holman RR, Egger M, et al. Glycemic control statement of the American Diabetes Associa- and macrovascular disease in types 1 and 2 34. DeFronzo R, Ratner RE, Han J, Kim DD, tion and the European Association for the diabetes mellitus: meta-analysis of random- Fineman MS, Baron AD. Effects of exenatide Study of Diabetes. Diabetes Care. 2009;32(1): ized trials. Am Heart J. 2006;152(1):27–38.
on glycemic control and weight over 30 weeks in Metformin-treated patients with type 2 di- 49. Guías ALAD recomendadas por OPS. Avail- Sivakumaran R, Nethercott S, Preiss D, et al.
abetes. Diabetes Care. 2005;28(5):1092–100.
Effect of intensive control of glucose on car- 35. Gerich J, Raskin P, Jean-Louis L, Purkayastha diovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of acy and safety of initial combination therapy randomised controlled trials. Lancet. 2009; formin. Diabetes Care. 2005;28(9):2093–100.
18. Action to Control Cardiovascular Risk in Dia- 36. Fonseca V, Rosentstock J, Patwardhan R, betes Study Group. Effects of intensive glu- Salzman A. Effect of Metformin and rosiglita- cose lowering in type 2 diabetes. N Engl J zone combination therapy in patients with type 2 diabetes mellitus. JAMA. 2000; 283(13): 19. ADVANCE Collaborative Group, Patel A, MacMahon S, Chalmers J, Neal B, Billot L, et 37. Strowig S, Aviles-Santa ML, Raskin P. Im- Manuscript received on 19 July 2010. Revised version ac- al. Intensive blood glucose control and vascu- cepted for publication on 5 November 2010.
Rev Panam Salud Publica 28(6), 2010 Guzmán et al. • Latin American consensus statement for type 2 diabetes treatment América Latina se enfrenta a algunos retos excepcionales en el tratamiento de la dia-betes mellitus tipo 2. La Asociación Latinoamericana de Diabetes (ALAD) reunió a lasasociaciones médicas de 17 países latinoamericanos con el fin de producir una decla- Tratamiento de la diabetes
ración de consenso sobre el tratamiento de la diabetes tipo 2. El objetivo de ese docu- tipo 2 en América Latina:
mento es brindar recomendaciones prácticas que guíen a los médicos a lo largo de unsencillo proceso decisorio para el tratamiento de los pacientes. Los elementos funda- declaración de consenso de
mentales para la toma de decisiones terapéuticas son la gravedad de la hiperglucemia, las asociaciones médicas de
el estado clínico del paciente (estable o con descompensación metabólica) y el índice 17 países latinoamericanos
de masa corporal. El documento contiene un apartado dedicado específicamente a lospacientes obesos y la información se presenta en forma de preguntas clínicas suma-mente pertinentes. El algoritmo se basa en las recomendaciones científicas de lasdirectrices de la ALAD del año 2006 (documento preparado con un método basado en datos probatorios) y en datos obtenidos de estudios controlados aleatorizadosrecientes.
Palabras clave
Diabetes mellitus tipo 2; obesidad; consenso; guías de práctica clínica como asunto;América Latina.
Rev Panam Salud Publica 28(6), 2010

Source: http://www.alad-latinoamerica.org/DOCConsenso/08--SPEC--Guzman---463-471.pdf

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