Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A Consensus Statement From the American Diabetes Association and the European Association for the Study of Diabetes

Abstract

We anticipated that our consensus algorithm (1) would generate some controversy, but we are pleased with the general level of appreciation expressed in the letters, albeit with some disagreements. Dr. Cryer (2) specifically endorses the recommendation in our consensus algorithm to use insulin earlier in the treatment course of type 2 diabetes but takes issue with the relatively low frequency of severe hypoglycemia that we cited for insulin-treated type 2 diabetes, which was defined in accordance with the Diabetes Control and Complications Trial and compared with the rate in type 1 diabetes. As Dr. Cryer notes, our estimates were based on data from “clinical trials aimed at normoglycemia and achieving a mean A1C of ∼7%.” Dr. Cryer cited review articles (including some referenced by us) and other empiric studies (uncontrolled clinical trials) that suggested a much higher risk for severe hypoglycemia in insulin-treated type 2 diabetic patients than we described. The reasons that we chose data from controlled clinical trials to establish the expected risk for severe hypoglycemia with insulin therapy, rather than refer to other clinical data referenced by Dr. Cryer, include their more careful and uniform assessment of adverse events, such as hypoglycemia; their use of consensus definitions established a priori; their ability to compare frequency of hypoglycemia among trials using intensive therapy in type 1 and type 2 diabetes; and, perhaps most …