[New treatment strategies for type-2 diabetes?].

Earlier guidelines for type 2 diabetes (Afssaps 1999 and Anaes 2000) were based on the UK Prospective Diabetes Study, published in 1998. These guidelines recommended treatment according to HbA1c value (< 6.5%, between 6.5 and 8% and > 8%): an oral antidiabetic agent for levels > 6.5% despite diet and exercise; combined metformin + sulfonylurea) if HbA1c >8%; and insulin if the latter failed. Blood pressure goals were < 130/80 mmHg, with the antihypertensives necessary to achieve it. The LDL-cholesterol target value was < 1 g/L (for primary prevention in the case of high cardiovascular risk or for secondary prevention) or between 1.3 and 1.6 g/l (primary prevention in the absence of elevated risk). Another reading of the UK study, associated with the arrival of glitazones led to a revision of these objectives with a more aggressive treatment approach ("earlier and stronger"): screen patients for type 2 diabetes earlier, set stricter goals (HbA1c < 6%), and promptly prescribe dual therapy (metformin + sulfonylurea). Should this fail, either glitazone should be added or insulin treatment begun. For most people with type 2 diabetes, the target blood pressure remains 130/80 mmHg, regardless of the type and number of antihypertensive agents necessary. The target drops to 125/75 mmHg for patients with > 300 mg/day microalbuminuria; in these cases, treatment with agents that block the renin-angiotensin system (ACE inhibitors or sartans) is recommended. The LDL cholesterol target value is 1.0 or 1.6 g/L, depending on the cardiovascular risk level. But these guidelines are applied insufficiently, especially in terms of clinical and laboratory follow-up of patients and choice of treatment. All health professionals must participate in the more effective diffusion and application of these guidelines. Patient education is fundamental. The establishment of care networks for these patients seems to us to be the best tool for meeting the objectives of these guidelines.