Never did I read a document so impregnated with intelligence and tenderness directed to the medical profession!!! I can say that I am happy to have already talked with Professor Derek R Matthews from Oxford (UK).
2. editorial DIABETES, OBESITY AND METABOLISM
range of agents have not been carried out, or drugs hypoglycaemia, social environment (e.g. living alone), age
used in previous trials are now no longer prescribed or or even life expectancy in some circumstances.
available or thought to be appropriate. In the Consensus
We have to begin an open dialogue about patient wishes,
statement Algorithm published in 2009 [5], for example,
fears, circumstances and resources. This is neither evidence-
after the use of metformin the only subset that was
based medicine nor solely knowledge-based medicine. It
labelled as having a ‘well-validated’ evidence base was
requires listening, thought, experience and wisdom. It is
for the use of sulphonylureas—based on the UKPDS.
rationally based medicine which in the best hands is
The guidelines explicitly suggested, however, that what
compassion-based medicine too.
should be used should be ‘sulfonylureas other than
glybenclamide (glyburide) or chlorpropamide’. However,
these agents were exactly the ones that were used in the D. R. Matthews
UKPDS. Professor of Diabetes Medicine, University of Oxford;
• The US and European regulators take a different view NIHR Senior Research Fellow;
about pharmaceutical agents, so there cannot be an agreed Oxford Centre for Diabetes, endocrinology and Metabolism
clinical view that has transatlantic credence, much less a
global one.
• ‘Expert’ committees may have their expertise limited References
by geographic experience, or by an approach that is
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clinically monocular. So clinician-based guidelines may
Archie Cochrane. London: British Medical Journal, 1989.
differ from those of providers (e.g. health management
2. Seino S, Takahashi H, Takahashi T, Shibasaki T. Treating diabetes today:
organizations in the USA and the National Institute
a matter of selectivity of sulphonylureas. Diab Obes and Metab 2012;
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these circumstances guidelines may suggest one path
3. Hamet P. What matters in ADVANCE and ADVANCE-ON. Diab Obes and
where public health or finance restraints may dictate Metab 2012; 14(Suppl. 1): 20–29.
another.
4. Avogaro A. Treating diabetes today with Gliclazide MR: a matter of numbers.
• Guidelines abstract public domain data (usually random-
Diab Obes and Metab 2012; 14(Suppl. 1): 14–19.
ized controlled trials from large research populations) for
5. Colagiuri S. Optimal management of type 2 diabetes: the evidence. Diab
evidence on how to treat individuals [7]. Although this is
Obes and Metab 2012; 14(Suppl. 1): 3–8.
better than prescribing on the basis of opinion, it does
6. Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R
not allow for the fact that patients differ widely in their
et al. Medical management of hyperglycemia in type 2 diabetes: a
pathology and phenotypes (phenotype may include age, consensus algorithm for the initiation and adjustment of therapy: a
sex, weight or co-morbidity). Physicians and governments consensus statement of the American Diabetes Association and the
espouse patient involvement in therapy [3,8] yet guidelines European Association for the Study of Diabetes. Diab Care 2009; 32:
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consultation. 7. Grant PJ. The EASD/ADA consensus: trick or treat?. Diabetes Vasc Dis Res
• Nodal decision points on guidelines may not be explicit in 2009; 6: 5–6.
terms of timing or reasons for increasing/altering therapy. 8. Glasgow RE, Peeples M, Skovlund SE. Where is the patient in diabetes
Adding or altering therapy may be based on complex performance measures? The case for including patient-centered and self-
decisions relating to such issues as co-morbidity, risks of management measures. Diabetes Care 2008; 31: 1046–1050.
2 doi:10.1111/j.1463-1326.2011.01514.x Volume 14 No. (Suppl. 1) January 2012