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      Comment on: Inzucchi et al. Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach. Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2012;35:1364–1379

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          Abstract

          Management of hyperglycemia in type 2 diabetes is certainly one of the most debated fields in medicine (1). Although poor possibilities in drug choice for years maintained the discussion only on what glucose target should be reached, the recent introduction of new drugs playing on different mechanisms of action compelled the debate on what drug should be chosen. Unfortunately, most drugs share similar efficacy, and this generated several comments and recommendations usually based on experts’ opinion rather than on evidence-based medicine (2,3). A clear demonstration of the subjectivity of the previous and the present consensus statements by the American Diabetes Association and the European Association for the Study of Diabetes is the profound changes observed between them (1–3). For example, dipeptidyl peptidase 4 inhibitors, previously excluded (3) for lower efficacy, are now included in the flowchart (1); certainly their efficacy has been known since their market launch. Glyburide (European glibenclamide) was banned for increased risk of severe hypoglycemia (3); in this last consensus it is included again, with the suggestion of particular care in prescribing it in patients with moderate to severe renal insufficiency (strange again—such contraindication is shared by almost all sulfonylureas). Strong evidence can hardly change in such a short period of time. The two Italian scientific diabetes societies (Società Italiana di Diabetologia and Associazione Medici Diabetologi) have provided specific recommendations (4) for the diagnosis and treatment of diabetes and its complications, including recommendations for oral medications for type 2 diabetes. An original processing system was used to create these recommendations: the document prepared by the editorial team was published online for 20 days, and the suggestions and criticisms of all of the members were evaluated and integrated with those from a panel of specialists and members of other health care professions committed to diabetes care, as well as lay members, including patient representatives. More importantly, each statement is accompanied by a predefined 6-scale grade of force and evidence for the recommendation, which helps the reader in distinguishing between opinion and proof. We hereby recognize that the last (1) consensus statement is based on evidence more than the previous ones. Actually, we are glad to observe that the proposed flowchart is almost identical to what has been proposed in the Italian document (4). Further, the choice between different therapeutic opportunities is predominantly based on well-known possible side effects (or absence of side effects) instead of pathophysiological wishes, with an attempt to cope with the patients’ needs. Nevertheless, the absence of any grade of evidence (the only grade is the eventual presence of a question mark) still leaves the readers too free to interpret them, assuring the false perception that their prescription/interpretation is following the American Diabetes Association and the European Association for the Study of Diabetes proposed consensus. Guidelines should serve as reference (5). A nonexpert practitioner can be particularly puzzled by the unexplained mix of evidence and opinions, especially if the latter change profoundly between the various consensus versions; the experts will read these consensus just to stimulate (successful) debates. We hope, for the future, that other models of reporting graded evidences, as ours (4), will be taken into account.

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          Most cited references1

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          Highlights from "Italian Standards of care for Diabetes Mellitus 2009-2010".

          L Monge, , G. Bruno (2011)
          The Italian Standards for the Treatment of Diabetes Mellitus represent a consensus document of the two Italian scientific diabetes societies (AMD and SID), providing specific recommendations for the diagnosis and treatment of diabetes and its complications. The level of scientific evidence behind every recommendation has been classified in accordance with the National Guidelines Plan. An original processing system was employed: the document prepared by the Editorial Team was published online for 20 days, and the suggestions and criticisms of about 30 persons were evaluated and integrated to those provided by a panel of diabetologists and members of other healthcare professions dedicated to diabetes care, as well as lay members. Lastly, the document was approved by AMD and SID National Steering Committees. In this version, some highlights of the full document (www.siditalia.it; www.aemmedi.it) concerning the main and most representative recommendations on diagnosis and treatment of diabetes and its complications as well as on diabetes care in some specific contexts, are reported. Copyright © 2010 Elsevier B.V. All rights reserved.
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            Author and article information

            Journal
            Diabetes Care
            Diabetes Care
            diacare
            dcare
            Diabetes Care
            Diabetes Care
            American Diabetes Association
            0149-5992
            1935-5548
            October 2012
            11 September 2012
            : 35
            : 10
            : e71
            Affiliations
            [1]From 1Endocrinology and Metabolic Diseases, Policlinico Gemelli, Catholic University of the Sacred Heart, Rome, Italy; the
            [2] 2Metabolism and Diabetes Unit, ASL Tourin 5, Ospedale Maggiore, Chieri, Italy; the
            [3] 3Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, Italy; the
            [4] 4Ligurian Health Agency, Genoa, Italy; the
            [5] 5Department of Internal Medicine, University of Turin, Turin, Italy; the
            [6] 6Diabetic Foot Unit, Orthopaedic and Trauma Center, Turin, Italy; and
            [7] 7Endocrinology and Metabolism, Department of Internal Medicine, Fatebenefratelli Hospital, University of Rome Tor Vergata, Rome, Italy
            Author notes
            Corresponding author: Andrea Giaccari, giaccari@ 123456rm.unicatt.it
            Article
            0784
            10.2337/dc12-0784
            3447846
            22996185
            a4fd1723-1f99-4ed1-88d3-7d478e89e054
            © 2012 by the American Diabetes Association.

            Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

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            Online Letters: Comments and Responses

            Endocrinology & Diabetes
            Endocrinology & Diabetes

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