Treating to goal: challenges of current management

University of Birmingham and Birmingham Heartlands Hospital, Department of Medicine Undergraduate Centre, Bordesley Green East, Birmingham, B9 5SS, UK. anthony.barnett@heartsol.wmids.nhs.uk

Extensive evidence supports the benefits of treating to glycated haemoglobin (HbA1c) goal, both in terms of health and economic outcomes. As shown by the UK Prospective Diabetes Study (UKPDS) and the Diabetes Control and Complications Trial (DCCT), the risk of patients with type 2 diabetes developing vascular complications is strongly correlated with HbA1c levels and the duration of poor glycaemic control. Moreover, good glycaemic control significantly reduces the risk of complications. In controlled clinical trials, a number of pharmacological agents have been shown to significantly reduce HbA1c levels in patients with type 2 diabetes. However, the reality is that most patients with type 2 diabetes have HbA1c levels above the recommended target levels. Although there are regional differences in the average HbA1c level, poor glycaemic control is a universal problem that will continue to grow in line with the rapidly increasing prevalence of type 2 diabetes. Barriers to good blood glucose control are present in almost every aspect of diabetes care. Furthermore, in patients with type 2 diabetes, therapy-, patient- and/or healthcare system-related barriers are compounded by an ongoing decline in beta-cell function that is characteristic of the progressive nature of the disease. Therapy-related barriers include reduced long-term efficacy with oral agents, fear of hypoglycaemia and a variety of issues related to flexibility and convenience that encourage poor compliance with therapy. From the patient perspective, issues relating to lifestyle, education, psychology and the environment can prevent optimum diabetes self-management. Poor access to and/or use of specialist healthcare resources also has a negative effect on treatment outcomes. These barriers to glycaemic control need to be overcome so that the established benefits of reducing glucose to normal or near-normal levels can be experienced by more people with type 2 diabetes.