Oral pharmacologic treatment of type 2 diabetes according to the American College of Physicians has a clinical practice guideline that is regularly updated; the recent update contained two recommendation of the practice (Qaseem & Barry & Humphrey & Forciea, 2017). In May 16th, 2017, the Food and Drug Administration in the United States concluded from two large clinical trials that the type 2 diabetes treatment using canagliflozin increased the patient’s risk of getting the leg or the foot amputated (National Guideline Clearinghouse, 2017): The two major recommendations by The American College of Physicians include:
Recommendation 1: Clinicians should prescribe metformin to type 2 diabetes patients when the pharmacologic therapy is required so that there is an improvement in the glycemic control; this recommendation strongly graded and the quality of evidence regarded as moderate. Metformin reduces glycemic levels and is connected with a loss of weight and little hypoglycemic episodes (Chatterjee ; Khunti ; Davies, 2017); the drug is also cheap compared to other pharmacologic agents; this recommendation is based on the strength that metformin beneficial over sulfonylurea monotherapy when cardiovascular mortality is considered.
Recommendation 2: Clinicians should consider adding a sulfonylurea, a thiazolidinedione, a sodium-glucose catransporter-2 (SGLT-2) inhibitor or a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin so as to improve the control of glycemic when the therapy is considered for the second time (Lipska ; Krumholz ; Soones ; Lee, 2016). This recommendation is graded as weak and its quality evidence being moderate; this is because the evidence is obtained from Randomized Controlled Trials (RCT) with limitations such as biased assessment of the effects of the treatment or unexplained heterogeneity.
However, clinicians should be very careful in selecting among the medications after assessing the benefits, risks, and costs.
The United States of America Preventive Services Task Force (USPSTF) issued a recommendation statement about screening for type 2 diabetes in adults, the statement which was updated after prior evidence review and addition of evidence; the new trials were used to estimate the balance between the benefits and harms of screening the disease (Lin ; Zhuo ; Bardenheier ; Rolka ; Gregg ; Hong ; Zhang, 2017). USPSTF recommended the screening for type 2 diabetes for adults who are asymptomatic and with sustained blood pressure above 135/80 mmHg; however, the evidence on routine screening is insufficient when the balance between benefits and harms are considered. The USPSTF also recommended the screening for abnormal glucose in the blood for adults aged 40 to 70 years as part of assessing cardiovascular risk for the adults who are obese (Selph ; Dana ; Bougatsos ; Blazina ; Patel ; Chou, 2015); the clinicians in this recommendation were strongly advised to refer such patients with abnormal blood glucose to intensive behavioral counseling as an intervention for promoting healthful diet and physical activity.
Evidence from recent studies provide low quality and insufficient information for evaluating clinical outcomes such as mortality, cardiovascular mortality, and morbidity; the recent studies composed of 52 Randomized Controlled Trials and 13 observational studies over a period of a year; the benefit of the oral pharmacologic treatment of type 2 diabetes using metformin were as follows;
All-Cause Mortality; the low-quality evidence between metformin monotherapy and sulfonylurea monotherapy proved that metformin is related with lower all-cause mortality: Cardiovascular Mortality; the review in cardiovascular mortality evidenced that metformin is associated with lower cardiovascular mortality compared to sulfonylurea both for the RCTs and the observational studies. Cardiovascular and Cerebrovascular Morbidity; the low-quality evidence again proved the benefit of metformin over sulfonylurea in morbidity, metformin was associated with lower cardiovascular morbidity compared to sulfonylurea; the same was realized for cerebrovascular morbidity; however, the evidence was inconclusive for the realized results were from insufficient and low-quality assessment.
The USPSTF found adequate evidence proving the significance of intensive behavioral counseling and reduction of cardiovascular disease; however, these benefits are shared with persons associated with obesity, overweight and possesses dyslipidemia or hyperlipidemia and hypertension (American Diabetes Association, 2017); the overall benefits of behavioral interventions are reduced blood pressure, body glucose and lipid levels, reduction in obesity with increased physical activities; all these interventions help prevent the development of diabetes; lifestyle interventions have a higher chance of reducing progression to diabetes compared to metformin or any other medications (Selph ; Dana ; Blazina ; Bougatsos ; Patel ; Chou, 2015).
Advanced Practice Registered Nurses have evidently been involved in improving the outcomes for patients with type 2 diabetes under primary care practices; advanced practice nurses through their capacity can initiate, adjust and change the medication of a diabetic patient without the authorization of a physician because they are well learned in the primary care capacity (Wheeler ; Schumann ; Harkless ; Ling ; Bird ; Maybee, 2015); such nurses embrace their nursing knowledge and experience which guides them in identifying the need for change in medication for a diabetic patients through assessments physically or even through the alternate communication channels such as telephone, e-mails, and e-visits. This experience reduces the costs of medication for the patient and increased the convenience and quality of care for the disease (Smith ; Satyshur, 2016). The practice guideline will assist an advanced practice nurse to be able to conduct the entire medication of type 2 diabetic patient without the aid of a physician; the nurse will have all the report on evidence and quality of evidence, the recommendation and the analysis of balance of benefits and harms associated with the recommendations; the guide also provides the major outcomes considered, such outcomes can be sued as a benchmark by the nurse in determining the effectiveness of the treatment of the patient.