Personalizing guidelines for diabetes management: twilight or dawn of the expert?

BACKGROUND: This opinion article on the management of type 2 diabetes considers the old and new format of guidelines and critical changes in the character of such guidelines. We highlight limitations of the guidelines and make recommendations for how treatment can be more personalised. DISCUSSION: Published guidelines for the management of adult-onset non-insulin requiring diabetes have adopted a formulaic approach to patient management that can be overseen centrally and delivered by personnel with limited training. Recently, guidelines have taken a patient-centered, multiple risk-factor approach. Importantly, local funding issues are considered, but drive the final action and not the decision-making process. The nature of the disease can be determined by laboratory tests, including screening for diabetes-associated autoantibodies. The strategy remains step-up, with intensification of drug or insulin dose. As with past guidelines, there is an assumption that in each patient with type 2 diabetes, metformin is used initially, but targets and therapies then veer in different directions to create a matrix of options based on the features and responses of each individual. Factors to consider include: (A)ge, (B)ody weight, (C)omplications and co-morbidities, Diabetes (D)uration and (E)xpense, but also patient preference and patient response. SUMMARY: Guidelines for the management of type 2 diabetes have important limitations and a patient-centered, multiple target, multiple therapy approach is proposed.