In Reply

Letters to the Editor regarding the article Shared Decision Making, Diagnostic Evaluation, and Pharmacotherapy in Type 2 Diabetes National Disease Management Guideline by Dr. med. Christina Brockamp, Prof. Dr. med. Rüdiger Landgraf, apl. Prof. Dr. med. habil. Ulrich Alfons Müller, MSc; Prof. Dr. med. Dirk Müller-Wieland, Prof. Dr. rer. soc. Frank Petrak, and Dr. med. Til Uebel in issue 47/2023

We are pleased that our colleague Mainz specifically mentions and appreciates the chapter on shared decision making and agreement on individual therapeutic goals. The guideline group also considers this topic area extremely important and has established the chapter as a central component of the National Disease Management Guideline (NDMG) for Type 2 Diabetes since 2021 (1, 2).

The concept of shared decision making is an overarching principle that includes non-treatment as a possible option after appropriate information about benefits and harms have been provided. The explanations regarding therapeutic options and targets for individual variables are therefore to be understood as an orientation. Deviations from these can and must be made according to individual therapy goals and patient factors (3). The goals are explicitly not limited to the HbA1c value in a glucocentric manner, but rather include overarching life goals.

The guideline group estimates that the available evidence does not allow for concluding clear HbA1c target values for individual patient groups—and not for individual age groups either. The reported target corridor serves as guidance and does not represent a fixed threshold. Because of the low certainty of the evidence, the primary goal is to plan any treatment jointly and in such a way that it is as compatible as can be with persons’ everyday lives and individual needs (1).

At the same time, the national disease management guideline raises awareness for the fact that excess mortality in persons with type 2 diabetes approaches that of the normal population with increasing age (4). The benefit that can be expected from therapy at advanced age therefore decreases. In various places, the guideline group also points out the diabetes-independent increase in HbA1c levels with increasing age (1).

In the current NDMG the topics of multimorbidity and very elderly people have not yet been dealt with. In the course of continuous updating this group of persons will be addressed separately.

DOI: 10.3238/arztebl.m2024.0020

On behalf of the authors
Dr. med. Christina Brockamp
Ärztliches Zentrum für Qualität in der Medizin (ÄZQ), Berlin

Conflict of interest statement
CB is a research scientist in the NDMG program, which is funded by the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV) and the German Medical Association (Bundesärztekammer, BÄK).

References

1. Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): Nationale VersorgungsLeitlinie Typ-2-Diabetes – Langfassung, Version 3.0 . (last accessed on 24 January 2024).

2. Brockamp C, Landgraf R, Müller UA, Müller-Wieland D, Petrak F, Uebel T, on behalf of the National Disease Management Guideline Group: Clinical practice guideline: Shared decision making, diagnostic evaluation, and pharmacotherapy in type 2 diabetes. National Disease Management Guideline. Dtsch Arztebl Int 2023; 120: 804–1

3. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF)-Ständige Kommission Leitlinien: AWMF-Regelwerk Leitlinien: Version 2.1. https://www.awmf.org/regelwerk (last accessed on 24 January 2024).

4. Nationale Diabetes-Surveillance am Robert Koch-Institut: Diabetes in Deutschland – Bericht der Nationalen Diabetes-Surveillance 2019. https://diabsurv.rki.de/SharedDocs/downloads/DE/DiabSurv/diabetesbericht2019.html (last accessed on 24 January 2024).