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To the Editor: We read the comments of Rodbard and Jellinger [1] with interest, but we feel that perhaps the very problem that the position statement of the ADA/EASD [2] was trying to circumvent comes across strongly in their communication. We have been cautious of certainty on the basis of the variety of clinical situations, the heterogeneity of response, the disparities of resource, the complexity of social or cultural environments and the manifold wishes of each of our patients. Indeed, the primary care physician may be best placed to implement a proper individualised and successful therapeutic strategy. Our position statement is not, and was not designed to be, an algorithm. The rationale for this is that we felt that expressing ‘strong preferences’ would not be correct, and think that the authors’ belief that specific prescriptive approach(es) are highly advantageous may be misplaced. Such robust views meld poorly with the concept of a patientcentred approach. More explicitly we do not think that ‘moving closer to’ a previously published algorithm is, of itself, a marker of dramatic improvement. Rather, we have been careful to cite and embrace the work of others upon whose shoulders we stand. Nor do we recognise ‘a three-pronged approach’, which seems to carry with it the concept of a coercing trident. We have been careful to avoid any dogmatic therapeutic propositions based on HbA1c levels above or below thresholds alone. Indeed, we are trying to encourage the process of decision-making on a flexible basis, individualising patient-centred care on criteria other than those simply obtained from a laboratory—without denying the profound importance of such measures. In the case of the choice of therapy, our statement that the ‘order is not meant to denote any specific preference’ should be read as meaning that! The English seems clear to us. Then, on matters of cost, it is imperative to recognise that resources may be paramount—both to governments and to those who need to use their own money to buy pharmaceutical agents. In some countries it is possible to fund 16.7 years of sulfonylurea treatment for the cost of one The ADA/EASD position statement was published simultaneously in Diabetologia and Diabetes Care. Both journals are publishing correspondence relating to the position statement and hence some of the text in this letter is also published in Diabetes Care.

diabetologia

ADA/EASD position statement of the treatment of type 2 diabetes: Reply to Rodbard HW and Jellinger PS [letter], Scheen AJ [letter] and Ceriello A, Gallo M, Gentile S et al [letter]