Following a review of the latest evidence --including a range of recent trials of drug and lifestyle interventions -- the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) have produced an updated consensus statement on how to manage hyperglycaemia (high blood sugar) in patients with type 2 diabetes. The consensus paper is being co-published in Diabetologia, the journal of EASD, and Diabetes Care, the journal of the ADA, during the annual meeting of EASD in Berlin, Germany.
The new recommendations from the expert panel from both societies, which update their previous 2015 guidance, include:
- Providers and healthcare systems should prioritise the delivery of patient-centred care
- Facilitating medication adherence should be specifically-considered when selecting glucose-lowering medications. (Ultimately, patient preference is a major factor driving the choice of medication. Even in cases where a patient's clinical characteristics suggest the use of a particular medication based on the available evidence from clinical trials, patient preferences regarding route of administration, injection devices, side effects or cost may prevent their use by some individuals)
- All patients should have ongoing access to diabetes self-management education and support
- Medical nutrition therapy (healthy eating advice and strategies) should be offered to all patients
- All overweight and obese patients with diabetes should be advised of the health benefits of weight loss and encouraged to engage in a programme of intensive lifestyle management, which may include food substitution
- Increasing physical activity improves glycaemic control and should be encouraged in all people with type 2 diabetes.
- Metabolic surgery is a recommended treatment option for adults with type 2 diabetes and (1) a BMI of 40 or over (or 37.5 or over in people of Asian ancestry) or (2) a BMI of 35.0 to 39.9 (32.5-37.4 kg/m2 in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities with reasonable non-surgical methods.
- Metformin continues to be the first-line recommended therapy for almost all patients with type 2 diabetes
- The selection of medication added to metformin is based on patient preference and clinical characteristics, including presence of cardiovascular disease, heart failure and kidney disease. The risk for specific adverse medication effects, particularly hypoglycaemia and weight gain; as well as safety, tolerability, and cost, are also important considerations.
- Regarding medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. Individual agents within these drug classes have been shown to have cardiovascular benefits.
- For patients with chronic kidney disease (CKD) or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit should be considered
- GLP-1 receptor agonists are generally recommended as the first injectable medication, except in settings where type 1 diabetes is suspected
- Intensification of treatment beyond dual therapy to maintain glycaemic targets requires consideration of the impact of medication side-effects on comorbidities, as well as the burden of treatment and cost
The panel say that the lack of evidence over specific combinations of glucose-lowering therapies remains an issue, and more research is needed. The say: "As the cost implications for these various approaches is enormous, evidence is desperately needed. Different models of care are being implemented globally. Defining optimal cost-effective approaches to care, particularly in the management of patients --including those with multi-morbidity --is essential."
They add: "New questions arise from the recent cardiovascular outcomes studies. Do the cardiovascular and renal benefits of SGLT2 inhibitors and GLP-1 receptor agonists demonstrated in patients with established CVD extend to lower-risk patients? Is there additive benefit of use of GLP-1 receptor agonists and SGLT2 inhibitors for prevention of cardiovascular and renal events? If so, in what populations? Addressing these and other vital clinical questions will require additional investment in basic, translational, clinical and implementation research."
They conclude: "The management of hyperglycaemia in type 2 diabetes has become extraordinarily complex with the number of glucose-lowering medications now available. Patient-centred decision making and support and consistent efforts to improve diet and exercise remain the foundation of all glycaemic management. Initial use of metformin, followed by addition of glucose-lowering medications based on patient comorbidities and concerns is recommended as we await answers to the many questions that remain."