New EASD-ADA consensus guidelines on managing hyperglycemia in T2DM
Presented by members of the Consensus Panel at the European Association for the Study of Diabetes (EASD) Annual Meeting in Berlin, Germany (1-5 October).
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 hyperglycemia in patients with T2DM.
The new recommendations from the expert panel from both societies, which update their previous 2015 guidance, include:
· Providers and healthcare systems should prioritize the delivery of patient-centered 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 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 program of intensive lifestyle management, which may include food substitution
· Increasing physical activity improves glycemic control and should be encouraged in all people with T2DM.
· Metabolic surgery is a recommended treatment option for adults with T2DM 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 T2DM
· The selection of medication added to metformin is based on patient preference and clinical characteristics, including presence of cardiovascular disease (CVD), HF and kidney disease. The risk for specific adverse medication effects, particularly hypoglycemia and weight gain; as well as safety, tolerability, and cost, are also important considerations.
· Regarding medication management, for patients with clinical CVD, an SGLT2 inhibitor or a GLP-1 receptor agonist with proven CV benefit is recommended. Individual agents within these drug classes have been shown to have CV benefits.
· For patients with CKD or clinical HF and atherosclerotic CVD, 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 T1DM is suspected
· Intensification of treatment beyond dual therapy to maintain glycemic targets requires consideration of the impact of medication side-effects on comorbidities, as well as the burden of treatment and cost
The panel says that the lack of evidence over specific combinations of glucose-lowering therapies remains an issue, and more research is needed. Defining optimal cost-effective approaches to care, particularly in the management of patients —including those with multi-morbidity —is essential.
They add that new questions arise from the recent CV outcomes studies. Do the CV 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 CV 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.
The panel concludes: “The management of hyperglycemia in T2DM has become extraordinarily complex with the number of glucose-lowering medications now available. Patient-centered decision making and support and consistent efforts to improve diet and exercise remain the foundation of all glycemic 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.”
- Our reporting is based on the information provided by the EASD press service -