New ESC/EASD Guidelines on diabetes no longer regard metformin as first-line therapy

ESC 2019 As a consequence of recent outcome trials of new therapies for diabetes, new treatment recommendations now include use of SGLT2 inhibitors and GLP-1RA.

Among the five new ESC guidelines presented at this year’s ESC congress, was the 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Since the publication of the previous version in 2013, a lot of new evidence has become available that has implications for daily clinical practice. The most important novel insights are the result of a number of CV safety trials for type 2 diabetes (T2DM) therapies. All have reported CV safety, but several have also demonstrated, for the first time in the diabetes field, clear evidence of CV benefit. This regards SGLT2 inhibitors and GLP-1 receptor agonists (GLP-1RAs).

In other ways, and on a global scale, little has changed. The prevalence of DM worldwide continues to increase, rising to 10% of the population in countries such as China and India, which are now embracing western lifestyles. Combining the increasing prevalence with the novel treatment opportunities, shows the relevance of an update to the earlier guidelines.

Here, we highlight some of the new recommendations in the 2019 ESC/EASD Guidelines on diabetes, pre-diabetes and CV diseases.

• Prevention of CVD: Lifestyle intervention is recommended to delay/prevent conversion from pre-DM to T2DM and to prevent CV complications of diabetes.
• Lipid targets: In line with the 2019 ESC/EAS Dyslipidaemia Guidelines, recommendations on lipid targets have been altered to LDL-c<2.5 mmol/L for T2DM patients at moderate CV risk, to <1.8 mmol/L for those at high risk and <1.4 mmol/L for those at very high risk.
• Glucose-lowering treatment: Metformin is no longer first-line therapy in patients with DM, but should now be considered in overweight patients with T2DM without CVD and at moderate CV risk.
• Glucose-lowering treatment: The SGLT2 inhibitors empagliflozin, canagliflozin, or dapagliflozin are recommended in patients with T2DM and CVD, or at very high/high CV risk, to reduce CV events. Empagliflozin is recommended in patients with T2DM and CVD to reduce the risk of death. The GLP-1RAs liraglutide, semaglutide, or dulaglutide are recommended in patients with T2DM and CVD, or very high/high CV risk, to reduce CV events. Liraglutide is recommended in patients with T2DM and CVD, or at very high/high CV risk, to reduce the risk of death.
• DM treatment to reduce HF risk: SGLT2 inhibitors are recommended to lower risk of HF hospitalization. Metformin should be considered in patients with DM and HF if eGFR >30 mL/min/1.73 m². GLP1-RAs and DPP4 inhibitors sitagliptin and linagliptin have a neutral effect on risk of HF and may be considered. Insulin treatment in HF may be considered. DPP4 inhibitor saxagliptin in HF is not recommended and thiazolidinediones (pioglitazone and rosiglitazone) in HF are not recommended.
• CVRM: Other changes to medication recommendations concern antiplatelet therapy (No aspirin for primary prevention in patients with T2DM at moderate CV risk, aspirin may be considered in those at very high/high risk), anticoagulation (NOACs are preferred over VKAs for management of atrial fibrillation), BP management (preference for RAAS blockers over beta-blockers/diuretics in pre-DM) and dyslipidemia (in those at very high risk with high LDL-c despite maximally tolerated statins plus ezetimibe, PCSK9 inhibitor is recommended).

For all new recommendations, we refer to the full guidelines (see link below).

- Our reporting is based on the information provided at the ESC congress -

The ESC/EASD guidelines have been simultaneously published at Eur Heart J