The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have issued an updated consensus statement outlining the management of hyperglycemia in type 2 diabetes (T2D). The report includes updated guidelines based on new literature published since 2014 and was co-published in Diabetologia and Diabetes Care during the 2018 EASD Annual Meeting in Berlin, Germany.
The guidelines were informed by an expert panel of members from both societies. Recommendations in the report highlight the importance of patient-centered decision making for glycemic management and improvement of diet and exercise for patients with T2D through diabetes self-management education and support.
Major recommendations in the statement include the following:
- Healthcare systems and providers should prioritize patient-centered care by being respectful and responsive to multiple morbidities and individual patient preferences in diabetes management.
- Patient preferences are a major factor in medication adherence and should be considered specifically when selecting glucose-lowering medications. Clinical characteristics — such as the presence of comorbid cardiovascular or renal conditions — should also inform medication choices. In addition, access, cost, and insurance coverage for glucose-lowering medications are important considerations when choosing a therapy.
- All patients with T2D should be offered access to diabetes self-management education and support programs.
- Metformin is the preferred first-line glucose-lowering medication for most patients with T2D. Stepwise addition to initial medications (ie, adding glucose-lowering medications to metformin treatment) is generally preferred over initial combination therapy.
- Sodium-glucose cotransporter-2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists with proven cardiovascular benefit should be used in patients with T2D who have atherosclerotic cardiovascular disease; SGLT2 inhibitors are recommended for patients in whom heart failure coexists or is of particular concern.
- SGLT2 inhibitors shown to reduce chronic kidney disease (CKD) progression should be considered for patients with T2D and CKD. If contraindicated, a GLP-1 receptor agonist shown to reduce CKD progression should be used.
- Individualized medical nutrition therapy should be offered to all patients with T2D. Clinicians should discuss the health benefits of weight loss with overweight and obese patients and encourage them to participate in a lifestyle management program. For all people with T2D, increased physical activity should be encouraged.
- Metabolic surgery is highly effective in improving glucose control and is a recommended treatment option for most adults with T2D who have a body mass index ≥40.0 kg/m2 or a body mass index of 35.0 to 39.9 kg/m2 who do not achieve durable weight loss with nonsurgical methods.
- For those who are unable to meet glycemic targets when taking basal insulin combined with oral medications, treatment can be intensified with SGLT2 inhibitors, GLP-1 receptor agonists, or prandial insulin.
- In patients who require injectable medications, GLP-1 receptor agonists are the preferred choice to insulin.
The panel suggested further research to examine cost-effectiveness of combination glucose-lowering therapies and the cardiovascular and renal benefits of SGLT2 inhibitors and GLP-1 receptor agonists.
“The management of hyperglycemia in type 2 diabetes 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,” the authors concluded.
Davies MJ, D’Alessio DA, Fradkin J, et al. Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) [published online October 5, 2018]. Diabetes Care. doi:10.2337/dci18-0033