ADA-EASD 2018 Guidelines for Mx of Hyperglycemia in Type 2 Diabetes
The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have jointly 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 the journals Diabetologia and Diabetes Care. The ADA has endorsed the ADA-EASD Consensus Report and incorporated the recommendations in the ADA’s Standards of Medical Care in Diabetes-2018 as a Living Standards Update.
The draft guideline document was announced in July earlier this year, which stressed that treatment approach to type 2 diabetes should begin with an assessment of cardiovascular disease (CVD) status, other comorbidities, and patient preferences. (Can be read here: https://pxmd.co/rkDvc)
The ADA-EASD Consensus Report features seven new graphic Figures that provide detailed health care roadmaps (algorithms) and two new Tables enumerating the multiple therapy and medication options for the care of adults with type 2 diabetes. While the algorithms focus on the choice of diabetes medications, the report also highlights the critical importance of comprehensive lifestyle management and diabetes self-management education and support in the overall health of people with type 2 diabetes.
The report’s central theme is conveyed in Figure 1-a Decision Cycle for Patient-Centered Glycemic Management in Type 2 Diabetes- representing a continuum of care for adults with type 2 diabetes throughout their lifetime. The Goals of Care are at the core- prevent complications and optimize quality of life.
The steps are:-
1) assess key patient characteristics
2) consider specific factors that impact choice of treatment
3) shared decision-making to create a management plan
4) agree on a management plan
5) implement management plan
6) ongoing monitoring and support including mental health, medication tolerance and adherence, monitoring of blood glucose, weight, nutrition, physical fitness and exercise, and smoking cessation counselling
7) review and agree on management plan; returning to step 1 and going through the full cycle at least twice each year, and as needed throughout each patient’s life
New recommendations include the following:-
• For the first time, the ADA-EASD Consensus Report includes specific pharmacologic recommendations based on a patient’s profile and health history (Figure 2), providing instructions in the context of ASCVD, heart failure, kidney disease, weight, risk for hypoglycemia, or a need for low-cost options. One thing that hasn’t changed is an emphasis on comprehensive lifestyle management and metformin, which remains the preferred first-line agent.
• There is a new guidance for glucagon-like peptide 1 (GLP-1) receptor agonists, which are now recommended as the first injectable medication prior to insulin for most adults with type 2 diabetes who need the greater blood glucose-lowering of an injectable medication.
• For patients with chronic kidney disease, the panel recommends consideration of a sodium-glucose cotransporter 2 (SGLT2) inhibitor with proven benefits. Individual medications in both the GLP-1 receptor agonist and SGLT2 inhibitor classes have been shown to have cardiovascular benefits.
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.
About the ADA, EASD
Founded in 1940, the American Diabetes Association (ADA) is the nation’s leading voluntary health organization whose mission is to prevent and cure diabetes, and to improve the lives of all people affected by diabetes. The ADA drives discovery by funding research to treat, manage and prevent all types of diabetes, as well as to search for cures; raises voice to the urgency of the diabetes epidemic; and works to safeguard policies and programs that protect people with diabetes.
The European Association for the Study of Diabetes e.V. (EASD) is a non-profit, medical scientific association, founded in 1965, and headquartered in Duesseldorf, Germany. The aims of EASD are to encourage and support research in the field of diabetes the rapid diffusion of acquired knowledge and to facilitate its application. EASD is one of the largest networks for diabetologists worldwide with more than 5,000 active members from over 100 countries throughout the world.
Note: This list is a brief compilation of some of the key points included in the guidelines and is not exhaustive and does not constitute medical advice. Kindly refer to the original publications here: https://pxmd.co/nEDS2 and https://pxmd.co/38uP8