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Leading diabetes groups stress patient-centered care, new therapies in updated consensus report
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Providers should prioritize patient-centered care for type 2 diabetes that incorporates therapy regimens tailored to specific patient goals, whereas new medications shown to reduce cardiovascular risk should be introduced earlier for high-risk patients, according to a joint consensus report published Friday by the American Diabetes Association and European Association for the Study of Diabetes.
“It has become a tradition — this is the third edition — to update the position statement, now renamed to consensus report, every 3 years,” Chantal Mathieu, MD, PhD, professor of medicine at Katholieke Universiteit Leuven, Belgium, told Endocrine Today. “The last statement was published in 2015. Considering the evolution of literature and accumulation of evidence on some classes of agents, we felt confident it was the right time to give strong and evidence-based advice on glucose lowering therapy in type 2 diabetes.”
The updated guideline includes new evidence published between 2014 and February 2018, including studies that examined the effectiveness or safety of pharmacological or nonpharmacological interventions in adults with type 2 diabetes.
Recommendations include the following:
- Providers and health care systems should prioritize the delivery of patient-center care.
- The ability to take medications as prescribed should be considered when selecting specific glucose-lowering therapies for patients.
- SGLT2 inhibitors and GLP-1 receptor agonists are recommended as part of glycemic management for adults with type 2 diabetes and established CVD, whereas SGLT2 are recommended for those with atherosclerotic CVD in whom heart failure coexists or is of special concern.
- An SGLT2 inhibitor shown to reduce chronic kidney disease progression should be considered for adults with type 2 diabetes and CKD, or a GLP-1 receptor agonist if SGLT2 inhibitors are contraindicated.
- Bariatric surgery is a recommended treatment option for those with type 2 diabetes and a BMI of at least 40 kg/m² or with a BMI between 35 kg/m² and 39.9 kg/m² with other comorbidities.
- In adults who need the greater glucose-lowering effect of an injectable medication, GLP-1 receptor agonists are the preferred choice to insulin.
The report also notes that glycemic targets should be individualized based on patient preferences and goals, risk of adverse effects of therapy and patient characteristics, including frailty and comorbid conditions.
“The most important point is that the patient is at the center of his/her own therapy, the goal of which is to prevent complications, but, foremost, to improve quality of life,” Mathieu said in an interview. “Lifestyle and multifactorial approaches are crucial and metformin should be present in all, if tolerated.”
Certain patient characteristics overrule all other choices, on basis of hard evidence, Mathieu said.
“If CVD is present, choose either an SGLT2 inhibitor or a GLP-1 receptor agonist,” she said. “If heart failure or CKD is present, choose an SGLT2 inhibitor. If these are not present, let other patient characteristics be the guide in choice of glucose lowering therapies, like risk for hypoglycemia or risk for weight gain. Cost is also an issue, with sulfonylureas and thiozoledinediones proposed if cost is on the forefront, with intensification of education.” Mathieu added that GLP-1 receptor agonists are the “preferred first injectable,” with basal insulin as an intensification strategy.
“We hope that this consensus will aid clinicians in feeling confident when choosing glucose lowering agents for the treatment of people with type 2 diabetes,” she said. The study was simultaneously published in both Diabetes Care and Diabetologia. – by Regina Schaffer
References:
Davies MJ, et al. Management of hyperglycemia in type 2 diabetes: ADA-EASD Consensus Report 2018. Presented at: European Association for the Study of Diabetes Annual Meeting; Oct. 1-5, 2018; Berlin.
Davies MJ, et al. Diabetologia. 2018;doi:10.1007/s00125-018-4729-5.
Davies MJ, et al. Diabetes Care. 2018; doi:10.2337/dci18-0033.
For more information:
Chantal Mathieu, MD, PhD, can be reached at Katholieke Universiteit Leuven, Oude Markt 13, 3000 Leuven, Belgium; email: chantal.mathieu@uzleuven.be.
Disclosures: Davies reports she has received personal fees and/or grants from AstraZeneca, Boehringer Ingelheim, Eli Lilly, Gilead Sciences, Intarcia, Janssen, Merck, Mitsubishi Tanabe Pharma Corp., Novo Nordisk, Sanofi and Takeda. Please see the consensus report for the other authors’ relevant financial disclosures.
Perspective
Back to TopDerek LeRoith, MD, PhD
Recent CV outcome studies have, for the first time, demonstrated definitive prevention of CVD in patients with type 2 diabetes. Both SGLT2 inhibitors and GLP-1 receptor agonists have successfully shown these effects. It is not surprising the ADA and EASD have released a consensus report dealing with this new information.
Until recently, most guidelines that pertained to therapy for adults with type 2 diabetes recommended diet, exercise and starting with metformin as the first-line antidiabetic medication. If the therapeutic HbA1c goal is not reached within 3 months of metformin treatment, second-line oral agents are added. This is often followed by a third oral agent or an injectable; either a GLP-1 receptor agonist or SGLT2 inhibitor injection. There has also been growing interest in combination therapies of either oral agents or injectables.
It is now recommended that an SGLT2 inhibitor or a GLP-1 receptor agonist be used early in the therapeutic regimen for those with type 2 diabetes and CVD. SGLT2 inhibitors, especially, reduce risk for those with heart failure, whereas as the GLP-1 receptor agonists should be considered where atherosclerotic CVD is present. These should be considered as second-line agents under these circumstances. Thus, our paradigms are rapidly and significantly changing. Hopefully, practitioners will be made aware of these important changes.
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