New recommendations on the management of type 2 diabetes were recently issued by the American Diabetes Association and the European Association for the Study of Diabetes.
The consensus statement updated the organizations' prior position statements, released in 2012 and 2015, respectively, and was based on a systematic evaluation of relevant literature published in English from Jan. 1, 2014, through Feb. 28, 2018. It was published online Oct. 5 by Diabetes Care and Diabetologia.
The recommendations support patient-centered care; provision of diabetes-self management education and support, including attention to medication adherence; and consideration of cardiovascular outcomes in medication choice. Examples of this consideration include a recommendation that patients with clinical cardiovascular disease take a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist with proven cardiovascular benefit. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended.
Additional recommendations cover the full range of therapeutic options, including medical nutrition therapy, physical activity, metabolic surgery, and medications. A section of the consensus statement on implementation offers stepwise recommendations from initial therapy to intensification beyond two medications and addition of injectable medications. Metformin is still the preferred initial glucose-lowering medication for most people with type 2 diabetes, according to the recommendations. Of note, GLP-1 receptor agonists are preferred to insulin as the first injectable medication for most patients, although insulin is still recommended for patients with extreme and symptomatic hyperglycemia. The statement also recommends considering access, cost, and insurance coverage when selecting a medication.
Finally, the statement reviews emerging technology and key knowledge gaps. “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. 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,” it concludes.