Recent WHO diabetes guideline summarized and critiqued

The World Health Organization (WHO) released an updated diabetes guideline in July and it was summarized by Annals of Internal Medicine on Sept. 4.

The guideline addresses treatment intensification in adults with type 1 or 2 diabetes in low-resource settings in low- or high-income countries, as well as disadvantaged populations in high-income countries. It was based on high-quality systematic reviews and includes five recommendations:

• Give a sulfonylurea to patients with type 2 diabetes who do not achieve glycemic control with metformin alone or who have contraindications to metformin (strong recommendation, moderate-quality evidence).
• Introduce human insulin treatment to patients with type 2 diabetes who do not achieve glycemic control with metformin and/or a sulfonylurea (strong recommendation, very low-quality evidence).
• If insulin is unsuitable, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium-glucose cotransporter-2 (SGLT2) inhibitor, or a thiazolidinedione may be added (weak recommendation, very low-quality evidence).
• Use human insulin to manage blood glucose in adults with type 1 diabetes and in adults with type 2 diabetes for whom insulin is indicated (strong recommendation, low-quality evidence).
• Consider long-acting insulin analogs to manage blood glucose in adults with type 1 or type 2 diabetes who have frequent severe hypoglycemia with human insulin (weak recommendation, moderate-quality evidence for severe hypoglycemia).

The synopsis noted that the recommendations are intended for settings with limited resources where health care budgets can be quickly exhausted by expensive medications. The guideline was published on the WHO website on July 25.

An editorial from ACP's High Value Care Committee was also published by Annals on Sept. 4 and analyzed some differences between the WHO guideline and ACP's 2017 diabetes guideline. The WHO guideline recommends sulfonylureas as second-line therapy based on effectiveness and cost, but the editorialists “worry about the cumulative effect of hypoglycemia,” they said. “The ACP recommends that clinicians and patients discuss benefits, adverse effects, and costs when choosing among second-line therapy options, including sulfonylureas, thiazolidinediones, SGLT-2 inhibitors, and DPP-4 inhibitors.” Future research into the effects of newer diabetes drugs will likely lead to changes in both guidelines, the editorial said.