After a review of the latest evidence from the literature including a series of recent trials of medication and lifestyle interventions, new consensus guidelines for the management of hyperglycemia in type 2 diabetes from the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA), have just been presented at the EASD annual meeting in Berlin and are published in the journal Diabetologia (1). We will retain an even greater priority, left to the preferences of the patient, in the choice of treatment, and with the aim of better compliance.
It is therefore a real paradigm shift in the management of the type 2 diabetic patient since these new guidelines, based on evidence, encourage the doctor, but also the various professionals who follow the patient (nutritionists, nurses) as well as the service providers of health care to adapt therapeutic and care decisions to the very characteristics of the patient. Thus, these different actors will now have to take into account, and in a priority manner, the patient's age, the anteriority of his diabetes but also possible comorbidities, the experience and the risk of side effects, in particular hypoglycemia, but also patient preferences. This with the aim of better compliance with the treatment which is one of the keys to its effectiveness and to promote a return to a better quality of life.
In addition, it is recalled that the care of glycemia is only part of the global strategy of cardiovascular risk reduction which is the major objective of the care of a type 2 diabetic.
Among the recommendations
of the group of experts from the two learned societies, which update previous guidelines from 2015 (2), which already recommended therapeutic decisions to be made with the patient, taking into account their preferences, needs and values and modeled clinical decision-making.
Already, the 2015 guidelines (2), described patient characteristics and disease factors to be considered by physicians to determine optimal HbA1c targets in patients with type 2 diabetes. more difficult characteristics and situations to the left warrant more rigorous efforts to reduce HbA1c levels.
- health professionals, providers and systems must prioritize the delivery of patient-centred care;
- the choice of hypoglycaemic drugs must specifically take into account the optimization of treatment compliance. Thus, “patient preference” is a determining factor in the choice of drug. Even in cases where a patient's clinical characteristics suggest the use of a particular drug based on available evidence from clinical trials, the patient's preferences regarding route of administration, injection devices, in the extent to which the effects or cost may in some cases interfere with adherence;
“ What is new since 2015 is that we recommend that these comorbidities be considered in priority, because they influence the choice of a particular hypoglycemic drug ”
- all patients should have permanent access to therapeutic education on the most independent possible management of their diabetes;
- nutritional therapy (dietary advice and strategies) should be offered to all patients,
- all obese or overweight diabetic patients should be educated about the health benefits of weight loss and encouraged to engage in an intensive lifestyle management program, which may include certain dietary substitutions or changes ;
- increased physical activity that improves glycemic control should be encouraged in all people with type 2 diabetes;
- bariatric surgery is a recommended treatment option for adults with type 2 diabetes and a BMI greater than or equal to 40 (or 37.5 in patients of Asian descent) who are unable to achieve sustained weight loss or an improvement in comorbidities with standard non-surgical methods;
- metformin remains the first-line treatment recommended for almost all patients with type 2 diabetes;
- the choice of drugs combined with metformin also depends on the patient's preferences and clinical characteristics, in particular the pre-existence of cardiovascular disease, heart failure and kidney disease;
- the risk of drug-specific adverse effects, in particular hypoglycaemia and weight gain, safety, tolerability and cost data are also to be taken into account by professionals, providers and health systems.
Medication management
- It is recommended that patients with clinical cardiovascular disease use a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with already documented cardiovascular benefits: it has Individual agents within these drug classes have been shown to provide cardiovascular benefits.
- in patients with chronic renal failure or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor also with demonstrated benefit should be considered;
- GLP-1 receptor agonists are generally recommended as the first-line injectable drug, except in settings where type 1 diabetes is suspected;
- scaling up treatment beyond dual therapy to maintain glycemic targets requires consideration of the impact of drug side effects on comorbidities, as well as the patient's burden of treatment and its cost.
The lack of evidence on specific combinations of blood sugar lowering treatments which remained an open question is confirmed and the expert panel calls for further research.
“ The costs associated with these different approaches being enormous, we desperately need evidence. Different models of care are currently being implemented around the world. We need to achieve optimal and cost-effective approaches to care, especially for the management of patients with comorbidities ”
So what are the differences vs the 2015 guidelines?
- These new guidelines are intended to help clinicians make their treatment decision in the context of a growing choice of increasingly complex options for the management of hyperglycemia in type 2 diabetes, in emphasizing the most recent data from the literature (published since 2014);
- But this consensus report does not only concern the glycemic and individualized target of the patient, but rather the way to reach it by taking into account, beyond the possible options, factors related to the patient and his preferences;
- While metformin is still recommended as first-line therapy, injectable GLP-1 agonists or SGLT2 inhibitors are promoted as second-line therapy after insulin, depending on patient characteristics;
- Other factors, hitherto “subsidiary” are better taken into account, such as the price, the accessibility of drugs and of course, their possible side effects in the patient; thus, it may be that a generic or older insulin may be considered “if that is all a given patient can afford”;
- the report, according to the experts, finally more clearly indicates the limits of the current evidence and commits to supplementing it with new research.
The evaluation of the cardiovascular state, an essential first step
The assessment of cardiovascular status is confirmed as the first step in determining the therapeutic approach with separate protocols for patients with atherosclerotic cardiovascular disease and heart failure. Indeed, in these new guidelines, these comorbidities are considered as a priority, because they influence the choice of hypoglycemic treatment.
In all these patients, adherence to a healthy lifestyle, and metformin is still considered the mainstay of treatment, particularly and also for reasons of cost, safety and of course efficacy. In patients with atherosclerotic cardiovascular disease, a GLP-1 receptor agonist with demonstrated cardiovascular benefit or an SGLT2 inhibitor is recommended, in that order. Patients for whom heart failure is predominant will be treated, first with an SGLT2 inhibitor then, as an alternative option, with a GLP-1 receptor agonist.
new questions
Recent studies have indeed raised the existence of cardiovascular effects associated with certain treatments.
The cardiovascular and renal benefits of tubular glucose reuptake inhibitors (or sodium-glucose co-transporter 2 -SGLT2 inhibitors) and GLP-1 receptor agonists (or glucagon-like peptide-1 – GLP-1 analogs ) shown to be better suited in patients with established cardiovascular disease need to be extended to patients at lower risk? What are the advantages or benefits of GLP-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors in preventing cardiovascular and renal events? If these advantages were demonstrated, it would be a question of better defining the groups of patients concerned…
It will therefore still be necessary to provide answers to these vital clinical questions, through additional investments in basic, translational and clinical research.
Indeed, the management of hyperglycaemia in type 2 diabetes has become extremely complex, particularly with regard to the number of hypoglycaemic drugs available. However, patient-centered decision-making, support, and ongoing efforts to improve diet and exercise remain the foundation of glycemic management. The first-line use of metformin, followed by the possible addition of hypoglycemic drugs based on comorbidities and patient concerns, is recommended pending answers to the many remaining questions.
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