medwireNews: The final version of the 2018 update to the consensus guidelines on managing hyperglycemia in people with type 2 diabetes is now published.
The update is published in Diabetologia and Diabetes Care. The draft version was presented at the ADA Scientific Sessions in June this year and the final version was presented this morning at the 54th EASD Annual Meeting in Berlin, Germany.
During the presentation, the guideline authors highlighted several key inclusions in this update, which supersedes the 2015 version:
- A greater focus on lifestyle interventions, including total meal replacement diets.
- Emphasis on patient-centric diabetes management, and patient self-management.
- Guidance on clinical inertia and medication adherence.
- Choosing diabetes medications guided by cardiovascular outcomes trial results and other individual patient considerations.
- Glucagon-like peptide (GLP)-1 receptor agonists are the preferred first-line injectable medications, rather than insulin.
The figures in the consensus report include a decision cycle for patient-centered care and a decision tree for choosing diabetes medications, based on whether patients have established atherosclerotic cardiovascular disease (ASCVD) as opposed to heart failure (HF) or chronic kidney disease (CKD); on their risk for hypoglycemia; their need for weight reduction; and cost.
Guideline author Melanie Davies (University of Leicester, UK) noted that the dichotomized impact of ASCVD and HF/CKD on medication choices has been introduced since the presentation of the draft guidelines in June. Clinicians are now guided towards sodium-glucose cotransporter 2 inhibitors as the first choice for patients with HF or CKD, as long as kidney function is sufficient, whereas GLP-1 receptor agonists have equal weight for those with ASCVD.
These medication recommendations are for patients who require treatment despite lifestyle intervention and metformin, which the guideline authors described as the foundation of hyperglycemic management. They advise stepwise addition of further medications rather than upfront combination therapy, although the latter may be considered if glucose control is particularly poor.
As noted by US guideline author John Buse (University of North Carolina School of Medicine, Chapel Hill, USA), although GLP-1 receptor agonists are the first-line choice for injectable medications, there is some flexibility to allow for “extreme and symptomatic” hyperglycemia, which could indicate underlying autoimmunity and make insulin the better option.
The guidelines also include advice on how to manage existing diabetes medications when a patient initiates insulin, and advice on when to consider metabolic surgery that is in line with existing guidelines.
Addressing the press, EASD Vice President Chantal Mathieu (KU Leuven, Belgium) emphasized the importance of the consensus report process in helping clinicians to decide “where we need to go in this forest of new glucose-lowering therapies.”
She also highlighted the e-learning module due to appear on the EASD website, part of the drive to “bring this consensus paper to life.” This free to access “super-module” is “rich in cases, really translating what does this document mean for me,” said Mathieu.
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