What are the 2018 ADA/EASD treatment guidelines for hyperglycemia in patients with type 2 diabetes?

Updated: Oct 23, 2019
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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Answer

In October 2018, in an update to previous position statements, the ADA and the European Association for the Study of Diabetes (EASD) released new recommendations regarding adults with type 2 diabetes. The guidelines, on the management of hyperglycemia, include the following [351] :

  • Providers and health-care systems should prioritize the delivery of patient-centered care
  • All people with type 2 diabetes should be offered access to ongoing diabetes self-management education and support (DSMES) programs
  • Facilitating medication adherence should be specifically considered when selecting glucose-lowering medications
  • Among patients with type 2 diabetes who have established atherosclerotic cardiovascular disease (ASCVD), sodium-glucose cotransporter 2 (SGLT2) inhibitors or glucacon-like peptide 1 (GLP-1) receptor agonists with proven cardiovascular benefit are recommended as part of glycemic management
  • Among patients with ASCVD in whom heart failure coexists or is of special concern, SGLT2 inhibitors are recommended
  • For patients with type 2 diabetes and chronic kidney disease (CKD), with or without CVD, consider the use of an SGLT2 inhibitor shown to reduce CKD progression or, if contraindicated or not preferred, a GLP-1 receptor agonist shown to reduce CKD progression
  • An individualized program of medical nutrition therapy (MNT) should be offered to all patients
  • All overweight and obese patients with diabetes should be advised of the health benefits of weight loss and encouraged to engage in a program of intensive lifestyle management, which may include food substitution
  • Increased physical activity improves glycemic control and should be encouraged in all people with type 2 diabetes
  • Metabolic surgery is a recommended treatment option for adults with type 2 diabetes and 1) a body mass index (BMI) of 40.0 kg/m 2 or higher (BMI of 37.5 kg/m 2 or higher in people of Asian ancestry) or 2) a BMI of 35.0-39.9 kg/m 2 (32.5-37.4 kg/m 2 in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities with reasonable nonsurgical methods
  • Metformin is the preferred initial glucose-lowering medication for most people with type 2 diabetes
  • The stepwise addition of glucose-lowering medication is generally preferred to initial combination therapy
  • The selection of medication added to metformin is based on patient preference and clinical characteristics; important clinical characteristics include the presence of established ASCVD and other comorbidities such as heart failure or CKD; the risk for specific adverse medication effects, particularly hypoglycemia and weight gain; and safety, tolerability, and cost
  • Intensification of treatment beyond dual therapy to maintain glycemic targets requires consideration of the impact of medication side effects on comorbidities, as well as the burden of treatment and cost
  • In patients who need the greater glucose-lowering effect of an injectable medication, GLP-1 receptor agonists are the preferred choice to insulin; for patients with extreme and symptomatic hyperglycemia, insulin is recommended
  • Patients who are unable to maintain glycemic targets on basal insulin in combination with oral medications can have treatment intensified with GLP-1 receptor agonists, SGLT2 inhibitors, or prandial insulin
  • Access, treatment cost, and insurance coverage should all be considered when selecting glucose-lowering medications

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