COMMENTARY

Tailoring Type 2 Diabetes Treatment: Updated Guidance

Anne L. Peters, MD

Disclosures

March 02, 2015

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Today I am going to discuss the 2015 update to the position statement on the treatment of hyperglycemia in patients with type 2 diabetes.[1]

This is a joint position statement by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). I actually get to proudly disclose that I was one of the people on the committee that wrote this position statement, so I really understand the process whereby we came up with these conclusions. I know there is no perfect way to do this, but hopefully you will find these conclusions useful.

First off, what is the same? We always start treating our patients with lifestyle and metformin. After that doesn't work—and in many cases it is not enough—we then move to a second agent. It is at that level that these guidelines are a bit different,[1] because we now include the sodium-glucose co-transporter 2 (SGLT2) inhibitor class at that step. Then we go on to third agents—to basal insulin—and then, finally, to more complicated insulin regimens.

In this particular algorithm, we try to tackle the point of moving to prandial insulin with a little more consideration, because for many patients, that step of adding mealtime insulin is quite complicated and may lead to hypoglycemia and weight gain. We discuss using the combination of basal insulin plus a glucagon-like peptide-1 (GLP-1) receptor agonist and, potentially, also the combination of insulin plus an SGLT2 inhibitor. Then we give more detailed guidelines as to how to use insulin: how to start with the basal dose, how to uptitrate, and then how to add in pre-meal insulin. That basically encapsulates what we did when we looked at these new treatment guidelines.

But for starters, remember: You must always individualize care.[2] I was hoping at some point in this process that we would come up with a simple algorithm for treating type 2 diabetes, an algorithm everyone can follow in every practice setting. That just isn't possible, though, given the diversity of our practice settings and all of the limits and restrictions we all face in terms of formularies and options for our patients.

Then there are the patients themselves, in terms of what their preferences are, who they are as individuals, and how they react to our treatments, because really, it is patients in their own homes who are most likely to be successful or not when it comes to controlling their blood sugar levels.

When I am picking drugs, I like to try to use drugs that don't cause hypoglycemia or weight gain. Now, that doesn't mean that I don't use all of the available drugs. I do, and frankly, I use insulin frequently in my patients. But if I have a choice, I find drugs that can help with weight loss, and that includes GLP-1 receptor agonists and SGLT2 inhibitors. Those agents are often helpful because patients will reach weight-loss targets—or at least they will begin to lose some weight—at the same time that their A1c's improve.

Other agents that don't cause hypoglycemia include the dipeptidyl peptidase 4 (DPP4) inhibitors, as well as the thiazolidinediones (TZDs). So we now have more agents than ever that we can combine and which don't increase the risk for hypoglycemia, and which can help patients, presumably, with weight loss, helping them reach the targets they have and not just lowering their glucose levels.

In the new position statement, we discuss SGLT2 inhibitors at length. We discuss the unfortunate lack of data that we have on the combination of SGLT2 inhibitors and GLP-1 receptor agonists. I like that combination because it uses drugs that are great at lowering blood glucose levels, that help with weight loss, and that don't cause hypoglycemia. However, because we don't have published data on that combination, we were unable to include it in the algorithms.

We talk about the fact that the TZD class has largely been cleared of causing a risk for bladder cancer, at least based on the data that we now have. We also talk a little bit about the congestive heart failure risk that was seen in one of the DPP-4 inhibitor trials with saxagliptin.[3] More data are likely to come out about that issue as well. And then, as I said, we go into detail discussing how to start and dose insulin, both basal insulin and mealtime insulin.

I hope these guidelines are useful to you in your practice and make it easier for you to choose among the various medications we have for treating patients with type 2 diabetes, and for helping them successfully achieve their targets.

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