COMMENTARY

'Really Good' New Guidelines for T2 Diabetes

Anne L. Peters, MD

Disclosures

July 16, 2018

Editor's Note: The diabetes guidelines discussed below are a draft version of a consensus statement to be issued in October at the annual meeting of the European Association for the Study of Diabetes in Berlin, Germany.

Hi. I am Dr Anne Peters, and today I'm going to talk about the new ADA/EASD treatment guidelines for managing patients with type 2 diabetes. First off, my "headline" is that I think these are really good guidelines. Although guiding people is difficult, these guidelines actually begin to guide us in the treatment of our patients with type 2 diabetes.

They basically start the same way that all the old guidelines did, which is with lifestyle and metformin. That is really going to be our foundational therapy for our patients with type 2 diabetes.

Then, where they really differ from the old guidelines is, what is the second therapy? The first thing you do is ask, Does the patient have known cardiovascular disease or not?

If the answer is yes, they have known cardiovascular disease, then you enter a decision box in the algorithm to consider whether the patient has an eGFR of above or below 45. The recommendation is to start a medication that reduces cardiovascular risk, and those are the SGLT2 inhibitors and some of the GLP-1 receptor agonists, but the SGLT2 inhibitors, as we know, are limited by renal function. You basically go into that box, decide which of those two agents is best for your patient, and treat them accordingly.

If a patient does not have known cardiovascular disease, then they go onto the other side of the algorithm and they basically have all of the medication choices. The new guidelines basically take sulfonylurea agents and put them off to the side. The recommendation is to try to use agents that do not cause hypoglycemia or weight gain, and to allow your patients to achieve their targets without those side effects.

Then, they stress—as we all stress—individualization of targets and treatments. It really depends on your patients and the health system in which you work—the formularies, for example—and the guideline does say that you can use sulfonylurea agents in patients who aren't at risk for hypoglycemia or weight gain.

Now, you're probably going to argue that most patients with type 2 diabetes are at risk for hypoglycemia and weight gain, but regardless, it's still there, it's still in the list, and I certainly have patients who were on formularies where I was required to use sulfonylurea agents as second-line therapy. Clearly, the writers of these new guidelines are suggesting that they really not be used as a first- or second-line choice in our patients with known cardiovascular disease and type 2 diabetes.

Then, the rest of it more or less follows through the treatment combinations, but there is a specific difference in terms of the use of an injectable therapy. They recommend that the first injectable treatment should be a GLP-1 receptor agonist and, in most cases, not insulin.

Remember, there are going to be patients who look more like they are evolving type 1's or they are very insulin deficient; they can obviously use insulin first, but by and large, most of the studies suggest that using a GLP-1 receptor agonist is the best injectable therapy for most patients, no matter what their A1c is. Then, if they need another agent, insulin can be added.

Those are just sort of the big headlines. There are many more details to these new guidelines, and I know that the people who wrote them reviewed thousands of articles and really reviewed the evidence very carefully to come up with these guidelines. I'm very happy to share them with you. Thank you.

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