COMMENTARY

ADA-EASD: More Holistic Approach Needed for Hyperglycemia Management

John B. Buse, MD, PhD; Mark Harmel, MPH, CDCES

Disclosures

June 23, 2022

This transcript has been edited for clarity.

In the 2022 Management of Hyperglycemia consensus statement from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), the focus has shifted. Regarding the management of hyperglycemia, we feel a more holistic approach is needed. What we mean by that is a four-part simultaneous attention on glycemic management, weight management, cardiovascular risk reduction, and application of cardiorenal therapies or organ protection.

Regarding glycemia management, we continue to emphasize the need for the use of glucagon-like peptide 1 (GLP-1) receptor agonists or sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with atherosclerotic cardiovascular disease or who are at high risk, and specifically, SGLT2 inhibitors in patients with chronic kidney disease or heart failure. If you need both classes of drugs, the idea is to use both the GLP-1 receptor agonist and the SGLT2 inhibitor together.

The other new emphasis in the Management of Hyperglycemia consensus statement is a need to simultaneously focus on achieving glycemic goals and weight goals in every patient with diabetes and recognizing that often, we have the opportunity to use highly effective therapies for both glucose lowering and weight management within a single agent.

There's been much discussion here at the ADA Scientific Sessions about potentially using alternative targets, like aiming for 15% weight loss as a strategy for reducing glycemia and managing diabetes in the long run as opposed to having the classic target of hemoglobin A1c. We embrace that conceptually but really present it as a need to focus on both glycemia management and weight management in every patient.

A third area of new emphasis in the 2022 ADA-EASD Management of Hyperglycemia consensus statement is a series of practical tips, which are really advice to providers broadly — from nutritionists and exercise therapists to primary care doctors and pharmacists — to enhance their ability to implement the recommendations that we provide and a focus on person-centered care, namely that the advice we're providing is really involved with the individual with diabetes as a leader of the healthcare team, and their preferences and values are at least as important as those of the provider.

All of this is really about improving outcomes in people with diabetes. Reflecting on this 100-year anniversary of the discovery of insulin — how fast they went from the first proof of principle in an animal model to initial human studies with insulin in just a matter of weeks to months, and then to having a marketed pharmaceutical product within a year in the United States, and within just a few years, insulin being available worldwide. Still, 100 years later, we have not fully implemented the promise of insulin therapy in our society.

Reflecting on the last few years' experience with COVID-19 and how we were able to very rapidly come up with diagnostic tests, preventive strategies in the form of vaccination, and therapeutic strategies in the form of both infused drugs and tablets… How fast we were able to make that progress with the spirit of collaboration and, really, implementation in a pretty remarkable way in hundreds of millions of people globally. But still, we fell a little short with regard to implementation.

Similarly, in diabetes today, we think that the major opportunity to improve the health of the world from a diabetes perspective is enhanced implementation of the best evidence that we know works in individual practices, in healthcare systems, and in nations. That will also require a greater focus on social determinants of health. For many people, it's not a lack of access to care that's really the barrier that we must overcome; it's social determinants of health, which require a completely different approach.

For us to improve the health of our society with regard to diabetes, we need to implement better and we need to pay closer attention to social determinants of health to ensure equity in the delivery of diabetes care for all people with type 2 diabetes.

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