What are the current recommendations from American and European professional societies for the treatment of type 2 diabetes?
The management of patients with type 2 diabetes continues to move away from glycemic goal chasing and toward a more holistic approach to patient care that also considers medications, weight management, attention to cardiovascular risk factors, and kidney protection. Metformin is recommended for most patients, though the new classes of medicines that affect the heart and kidneys should also be considered for many patients. Sulfonylureas, thiazolidinediones, and insulin, all of which have little effect except to lower blood glucose levels, are distinctly de-emphasized.
Plan de l'etude:
These guidelines were developed by a working group composed of members from 2 professional societies, and included endocrinologists and researchers (that is, no patients or primary care clinicians). Most of the working group members had substantial relationships with the pharmaceutical industry. The group systematically reviewed the evidence and assessed its quality. Rather than strict guidelines ("do this, don’t do that"), these guidelines continue to move away from an emphasis on markers of glucose control and toward an emphasis on modifiable risk factors to prevent complications and optimize quality of life. However, they also recommend an HbA1c goal of less than 7% (53 mmol/mol) in most adults with a life expectancy of 10 years or more. The authors also suggest principles of care that are much more holistic, including emphasis on social determinants, psychosocial factors, and shared decision-making. The 4 buckets of care include weight management, medications for glycemia management, attention to cardiovascular risk factors, and kidney protection. Metformin remains a mainstay of treatment, though the authors also suggest treatment that controls glycemia and offers cardiorenal protection — that is, a sodium–glucose cotransporter 2 inhibitor (SGLT2i) and glucagon-like peptide 1 receptor agonist (GLP-1 RA) medication, alone or in combination. Insulin is pushed to the back of the line, to be used when needed to provide further control of blood sugar.
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine