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Individualizing T2DM goals is paramount, according to experts
Clinical Question
What do European and US diabetes experts recommend regarding the management of adults with type 2 diabetes?
Bottom line
These expert-consensus recommendations attempt to shift responsibility and decision-making to where it belongs—with the patients. Rather than issuing diktats that identify treatment failure, the recommendations suggest making diabetes self-management education and support a cornerstone of the treatment approach. Another pillar of this new approach is selecting medication treatment according to which one is most likely to be taken regularly and over time by a particular patient. The third pillar continues to be metformin. If additional control is needed, the group suggests adding one or more oral hypoglycemic to the metformin. For patients with known heart disease, the panel suggests additional treatment with liraglutide (Victoza) or empagliflozin (Jardiance), or other medications in these categories. Sulfonylureas and glitazones remain less-expensive options. 5
Reference
Study design: Practice guideline
Funding: Foundation
Setting: Various (guideline)
Synopsis
These guidelines represent expert consensus among members of 2 diabetes associations. The recommendations are rooted in a systematic review of recent literature, but the guideline writers ask us to trust them, rather than show us their review. As such, this document is more of a philosophy statement than rigorous evidence-linked guidance. All the recommendation writers have extensive ties to the pharmaceutical industry. Though they had input from a wide variety of specialists, all the writers are diabetes experts. The guidelines emphasize a move away from strict biochemical cutoffs to define treatment goals, instead they recommend treating each patient on the basis of their specific baseline risk, preferences and desires, and capabilities. As such, they emphasize the role of education aimed at making patients capable of self-management. Metformin continues to be the first-line treatment, with other medications chosen after a discussion with patients. Using recent new evidence from cardiovascular outcomes trials, the guideline authors suggest treating patients with heart disease with either a GLP-1 receptor agonist such as liraglutide or an SGLT2 inhibitor such as empagliflozin, the latter category preferred for patients with heart failure or chronic kidney disease. Nutrition is key, though the authors recommend against a rigid approach. For readers who want more detail, the article is open access here and has several useful flow charts to help with decision-making.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA