Leicester, UK—Patient preference should be a major factor that drives the choice of type 2 diabetes (T2D) therapy, according to new guidelines.

An updated consensus statement on how to manage hyperglycemia in T2D patients from the American Diabetes Association and the European Association for the Study of Diabetes emphasizes that, even when a patient’s clinical characteristics suggest the use of a specific medication based on the available evidence from clinical trials, preferences regarding route of administration, injection devices, side effects, or cost still might prevent their use in some cases.

The consensus paper was copublished in Diabetologia, the journal of EASD, and Diabetes Care, the journal of the ADA, during the annual meeting of EASD in Berlin, Germany. The review, led by researchers from the United Kingdom’s University of Leicester, also included participation from the National Institute of Diabetes and Digestive and Kidney Diseases and several top universities in the U.S.

The guidelines, which update a 2015 document, recommend that all patients should have access to diabetes self-management education and support, as well as medical nutrition therapy and weight-loss programs. The review also underscores the positive effect of increased physical activity on glycemic control.

The guidance addresses metabolic surgery, recommending it as a treatment option for adults with type 2 diabetes and a BMI of 40 or over (or 37.5 or over in people of Asian ancestry) or a BMI of 35.0 to 39.9 (32.5-37.4 kg/m2 in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities with reasonable nonsurgical methods.

In terms of pharmaceutical treatment, the document includes the following advice:
• Metformin remains the first-line recommended therapy for almost all patients with T2D.
• The selection of medication added to metformin is based on patient preference and clinical characteristics, including presence of cardiovascular disease, heart failure, and kidney disease. Other important considerations include the risk for specific adverse medication effects—particularly hypoglycemia and weight gain—and safety, tolerability, and cost.
• A sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended for patients with clinical cardiovascular disease.
• For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit should be considered.
• GLP-1 receptor agonists are generally recommended as the first injectable medication, except in settings where type 1 diabetes is suspected.

As for intensification of treatment beyond dual therapy to maintain glycemic targets, the guidelines urge consideration of medication side effects on comorbidities, as well as the burden of treatment and cost.

The article cautions that many questions remain about optimal treatment, pointing out, “New questions arise from the recent cardiovascular outcomes studies. Do the cardiovascular and renal benefits of SGLT2 inhibitors and GLP-1 receptor agonists demonstrated in patients with established CVD extend to lower-risk patients? Is there additive benefit of use of GLP-1 receptor agonists and SGLT2 inhibitors for prevention of cardiovascular and renal events? If so, in what populations? Addressing these and other vital clinical questions will require additional investment in basic, translational, clinical and implementation research.

“The management of hyperglycemia in type 2 diabetes has become extraordinarily complex with the number of glucose-lowering medications now available,” the guideline panel concludes. “Patient-centered decision making and support and consistent efforts to improve diet and exercise remain the foundation of all glycemic management. Initial use of metformin, followed by addition of glucose-lowering medications based on patient comorbidities and concerns is recommended as we await answers to the many questions that remain.”

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