Hyperglycemia management in type 2 diabetes: Consensus update by ADA/EASD

USA: The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have released a new consensus update on the management of hyperglycemia in type 2 diabetes. The guideline, published in 2006, was last updated in 2019. 

The guideline, published in the ADA journal Diabetes Care and EASD's journal Diabetologia, is a 42-page document, that described the target audience as a "full spectrum of the professional health care team providing diabetes care in the U.S. and Europe." 

A draft version of the report was presented at ADA's 82nd Scientific Sessions in June 2022, and it was open for feedback. Suggested changes included more focus on person-centered care, managing weight loss, and equity of care. 

The update guides in improving equity of care and reviews how social determinants of health (SDOH) affect hyperglycemia management. Also, it focuses on the importance of weight loss and the use of evidence from randomized controlled trials on glucose-lowering medications to support evidence on weight loss/weight gain.

As is in other ADA-EASD joint consensus reports, significant attention is given to the person's involvement in their own diabetes care, including their home and economic circumstances, how they feel about the side effects of different possible medications, and helping to choose their medication(s), and playing a full part in forming a regularly monitored care-management plan with their doctor.

The document also included several recommendations on physical activity, including light exercise/resistance training every 30 minutes while sitting; an extra 500 daily steps; 150 minutes of moderate to vigorous physical activity each week; strength training two or three times per week; and getting between 6 and 9 hours of sleep each night.

The guideline also provides updates on glucose-lowering therapies, including recommendations on the use of oral GLP-1 receptor agonists (RAs), higher doses of dulaglutide and semaglutide, the GIP/GLP-1 RA class, and combination GLP-1 RA and insulin. It also describes specific information on comorbid conditions (e.g., heart failure, atherosclerotic cardiovascular disease, and chronic kidney disease). 

Finally, the updated consensus report covers many intersecting themes regarding person-centered care. These include the language used in discussing care with patients, shared decision-making, access to diabetes self-management education and support, considering the local care environment and the resources available, avoiding inertia in patient management plans, and the consideration of more aggressive and proactive treatment at initiation, such as the potential use of combination therapy immediately. 

The authors wrote in their report, "a systematic examination of publications since 2018 informed new recommendations. These include an additional focus in social determinants of the health care system, health, and physical activity behaviors, including sleep."

"Greater emphasis is laid on weight management as part of the e holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease."

Some of the recommendations are given below:

 • All people with type 2 diabetes should be offered access to ongoing DSMES programs.

• Providers and health care systems should prioritize the delivery of person-centered care.

• Optimizing medication adherence should be specifically considered when selecting glucose-lowering medications.

• MNT focused on identifying healthy dietary habits that are feasible and sustainable is recommended in support of reaching metabolic and weight goals.

• Physical activity improves glycemic control and should be an essential component of type 2 diabetes management.

• Adults with type 2 diabetes should engage in physical activity regularly (>150 min/week of moderate- to vigorous-intensity aerobic activity) and be encouraged to reduce sedentary time and break up sitting time with frequent activity breaks.

• Aerobic activity should be supplemented with two to three resistance, flexibility, and/or balance training sessions/week. Balance training sessions are particularly encouraged for older individuals or those with limited mobility/poor physical function.

• Metabolic surgery should be considered as a treatment option in adults with type 2 diabetes who are appropriate surgical candidates with a BMI $40.0 kg/m2 (BMI $37.5 kg/m2 in people of Asian ancestry) or a BMI of 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods.

• In people with established CVD, a GLP-1 RA with proven benefit should be used to reduce MACE, or an SGLT2i with proven benefit should be used to reduce MACE and HF and improve kidney outcomes.

• In people with CKD and an eGFR $20 ml/min per 1.73 m2 and a UACR >3.0 mg/mmol (>30 mg/g), an SGLT2i with proven benefit should be initiated to reduce MACE and HF and improve kidney outcomes. Indications and eGFR thresholds may vary by region. If such treatment is not tolerated or is contraindicated, a GLP-1 RA with proven cardiovascular outcome benefit could be considered to reduce MACE and should be continued until kidney replacement therapy is indicated.

• In people with HF, SGLT2i should be used because they improve HF and kidney outcomes.

• In individuals without established CVD but with multiple cardiovascular risk factors (such as age $55 years, obesity, hypertension, smoking, dyslipidemia, or albuminuria), a GLP-1 RA with proven benefit could be used to reduce MACE, or an SGLT2i with proven benefit could be used to reduce MACE and HF and improve kidney outcomes.

• In people with HF, CKD-established CVD, or multiple risk factors for CVD, the decision to use a GLP-1 RA or SGLT2i with proven benefit should be independent of background use of metformin.

• SGLT2i and GLP-1 RA reduce MACE, which is likely to be independent of baseline HbA1c. In people with HF, CKD established CVD, or multiple risk factors for CVD, the decision to use a GLP-1 RA or an SGLT2i with proven benefit should be independent of baseline HbA1c.

• In general, the selection of medications to improve cardiovascularly and kidney outcomes should not differ for older people.

• In younger people with diabetes (<40 years), consider early combination therapy.

• In women with reproductive potential, counseling regarding contraception and taking care to avoid exposure to medications that may adversely affect a fetus are important.

Reference:

Melanie J. Davies, Vanita R. Aroda, Billy S. Collins, Robert A. Gabbay, Jennifer Green, Nisa M. Maruthur, Sylvia E. Rosas, Stefano Del Prato, Chantal Mathieu, Geltrude Mingrone, Peter Rossing, Tsvetalina Tankova, Apostolos Tsapas, John B. Buse; Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2022; dci220034. https://doi.org/10.2337/dci22-0034