Pharmacological Treatment of Diabetes: ADA 2022 explores beyond metformin as initial therapy

New Delhi: Metformin has been the cornerstone of Diabetes management for a long time. However, with the growing research in the field of diabetes and the greater emphasis being laid on management of co-morbidities in diabetes, the medical fraternity now also relies on the battery of other interventions including pharmacological as well as emphasized focus on lifestyle management to treat diabetes. 

This practice is also finding its place in the guidelines, with the American Diabetes Association (ADA) in its much anticipated yearly document also now laying stress on the lifestyle therapy for diabetes management as well as linking any treatment to first assessment of co-morbidities as well as patient centered treatment factors. 

Though metformin maintains its status as the first- line in the treatment of diabetes, the ADA has also broken down some of its recommendation to explore use of glucagonlike peptide 1 receptor agonists (GLP1-RA) and sodium–glucose cotransporter 2 inhibitors ( SGLT-2 Inhibitors) as appropriate initial therapy for individuals with type 2 diabetes in case of patients with atherosclerotic cardiovascular disease (CVD), heart failure, and/or chronic kidney disease (CKD). The point to note here is the guidelines stating that these therapies may be considered " with or without" metformin, marking a change from the previous guidelines.

 Medical Dialogues team had earlier reported that the American Diabetes Association® (ADA) released its much-anticipated annual Standards of Medical Care in Diabetes (Standards of Care). Based upon the latest scientific diabetes research and clinical trials, Standards of Care is the gold-standard for professionals in the medical field and includes vital new and updated practice guidelines to care for people with diabetes and prediabetes. 

Chapter 9 of the guidelines deal with Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2022

Section 9.4 of The ADA guidelines - Standard of Medical Care in Diabetes 2021 called for Metformin as the preferred initial pharmacologic agent for the treatment of type 2 diabetes. This Recommendation 9.4 has been revised and is now two recommendations (Recommendations 9.4a and 9.4b) on first line therapies and initial therapies, all based on comorbidities, patient-centered treatment factors, and management needs. The recommendation now states

9.4A- First-line therapy depends on comorbidities, patient-centered treatment factors, and management needs and generally includes metformin and comprehensive lifestyle modification. A
9.4B- Other medications (glucagonlike peptide 1 receptor agonists, sodium–glucose cotransporter 2 inhibitors), with or without metformin based on glycemic needs, are appropriate initial therapy for individuals with type 2 diabetes with or at high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease. A

With this the guidelines explores other medications including GLP 1 RA and SGLT2 inhibitors as initial therapy WITH or WITHOUT metformin based on the individual assessment of the patient.