The European Association for the Study of Diabetes (EASD) held their 54th Annual Meeting in Berlin, Germany, where new insights and the most recent research findings in the field of diabetes were presented. One of the highlights in this year’s event was the release of the finalized joint consensus guidelines on the patient-centered management of type 2 diabetes by the American Diabetes Association (ADA) and EASD, which were simultaneously published in both Diabetologia1 and Diabetes Care.2 The finalized guidelines made a few noteworthy changes from the draft version that was presented earlier this year in the ADA 78th Annual Scientific Sessions.
Reinforcing personalized diabetes management
The draft version of the joint ADA/EASD consensus guidelines was first presented in June 2018 at the ADA 78th Annual Scientific Sessions. This was previously covered by the article ‘Shifting the focus of diabetes management – joint ADA/EASD consensus statement update’ in issue 11 of Omnihealth Practice.
After the initial presentation at the ADA meeting, the statements were peer-reviewed and revised to produce the finalized guidelines, which were released at the recent EASD meeting.1,3 The new guidelines continue to urge for a patient-centered care approach, suggesting to consider individual patient preferences and barriers to make a decision that can result in effective diabetes management.1
Early kidney assessments now included in the guidelines
The updated recommendations in the finalized guidelines “address the approaches to management of glycemia in adults with type 2 diabetes, with the goal of reducing complications and maintaining quality of life in the context of comprehensive cardiovascular risk management and patient-centered care,” the ADA/EASD panel wrote.1
With patient-centered care placed centrally in the guidelines, the algorithm for choosing a glucose-lowering medication for adults with type 2 diabetes was also modified to emphasize this principle.1 The overall approach of the treatment algorithm is presented in Figure 1 to aid clinicians with their decision-making under different scenarios.1
One of the major changes in the finalized guidelines was the early assessment of chronic kidney disease (CKD) alongside with atherosclerotic cardiovascular disease (ASCVD) and heart failure (HF).1 In the initial statements presented at the ADA, CKD status was only assessed at a later phase in the treatment algorithm.4
In patients with established ASCVD, HF, or CKD, who cannot control their hemoglobin A1c (HbA1c) with metformin, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) receptor agonist with proven benefit from cardiovascular outcomes trials (CVOTs) should be added in the glycemic management.1
The finalized guidelines also added recommendations for patients with established ASCVD, HF, or CKD, but with HbA1c within the recommended target on metformin alone.1 If the patient has not received an SGLT-2 inhibitor or GLP-1 receptor agonist, the guidelines would then recommend one of the following actions to be taken: 1) If the patient is already on dual or multiple therapies, consider switching one of the agents to an SGLT-2 inhibitor or GLP-1 receptor agonist; 2) Reconsider or lower the individual HbA1c target and introduce SGLT-2 inhibitor and GLP-1 receptor agonist; 3) Reassess HbA1c test every 3 months and add SGLT-2 inhibitor or GLP-1 receptor if HbA1c level exceeded the individual target.
Consider patients’ preferences
In the cases of patients without ASCVD, HF, or CKD, the expert panel recommend clinicians to consider patients’ preferences on the need to minimize hypoglycemia, weight gain, or cost.1
If the need to avoid hypoglycemia becomes an influential factor, the panel recommends the use of SGLT-2 inhibitors, GLP-1 receptor agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, and thiazolidinediones (TZD); each was given equal weighting regarding preferences.1
If losing weight is the compelling factor, the panel recommends the use of SGLT-2 inhibitors or GLP-1 receptor agonists that can produce weight loss.1 Whereas if the cost is the major concern, the panel recommends the use of sulfonylurea (SU) or TZD.1
“There is a balancing of risk, but the reality is that you have to think extremely hard with your patients about what those balances are. This is a complex thing to do, and we encourage you to do this…. What you have here is a wonderful handbook to guide you in your decision-making,” said Professor David R. Matthews of the Oxford Centre for Diabetes, United Kingdom.4
Combining oral therapy with injectable therapies
For some patients with extreme and symptomatic hyperglycemia, basal insulin injection is recommended in combination with oral medications.1 The panel introduced the “traffic light” concept that helps clinicians to determine whether the oral therapy can be used together with injectable therapies (Figure 2).
Comments on the new guidelines
The finalized guidelines placed the focus on the collaboration between clinicians and patients, which can lead to the delivery of a personalized treatment plan that is the best for the patients.1 “You can’t simply look at all the science… The patient has to be at the center of all of this. You need key patient characteristics, you consider the factors, you share the decision-making, agree on management, and you go round and round… because our science is held by human hands,” said Prof. Matthews at the EASD meeting.4
Professor Chantal Mathieu of the Katholieke Universiteit Leuven, Belgium, and chair of endocrinology at the University Hospital Gasthuisberg Leuven also agreed as she commented, “the patient is at the center of everything… We should assess key patient characteristics and consider specific factors that will impact choice of treatment, and then come to shared decision-making to create a management plan.”4
Is this the end goal for type 2 diabetes management?
Even though the guidelines are seen as a ‘handbook’ to guide clinicians to make patient-centered decisions for patients with type 2 diabetes, there are still many questions that are challenging the guidelines and are desperately needing evidence to address them.1
Some of the questions include the doubts on the use of metformin as first-line medication in managing type 2 diabetes, considering the lack of evidence for cardiovascular benefits. Meanwhile, there has also been an interest in using specific combination therapy to target normal levels of glycemia in early diabetes, but the evidence to support this is practically non-existent.
More importantly, it is crucial to establish whether the CV and renal benefits of SGLT-2 inhibitors and GLP-1 receptor agonists in patients with established CVD can be extended to low-risk patients. There are also questions on the potential additive benefits with the use of GLP-1 agonist receptors and SGLT-2 inhibitors for the prevention of CV and renal events.1
“The management of hyperglycemia in type 2 diabetes has become extraordinarily complex with the number of glucose-lowering medications now available,” the expert panel wrote. However, the principal of patient-centered decision will always be the foundation of glycemic management.
“We are proud to call for this paradigm shift as the most logical and appropriate next steps in care through this joint consensus report with EASD. The needs of our patients require that we consider the many individual life factors in order to improve quality and length of life for as many people as possible,” said Dr. William T. Cefalu, the ADA’s Chief Scientific, Medical and Mission Officer.5
1. Davies MJ, D’Alessio DA, Fradkin J, et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2018:1-38.
2. Davies MJ, D’Alessio DA, Fradkin J, et al. Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2018.
3. Scientific Sessions attendees to get first look at revised consensus report on hyperglycemia management in type 2 diabetes. ADA Daily. 2018 (Accessed October 15, 2018, at https://www.adadaily.org/scientific-sessions-attendees-to-get-first-look-at-revised-consensus-report-on-hyperglycemia-management-in-type-2-diabetes/)
4. Personalize Diabetes Therapy, New EASD-ADA Guidelines Stress. Medscape. 2018 (Accessed October 15, 2018, at https://www.medscape.com/viewarticle/903090#vp_1)
5. New Consensus Report from the American Diabetes Association® (ADA) and the European Association for the Study of Diabetes (EASD) Calls for Paradigm Shift to Patient-Centered Care for Type 2 Diabetes. American Diabetes Association® Press Release. 2018 (Accessed October 19, 2018, at http://www.diabetes.org/newsroom/press-releases/2018/consensus-report-ada-easd-type-2-diabetes.html)