See also (4) Links To The Complete “Standards Of Medical Care In Diabetes – 2018” With Link To The Update And Additional Resources Posted on October 16, 2018 by Tom Wade MD.
In this post, I’ve listed all the consensus recommendations from 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) [PubMed Abstract] [Full Text HTML] [Full Text PDF]. (Resource 1 below):
Principles of care:
Providers and healthcare systems should prioritise the
delivery of patient-centred care.
DSMES [Diabetes self-management education and support]:
All people with type 2 diabetes should be offered access
to ongoing DSMES programmes.
Facilitating medication adherence should be specifically
considered when selecting glucose-lowering
Implications of new evidence from cardiovascular
Among patients with type 2 diabetes who have
established ASCVD, SGLT2 inhibitors or GLP-1
receptor agonists with proven cardiovascular benefit
are recommended as part of glycaemic management
(Figs 2 and 3).
Among patients with ASCVD in whom HF coexists or is
of special concern, SGLT2 inhibitors are recommended
(Figs 2 and 3).
For patients with type 2 diabetes and CKD, with or
without CVD, consider the use of an SGLT2 inhibitor
shown to reduce CKD progression or, if contraindicated
or not preferred, a GLP-1 receptor agonist shown to
reduce CKD progression (Figs 2 and 3).
An individualised programme of MNT should be offered
to all patients.
Medical nutrition therapy:
All overweight and obese patients with diabetes should
be advised of the health benefits of weight loss and
encouraged to engage in a programme of intensive
lifestyle management, which may include food
Increasing physical activity improves glycaemic control
and should be encouraged in all people with type 2
Metabolic surgery is a recommended treatment option
for adults with type 2 diabetes and (1) a BMI ≥ 40.0 kg/m2
(BMI ≥ 37.5 kg/m2 in people of Asian ancestry) or (2) 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 with reasonable non-surgical methods.
Metformin is the preferred initial glucose-lowering
medication for most people with type 2 diabetes.
Initial combination therapy compared with stepwise
addition of glucose-lowering medication:
The stepwise addition of glucose-lowering medication is
generally preferred to initial combination therapy.
Choice of glucose-lowering medication after metformin:
The selection of medication added to metformin is based on patient preference and clinical characteristics. Important clinical characteristics include the presence of established ASCVD and other comorbidities such as HF or CKD; the risk for specific adverse medication effects, particularly hypoglycaemia and weight gain; as well as safety, tolerability and cost (Figs 2–6).
Intensification beyond two medications:
Intensification of treatment beyond dual therapy to
maintain glycaemic targets requires consideration of the
impact of medication side effects on comorbidities, as
well as the burden of treatment and cost.
Addition of injectable medications:
In patients who need the greater glucose-lowering effect
of an injectable medication, GLP-1 receptor agonists
are the preferred choice to insulin. For patients with
extreme and symptomatic hyperglycaemia, insulin is
recommended (Fig. 7).
Beyond basal insulin:
Patients who are unable to maintain glycaemic targets
on basal insulin in combination with oral medications
can have treatment intensified with GLP-1 receptor
agonists, SGLT2 inhibitors or prandial insulin (Figs 7
Access and cost:
Access, treatment cost and insurance coverage should
all be considered when selecting glucose-lowering
(1) 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) [PubMed Abstract] [Full Text HTML] [Full Text PDF].
(2) Cardiovascular disease and glycemic control in type 2 diabetes: now that the dust is settling from large clinical trials [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Ann N Y Acad Sci. 2013 Apr;1281:36-50. doi: 10.1111/nyas.12044. Epub 2013 Feb 6.
(3) Hemoglobin A1c Targets for Glycemic Control With Pharmacologic Therapy for Nonpregnant Adults With Type 2 Diabetes Mellitus: A Guidance Statement Update From the American College of Physicians [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Ann Intern Med. 2018 Apr 17;168(8):569-576. doi: 10.7326/M17-0939. Epub 2018 Mar 6.
(4) Links To The Complete “Standards Of Medical Care In Diabetes – 2018” With Link To The Update And Additional Resources Posted on October 16, 2018 by Tom Wade MD.