Patient-centered hyperglycemia guidelines from ADA and EASD: Holistic approach revised, but there is still more to be done to individualize treatment.
The American Diabetes Association (ADA) and the European Association of the Study of Diabetes (EASD) got together in Berlin in the first week of October at EASD’s 2018 annual meeting to present their new patient-centered hyperglycemia guidelines for treating hyperglycemia in patients who have type 2 diabetes. According to Professor Simon Heller, the old guidelines were too simplistic for the complexity of newer medications and their added benefits. The previous guidelines listed the medications and let the prescriber choose from the list without much guidance. The new guidelines are patient-centered and guide the provider step by step to alter therapy based on A1C response, specific medications the patient is already taking, and their concurrent disease states.
Researchers took the findings of 479 cardiovascular outcome trials from the last four years and condensed them into seven patient-centered algorithms. The new guidelines encourage practitioners to take all of the patient’s concerns into account before prescribing a therapy regimen and share the decision making process with the patient. Today up to 50% of patients do not adhere with their glycemic regimen. The idea behind patient-centered care is that if a patient is more involved in the decision making for their treatment they will adhere more to the treatment, have fewer complications, and enjoy a higher quality of life.
With the additional benefits seen in today’s new therapies, health care providers can prescribe based on specific comorbidities, cost, or lifestyle concerns the patient has. The algorithm is divided based on disease states, but metformin is still first-line therapy. If patients have chronic kidney disease, heart failure, or ASCVD the sodium glucose transport protein-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists are recommended. SGLT-2 inhibitors, which work by reducing the reuptake of glucose in the kidney, are excellent choices for ceasing the progression of chronic kidney disease and decreased water retention in heart failure. GLP-1 agonists are also a good alternative in these conditions and are preferred in patients with ASCVD. GLP-1 agonists mirror the action of incretin, preventing the increased glycemia and stimulating the release of insulin.
Because of this, in patients with worsening diabetes, a GLP-1 agonist should be considered before insulin. Both drug classes have been shown to reduce mortality, however head-to-head trials within classes will be beneficial. For patients who do not have the previously stated comorbidities, the guidelines separate them by what they want out of their therapy: reducing hypoglycemia, weight gain/loss, or cost of the medication.
Improving diet and exercise are core lifestyle changes the patient can make for better health. Patients should be referred to a lifestyle management program to help manage their weight. The guideline also says for those patients with a BMI greater than 40, metabolic surgery is an option.
Heller says that the next step now is to conduct head-to-head studies between newer drugs to further refine treatment. In previous trials, we saw that patients treated with Tresiba or Toujeo had fewer instances of hypoglycemia than when treated with other medications.
However, the BRIGHT study, a head-to-head study between Tresiba and Toujeo, revealed that they are both equivalent in reducing the occurrence of hypoglycemia as well as reducing A1C. This type of information can play a role in the real world since insurance plans and even patient preferences play a role in adherence.
A new initiative is taking place in Europe to better understand the complexity brought on by new drug treatments. The Innovation Medicines Initiative is a database that will combine clinical trial data from academia, insulin manufacturers, and continuous glucose companies. With all this data in one place, statistical analysis can be performed to compare treatments and choose the most cost-effective, personalized treatment for each patient.
Practice Pearls: Updated Patient-Centered Hyperglycemia Guidelines for 2018
- New guidelines are much more comprehensive, patient-centered, and guide the prescriber based on the patient’s comorbidities, treatment needs, cost, and choice.
- SGLT-1 Inhibitors are excellent choices for chronic kidney disease and heart failure, while GLP-1 agonists are better for ASCVD [see comment from George Bakris, MD below].
- More head-to-head trials of medications must be done in order to determine the most cost-effective and personalized treatment options based on patient’s needs and choices.
|Comment from George Bakris, MD:
Joy Pape, FNP-C, CDE asked George Bakris, MD, Diabetes In Control Advisory Board Member and Member of the National Kidney Foundation’s Board of Directors for comment. He is Professor of Medicine and Director of the American Society of Hypertension’s Comprehensive Hypertension Center at the University of Chicago Medicine.
“What about the patients who have a eGFR >60 and a rise in creatinine in some patients who take SGLT2i?”
“The changes in creatinine seen with SGLT2 inhibitors are no more than 2-4 ml/min declines. If see greater declines in people with better kidney function the most common causes are poor oral intake or poor adherence with low glucose diet. This will result in higher urine outputs due to osmotic diuresis. Just like you know people are not always knowledgeable or truthful with salt intake when complaining of cramps when on diuretics same with sglt2 i and glucose intake.” — George Bakris, MD
References for Updated Patient-Centered Hyperglycemia Guidelines for 2018:
American Diabetes Association. “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.” PR Newswire: Press Release Distribution, Targeting, Monitoring and Marketing, American Diabetes Association , 5 Oct. 2018, www.prnewswire.com/news-releases/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-300724946.html.
“Updated ADA, EASD Consensus Guidelines for Managing Hyperglycemia in T2D.” Endocrinology Advisor, 5 Oct. 2018, www.endocrinologyadvisor.com/type-2-diabetes/american-european-diabetes-associations-update-position-statement/article/805622/.