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WHO Guidelines Recommend Treatment Intensifications in Type 2 Diabetes

Oct 6, 2018
 
Editor: Steve Freed, R.PH., CDE

Author: Melissa Bailey, Pharm.D. Candidate, USF College of Pharmacy

WHO diabetes guidelines suggest medications for second- and third-line treatments for diabetes management following treatment failure with metformin and sulfonylureas.

“One of WHO’s core functions is to provide technical guidance for a broad range of public health problems that is intended for a global audience but focuses on low- and middle-income countries, where technical expertise and financial resources are often lacking,” researchers explain. “The public health approach in WHO guidelines addresses the health needs of a population rather than focusing primarily on individual patients.”

For diabetes management, WHO aims to ensure the largest possible access to services and medications at the population level and to find a middle ground between implementing the best standard of care and what is achievable in a resource-limited setting.

The two objectives for these guidelines were to consider medications (DPP-4 inhibitors, SGLT-2 inhibitors, TZDs, and insulin) as second- and third-line treatments for diabetes management after treatment failure with metformin and sulfonylureas, and provide guidance for insulin analog use in patients with type 1 and 2 diabetes.

Recommendations from WHO:

  1.    Give a sulfonylurea to patients with T2D who do not achieve glycemic control with metformin alone or who have contraindications to metformin

(strong recommendation, moderate-quality evidence).

  1.    Introduce human insulin treatment to patients with T2D who do not achieve glycemic control with metformin and/or a sulfonylurea

(strong recommendation, very-low-quality evidence).

  1.    If insulin is unsuitable, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium–glucose cotransporter-2 (SGLT-2) inhibitor, or a thiazolidinedione (TZD) may be added

(weak recommendation, very-low-quality evidence).

  1.    Use human insulin to manage blood glucose in adults with T1D and in adults with T2D for whom insulin is indicated

(strong recommendation, low-quality evidence).

  1.    Consider long-acting insulin analogues to manage blood glucose in adults with type 1 or type 2 diabetes who have frequent severe hypoglycemia with human insulin

(weak recommendation, moderate-quality evidence for severe hypoglycemia).

Type 2 diabetes is highly prevalent in most areas, and there has been an increase in patients diagnosed with type 2, mainly in low- and middle-income countries in the past 20 years. The guidelines listed above are designed for areas with limited health care resources where budgets may be quickly drained on brand name, expensive medications and patients are most likely to have to pay out-of-pocket for such expenses. The guidelines are also intended for high-income countries where resources are minimal and evidence-based care is needed in order to take into account the costs and value of medications.

Practice Pearls:

  • These guidelines are intended for low- to moderate-income settings, as well as high-income settings with minimal resources and the need for evidence-based care to take into account the costs and value of medications.
  • Sulfonylureas are recommended in T2D when metformin is contraindicated or fails; use human insulin in patients where metformin and/or sulfonylurea fail; if insulin is not suitable, add a DPP4 inhibitor, SGLT2 inhibitor, or TZD; use human insulin in patients with type 1 and in patients with type 2 for whom insulin is indicated.
  • Patients diagnosed with type 1 or type 2 who have frequent severe episodes of hypoglycemia should consider long-acting insulin analogues to manage blood glucose in adults.

Reference:

Roglic G, Norris SL. “Medicines for Treatment Intensification in Type 2 Diabetes and Type of Insulin in Type 1 and Type 2 Diabetes in Low-Resource Settings: Synopsis of the World Health Organization Guidelines on Second- and Third-Line Medicines and Type of Insulin for the Control of Blood Glucose Levels in Nonpregnant Adults With Diabetes Mellitus.” Ann Intern Med. [Epub ahead of print ] doi: 10.7326/M18-1149