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Controversial metformin recommendations in new ESC guidance

By Colin Kenny, Editor – Diabetes Distilled
The latest European Society of Cardiology guidelines on diabetes, pre-diabetes and cardiovascular diseases (CVDs) recognise that considerable emerging evidence should have implications for daily clinical practice. Controversially, metformin is no longer recommended as first-line treatment in type 2 diabetes (T2D). Suggestions for the prevention of CVD, advice on lifestyle intervention, new lipid and blood pressure targets, a novel approach to glucose-lowering treatment, diabetes treatment aimed at reducing heart failure risk, and cardiovascular (CV) risk management are included. The guidance has been developed in collaboration with the European Association for the Study of Diabetes and updates recommendations made in 2013.​

This guidance recognises that the most important recent insights into diabetes management are the result of several CV safety trials for T2D therapies. All have reported CV safety, but several have also demonstrated evidence of CV benefit. Lifestyle intervention is recommended to prevent conversion from non-diabetic hyperglycaemia to T2D and to prevent the CV complications of diabetes. The guidance recommends grading CV risk as very high, high or moderate and individualising blood pressure accordingly.
The recommended lipid target in dyslipidaemia has been altered. Now, clinicians should aim to achieve a LDL-cholesterol level <2.6 mmol/L in T2D patients at moderate CV risk, <1.8 mmol/L in those at high risk and <1.4 mmol/L in those at very high risk. Controversially, this guidance suggests that metformin should no longer be first-line therapy in patients with diabetes but should now be considered in overweight patients with T2D without CVD who have a moderate CV risk. It recommends SGLT2 inhibitors be used in patients with T2D and CVD, or who have a very high/high CV risk, in order to reduce CV events. This does not align with National Institute for Health and Care Excellence, European Association for the Study of Diabetes nor Scottish Intercollegiate Guidance Network guidance.  To access the publication, click here

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