Diabetes Distilled: Draft ADA/EASD consensus update on management of hyperglycaemia in type 2 diabetes

The Chairs and writing group members presented the 2022 draft of the ADA/EASD consensus report on the management of hyperglycaemia in type 2 diabetes on the penultimate day of the ADA 82^nd Scientific Sessions. The draft updates the 2018 consensus and its 2019 update, based on evidence from the last 3 years. The final consensus is due to be presented and published in September 2022 at the EASD conference. A webinar of the presentation is available here, and the diabetes healthcare community is invited to view the presentation and provide feedback; the consultation is open until 21^st June.

Perspective

● There is a greater focus on the social determinants of health (SDOH), systems and equity of care.

● Emphasis on holistic, person-centred care and a greater focus on weight goals and cardiovascular outcome trials.

● For each intervention area, a summary of the supporting evidence base will be provided.

Rationale, importance and context

● Goals:

• Prevention of complications (focus on glucose control, cardio-renal protection, weight management, cardiovascular risk and complications).

• Optimise quality of life.

● More emphasis on Language Matters and aspects of SDOH to consider and incorporate in management.

● Weight reduction as a targeted intervention, exploring benefits of different levels of weight reduction from 5% to >15%, which is now achievable.

● Ongoing importance of putting the person with diabetes at the centre of care, and empathic, patient-centred care. The decision cycle diagram from the 2018 consensus has been updated to include:

• Assess key individual characteristics, including SDOH.
• Consider specific factors impacting choice of treatment.
• Shared decision-making to create a management plan.
• Agree on management plan.
• Implement the management plan, with focus on avoiding clinical inertia by healthcare professionals.
• Ongoing support and monitoring.
• Review and agree on management plan.

Therapeutic options

● Responding to the obesity pandemic by increased focus on weight reduction using lifestyle behavioural changes (medical nutrition therapy and physical activity), drug therapy and metabolic surgery.

● Importance of 24-hour physical behaviours for type 2 diabetes – for the first time, includes sleep.

• Sitting – light activity or resistance exercise for a few minutes every 30 minutes.
• Stepping – an additional 500 steps daily can impact glycaemic control and cardiovascular mortality, prolonging life.
• Sweating – 150 minutes of moderate-to-vigorous aerobic activity (or 75 minutes of vigorous activity if safe) per week, supplemented by flexibility and balance exercises.
• Strengthening – two to three sessions per week to aid function, frailty and sarcopenia.
• Sleep – quality, quantity (>6 and <9 hours per night); recognition of chronotype impact.

● Glucose-lowering drug treatments – summary of benefits and risks of classes:

• Updated to include oral GLP-1 RAs, higher doses of dulaglutide and semaglutide, the GIP/GLP-1 RA class, combination GLP-1 RA and insulin.
• Side effects of TZDs can be mitigated by optimising dosing and combining with other medications such as SGLT2 inhibitors and GLP-1 RAs.
• Importance of increased “Education and explanation” about drug therapies offered to improve adherence, and “Escalation” to appropriate doses to achieve agreed glycaemic goals.
• Updated patient-centred care diagram, emphasising a circular, not sequential, care pathway.

● ASCVD or high risk of ASCVD: offer a GLP-1 RA or SGLT2 inhibitor. Intensify, if needed, with the other class or with pioglitazone. Reassurance that combination with metformin does not have negative impact.

● Heart failure: Offer an SGLT2 inhibitor; if this is unsuitable, offer a GLP-1 RA.

● CKD: section updated to differentiate between:  

• Advanced albuminuria (>200 mg/g [22.6 mg/mmol]): an SGLT2 inhibitor with demonstrated renal benefits is the preferred treatment. If not suitable, consider another SGLT2 inhibitor or a GLP-1 RA with evidence of renal benefits.
• CKD with albuminuria <200 mg/g (22.6 mg/mmol): focus on decreasing ASCVD risk using a GLP-1 RA or SGLT2 inhibitor.

Strategies for implementation

● Holistic approach to type 2 diabetes management with the patient at the centre, and goals to prevent complications and optimise quality of life.

● Four areas of focus: glycaemic management, weight management, cardiovascular risk factor management and cardio-renal protection. All equally important when considering therapies.

● Principles of care – all equally important, without any one priority:

• Language Matters.
• Shared decision-making.
• Access to diabetes self-management education and support.
• Taking into account psychosocial factors and SDOH.
• Consider local healthcare systems/resources.
• Be an advocate to promote diabetes care.
• Avoid therapeutic inertia.
• More aggressive and proactive treatment, including consideration of initial combination therapy.
• Surveillance and screening for complications.
• Health behaviour modification very important.
• Monitor and review therapies for side effects.
• Consider therapies that allow avoidance of  hypoglycaemia risk.
• Consider the balance of efficacy and side effects of therapies.
• Review the organisation of care where you work.
• When making choices of therapy, consider underlying physiology.

● The final consensus document will include:

• An expanded patient-centred care diagram integrating the four areas of focus, the principles of care and summarising the specific management options for those with co-morbidities.
• An updated, simplified algorithm, including recommendations depending on co-morbidities and giving equal focus to glycaemic control and weight management/maintenance, colour-coded by efficacy of therapy options.

Practical tips for implementation

● Importance of integrated care and knowing local resources.

● Diabetes self-management education and support at any time, not just at diagnosis.

● Facilitate healthy behaviours and weight management, with focus on self-management and education.

● Proactive care:

• Consider initial combination therapy.
• Avoid inertia.
• Consider de-escalation.
• GLP-1 RA before insulin for most.
• On insulin, if fasting glucose to target but HbA_1c and time in range are not: add mealtime insulin.
• Use technology as part of holistic care and, if using CGM, ensure education and understanding of results.
• Identify education needs and ensure education for all healthcare professionals.
• Team-based care and coordinated care.
• Ongoing quality improvement of all aspects of care delivery.

Call to action from John Buse 

● Major opportunities to improve diabetes outcomes by effective implementation of the available best evidence.

• Everyone has a role in better implementation and ensuring equity of access and care.

● Individualising care is important to ensure that the right person is getting the right therapy at the right time, independent of their SDOH.

● Key knowledge goals and ongoing research are needed to better understand: 

• How to manage young, old and frail, and to address the gender balance.
• The comparative effectiveness of weight management options.
• How to set appropriate targets for HbA_1c, time in range, weight and remission.
• The comparative effectiveness of cardio-renal protective drugs, including their cost-effectiveness in moderate-risk populations, and effects of combinations of SGLT2 inhibitors and GLP-1 RAs.
• How best to prevent and manage co-morbidities such as NAFLD, cognitive impairment and advanced CKD.
• How to optimise screening and prevention of type 2 diabetes taking into account current higher BMI populations.
• How to advance evidence on sleep and chronotypes.