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

Pam Brown
The American Diabetes Association (ADA) 82nd Scientific Sessions were held in New Orleans and online from 3rd to 7th June 2022. One highlight was a session in which draft changes to the ADA/EASD Consensus Report were reviewed. The proposed changes give the guidance a greater focus on holistic, person-centred care, weight loss and equity of care. The presentation can be viewed here, and viewers are encouraged to submit feedback.

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 82nd 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 21st 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 HbA1c 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 HbA1c, 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.
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