The 2022 ADA/EASD consensus: Great advice if we can get past the drug shortages!

We are currently facing a shortage of the two leading weekly GLP-1 receptor agonists – dulaglutide (Trulicity) and semaglutide (Ozempic) – across the UK. This issue is not confined to the UK alone but is indeed a worldwide shortage. Owing to a huge increase in demand for the drugs globally, the shortfall is in fact due to lack of capacity to manufacture the pen devices which carry the medication. Earlier this year, we faced shortages of the higher doses of dulaglutide, and now we face it again for both dulaglutide (all doses) and semaglutide (1 mg dose).

The shortage has had an immediate impact across the country, with people finding they could not fill their prescriptions for semaglutide 1 mg as soon as the announcements were made on Friday 30^th September. In my service, we were receiving calls from both patients and healthcare professionals on the Monday morning asking for advice and alternative choices.

I must make it clear, at this point, that assurances have been given that sufficient stocks of dulaglutide are available across the UK for those patients already receiving this medication, but the advice is that no new patients are to be offered dulaglutide for the foreseeable future.

The Primary Care Diabetes Society committee moved swiftly to offer advice and suggest alternatives until regular stocks of the two GLP-1 RAs are resumed. This advice covers not only those individuals who are currently on semaglutide 1 mg and may need to switch, but also those in whom a GLP-1 RA is considered the medication of choice to commence.

Since this shortage was announced, it has become abundantly clear just how valuable this medication class is in the management of type 2 diabetes; after only 3 weeks, the PCDS consensus statement has had over 17000 downloads. I wish to thank and offer my congratulations to Hannah Beba, Jane Diggle and the other PCDS committee members who moved so quickly to create such a coherent and beneficial document.

The legacy effect of early glycaemic control

The European Association for the Study of Diabetes (EASD) Annual Meeting, held in September, brought us a wide and varied programme, as ever. Of particular interest to me was the 44-year follow-up data from the UKPDS (UK Prospective Diabetes Study). This demonstrated that early intensive glycaemic management from diagnosis of type 2 diabetes reduces the risk of complications. The reduction in risk of microvascular complications was seen rapidly, whereas it takes 20 years to see the same reduction in risk of macrovascular complications. I think it is remarkable that the study group is continuing to follow up these participants, and now we have data 44 years after the trial began that demonstrate the continued legacy effect of this early tight control.

The UKPDS is regarded as a landmark trial in diabetes, and it is so refreshing to see the commitment to continue the follow-up. This trial has spanned my career in diabetes nursing, and still it keeps delivering!

Updated ADA/EASD consensus

In other news from the EASD meeting, we now have the newly updated joint consensus report on type 2 diabetes management from the EASD and American Diabetes Association (Davies et al, 2022). I specifically recommend readers look at the graphic on lifestyle and physical activity (Figure 1). This consensus considers the whole person and the advice that we need to offer regarding all aspects of a healthy lifestyle. The importance of breaking up extended hours of sitting and the various types of physical activity, from cardiovascular to strengthening and balance exercises, are emphasised, and then there is a new focus on sleep.

Sleep hygiene is clearly recognised as having a major impact on both physical and mental health. Sleep disorders are common in people with type 2 diabetes. Frequent disturbances to sleep patterns, too much or little sleep, and the times when sleep takes place can all have an adverse effect on health. These adverse effects include an increased risk of obesity, diminished ability to function during the day and impairments to glucose metabolism. Additionally, over half of those with type 2 diabetes are also believed to have obstructive sleep apnoea, which itself has effects on glycaemic control. With this guide, we can constructively have conversations with our patients to help address and promote improved sleep hygiene.

Finally, the updated consensus statement has taken a major shift in how we manage type 2 diabetes. The term “organ protection” is now used when discussing the SGLT2 inhibitor and GLP-1 RA classes and their cardiorenal benefits. For the first time in any consensus document, the advice to aim for organ protection in high-risk patients is now separate from advice on glycaemic management, and here we see the use of SGLT2 inhibitors and GLP-1 RAs prior to the use of metformin. Metformin and other glucose-lowering agents sit clearly in the glycaemic management arm and are to be considered once the cardiorenal risk has been assessed and addressed. Further agents in the incretin family are also included in the report. Some of these are yet to be available in the UK, but there is great excitement regarding tirzepatide, a newly approved dual incretin agent targeting both GLP-1 and GIP.

As I started this editorial discussing the global shortage of GLP-1 RAs, we really do hope that production can get back on track as soon as possible, and that the latest incretin agents will be available to us soon, without supply issues, for the benefit of those with type 2 diabetes.