Type 2 diabetes: Managing more than just glycaemia

Having read with interest the reviews from the American Diabetes Association (ADA) meeting this year and following the recent media and Parliamentary discussions on diabetes, I am left in a state of increasing confusion as to the best approach to take in helping people manage their diabetes. Do we increase our support and guidance with aggressive weight management or look to therapeutically target those with existing cardiovascular disease?

Let me explain this further. The greatest challenge at the current time appears to be surrounding the first steps following diagnosis of type 2 diabetes. We have for many years encouraged diet and lifestyle, and then the use of metformin. This remains the case in many guidelines; however, we have emerging evidence that focuses at the heart of this crucial starting point. Metformin as a first-line medication remains undisputed; however, the initial diet and lifestyle interventions are now increasingly under debate. We have many unanswered questions as to whether we should be aiming for weight loss by any means or by a more targeted low/very-low-carbohydrate approach.

As I have mentioned in previous editorials, the DiRECT (Diabetes In REmission Clinical Trial) study has captured the imagination, with amazing results in people who achieve a significant weight loss (Lean et al, 2018). Remission is now tantalisingly possible. With more information coming from this study in terms of the patients who are most likely to achieve remission (i.e. older, shorter duration of diabetes, fewer medications), and with further follow-up data to be reported, DiRECT will be of great interest and relevance for years to come.

The All-Party Parliamentary Group for Diabetes has also acknowledged the importance of this area of care, and held a session in June discussing the reversal of type 2 diabetes. From this meeting, a strategy document with seven clear recommendations to help achieve this has been produced.

So while all of this appears to suggest we should spend far more time approaching type 2 diabetes with a weight-reduction strategy aiming for remission, I feel we also need to consider whether there are other health factors that should take priority in our decision-making.

The 6-year follow-up of the EDICT (Efficacy and Durability of Initial Combination Therapy for Type 2 Diabetes) study demonstrated that an aggressive, very early, multi-therapeutic intervention – with the use of metformin, a thiazolidinedione and a long-acting glucagon-like peptide-1 receptor agonist (GLP-1 RA) from as little as 5 months after diagnosis – was more likely to keep HbA1c at target levels over the longer term compared with sequential add-on therapy (Abdul-Ghani et al, 2018).

The draft ADA/EASD type 2 guidelines are taking the approach of using cardiovascular status as a key decider in what treatment should be added after metformin. If there is established cardiovascular disease then a GLP-1 RA or sodium–glucose cotransporter 2 inhibitor (SGLT2i) should be started. Medications in both of these classes have demonstrated improvements in not only blood glucose but also in cardiovascular outcomes. Ongoing studies are also looking at the potential benefits of the SGLT2i class from a renal perspective; in addition, evidence of reductions in hospitalisation from heart failure is capturing the attention of our cardiology colleagues.

These findings should dissuade us from medicating diabetes purely from the glucose perspective and encourage us to manage the whole cardiovascular picture, as we now have drugs at our disposal that can improve outcomes from multiple angles.

As nurses, one of our greatest challenges is not only to remain abreast of all new thinking and evidence but also to be able to interpret what the literature is and isn’t telling us. At the same time, we must also be able to have meaningful discussions with our patients and ensure they can make fully informed decisions about the right strategy for them. Guidelines take a population-level approach to management; however, within that it is imperative that we remain focused on delivering truly individualised care. The management of type 2 diabetes is becoming ever more complex, with multiple considerations to be made.