PracticeUpdate Diabetes Best of 2018

TOP STORIES 2018 9

" I think the writing committee did a great job in incorporating new and emerging data into a solid set of evidence-based guidelines, including user- friendly figures. They represent a true sea-change on the evolution of type 2 diabetes treatment. "

into a solid set of evidence-based guide- lines, including user-friendly figures. They represent a true sea-change on the evolu- tion of type 2 diabetes treatment. I did have three main criticisms. First, piogl- itazone appears to be relegated to almost an afterthought. Although understanda- ble given its known side effects, this very cost-effective agent is well-tolerated by many patients at low doses and has its own evidence for an ASCVD benefit. Second, the committee may have pushed the enve- lope a bit in coming out with such strong recommendations for HF and CKD patients. SGLT2 inhibitor studies published to date have included these outcomes solely as secondary endpoints. The committee should have waited for the dedicated HF and CKD trials to be completed. Finally, there is a recommendation to use a GLP-1 receptor agonist in HF and CKD patients if an SGLT2 inhibitor cannot be used. I’m not sure where the group came up with this recommendation, as there is very little evidence for benefit from this class in HF patients and any benefit on CKD is solely on albuminuria – certainly a “soft” outcome. But, in all, I was very pleased with the new guidelines, and I suspect they will influence

and metformin, with additional therapies added sequentially to achieve the HbA1c target. There are several other important differences from prior algorithms, however. First, the choice of glucose-lowering agents after metformin should be driven by the presence or absence of heart (and, to some degree, renal disease). If athero- sclerotic cardiovascular disease (ASCVD) predominates the clinical picture, either a GLP-1 receptor agonist or an SLGT2 inhibi- tor would now be the preferred next choice – preferably a drug shown to improve out- comes in a large CV outcome trial. If HF or CKD predominates, then an SGLT2 inhibi- tor would be the optimal selection. This is a major departure from the 2015 position statement, where there was no guidance based on these comorbidities. The other big change is that, the Con- sensus Report now recommends that the first choice of injectable therapy (barring any contraindications) should be a GLP-1 receptor agonist and no longer insulin – irrespective of heart or kidney disease. This recommendation is based on several trials showing equivalent glucose-lowering efficacy compared with insulin, with less hypoglycemia and weight gain. I think the writing committee did a great job in incorporating new and emerging data

References 1. Davies MJ, D’Alessio DA, Fradkin J, et al. Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2018 Oct 4. doi: 10.2337/ dci18-0033. [Epub ahead of print.] 2. Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2006;29(8):1963-1972. 3. Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: update regarding thiazolidinediones: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2008;31(1):173-175. 4. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2012;35(6):1364-1379. 5. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2015;38(1):140-149.

clinical care for many years. www.practiceupdate.com/c/76213

VOL. 2 • NO. 4 • 2018