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Hyperglycaemia management in type 2 diabetes guidance updated

By Editor
9th January 2020
Cardiovascular disease, Care planning Clinical guidance Type 2 diabetes

Recommendations made relating to the management of hyperglycaemia in type 2 diabetes have been updated following last year’s cardiovascular study outcomes.

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) began work on the update in July last year and the updated document has recently been published.

Important changes include:

(1) the decision to treat high-risk individuals with a glucagon-like-peptide 1 (GLP-1) receptor agonist or sodium–glucose cotransporter 2 (SGLT2) inhibitor to reduce major adverse cardiovascular events (MACE), hospitalisation for heart failure (hHF), cardiovascular death or chronic kidney disease (CKD) progression should be considered independently of baseline HbA1c or individualised HbA1c target

(2) GLP-1 receptor agonists can also be considered in patients with type 2 diabetes without established cardiovascular disease (CVD) but with the presence of specific indicators of high risk

(3) SGLT2 inhibitors are recommended in patients with type 2 diabetes and heart failure, particularly those with heart failure with reduced ejection fraction, to reduce hHF, MACE and CVD death, as well as in patients with type 2 diabetes with CKD (eGFR 30 to ≤60 ml min−1 [1.73 m]−2 or urinary albumin-to-creatinine ratio >30 mg/g, particularly >300 mg/g) to prevent the progression of CKD, hHF, MACE and cardiovascular death.

The recommendations had previously stated that, in the setting of type 2 diabetes, established CVD was a compelling indication for treatment with a GLP-1 receptor agonist or SGLT2 inhibitor.

Now both organisations are suggesting the following:

General consideration

  • In appropriate high-risk individuals with established type 2 diabetes, the decision to treat with a GLP-1 receptor agonist or SGLT2 inhibitor to reduce MACE, hHF, CV death or CKD progression should be considered independently of baseline HbA1c or individualised HbA1c target.
  • Providers should engage in shared decision making around initial combination therapy in new-onset cases of type 2 diabetes.

GLP-1 receptor agonist recommendations

  • For people with type 2 diabetes and established atherosclerotic CV disease (such as those with prior myocardial infarction, ischaemic stroke, unstable angina with ECG changes, myocardial ischaemia on imaging or stress test, or revascularisation of coronary, carotid or peripheral arteries) where MACE is the gravest threat, the level of evidence for MACE benefit is greatest for GLP-1 receptor agonists.
  • To reduce risk of MACE, GLP-1 receptor agonists can also be considered in patients with type 2 diabetes without established CVD with indicators of high risk, specifically, patients aged 55 years or older with coronary, carotid or lower extremity artery stenosis >50%, left ventricular hypertrophy, eGFR <60 ml min–1 [1.73 m]–² or albuminuria.

SGLT2 inhibitor recommendations

    • For people with or without established atherosclerotic CVD, but with HFrEF (EF <45%) or CKD (eGFR 30 to ≤60 ml min–1 [1.73 m]–² or UACR >30 mg/g, particularly UACR >300 mg/g), the level of evidence for benefit is greatest for SGLT2 inhibitors.
    • SGLT2 inhibitors are recommended in patients with type 2 diabetes and HF, particularly those with HFrEF, to reduce hHF, MACE and CV death.
    • SGLT2 inhibitors are recommended to prevent the progression of CKD, hHF, MACE and CV death in people with type 2 diabetes with CKD.
    • Patients with foot ulcers or at high risk for amputation should only be treated with SGLT2 inhibitors after careful shared decision making around risks and benefits with comprehensive education on foot care and amputation prevention.

To read the full document, click here.

Picture credit: Green Chameleon

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