Hyperglycemia Management Should Include Focus on Lifestyle, Obesity, Concurrent Diseases

By Will Boggs MD

NEW YORK (Reuters Health) - The management of hyperglycemia in patients with type 2 diabetes should include attention to lifestyle, diabetes self-management, obesity and cardiovascular and other concurrent diseases, according to a new consensus report from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).

"Engaging patients as partners in developing a treatment plan based on understanding relative benefits and risks enhances the likelihood that patients embrace the plan," said Dr. John B. Buse from University of North Carolina School of Medicine at Chapel Hill.

"Patients with diabetes must take care of their diabetes 24 hours a day, 7 days a week, usually for the rest of their lives. They have to be engaged as full participants from decision-making to implementation," he told Reuters Health by email.

The consensus report prepared by Dr. Buse and colleagues addresses the approaches to management of glycemia in adults with type 2 diabetes, with the goal of reducing complications and maintaining quality of life in the context of comprehensive cardiovascular risk management and patient-centered care.

The cycle of management begins with an assessment of key patient characteristics and proceeds through consideration of specific factors that affect the choice of treatment, shared decision-making to create a management plan, agreement on the plan, implementation of the plan, ongoing monitoring and support, and periodic review and agreement on changes of the management plan. Patients should be involved in every phase of this cycle, the team says.

Key changes in the new recommendations address the management of obesity, patients with clinical cardiovascular disease, and patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease.

Lifestyle management, medications and surgical interventions should be employed to facilitate weight loss in patients with obesity, according to the report, online October 4 in Diabetes Care.

A sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended for patients with clinical cardiovascular disease.

Similarly, an SGLT2 inhibitor with proven benefit is recommended for patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease.

"Though the evidence of benefit of these newer approaches is substantial and compelling, they are more expensive and newer treatments," Dr. Buse said.

Otherwise, GLP-1 receptor agonists are generally favored as the first injectable medication for patients with type 2 diabetes.

"When patients need the greater glucose-lowering power of injectable treatments in type 2 diabetes, they should generally be treated with GLP-1 receptor agonists instead of insulin," Dr. Buse said.

Apart from these preferences, access, treatment cost and insurance coverage should all be considered when selecting glucose-lowering medications.

Dr. Basem M. Mishriky from East Carolina University, in Greenville, North Carolina, who studies type 2 diabetes, told Reuters Health by email, "This version of the recommendations finally honors that patients with increased cardiovascular risk warrant more attention and that insulin may not be the medicine to serve those patients. Thus, when metformin fails, the question is directed to whether the patient would benefit from medications that would have cardiovascular benefit."

"While this is a wonderful update of the recommendations, it needs continuous updates in the near future to better serve our patients with diabetes," said Dr. Mishriky, who was not linked to the report.

SOURCE: https://bit.ly/2AfBQdb

Diabetes Care 2018.

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