2019 update to: Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

Abstract

The American Diabetes Association and the European Association for the Study of Diabetes have briefly updated their 2018 recommendations on management of hyperglycaemia, based on important research findings from large cardiovascular outcomes trials published in 2019.

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 HbA or individualised HbA 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; and

(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 [1.73 m] or urinary albumin-to-creatinine ratio >30 mg/g, particularly >300 mg/g) to prevent the progression of CKD, hHF, MACE and cardiovascular death.

Statements in summary

1. We now also suggest that 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, an eGFR <60 ml min⁻¹[1.73 m]⁻²or albuminuria. 

2. We now suggest that SGLT2 inhibitors are recommended in patients with type 2 diabetes and HF, particularly those with HFrEF, to reduce hHF, MACE and CV death.

3. We now recommend that 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, cardiovascular death or CKD progression should be considered independently of baseline HbA_1cor individualised HbA_1ctarget. 

4. We now recommend that SGLT2 inhibitors should be used to prevent hHF, MACE and CV death and the progression of CKD in patients with type 2 diabetes with CKD. 

5. We now recommend that 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.

6. we believe that for patients with type 2 diabetes and established atherosclerotic CVD (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, that the level of evidence for MACE benefit is greatest for GLP-1 receptor agonists.

7. For patients with or without established atherosclerotic CVD, but with HFrEF or CKD (eGFR 30 to ≤60 ml min⁻¹[1.73 m]⁻²or UACR >30 mg/g, particularly UACR >300 mg/g), the level of evidence for benefit is greatest for SGLT2 inhibitors.

8. We now suggest that providers should engage in shared decision making around initial combination therapy in new-onset cases of type 2 diabetes.

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