2022 update to the Position statement by Primary Care Diabetes Europe: a disease state approach to the pharmacological management of type 2 diabetes in primary care
S.Seidua1X.Cosb1S.BruntoncS.B.Harrisd STEFAN P.O.Janssone M.Mata-CasesfA.M.J.NeijensgP.TopseverhK.Khuntia
Highlights
• Primary care professionals face growing complexity of treatment options.
• This consensus recommends a simple, evidence-based CV risk stratification rubric.
• HCPs should consider early combination options for people with various comorbidities.
• A comprehensive summary of prescribing tips and side effects by drug class is given.
Abstract
Type 2 diabetes and its associated comorbidities are growing more prevalent, and the complexity of optimising glycaemic control is increasing, especially on the frontlines of patient care. In many countries, most patients with type 2 diabetes are managed in a primary care setting. However, primary healthcare professionals face the challenge of the growing plethora of available treatment options for managing hyperglycaemia, leading to difficultly in making treatment decisions and contributing to treatment and therapeutic inertia.
This position statement offers a simple and patient-centred clinical decision-making model with practical treatment recommendations that can be widely implemented by primary care clinicians worldwide through shared-decision conversations with their patients.
It highlights the importance of managing cardiovascular disease and elevated cardiovascular risk in people with type 2 diabetes and aims to provide innovative risk stratification and treatment strategies that connect patients with the most effective care.
Box 1
How to use this position statement.
This position statement summarises the current evidence for glycaemic efficacy, cardiovascular and renal risk, and side effects for a wide variety of therapies for T2D.
Box 2 suggests a simple and pragmatic cardiovascular risk assessment to help inform patient-centred treatment decisions.
Boxes 3–8Box 3 summarise the treatment recommendations by cardiovascular/renal disease or risk factor.
Table 1 summarises the prescribing tips and side effects related to each drug class discussed.
Box 2
Cardiovascular risk stratification in patients with T2D
Patients with T2D are considered to be at very high cardiovascular risk if they have any of the following:
History of CVD (A)
Multiple uncontrolled CVD risk factors, including hypertension, hyperlipidaemia, obesity, smoking and/or physical inactivity (A)
Estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 (B)4
Albuminuria (B)
Age at diagnosis <40 years (C)
All other patients with T2D, including patients ≥65 years, are considered to be at high cardiovascular risk
Box 3
Treatment recommendations for patients with ASCVD.
Consider initiating metformin + SGLT-2i/GLP-1RA rather than stepwise (E)
Metformin as first-line therapy (A)
SGLT-2i or GLP-1RA with proven cardiovascular benefit as second-line therapy (A)
Use basal insulin with caution when other options have failed, and glycaemic targets are not met (E)
Box 4
Treatment recommendations for patients with HF.
Consider initiating metformin + SGLT-2i rather than stepwise (E)
Metformin as first-line therapy (A)
SGLT-2i as second-line therapy (A)
Avoid pioglitazone (A) and saxagliptin (A) and use basal insulin with caution (B)
Box 5
Treatment recommendations for patients with CKD.
Consider initiating metformin + SGLT-2i rather than stepwise (E), according to the approved restrictions of dose and indications by eGFR
Metformin as first-line therapy if eGFR ≥30 mL/min/1.73 m2 (A)
SGLT-2i as second-line therapy (eGFR range as determined per local label) (A), even when well-controlled on metformin alone (E)
GLP-1RA as third-line therapy or if previous treatments are not tolerated (A), followed by DPP-4i (A)
Reduce dose of glinides and reduce dose or discontinue SUs if eGFR <45 mL/min/1.73 m2 to reduce the risk of hypoglycaemia (A)
Box 6
Treatment recommendations for patients at high cardiovascular risk.
Consider initiating metformin + SGLT-2i/GLP-1RA/DPP-4i rather than stepwise (E)
Metformin as first-line therapy (A)
SGLT-2i or GLP-1RA or DPP-4i as second-line therapy where cost is not prohibitive (A). Of these, SGLT-2i or GLP-1RA with proven cardiovascular benefit is preferred (E)
Newer-generation SUs or glinides when drug cost must be minimised (A)
Pioglitazone in patients with NAFLD and where insulin resistance predominates (A)
Basal insulin when other therapies have been explored and glycaemic targets are not met (E)
Full basal-bolus insulin therapy only as a last resort (E)
Box 7
Treatment recommendations for patients with obesity.
Consider initiating metformin + GLP-1RA/SGLT-2i rather than stepwise (E)
Metformin as first-line therapy (A)
GLP-1RA or SGLT-2i as second-line therapy (A)
Where possible, avoid treatments that cause weight gain, including most SUs, glinides, pioglitazone and insulin (A)
If basal insulin is required, consider fixed-ratio insulin/GLP-1RA combinations, if available (A)
Box 8
Treatment recommendations for elderly/frail patients.
Avoid stringent glycaemic targets that increase risk of hypoglycaemia (E)
Metformin as first-line therapy if tolerated and not contraindicated (A)
DPP-4i is a safe and easy to use option (A)
Assess adherence and avoid multiple daily injectable medications when possible (E)
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