What's New in Diabetes? Individualizing Care Takes Priority

With John Buse, MD, PhD, and Thomas Buchanan, MD

Whether you’ve had type 2 diabetes (T2D) for a while or were recently diagnosed, don't be surprised if your next doctor appointment has some surprises. A new consensus report,produced by a panel of experts who reviewed nearly 500 manuscripts, has presented some recommendations to improve the way you and your health provider manage your diabetes.

2 women in kitchen discussing healthy eatingLearning healthy ways to cook your favorite meals will improve your blood sugar, weight, and reduce the health risks associated with type 2 diabetes. Photo: 123RF

The updated treatment guidelines, based on substantial recently research, call for more active patient involvement and recommends more consistent ongoing nutrition and lifestyle support, reflecting our increased understanding of what it takes to manage type 2 disease.

The report—The management of hyperglycemia in type 2 diabetes, 2018—issued jointly by the American Diabetes Association and the European Association for the Study of Diabetes, was published in Diabetes Care.1

Active Patient Participation Becomes Top Goal in Diabetes Management 

"Important for all patients to know: the focus of care is shifting to better account for the individual needs and preferences of patients, along with an effort to actively engage patients to take a more active role in educating themselves about the disease and managing it," says John Buse, MD, PhD, the Verne S. Caviness Distinguished Professor and chief of endocrinology at the University of North Carolina School of Medicine in Chapel Hill who co-chaired the expert panel.

Doctors are being encouraged to consider factors such as your willingness to take more medication, the costs of the prescription, and your insurance coverage, 1

Other changes involve tailoring the medications to more closely match your risks and health goals, based on whatever coexisting health problems you might have, such as heart disease, high blood pressure, kidney disease, or concerns about excess body weight.

Thomas Buchanan, MD, professor of medicine and co-director of the Diabetes and Obesity Research Institute at USC Keck School of Medicine, Los Angeles, reviewed the report for EndocrineWeb and shared his views on what this report means for patients. 

''It's becoming much more of a precision medicine approach," he says. That means your doctor will look at your individual health characteristics and decide the best treatment plan with you, rather than working from what seems best for most people, in general.

Tailoring Medical Recommendations to Meet the Specific Needs of Each Patient

The report, evaluated a great deal of new data, ''is not necessarily new information but an assimilation of existing knowledge that allows doctors to make a more focused selection of the right therapy for each individual patient," Dr. Buchanan says.

"Probably the most impactful change coming from this report is that for patients with diabetes who have atherosclerotic [heart] disease or chronic kidney disease that if they are not meeting their glycemic target they should be treated with SGLT2 agonists with proven cardiovascular benefits, " Dr. Buse tells EndocrineWeb. Among the SGLT2i medications are empagliflozin (Jardiance) and canagliflozin (Invokana).2,3

Dr. Buse says the evidence is strong that these drugs, as well as with the GLP-1 receptor agonists such as liraglutide (Victoza) and semaglutide (Ozempic) can help reduce long-term complications common in people with diabetes.4,5 The health benefits of these new drugs are substantial. However, he acknowledges that because they are expensive drugs, cost definitely could be a barrier for some patients.

"These drugs are associated with reduced risks of heart attack, stroke, progressive renal disease, kidney failure, heart failure, and even death," he says, “in addition to lowering of blood pressure, blood sugar, and supporting weight loss."

More Highlights from the Updated ADA Diabetes Guidelines

The report is hefty,1 so here are some of the more relevant points to help you better manage your diabetes going forward:

  • Patient education is being encouraged, and you will fare much better if you are willing to take a more active role in your own care. Your doctor will direct you to helpful resources and recommend that you consider making lifestyle changes that may include seeing a dietitian or trying a virtual coaching program so you get appropriate dietary guidance, and you’ll be encouraged to exercise regularly.
  • If your body mass index (BMI) is 40 kg/m2 or higher, or you have a BMI of 35-39.9 and are struggling to keep any lost weight off with diet and exercise measures, the experts strongly suggest you consider bariatric surgery, which reverses not only diabetes but the serious consequences that go along with them and are worsened by excessive weight.
  • That is probably the most important impact to understand about diabetes. As you will learn, a diagnosis of type 2 diabetes means you are likely at increased risk for a variety of serious complications, including heart failure and other heart-related problems, and kidney issues. Your doctor will discuss what it will take to reduce your risks; or, if you already have any of those conditions, what you can do now to improve your health.
  • Your feelings about taking medications—knowing both the benefits and possible side effects— and your tolerance for the medications will be taken into account when you discuss your care with your doctor, in addition to the realities of cost and insurance coverage.
  • As for specific medicines, metformin remains the first anti-diabetes drug to control blood glucose. One area of debate, he says, is what should be done in individuals whose overall diabetes control is adequate but they still face risks. The experts recommend that another anti-diabetes medicine could be substituted, the target could be lowered, or you could wait to see if your blood sugar control gets worse.
  • However, when your blood glucose targets are not met, your doctor is likely to add other medications that will help improve your blood glucose levels (ie, hemoglobin A1c) as well as to address problems like high blood pressure or high cholesterol. The generally accepted upper limit for hemoglobin A1c is less than 7%.
  • If you are at risk for cardiovascular disease (CVD, or heart disease), you can expect your doctor to suggest adding either an SGLT2 inhibitor or GLP-1 receptor agonist.

While the report does not address exactly when these drugs should be introduced, Dr. Buse offered his personal opinion to EndocrineWeb:  "I would recommend starting an SGLT2i or GLP-1 RA as soon as practical after an acute event is resolved and the patient is stable." 

For those of you are on oral medicine and insulin who can't seem to reach your glucose target, your doctor might suggest adding prandial insulin. If you need injectable medications, GLP-1 RAs are the preferred next-line drug. 

Dr. Buse is a consultant to several companies and holds stock in others so please see the full study to review a full list of disclosures; Dr. Buchanan has no relevant financial disclosures regarding this article.

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