ADA Prioritizes Active Patient Engagement to Improve Diabetes Care

The joint consensus report on type 2 diabetes treatment—issued by American Diabetes Association and European Association for the Study of Diabetes—calls for priority shift in patient management to optimize blood glucose control, improve outcomes, and minimize complications by individualizing patient care.

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

After reviewing a substantial number (n=479)  published studies, experts from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) issued new guidance for treating hyperglycemia in type 2 diabetes.1

The consensus report,unveiled at the EASD annual meeting in Berlin and simultaneously published in two journals—Diabetes Care and in Diabetologica—calls for a paradigm shift in clinical practice to improve patient care and better clinical outcomes.

Accounting for tolerance, cost, and insurance coverage are necessary in type 2 diabetes care.

Evolving Diabetes Care: Balancing Patient Realities with Research 

"Probably the most impactful change is that for patients with type 2 diabetes who have atherosclerotic cardiovascular disease or chronic kidney disease who are not meeting their glycemic target, clinicians should recommend adding sodium-glucose cotransporter-2 inhibitors (SGLT2i) or glucagon-like peptide-1 receptor agonists (GLP-1 RA), both of which have proven cardiovascular benefits," co-chair of the expert panel, 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, told EndocrineWeb.

"The second most impactful change in the guidelines for diabetes care,"he said, “is that the GLP-1 receptor agonists are preferred as the initial choice in those who require the greatest glucose-lowering using injectable insulin.” 

Despite the research showing significant benefits of the newer drugs,2-4 we now know that achieving a lower blood glucose (ie, hemoglobin A1c) is not enough; we need to also address blood pressure, lipids, body weight, and lower the risks of heart attack, stroke, progressive renal disease, kidney failure, heart failure, and cardiovascular-related deaths, said Dr. Buse. He estimated that only about 10 to 12% of people in the US who might benefit from GLP-1 RA or SGLT2i are on them.

Limitations Affecting Treatment Strategies and Timing  

The research, demonstrating the efficacy of these newer classes of anti-diabetes medications, has been accumulating over the past few years. “While the data is solid, these [SGLT2i and GLP-1 RA] are expensive drugs," he said, and cost may indeed be a barrier for some patients; therefore, it’s important that clinicians be mindful of this when formulating patient-specific care plans for diabetes management.

Since the new guidance is focused on individualized care, said Dr. Buse, and “the generally accepted target of less than 7% for hemoglobin A1c (HbA1c), if you have a patient at 6.5% who doesn't want to take another drug, for example, that might be fine, so long as any potential risks are shared with and understood by the patient."

"It should be acknowledged that metformin remains first-line therapy not because it is necessarily the best therapy but because in the cardiovascular outcome trials that demonstrated the benefits of these new classes of drugs, patients were taking metformin, and it is cheap and safe, Dr. Buse said. "So for many patients, switching to one of the newer drugs, or adding one to the existing regimen may be a lifesaving move."  

Since the ADA/EASD guidance did not address the “when” to initiate additional medications beyond metformin, Dr. Buse offered his personal opinion. “I would recommend starting an SGLT2i or GLP-1RA as soon as practical after an acute event is resolved and the patient is stable,” he said. “The area of controversy is what to do with patients whose overall diabetes control is already adequate; the statement recommends that another non-metformin medication may be substituted, the target could be lowered, or wait until the glycemic control has worsened.”

Tipping Point in Diabetes: Need for Precision Medicine Approach 

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 and offered independent comment in an interview with EndocrineWeb.

In preparing the consensus guidance, the expert panel looked at a very large amount of literature, encompassing more than 500 published studies and a substantial number of experts analyzing the data. "This is what is needed to sort out the trends," Dr. Buchanan said.

What is clear from the recommendations,1 is that ''it's becoming much more of a precision medicine approach. Different characteristics of patients are assessed and factored when making treatment decisions,” he said.

While much of the report is not new information, Dr. Buchanan said, "it is an assimilation of existing information that allows more rational selection of the right therapy for each individual patient." That and if the likelihood that "even type 2 diabetes is probably not one disease."

In his own research, Dr. Buchanan had focused on preserving the beta cell functioning. ''The one thing most studies about diabetes have not addressed is the loss of stability'' of blood sugar,” he said, “rather the focus has been how quickly blood sugar [HbA1c] goes down. Yet, 'it's not just [about] controlling blood sugar well, additional consideration should be given to the stability of blood sugar levels."

More Global, Responsive Approach to Diabetes Management

This hefty consensus report includes guidance that shifts the focus of care to the individual needs of each patient as this is a more effective approach to treating type 2 diabetes. Among the more noteworthy recommendations, according to the ADA writing group,1 are:

  • Addressing each patient's circumstances should include access to and affordability of options for education and clinical feedback, whether delivered on-site or by directing individuals to appropriate programs and support services to receive individual medical nutrition therapy, including weight control support (as needed) and encouragement to prioritize lifestyle changes, including physical activity and meal planning instruction.
  • In addition to usual clinical follow-up care, resources may include quality online educational sources and virtual coaching with certified diabetes educators; this will depend upon the level of care needed (eg, weight management, cardiovascular risks, liver involvement), interest and motivation of the patient.
  • Patient preferences must be addressed when recommending medication(s). As such, practitioners should consider patient responsiveness to and tolerance for medications as well as factors such as the feasibility of taking the medications in a timely and consistent fashion, cost, and insurance coverage.
  • Beyond these fundamental concerns, metformin remains the preferred first-line agent to prompt sufficient glucose-lowering for most individuals with T2D. However, when glycemic targets are not met, adding medications to improve glycemic levels that also address anticipated comorbid complications should be recommended, as needed.
  • For anyone at risk for atherosclerotic cardiovascular disease, introducing SGLT2i or GLP-1 RA should be considered. SGLT2i is recommended in those with chronic kidney disease, otherwise, a GLP-1 RAs should be considered.
  • Patients on oral medication (ie, metformin, sulfonylurea) plus insulin who still do not meet glycemic targets should consider adding prandial insulin.
  • In patients who need injectables, GLP-1 receptor agonists are preferred to insulin.
  • Suggesting bariatric surgery is recommended for most individuals who have a body mass index (BMI) of 40 kg/m2 or higher, and for those with a BMI of 35 to 39.9 kg/m2 who have not been able to achieve durable weight loss with nonsurgical approaches.

The priority in tackling diabetes must shift to self-managed care as the best way forward to assure that patients have the best chance of achieving desirable outcomes,1 according to the expert panel.

Pertaining to both healthcare systems and practitioners, diabetes practice should move away from the current didactic treatment to a more active engagement with patients so they are better prepared to assume an active role in their own care. This means being responsive to the reality that a diagnosis of T2D comes with multiple morbidities that may need to be addressed in consultation with the patient.

Dr. Buse is a consultant to Neurimmune AG and holds stock options in Mellitus Health, Phase Bio and Stability Health, among others, so please see the original paper for a full disclosure; Dr. Buchanan has no relevant financial disclosures regarding this article.

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