TREATMENTS

Diabetes has no cure. It is a chronic disease that requires life-long medical care paired with multifactorial strategies to reduce the risk of acute complications and serious long-term complications. Collaborating with patients to develop individualized management plans and glycemic targets and supporting their efforts to change behaviors are important components of improving outcomes. 1

Lifestyle interventions include healthy eating, regular exercise, smoking cessation, weight management, and adopting strategies for coping with stress. Patients may need support with taking and managing medications; monitoring glucose levels and blood pressure; actively participating in screenings for eye, foot, and renal complications; adhering to the recommended immunization schedule; and identifying self-management problems in order to develop strategies to overcome them.1

Management plans should reflect key patient characteristics and specific factors that impact choice of treatment. A comprehensive medical evaluation should be conducted at diagnosis.1

Reference 1

Reference 2

Unless there are contraindications, pharmacological treatment for patients with type 2 diabetes should begin with metformin at diagnosis. When metformin is contraindicated or if the patient cannot tolerate it, consideration should be given to a drug from another class, such as a sulfonylurea, thiazolidinedione, DPP-4 inhibitor, SGLT inhibitor, GLP-1 receptor agonist, or insulin. Dual therapy should be considered for patients with newly diagnosed type 2 diabetes who have A1C ≥1.5% (12.5 mmol/mol) above their glycemic target. Insulin therapy should be considered when blood glucose is ≥300 mg/dL (16.7 mmol/L) or A1C is ≥10% (86 mmol/mol) or if the patient has symptoms of hyperglycemia (i.e., polyuria or polydipsia), even at diagnosis or early in the course of treatment. 1

The 2019 ADA Standards of Medical Care in Diabetes recommend a patient-centered approach to treatment selection that factors in comorbidities (atherosclerotic cardiovascular disease, heart failure, chronic kidney disease), hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences.1

Reference 1

The prevention of adverse cardiovascular outcomes is a key component of diabetes management.

  • Among patients with T2D older than 65 years, atherosclerotic CVD (ASCVD) accounts for up to 7 of 10 deaths2
  • Women with diabetes have more than a 40% increased risk of incident CHD
  • compared with men with diabetes2
  • ASCVD results in an estimated $37.3 billion in cardiovascular-related spending per year associated with diabetes.3
  • Rates of incident heart failure hospitalization are twofold higher in patients with diabetes compared with those without.4

Referennce 5

Use of statins, aspirin, glucose-lowering therapies, and BP reduction should be considered on a background of intensive lifestyle management including exercise, nutrition, and weight management, in all patients with T2D.5

Selecting medications based solely on their potential to lower hemoglobin A1C is an outdated therapeutic approach. The recent development of 2 novel classes of therapies—SGLT2 inhibitors and GLP-1RAs—has provided evidence that treatments developed for glucose lowering can directly improve CV outcomes.

Reference 5

Complete guidelines for diabetes treatment can be found at:

http://care.diabetesjournals.org/content/42/Supplement_1

https://www.aace.com/publications/algorithm

 

    References

    1. American Diabetes Association. Standards of Medical Care in Diabetes—2019 Abridged for Primary Care Providers. Clinical Diabetes. 2019;37(1):11-34. doi:10.2337/cd18-0105
    2. Pasquel FJ, Gregg EW, Ali MK. The Evolving Epidemiology of Atherosclerotic Cardiovascular Disease in People with Diabetes. Endocrinol Metab Clin North Am. 2018;47(1):1-32. doi:10.1016/j.ecl.2017.11.001
    3. American Diabetes Association. 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019;42(Supplement 1):S103-S123. doi:10.2337/dc19-S010
    4. Newman JD, Schwartzbard AZ, Weintraub HS, Goldberg IJ, Berger JS. Primary Prevention of Cardiovascular Disease in Diabetes Mellitus. Journal of the American College of Cardiology. 2017;70(7):883-893. doi:10.1016/j.jacc.2017.07.001
    5. Das SR, Everett BM, et al. 2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. Journal of the American College of Cardiology. November 2018:25566. doi:10.1016/j.jacc.2018.09.020