This transcript has been edited for clarity.
I’m Dr. Neil Skolnik. Today we’re going to talk about the consensus report by the American Diabetes Association and the European Association for the Study of Diabetes on the management of hyperglycemia.
After lifestyle modifications, metformin is no longer the go-to drug for every patient in the management of hyperglycemia. It is recommended that we assess each patient’s personal characteristics in deciding what medication to prescribe. For patients at high cardiorenal risk, refer to the left side of the algorithm and to the right side for all other patients.
American Diabetes Association
Cardiovascular disease. First, assess whether the patient is at high risk for atherosclerotic cardiovascular disease (ASCVD) or already has ASCVD. How is ASCVD defined? Either coronary artery disease (a history of a myocardial infarction [MI] or coronary disease), peripheral vascular disease, stroke, or transient ischemic attack.
What is high risk for ASCVD? Diabetes in someone older than 55 years with two or more additional risk factors. If the patient is at high risk for or has existing ASCVD then it is recommended to prescribe a glucagon-like peptide 1 (GLP-1) agonist with proven CVD benefit or an sodium-glucose cotransporter 2 (SGLT-2) inhibitor with proven CVD benefit.
For patients at very high risk for ASCVD, it might be reasonable to combine both agents. The recommendation to use these agents holds true whether the patients are at their A1c goals or not. The patient doesn’t need to be on metformin to benefit from these agents. The patient with reduced or preserved ejection fraction heart failure should be taking an SGLT-2 inhibitor.
Chronic kidney disease. Next up, chronic kidney disease (CKD). CKD is defined by an estimated glomerular filtration rate < 60 mL/min/1.73 m2 or a urine albumin to creatinine ratio > 30. In that case, the patient should be preferentially on an SGLT-2 inhibitor. Patients not able to take an SGLT-2 for some reason should be prescribed a GLP-1 receptor agonist.
If someone doesn’t fit into that high cardiorenal risk category, then we go to the right side of the algorithm. The goal then is achievement and maintenance of glycemic and weight management goals.
Glycemic management. In choosing medicine for glycemic management, metformin is a reasonable choice. You may need to add another agent to metformin to reach the patient’s glycemic goal. If the patient is far away from goal, then a medication with higher efficacy at lowering glucose might be chosen.
Efficacy is listed as:
- Very high efficacy for glucose lowering: dulaglutide at a high dose, semaglutide, tirzepatide, insulin, or combination injectable agents (GLP-1 receptor agonist/insulin combinations).
- High glucose-lowering efficacy: a GLP-1 receptor agonist not already mentioned, metformin, SGLT-2 inhibitors, sulfonylureas, thiazolidinediones.
- Intermediate glucose lowering efficacy: dipeptidyl peptidase 4 (DPP-4) inhibitors.
Weight management. For weight management, lifestyle modification (diet and exercise) is important. If lifestyle modification alone is insufficient, consider either a medication that specifically helps with weight management or metabolic surgery.
We particularly want to focus on weight management in patients who have complications from obesity. What would those complications be? Sleep apnea, hip or knee pain from arthritis, back pain – that is, biomechanical complications of obesity or nonalcoholic fatty liver disease. Medications for weight loss are listed by degree of efficacy:
- Very high efficacy for weight loss: semaglutide, tirzepatide.
- High efficacy for weight loss: dulaglutide and liraglutide.
- Intermediate for weight loss: GLP-1 receptor agonist (not listed above), SGLT-2 inhibitor.
- Neutral for weight loss: DPP-4 inhibitors and metformin.
Where does insulin fit in? If patients present with a very high A1c, if they are on other medications and their A1c is still not to goal, or if they are catabolic and losing weight because of their diabetes, then insulin has an important place in management.
These are incredibly important guidelines that provide a clear algorithm for a personalized approach to diabetes management.
Dr. Skolnik is professor, department of family medicine, Sidney Kimmel Medical College, Philadelphia, and associate director, department of family medicine, Abington (Pa.) Jefferson Health. He reported conflicts of interest with AstraZeneca, Teva, Eli Lilly, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, and Bayer. A version of this article first appeared on Medscape.com.