The European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) have produced an updated consensus statement on how to manage hyperglycemia (high blood sugar) in patients with type 2 diabetes.

The consensus paper is being published in the EASD’s journal, Diabetologia, and the ADA’s journal, Diabetes Care. This publication coincides with the EASD annual meeting in Berlin, Germany.

The new recommendations from an expert panel of EASD and ADA members follow a review of the latest evidence—including a range of recent trials of drug and lifestyle intervention—and update the last recommendations issued in 2015.

UNC School of Medicine’s John Buse, MD, PhD, senior author of the paper and co-chair of the ADA consensus statement writing group, says there are two key changes in the updated recommendations.

“We have suggested changing the focus of why drugs are prescribed to patients. Instead of primarily focusing on lowering blood sugar, we now suggest physicians primarily focus on treatment to prevent heart attack, stroke, heart failure, and kidney disease,” said Buse, director of the UNC Diabetes Care Center and director of the NC Translational and Clinical Sciences (NC TraCS) Institute.

The new recommendations say type 2 diabetes patients with clinical cardiovascular disease should take a glucagon-like peptide 1 (GLP-1) receptor agonist or sodium-glucose co-transporter 2 (SGLT2) inhibitor. Buse says they also now recommend that if a patient needs to take an injection, they should start with a GLP-1 receptor agonist instead of insulin, which has been the classical approach. There is also more focus on diet, weight loss medications, and weight loss surgery as strategies for diabetes control.

“Less than 20% of patients in the US are getting the recommended treatments,” Buse said. “I do not know how much these new recommendations will change provider behavior or insurance coverage, but we do believe it is absolutely the right way to approach treatment in these patients.”

Below are more details on the new recommendations:

• Providers and health-care systems should prioritize the delivery of patient-centered care.
• Facilitating medication adherence should be specifically considered when selecting glucose-lowering medications. (Ultimately, patient preference is a major factor driving the choice of medication. Even in cases where a patient’s clinical characteristics suggest the use of a particular medication based on the available evidence from clinical trials, patient preferences regarding route of administration, injection devices, side effects, or cost may prevent their use by some individuals.)
• All patients should have ongoing access to diabetes self-management education and support.
• Medical nutrition therapy (healthy eating advice and strategies) should be offered to all patients.
• All overweight and obese patients with diabetes should be advised of the health benefits of weight loss and encouraged to engage in a program of intensive lifestyle management, which may include food substitution.
• Increasing physical activity improves glycemic control and should be encouraged in all people with type 2 diabetes.
• Metabolic surgery is a recommended treatment option for adults with type 2 diabetes and a BMI of 40 or over (or 37.5 or over in people of Asian ancestry) or a BMI of 35.0 to 39.9 (32.5–37.4 kg/m2 in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities with reasonable non-surgical methods.
• Metformin continues to be the first-line recommended therapy for almost all patients with type 2 diabetes.
• The selection of medication added to metformin is based on patient preference and clinical characteristics, including presence of cardiovascular disease, heart failure, and kidney disease. The risk for specific adverse medication effects, particularly hypoglycemia, weight gain, safety, tolerability, and cost, are also important considerations.
• Regarding medication management, for patients with clinical cardiovascular disease, a SGLT2 inhibitor or a GLP-1 receptor agonist with proven cardiovascular benefit is recommended. Individual agents within these drug classes have been shown to have cardiovascular benefits.
• For patients with chronic kidney disease (CKD) or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit should be considered.
• GLP-1 receptor agonists are generally recommended as the first injectable medication, except in settings where type 1 diabetes is suspected.
• Intensification of treatment beyond dual therapy to maintain glycemic targets requires consideration of the impact of medication side effects on comorbidities, as well as the burden of treatment and cost.