Newer Pharmacologic Treatment guide for Adults With Type 2 Diabetes.

<h2 id="introduction">Introduction</h2><ul><li>The American College of Physicians (ACP) developed this clinical guideline to update recommendations on newer pharmacologic treatments of type 2 diabetes.</li><li>This clinical guideline is based on the best available evidence for effectiveness, comparative benefits and harms, consideration of patients’ values and preferences, and costs.</li></ul><h3>Evidence for recommendations:</h3><ul><li>This clinical guideline is based on a systematic review of the effectiveness and harms of newer pharmacologic treatments of type 2 diabetes, including glucagon-like peptide-1 (GLP-1) agonists, a GLP-1 agonist and glucose-dependent insulinotropic polypeptide agonist, sodium-—glucose cotransporter-2 (SGLT-2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and long-acting insulins, used either as monotherapy or in combination with other medications.</li><li>The Clinical Guidelines Committee (CGC) prioritized the following outcomes, which were evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach: all-cause mortality, major adverse cardiovascular events, myocardial infarction, stroke, hospitalization for congestive heart failure, progression of chronic kidney disease, serious adverse events, and severe hypoglycemia.</li><li>Weight loss, as measured by percentage of participants who achieved at least 10% total body weight loss, was a prioritized outcome.</li></ul><h2 id="population">Population:</h2><p>The patient population is nonpregnant adults with type 2 diabetes.</p><h2 id="intended-audience">Intended Audience</h2><p>The intended audience is physicians and other clinicians caring for adults with type 2 diabetes.</p><h2 id="grading-system">Grading System</h2><p>The CGC used the Evidence-to-Decision framework when reporting evidence and rated the recommendations using the GRADE approach (Figure 1).</p><p>Figure 1. Grading the certainty of evidence and strength of recommendations in ACP clinical guidelines using GRADE.</p><figure class="image"><img style="aspect-ratio:1087/438;" src="https://cdn.megawecare.com/GHBY/Internal-Images/recommendations-acp.webp" width="1087" height="438"></figure><p>Evidence from systematic reviews alongside interpretation and judgements made by the CGC, which are briefly summarized in Figures 2 and 3.</p><p>Figure 2. Summary of CGC interpretation of evidence for newer diabetes medications compared with usual care or placebo.</p><figure class="image"><img style="aspect-ratio:1081/430;" src="https://cdn.megawecare.com/GHBY/Internal-Images/summary-of-cgc-interpretation.webp" width="1081" height="430"></figure><p>Figure 3. Summary of CGC interpretation of evidence for GLP-1 agonists, and SGLT-2 inhibitors compared with other active treatments.</p><figure class="image"><img style="aspect-ratio:1095/541;" src="https://cdn.megawecare.com/GHBY/Internal-Images/summary-of-cgc-interpretation-2.webp" width="1095" height="541"></figure><figure class="image"><img style="aspect-ratio:744/436;" src="https://cdn.megawecare.com/GHBY/Internal-Images/summary-of-cgc-interpretation-3.webp" width="744" height="436"></figure><h2 id="recommendations">Recommendations</h2><p>ACP recommends adding a sodium-glucose cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist to</p><p>metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control <strong>(strong recommendation; high-certainty evidence).</strong></p><p>Use anSGLT-2 inhibitor to reduce the risk for all-cause mortality, major adverse cardiovascular events, progression of chronic<br>kidney disease, and hospitalization due to congestive heart failure.</p><p>Use a GLP-1 agonist to reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke.</p><h2 id="clinical-considerations">Clinical Considerations</h2><ul><li>Metformin (unless contraindicated) and lifestyle modifications are the first steps in managing type 2 diabetes in most patients.</li><li>When selecting an additional therapy, clinicians should consider the evidence of benefits, harms, patient burden, and cost of medications in addition to performing an individualized assessment of each patient’s preferences, glycemic control target, comorbid conditions, and risk for symptomatic hypoglycemia.<ul><li>Clinicians should prioritize adding SGLT-2 inhibitors in patients with type 2 diabetes and CHF or CKD.</li><li>Clinicians should prioritize adding GLP-1 agonists in patients with type 2 diabetes and an increased risk for stroke or for whom total body weight loss is an important treatment goal.</li></ul></li><li>Clinicians should aim to achieve HbA1c levels between 7% and 8% in most adults with type 2 diabetes and deintensify pharmacologic treatments in adults with HbA1c levels less than 6.5%.</li><li>An individualized glycemic goal should be based on risk for hypoglycemia, life expectancy, diabetes duration, established vascular complications, major comorbidities, patient preferences and access to resources, capacity for adequate monitoring of hypoglycemia, and other harms.</li><li>Self-monitoring of blood glucose might be unnecessary in patients receiving metformin combined with either an SGLT-2 inhibitor or a GLP-1 agonist.</li><li>When adding an SGLT-2 inhibitor or a GLP-1 agonist results in adequate glycemic control, clinicians should reduce or discontinue existing treatment with sulfonylureas or long-acting insulins due to increased risk for severe hypoglycemia.</li><li>Sulfonylureas and long-acting insulins are inferior to SGLT-2 inhibitors and GLP-1 agonists in reducing all-cause mortality and morbidity but may still have some limited value for glycemic control.</li><li>Benefits and harms of additional pharmacologic treatment beyond the initial add-on treatment are unknown (for example, a patient who receives metformin plus an SGLT-2 inhibitor but in the future receives an additional GLP-1 agonist). Further, clinical evidence on patient mortality, morbidity, and hospitalizations and economic evidence are lacking for use of SGLT-2 inhibitors and GLP-1 agonists as initial treatment for patients with type 2 diabetes.</li><li>Collaborative care plans should include integrated efforts with dietary improvement and weight management, sleep health, physical activity, stress management, and management of comorbidities and concomitant medications.</li><li>Type 2 diabetes management should be based on collaborative communication and goal setting among all team members, including clinical pharmacists, to reduce the risk for polypharmacy and associated harms.</li><li>Health systems should have a process in place to assess social risk factors. All relevant entities and stakeholders should intervene to connect adults with type 2 diabetes and adverse social risk factors to social and community services.</li><li>There are currently no generic SGLT-2 inhibitors or GLP-1 agonists, but these formulations may become available. Clinicians should prescribe generic medications when they are available rather than more expensive brand-name medications.</li><li>Clinicians and patients should discuss the cost of an add-on SGLT-2 inhibitor or GLP-1 agonist when selecting a medication from either drug class.</li><li>Clinicians should be attentive to patient race and ethnicity as a social risk factor for diabetes. Worse health outcomes for type 2 diabetes may be mediated by such factors as social determinants of health.</li></ul>

DIABETES UPDATES 2024 ISSUE 3

<ul><li><a href="#introduction">Introduction</a></li><li><a href="#population">Population</a></li><li><a href="#intended-audience">Intended Audience</a></li><li><a href="#grading-system">Grading System</a></li><li><a href="#recommendations">Recommendations</a></li><li><a href="#clinical-considerations">Clinical Considerations</a></li></ul><p>&nbsp;</p>

Newer Pharmacologic Treatment guide for Adults With Type 2 Diabetes.

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