What a great start to the beginning of a new year!
Every year in late December, I look forward to the American Diabetes Association (ADA) guidelines for diabetes. The standards were released and there were several updates. However, there was one update that I was not expecting, which was the updated ADA and European Association for the Study of Diabetes (EASD) position statement on the management of hyperglycemia. I wanted to provide a brief review of the position statement.
The ADA/EASD have typically provided an update in the position statement every three years. The position statements have evolved based on new evidence, particularly newly approved antihyperglycemic agents. In the 2012 position statement, the document listed Step 1 as lifestyle modifications plus metformin for an adequate period of time (i.e. three months). Lifestyle modifications are recommended in conjunction with any pharmacologic agent. Following Step 1, additional glycemic control may be needed if desired glycemic goals have not been achieved. If so, there were five options: sulfonylureas, TZD, DPP-IV inhibitors, GLP-1 agonists or basal insulin. It should be noted that if the person's A1C is above 9%, then dual therapy is the direct option. Now, these organizations have updated the standards to include SGLT2 inhibitors as a sixth option for dual therapy.
In comparison, the American Association of Clinical Endocrinology (AACE) published an algorithm in April 2013. This organization has similarities, such as lifestyle modification plus metformin as first-line therapy. However, AACE recommends a hierarchy of medications for dual or triple therapy. The hierarchy is based on the clinical evidence; within this algorithm, if a patient’s A1C remains above 7.5% after three months, then the hierarchy can be followed in this specific order: GLP-1 agonists, DPP-IV inhibitors, TZD, SGLT2 inhibitors, basal insulin, colesevelam, bromocriptine, alpha-glucosidase inhibitors, and sulfonylureas.
Both of these guidelines recommend certain factors that should be considered for the medication options; these factors include degree of hyperglycemia, the risk of hypoglycemia, cost, effects on weight, and patient preference.
There are other updates in the ADA/EASD 2015 position statement, which include less stringent prescribing of metformin (based on glomerular filtration rate) and additional details on insulin initiation and titration.
If you have not had a chance to read the position statement, you can get a free electronic copy of the document from Diabetes Care. However, if you have read and reviewed the position statement, what are your thoughts?