Recently, I updated my lecture titled “Pharmacotherapy of Type 2 Diabetes” for the third-year professional students at my institution. I had to update my slides due to the updates published in Diabetologia for the 2018 American Diabetes Association and European Association for the Study of Diabetes consensus guidelines. For this blog, I wanted to provide the top ten things to know regarding these guidelines, particularly for pharmacotherapy.
- It is important to evaluate a patient’s cardiovascular status when considering pharmacotherapy. If a person has atherosclerotic cardiovascular disease (ASCVD), then a SGLT-2 inhibitor or GLP-1 receptor agonist should be considered. If a patient has heart failure or chronic kidney disease, then a SGLT-2 inhibitor could be considered with GLP-1 receptor agonist as an alternative medication.
- The preferred GLP-1 receptor agonist for people with ASCVD is liraglutide, followed by semaglutide and exenatide extended-release.Remember, lixisenatide has neutral data regarding macrovascular events.
- The preferred SGLT-2 inhibitor for people with ASCVD is empagliflozin, followed by canagliflozin.
- It is important to evaluate and consider the patient’s weight as a factor before initiating pharmacotherapy. Metformin remains to be first-line therapy, even though it is not a miracle drug for weight loss. Second-line options would include a GLP-1 receptor agonist in the following order: semaglutide, liraglutide, dulaglutide, exenatide, and lixisenatide.SGLT-2 inhibitors can be third-line options to promote weight loss through glucosuria, whereas DPP-IV inhibitors would be the last line due to weight neutral effects.
- It is important to evaluate a patient’s risk for hypoglycemia. The medications that have a minimum to no risk of hypoglycemia following metformin would include a DPP-IV inhibitor, TZD, SGLT-2 inhibitor and GLP-1 receptor agonist.
- In terms of insulin therapy and hypoglycemia, insulin degludec would be superior to insulin glargine, even though both have neutral facts on macrovascular events.
- Pharmacotherapy and related costs to the patient should be considered. Due to extensive evidence and availability over many years, sulfonylureas and TZDs remain viable options if a patient is on a fixed budget or does not have insurance.
- Due to lack of evidence, a DPP-IV inhibitor should not be used with a GLP-1 receptor agonist. The guidelines specifically state that a DPP-IV inhibitor should be discontinued if initiating a GLP-1 receptor agonist.
- Initiation and titration of insulin is very similar to guidance in the American Diabetes Association guidelines. The one difference noticed is “overbasalization” would be considered if the person is injecting >0.7 units per kilogram per day of the basal insulin, whereas >0.5 units per kilogram per day was stated in previous documents.
- This publication is very timely based on cardiovascular evidence that has been published. However, most of these algorithms may have already been implemented to clinical practice but can now be supported by these consensus guidelines.
So, have you read the recent consensus guidelines supported by these two associations? If so, what are your thoughts regarding pharmacologic therapy? Have you implemented these guidelines into practice, or what are your providers saying about these consensus guidelines? Please share your thoughts.
About the Author
Jennifer Clements received her Doctorate of Pharmacy from Campbell University in 2006 and completed a primary care residency at a Veterans Affairs Medical Center in 2007. She is also a certified diabetes educator and board certified in pharmacotherapy. Currently, she is an Associate Professor of Pharmacy Practice at Presbyterian College School of Pharmacy.