Sunday, October 14, 2018

New ADA-EASD guidelines on type 2 diabetes highlight patient-centered care

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have highlighted “patient-centered care” that accounts for each individual’s health history and status, weight, costs of care and preferences, in a new consensus report on the management of type 2 diabetes.

A “decision cycle” representing a continuum of care for adults with type 2 diabetes throughout their lifetime has been described towards this end. The goals of care, to prevent complications and optimize quality of life, are at the core of this decision cycle.

The steps in the decision cycle are:

1.    Assess key patient characteristics
2.    Consider specific factors that impact choice of treatment
3.    Shared decision-making to create a management plan
4.    Agree on a management plan
5.    Implement management plan
6.    Ongoing monitoring and support including mental health, medication tolerance and adherence, monitoring of blood glucose, weight, nutrition, physical fitness and exercise, and smoking cessation counseling
7.    Review and agree on management plan

Then returning to step 1 and going through the full cycle at least twice each year, and as needed throughout each patient’s life.

The patient remains at the center, and the intensification, deintensification or shift in the diabetes care plan should take into consideration the life and circumstances of the patients. The target A1c is ≤7%.

The stepwise addition of antidiabetic drugs is generally preferred to initial combination therapy. When more than two medications are needed to maintain glycemic target, the impact of medication side effects on comorbidities, as well as the burden of treatment and cost should be taken into consideration. Access, treatment cost and insurance coverage should all be considered when selecting glucose-lowering medications.

Some key recommendations include:

·         All patients should be offered access to ongoing Diabetes self-management education and support (DSMES) programs to help them cope with the daily challenges of living with diabetes and promote treatment adherence.
·         Metformin is the preferred first-line agent for most patients.
·         For patients with type 2 diabetes who have established ASCVD, SGLT2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefit are recommended.
·         Patients with ASCVD in whom HF coexists or is of special concern, SGLT2 inhibitors are recommended.
·         A SGLT2 inhibitor should be considered for patients with chronic kidney disease.
·         GLP-1 receptor agonists are now recommended as the first injectable medication prior to insulin for most patients, who need the greater blood glucose-lowering of an injectable medication.
·         An individualized program of MNT 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 and increasing physical activity.
·         Metabolic surgery is a recommended treatment option for adults with type 2 diabetes and (1) a BMI ≥ 40.0 kg/m2 (BMI ≥ 37.5 kg/m2 in people of Asian ancestry) or (2) a BMI of 35.0–39.9 kg/m2 (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.

(Source: Diabetologia, ADA Press Release)

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

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