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
