Standard of Care for Type 2 Diabetes


Key opinion leaders review the recent ADA standards of care for type 2 diabetes.

Dennis Bruemmer, MD, PhD: How about at Duke University? How do you see this being implemented in the broader North Carolina area?

Jennifer B. Green, MD: It sounds like you essentially have the gold standard to which we should all aspire. We need to expand our multidisciplinary clinic availability. The other place we’re trying to effectively change care in the highest-risk patients is in the hospital, and to make sure that we’ve had patients on the cardiology service who have diabetes at least touched by or had their care reviewed at least briefly by our diabetes inpatient team. The diabetes team is primarily serving as a resource in that situation when cardiologists want to add an SGLT2 inhibitor or a GLP-1 receptor agonist, and looking to see if anything else might need to be altered with respect to the patient’s background or usual care for those drugs that improve cardiovascular and kidney outcomes to be implemented as safely as possible. The overarching goal needs to be ownership, that we’re all responsible for the outcomes of our patients irrespective of what body part or discipline. We’re officially caring for the person as a whole, and looking to see if there’s an opportunity to improve that person’s overall care and outcomes. We all share in that responsibility to address it, but communication is key.

I’m involved with an implementation trial geared at helping cardiologists feel more comfortable in use of what we’ve traditionally described as diabetes drugs for nonglycemic reasons. One of the things that I’ve learned from working on this study is that some cardiologists worry that if they start prescribing 1 diabetes drug that the diabetes care doctor is going to be angry and then tell them, “You’re in charge of all of the diabetes now.” It’s not something that I would have expected, but I’ve heard this repeatedly from cardiology practices in the community. We all need to get together and make sure we’re working together and that this isn’t a hot potato issue that gets tossed around between various providers and is never effectively incorporated into the care of the high-risk patient.

This is a good time to briefly review what’s happened with the recent ADA [American Diabetes Association] standards of care and the corresponding and similar guidelines issued by cardiologic societies. I wish I could show on the screen the ADA algorithm for choices of pharmacologic therapy. You’ll just have to envision it as I talk about it. There have been some recent important developments, but there’s so much fine print in these algorithms that it’s easy for it all to get lost in the shuffle. But if you think about that big colorful algorithm guideline, you can see that in general, metformin remains the recommended initial therapy for patients diagnosed with type 2 diabetes, but that doesn’t have to be the first choice for everyone.

The next step in care is to determine your individual patient’s risk for cardiovascular or kidney complications. If you have a patient with diabetes who’s at low risk for these complications, which probably applies to an ever-shrinking percentage of people with type 2 diabetes, then care focuses on things like concerns about weight, hypoglycemia risk, or costs. Those are of greatest importance. But then when you go down the left-hand side of that algorithm, if you have the patient at high risk or who has established cardiovascular or kidney complications, there are very well-defined pathways and choices for those patients.

What really changed in 2021 is that we steer patients toward the use of SGLT2 inhibitors and/or GLP-1 receptor agonists as most appropriate irrespective of whether they’re already taking metformin or need additional glucose lowering, because it’s very clear from the outcomes trials that the benefits that we see with use of those classes of drugs aren’t mediated through glucose lowering and have no relationship to whether a person is taking metformin. For example, as you have mentioned, many patients on the cardiology service are people who are admitted with an MI [myocardial infarction], have diabetes, and may be diagnosed with diabetes during that hospitalization. In that case, that person might not necessarily need or benefit most from starting metformin as their first therapy for diabetes. They can head right toward the SGLT2 inhibitor or GLP-1 receptor agonist pathway if they only need 1 medication. Then you can benefit from this vast array of improvement in cardiovascular, kidney, and metabolic outcomes as well. That’s 1 big change in the ADA guidelines for this year that I fear might be very easily overlooked.

Dennis Bruemmer, MD, PhD: Yes. You mentioned an interesting point. If you look at European guidelines from the European Society of Cardiology, here now the cardiologist has made recommendations for patients with diabetes fairly early on. Their guideline recommendations did catch on much quicker. Their guidelines clearly say for atherosclerotic cardiovascular disease and type 2 diabetes in a drug naive patient to start an SGLT2 inhibitor or GLP-1 receptor agonist, and then consider metformin if additional glycemic control is required. They’ve already switched to what I’d consider a good direction because of the quite powerful cardiovascular event reduction seen in the studies with these medications as opposed to metformin, which has some mild data from UKPDS [United Kingdom Prospective Diabetes Study]. But oftentimes, patients will need combination therapy, and it’s quite easy to agree that if patients need more medications, an ideal combination seems to be metformin plus an SGLT2 inhibitor or the GLP-1 receptor agonists. That would be what I’d consider an ideal combination.

Jennifer B. Green, MD: I agree. Metformin is a good medication. We have obviously been using it for decades. And as you mentioned, there’s a bit of an outcomes benefit in the UKPDS, but it took 20 years of follow-up for that to become evident. It’s a great drug, but you won’t see the kind of risk reduction within the time frames of the newer classes of drugs that have been studied.

Thank you, Dr Bruemmer. And I’d like to thank everyone for watching this HCPLive® Peers & Perspectives. If you enjoyed the content, please subscribe to the e-newsletters to receive upcoming Peers & Perspectives and other great content right in your inbox. Thank you very much.

Transcript edited for clarity.

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