Experts Javier Morales, MD, and Dhiren Patel, PharmD, CDE, BC-ADM, BCACP, outline the American Diabetes Association and American Association of Clinical Endocrinologists guidelines that aid in managing type 2 diabetes and reflect on recommended goals and therapeutic sequencing.
Javier Morales, MD: We have 2 large agencies that are respected worldwide: the American Diabetes Association and the American Association of Clinical Endocrinologists. They both established recommendations in terms of which agents to use for the management of type 2 diabetes. The American Diabetes Association guidelines list all of these agents not in a numerical or stepwise fashion but, rather, as a straight line. Each of these agents has its individual attributes. Some of them actually increase the risk of having hypoglycemic events, whereas others don’t. Some may actually lead to an increase in the risk of weight gain, and others may not.
The American Association of Clinical Endocrinologists guidelines, however, list their therapeutic choices on the basis of safety and efficacy. They’re actually listed in a stepwise fashion. At the top of the list, if you look at add-on therapy to metformin, they advocate the use of a GLP-1 receptor agonist. Next in line would be the urinary SGLT2 inhibitors, followed by the DPP-4 inhibitors, and so on and so forth, following suit.
Now, there’s oftentimes much confusion in the practice of medicine. Not only are there guidelines for practitioners to follow when it comes to managing diabetes, but we also have lipid guidelines and hypertension guidelines. It becomes really, really difficult to follow these ascribed guidelines. But nonetheless, I think the choices regarding which agents to institute are solely based on multiple factors that include individualization of therapy. But in addition to that, we have to take into consideration ease of administration and the financial burden that could be imparted on the patient with respect to their selection.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Both the ADA and the AACE guidelines recommend certain steps for tight glycemic control. One of those steps in both guidelines after first-line therapy—which is metformin, supported by both guidelines—is making sure that you intensify treatment in a reasonable amount of time. Most of them define that as a 3-month period. What you don’t want to do is wait months, and years in between advancing therapy, because we know that there’s an impact on the morbidity to mortality standpoint when you achieve tight glycemic control early on. We know that it sometimes takes many years before an advance to new therapy happens. There are a lot of data on early, and tight glycemic control. Specifically, in the guidelines there’s a callout regarding an A1C level greater than 8%, where they specifically mention considering dual therapy. A1C levels greater than 9% also support the use of starting insulin right way if the patient has been uncontrolled and is symptomatic.