Correct Answer: C.
New ADA guidelines recommend the use of GLP-1 inhibitors…
For most type 2 diabetes patients, new guidelines recommend glucagon-like peptide-1 (GLP1) receptor agonists as preferable to insulin as a first injectable agent.
The exceptions, according to an updated consensus statement from the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA), are when T2D patients with extreme and symptomatic hyperglycemia or when type 1 diabetes is suspected.
“In patients who need the greater glucose-lowering effect of an injectable medication, GLP-1 receptor agonists are the preferred choice to insulin,” state the guidelines released at the recent EASD annual meeting. The consensus paper also was co-published in Diabetologia, the journal of EASD, and Diabetes Care, the journal of the ADA.
“Patients often prefer combinations of oral medications to injectable medications,” the guideline panel writes. “The range of combinations available with current oral medications allows many people to reach glycemic targets safely. However, there is currently no evidence that any single medication or combination has durable effects and, for many patients, injectable medications become necessary within 5–10 years of diabetes diagnosis. Evidence from trials comparing GLP-1 receptor agonists and insulin (basal, premixed or basal-bolus) shows similar or even better efficacy in HbA1c reduction.”
One reason for the recommendation, according to the report, is that GLP-1 receptor agonists have a lower risk of hypoglycemia and have been linked to body weight reductions, as opposed to the common weight gain occurring with insulin use. The guidelines also point out that patients have the options of once-weekly GLP-1 receptor agonist injections vs. the daily or more shots required with insulin.
“Based on these considerations, a GLP-1 receptor agonist is the preferred option in a patient with a definite diagnosis of type 2 diabetes who needs injectable therapy,” the guidance notes. “However, the tolerability and high cost of GLP-1 receptor agonists are important limitations to their use.”
The report also emphasizes another key advantage of prescribing GL-1 receptor agonists to T2D patients with co-morbid clinical cardiovascular disease. In those cases, the authors note, “a sodium–glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. Individual agents within these drug classes have been shown to have cardiovascular benefits.”
“The major change from prior consensus reports is based on new evidence that specific sodium–glucose cotransporter-2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists improve cardiovascular outcomes, as well as secondary outcomes such as [heart failure] and progression of renal disease, in patients with established CVD or CKD,” the document explains.
Because of that, the guidelines advise clinicians to evaluate type 2 diabetes patients for atherosclerotic cardiovascular disease, heart failure or chronic kidney disease, which affect as many as a fourth of type 2 diabetes patients.
“New questions arise from the recent cardiovascular outcomes studies,” the panel suggests. “Do the cardiovascular and renal benefits of SGLT2 inhibitors and GLP-1 receptor agonists demonstrated in patients with established CVD extend to lower-risk patients? Is there additive benefit of use of GLP-1 receptor agonists and SGLT2 inhibitors for prevention of cardiovascular and renal events? If so, in what populations? Addressing these and other vital clinical questions will require additional investment in basic, translational, clinical and implementation research."
The review, led by researchers from the UK’s University of Leicester, also included participation from the U.S. National Institute of Diabetes and Digestive and Kidney Diseases and several top universities in the United States. Overall, the new clinical recommendations push the concept that patient preference should be a major factor that drives the choice of type 2 diabetes therapy.
The guidelines, which update a 2015 document, advise that all patients should have access to diabetes self-management education and support, as well as medical nutrition therapy and weight loss programs. The review also promotes physical activity, noting its positive effect on glycemic control.
The guidance addresses metabolic surgery, recommending it as a treatment option for adults with type 2 diabetes and a BMI of 40 or over (or 37.5 or over in people of Asian ancestry) or a BMI of 35.0 to 39.9 (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.
In terms of pharmaceutical treatment, the guidelines state that metformin remains the first-line recommended therapy for almost all patients with type 2 diabetes. As for a second agent, the authors emphasize that the choice should be based on patient preference and clinical characteristics, including presence of cardiovascular disease, heart failure and kidney disease. Other important considerations are the risk for specific adverse medication effects, particularly hypoglycemia and weight gain; as well as safety, tolerability, and cost, they write.
“The management of hyperglycemia in type 2 diabetes has become extraordinarily complex with the number of glucose-lowering medications now available,” the guideline panel concludes. “Patient-centered decision making and support and consistent efforts to improve diet and exercise remain the foundation of all glycemic management. Initial use of metformin, followed by addition of glucose-lowering medications based on patient comorbidities and concerns is recommended as we await answers to the many questions that remain."
