ADA 2018: Critical Changes in the New ADA Guidelines for Type 2 Diabetes

Well, the current guidelines are still mainly based on glycemic targets, so if the patients have not achieved their glycemic target based on hemoglobin A1C after metformin, a second agent is added to that drug. Now, the decision point is based on whether there is any cardiovascular disease, and the last iteration of the guidelines that was published in January 2018 clearly states that if somebody has cardiovascular disease, after metformin, the choice of drug should be either a GLP-1 receptor agonist or an SGLT2 inhibitor with the notation that you choose members of those classes that have been demonstrated to reduce cardiovascular risk in large cardiovascular outcome trials. In the situation, which is the majority of patients where there is no prevalent cardiovascular disease, then any of 6 drugs could be used—the traditional sulfonylureas, thiazolidinedione, a GLP-1 receptor agonist, or a DPP-4 inhibitor, an SGLT2 inhibitor, or basal insulin.

Well, the major changes over the past couple of years has been the incorporation of data from these large cardiovascular outcome trials. When we put together the position statement back in 2012, and then updated in 2015, there really wasn’t a lot of data to base this important decision what to use after metformin, and over the past 2 or 3 years, there have been at least 4 large clinical trials disclosing specific cardiovascular benefits from certain drugs to SGLT2 inhibitors and 2 GLP-1 receptor agonists. So again, over the past 1 to 2 years, there’s been a specific stipulation that, all of the things being equal, if there is cardiovascular disease, drug number two should be chosen from one of those two drug categories.

The American Association of Clinical Endocrinologists has their own guidelines, which are not dissimilar from those of the American Diabetes Association. Tomorrow, here at the American Diabetes Association Scientific Sessions, the new consensus report from the American Diabetes Association as well as the European Association for the Study of Diabetes will be announced, at least in draft form, and we look forward to those recommendations.

Well, in individuals that are older, there is more concern about avoiding hypoglycemia, especially if there is the presence of cardiovascular disease or chronic kidney disease. So a couple of years ago, the American Diabetes Association set forth specific hemoglobin A1C targets for those individuals that are older, and basically, they’re less intensive than individuals who are less than 65.

Well, I think that’s a fluid discussion. The hemoglobin A1C, on average, should be reduced to 7% or slightly less, and I think we’ve always felt that those individuals that are younger, or healthier, have longer life expectancy might benefit from even tighter hemoglobin A1C control down to 6 or even 6.5%. In those individuals that are older, however, particularly if they have multiple comorbidities, if they’re infirm, I think that being a bit more judicious in terms of allowing the hemoglobin A1C to climb above 7 or even above 8% makes a lot of sense.