Treatment of Type 2 Diabetes: From “Guidelines” to “Position Statements” and Back

Abstract

Given the increased prevalence of type 2 diabetes worldwide, most patients are treated by their primary health care team (PHCT). PHCTs need guidance in choosing the best treatment regimen for patients, since the number of glucoselowering agents (GLAs) is rapidly increasing, as is the amount of clinical data regarding these drugs. The American Diabetes Association/European Association for the Study of Diabetes Position Statement emphasizes the importance of personalized treatment and lists drug efficacy, risk of hypoglycemia, effect on weight, side effects, and cost as important parameters to consider when choosing GLAs. The suggested Israeli guidelines refocus earlier international recommendations from 2012 and 2015, based on emerging data from cardiovascular outcome trials as well as what we believe are important issues for patient care (i.e., durability, hypoglycemia risk, and weight gain).We suggest prioritizing glucose-lowering agents (GLAs) according to their effects on the parameters listed above as well as adherence to therapy and cardiovascular (CV) safety. We suggest, in parts of the world where it is economically feasible, treatment with second-line therapy drugs that have a decreased side effect profile, do not cause hypoglycemia or weight gain, and have established CV safety. Using these presumably "safer" drugs allows us to strive for tighter glucose control. The three groups of GLAs that meet these criteria are dipeptidyl peptidase (DPP)-4 inhibitors, glucagon-like peptide 1 receptor agonists (GLP-1 RAs), and sodium-glucose cotransporter (SGLT) 2 inhibitors. For patients with an HbA 1c .7.5% at diagnosis, initial combination therapy should be considered, and for those with symptomatic hyperglycemia or HbA 1c .9%, initial (possibly short-term) insulin therapy should be considered. For most patients, we consider BMI the leading reference for choosing between the three groups: DPP-4 inhibitors or SGLT2 inhibitors for BMI ,30 kg/m 2 , GLP-1 RAs or SGLT2 inhibitors for BMI 30-35 kg/m 2 , and GLP-1 RAs for BMI .35 kg/m 2 . Often, combination of two GLAs is not enough to achieve target glucose control; the addition of a third GLA can be determined by different patient characteristics including age, renal function, presence of previous CV disease, etc.

Deintensification in older patients with type 2 diabetes: A systematic review of approaches, rates and outcomes

“…For several decades, clinical practice guidelines for glycaemic control have focused on intensifying therapy to achieve target levels of risk factors, such as reducing HbA1c levels to less than 7.0% . However, it appears this overtreatment or treatment intensification is not harmless or associated with more benefits.…”

“…For several decades, clinical practice guidelines for glycaemic control have focused on intensifying therapy to achieve target levels of risk factors, such as reducing HbA1c levels to less than 7.0%. 44,45 However, it appears this overtreatment or treatment intensification is not harmless or associated with more benefits. A number of RCTs have shown that intensive glycaemic control directed at lower HbA1c targets is associated with only minor cardiovascular benefits, but increased adverse events such as mortality.…”

Role of Ketotifen on metabolic profiles, inflammation and oxidative stress in diabetic rats

“…However, type 2 diabetes is a complex disease for treatment, and there is no specific treatment algorithm that will be appropriate for all patients [17]. Recently, it has been reported that ketotifen as a mast cell stabilizer has a novel medication for obesity and diabetes [14].…”

Short‐term intensive insulin therapy could be the preferred option for new onset Type 2 diabetes mellitus patients with HbA1c > 9%

“…Based on accumulating evidence, an expert group has endorsed the concept of short‐term intensive insulin (STII) therapy as an option for some patients with T2DM at the time of diagnosis . Notably, the latest Israeli guidelines suggest considering immediate, sometimes short‐term, insulin treatment for patients with HbA1c >9% or with symptoms …”

“…5 Notably, the latest Israeli guidelines suggest considering immediate, sometimes short-term, insulin treatment for patients with HbA1c >9% or with symptoms. 6 It has been reported that nearly one-quarter (23%) of newly diagnosed T2DM patients in the US had an HbA1c ≥9.0% prior to initiation of treatment. 7 For such patients, initiating insulin is difficult, although it has been almost 10 years since the ACE/AACE Diabetes Road Map suggested insulin therapy for treatment-naïve patients with high HbA1c.…”