Management of Type 2 Diabetes Consensus Guidelines (ADA and EASD, 2018)

American Diabetes Association and the European Association for the Study of Diabetes

Reviewed and summarized by Medscape editors

November 01, 2018

Consensus guidelines on the management of type 2 diabetes were released on October 5, 2018, by the American Diabetes Association and the European Association for the Study of Diabetes.[1,2]

Diabetes Self-Management Education and Support Programs

Diabetes self-management education and support programs should be offered to all people with type 2 diabetes.

Medication adherence should be specifically considered when glucose-lowering medications are selected.

Treatment Selection

Providers should consider a history of cardiovascular disease very early in the process of treatment selection. Weight, hypoglycemic risk, treatment cost, and other patient-related factors that may influence treatment selection are also recommended early in the treatment selection process.

Sodium–glucose cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists with proven cardiovascular benefit are recommended as part of glycemic management for patients with type 2 diabetes who have established atherosclerotic cardiovascular disease (ASCVD).

SGLT2 inhibitors are recommended for patients who have atherosclerotic cardiovascular disease and heart failure or who are a special concern.

Consider the use of an SGLT2 inhibitor for patients with type 2 diabetes and chronic kidney disease. If that is contraindicated or not preferred, consider the use of a GLP-1 receptor agonist.

Lifestyle Management

All patients should be offered an individualized medical nutrition therapy program.

Advise all overweight and obese patients with diabetes on the health benefits of weight loss and encourage them to engage in an intensive lifestyle management program that may include food substitution.

Encourage all people with type 2 diabetes to increase physical activity to improve glycemic control.

Metabolic Surgery

Recommend metabolic surgery for adults with type 2 diabetes and a (1) a BMI ≥40.0 kg/m2 (BMI ≥37.5 kg/m2 in people of Asian ancestry) or (2) a BMI of 35.0–39.9 kg/m2 (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.

Medication Selection

Metformin is the preferred initial glucose-lowering medication for most people with type 2 diabetes.

The stepwise addition of glucose-lowering medication is usually preferred to initial combination therapy.

Base the selection of medication added to metformin on patient preference and clinical features. Important clinical features include the presence of established ASCVD and other comorbidities such as heart failure or chronic kidney disease; the risk for specific adverse medication effects, particularly hypoglycemia and weight gain; safety; tolerability; and cost.

Consideration of the impact of medication side effects on comorbidities, as well as the burden of treatment and cost, should be made when intensifying treatment beyond dual therapy to maintain glycemic targets.

GLP-1 receptor agonists are the preferred choice to insulin for patients who need the greater glucose-lowering effect of an injectable medication. Insulin is recommended for patients with extreme and symptomatic hyperglycemia.

Treatment should be intensified with GLP-1 receptor agonists, SGLT2 inhibitors, or prandial insulin for patients who are unable to maintain glycemic targets on basal insulin in combination with oral medications.

For more information, go to Type 2 Diabetes Mellitus.

For more Clinical Practice Guidelines, please go to Guidelines.

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