Clinical Practice Guidelines on Pharmacologic Glycemic Treatment in Type 2 Diabetes (ADA, 2020)

American Diabetes Association

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

September 30, 2020

In September 2020, the American Diabetes Association (ADA) published clinical practice guidelines on pharmacologic glycemic treatment in patients with type 2 diabetes mellitus, as an update to the ADA’s Standards of Medical Care in Diabetes.[1,2]

It is preferred that metformin be employed as the initial pharmacologic agent for type 2 diabetes treatment.

To lengthen the time to treatment failure, consideration in some patients can be given to early combination therapy at initiation of treatment.

Consideration should be given to the early introduction of insulin if evidence exists of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when hemoglobin A1c (HbA1c) or blood glucose levels are very high (HbA1c >10% [86 mmol/mol], blood glucose ≥16.7 mmol/L [300 mg/dL]).

Guidance regarding the choice of pharmacologic agents should arise from a patient-centered approach. Cardiovascular comorbid conditions, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences are among the factors that should be taken into consideration.

A sodium-glucose cotransporter-2 (SGLT2) inhibitor or glucagon-like peptide-1 receptor agonist (GLP-1 RA) with demonstrated cardiovascular disease (CVD) benefit is recommended for patients with type 2 diabetes who have established atherosclerotic CVD (ASCVD) or indicators of high risk or who are suffering from established kidney disease or heart failure.

When, in patients with type 2 diabetes, glucose needs to be lowered to a greater extent than can be accomplished with oral agents, the use, when possible, of GLP-1 RAs is preferred to that of insulin.

Reevaluate the patient’s medication regimen and medication-taking behavior at regular intervals (every 3-6 months), adjusting them as needed to incorporate specific factors that affect treatment choice.

An SGLT2 inhibitor is recommended in patients with heart failure of chronic kidney disease (CKD). A GLP-1 RA should be administered in those cases in which an SGLT2 inhibitor cannot be employed.

In deciding which medication to add to metformin, it must first be determined whether the patient has established ASCVD or a high ASCVD risk (patients aged ≥55 years with coronary, carotid, or lower-extremity artery stenosis >50% or left ventricular hypertrophy), heart failure, or established CKD. If one of these characteristics if present, it is recommended that an SGLT2 inhibitor or a GLP-1 RA with demonstrated CVD benefit be used.

It is recommended that insulin therapy be administered to reduce glucotoxicity and lipotoxicity in patients with symptoms from advanced hyperglycemia.

For more information, please go to Type 2 Diabetes Mellitus.

For more Clinical Practice Guidelines, please go to Guidelines.

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