Announcement of the 2022 ADA/EASD: Consensus on the Management of Hyperglycemia in Type 2 Diabetes (Draft), Compared with the old version, the new version of the consensus has obvious adjustments in the following four aspects.
Update point one: officially list “weight loss” One of the goals of type 2 diabetes management
Type 2 diabetes is closely related to obesity, and by 2030, it is estimated that there will be 1 billion People suffer from obesity. The new version of the consensus (draft) improves the status of weight loss in the management of type 2 diabetes, and forms a comprehensive management strategy for type 2 diabetes together with hypoglycemic, cardio-renal protection (related medication), and cardiovascular risk factor management, pointing out:
➤ Weight loss should be considered as a treatment strategy to improve glycemic control and reduce the risk of weight-related complications;
➤Recent evidence suggests that for some patients with type 2 diabetes, weight loss of 5%-15% should be the primary goal of treatment; p>
➤The greater the magnitude of the weight loss, the greater the potential benefit: 5%-10% weight loss can improve metabolic status, and weight loss 10%-15% or more can improve disease and even bring about remission of diabetes;
➤weight loss may Delivers benefits beyond glycemic control, thereby improving cardiometabolic disease risk factors and quality of life.
Figure 1 A person-centered comprehensive management strategy for type 2 diabetes Update 2: New “Drug Recommendation Roadmap”
The “Drug Recommendations for Type 2 Diabetes Management” in the new consensus (draft) The “Road Map” has changed significantly, and according to the characteristics of the patient’s own disease, recommendations are made according to different “treatment goals”:
➤ Treatment goal 1: Type 2 diabetes mellitus with high risk of cardio-renal disease, with the goal of “reducing the risk of adverse cardio-renal events”;
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➤Treatment goal 2: Two people with type 2 diabetes with the goal of “lowering/maintaining blood sugar and body weight”.
Figure 2 Recommended route for type 2 diabetes management drugs < 1. For patients with type 2 diabetes and "ASCVD or with multiple risk factors" The new consensus (draft) recommendation:
➤GLP-1RA and SGLT2i can reduce MACE and improve other cardio-renal outcomes in patients with established ASCVD;
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➤ In patients with established ASCVD, the proven beneficial GLP-1RA should be used to reduce MACE, or the proven beneficial SGLT2i should be used to reduce MACE, HF and Improved renal outcomes;
➤In people with undiagnosed ASCVD but multiple CV risk factors, including age, Such as age ≥55 years, obesity, hypertension, smoking, dyslipidemia or proteinuria) GLP-1RA may reduce MACE, SGLT2i may reduce MACE, heart failure and improve renal prognosis;
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➤ In people with undiagnosed ASCVD but multiple CV risk factors, the proven beneficial GLP-1RA can be used to reduce MACE, and the proven beneficial SGLT2i can be used to reduce MACE Reduced MACE, heart failure and improved renal outcomes;
➤in heart failure, CKD, established CVD or concomitant In a population with multiple risk factors for CVD, both SGLT2i and GLP-1RA had favorable effects on cardiorenal outcomes regardless of metformin use. Therefore, in these patients, the decision to use GLP-1RA or SGLT2i with proven benefit should be independent of metformin use;
➤SGLT2i and GLP-1RA reduce MACE likely independent of baseline HbA1c. For patients with heart failure, CKD, established CVD, or multiple risk factors for CVD, the decision to use a proven beneficial GLP-1RA or SGLT2i should be independent of baseline HbA1c.
2. For patients with type 2 diabetes and “heart failure”< span> New consensus (draft) recommendation:
➤ For patients with concomitant heart failure, SGLT2i should be used because it can improve heart failure and renal outcomes .
3. For patients with type 2 diabetes and “CKD” The new version of the consensus (draft) recommends:
➤ In patients with CKD, SGLT-2i and GLP-1RA reduce the risk of MACE The benefit is independent of eGFR.
➤ SGLT2i also reduces HF and adverse renal outcomes (including end-stage renal disease) in patients with CKD disease) risk.
➤ In patients with CKD and eGFR ≥ 20ml/min/1.73 m^2, a proven benefit should be initiated SGLT2i to reduce the risk of MACE, HF and renal outcomes.
➤ If treatment is not tolerated or contraindicated, GLP- 1RA.
Update Point 3: Add a new class of drugs—GIP/GLP-1 dual Agonists
The new consensus (draft) adds a new class of drugs—GIP/GLP-1 dual receptor agonist, the specific drug involved is Tirzepatide, The hypoglycemic mechanism and drug action characteristics are as follows:
➤Mechanism of hypoglycemic action: dependent on glucose enhances insulin secretion in the first and second phases and reduces glucagon levels;
➤Clinical Efficacy Overview: Very High Efficacy for Hypoglycemia; Low Risk for Hypoglycemia; Weight Loss Effect is “highly effective”; cardiorenal effects unknown (trial ongoing).
The new consensus (draft) also describes other drugs: Metformin:< /strong>Traditionally recommended as first-line hypoglycemic therapy for type 2 diabetes because of its significant efficacy in lowering glycated hemoglobin, minimal hypoglycemia risk as monotherapy, potential for moderate weight loss, and safety Good sex and low cost. Sulfonylureas: “highly effective”, inexpensive, and readily available; Choose a sulfonylurea with a lower risk of hypoglycemia; there was no difference in the incidence of MACE in high CV risk populations treated with glimepiride or linagliptin. thiazolidinediones: the hypoglycemic effect is “highly effective”, and the hypoglycemic effect is lasting; beneficial effects; adverse effects (eg, weight gain, fluid retention) can be reduced by optimizing dosing strategies (eg, using lower doses) and combination therapy with other drugs that promote weight loss and sodium excretion (SGLT-2i, GLP-1RA) . DPP-4i: “moderate” hypoglycemic effect, no effect on body weight, generally well tolerated , the risk of hypoglycemia is minimal; early combination therapy with metformin and DPP-4i (vildagliptin) can prolong the duration of blood glucose management compared with stepwise treatment; proven cardiovascular safety is good. SGLT-2i: “moderate to highly effective” hypoglycemic effect, decreasing at lower eGFR, Low risk of hypoglycemia, ‘moderate’ weight loss effect; demonstrated cardiorenal protection in trial population [reduction in major adverse cardiovascular events; reduction in overall CV deaths (heterogeneity among drugs in class); reduction in risk of heart failure hospitalization ; reduced risk of adverse renal outcomes] GLP-1RA: glycemic effect ‘high to very high’, low Low glycemic risk, “moderate to high” weight loss; cardiorenal protection with evidence of major adverse cardiovascular events, CV death, fatal or non-fatal myocardial infarction, fatal or non-fatal stroke, all-cause mortality , Reduced complex renal outcomes due to massive proteinuria. Insulin: lowers blood sugar in a dose-dependent manner and can address any level of blood sugar; hypoglycemic effect” High to very high” with risk of hypoglycemia and weight gain; neutral cardio-renal effects; efficacy and safety largely dependent on patient education and support for self-management; emphasis on matching insulin to physiological needs importance.
Update 4: Emphasis on “24 hours a day” behavior management p> Consensus (draft) points out that good physical behavior can have a healthy impact on cardiometabolism. Table 1 Effects of physical behavior on cardiometabolic health in patients with type 2 diabetes < span>1. Reduce sedentary time, exercise once every 30 minutes Reduce sedentary time, it is recommended to exercise once every 30 minutes, with regular Short brisk walks/simple resistance exercise can improve glucose metabolism. 2. Make your body sweat (moderate toVigorous activity)
➤ Moderate-intensity exercise: ≥150 minutes of moderate-intensity exercise per week is recommended, and large muscles should be exercised group and rhythmic;
➤ High-intensity exercise: or ≥75 minutes of high-intensity exercise per week, 3 days a week, with an interval of no more than 2 days between exercises ;
➤Other training: Resistance, flexibility and/or balance training is recommended, two to three times per week;
➤ 30 minutes of moderate-intensity exercise per week can improve metabolic control. 3. Walking/Brisk walking
➤ An increase of 500 steps per day was associated with a 2%-9% reduction in cardiovascular morbidity and all-cause mortality.
➤ 5-6 minutes of brisk walking a day is equivalent to extending life expectancy by 4 years. 4. Moderately increase strength training strength training Including resistance exercise (including using your own body weight) can improve insulin sensitivity and glucose tolerance: Exercises such as Tai Chi and yoga also develop flexibility and balance. 5. Go to bed early and get up early to maintain regular sleep Maintain consistent, uninterrupted sleep, even on weekends:➤ Too much or too little sleep is bad: both long (>9h) and short (<6h) sleep durations have negative effects on HbA1c . ➤ Quality of sleep is important: Irregular sleep leads to poor glycemic control and may be influenced by the increased prevalence of insomnia, obstructive sleep apnea, and restless legs syndrome in patients with type 2 diabetes. ➤Emphasis on “early to bed and early to rise”: “Early to bed and early to rise” may lead to worse blood sugar control and lack of exercise than “early to bed and early to rise”.