Guideline Essentials: Key Takeaways from the ADA/EASD 2022 Consensus on Hyperglycaemia Management in Type 2 Diabetes

Guidelines presents Guideline Essentials, a new type of summary that: 

• features expert clinician commentary on the guidance
• adds context through comparisons with other guidelines
• makes lengthy guidelines easier to navigate for healthcare professionals.

Overview

Type 2 diabetes is a complex condition that affects millions of people worldwide. Diabetes UK estimates that more than 5 million people live with diabetes in the UK.¹ Of those, around 90% live with type 2 diabetes.¹

Management of type 2 diabetes must encompass not only blood glucose level control, but also consider weight and cardiovascular (CV) risk, as well as any interactions between the condition and its treatments with other comorbidities.

The American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) published its consensus report on management of hyperglycaemia in type 2 diabetes in 2022.² This provided an update to the consensus report published in 2018³ (with a 2019 update published in 2020 with a focus on new data on CV outcomes⁴).

It is important to note that the consensus report recommendations ‘are not generally applicable to individuals with diabetes due to other causes’,² do not cover type 1 or paediatric diabetes, and does not discuss detection or diagnosis.

What Has Been Updated?

• New principles of care, including advice on language choice, as well as treatment behaviours, persistence, and adherence²
• Continuous glucose monitoring (CGM) and blood glucose monitoring (BGM) advice²
• Interventions beyond glycaemic control, including expanded discussion of eating patterns, sleep quality, and newer weight management therapies²
• Pharmacological treatment options for glycaemic control, including:
  • sodium–glucose co-transporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), now covered under a heading of ‘cardiorenal-protective glucose-lowering medications’²
  • inclusion of the 2019 review changes regarding the CV outcome evidence on other pharmacotherapy for glycaemic control.^2,4

Guidance Landscape

In the UK, the primary sources of guidance on the management of type 2 diabetes are NICE and the Scottish Intercollegiate Guidelines Network (SIGN). Other bodies, such as the All Wales Medicines Strategy Group and the Primary Care Diabetes Society, do provide information on pharmacological treatments or more specific patient populations, but do not publish overarching guidance. The current landscape of guidance on type 2 diabetes management is explored in Table 1.

Table 1: Current Guidance on Type 2 Diabetes Management

Guidance produced by SIGN is accredited by NICE⁷ and respected in the UK; however, the latest evidence in the landscape of type 2 diabetes management may not be reflected by advice last updated in 2017. The World Health Organization has also published advice on type 2 diabetes management in primary care (as part of a combined diagnosis and management guideline),⁶ but is less comprehensive than NICE or ADA/EASD.

As such, this Guideline Essentials article will focus on the ADA/EASD consensus report, and will use the NICE guideline as the primary comparator.

In an expert commentary, Dr Kevin Fernando assesses the significance of the guidance for the primary care management of type 2 diabetes.

Please refer to the full guideline for the complete recommendations.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

General Principles of Care

The consensus report leads with comprehensive advice about how to structure and conduct holistic care for patients with type 2 diabetes. This includes a new section, entitled ‘Language matters’, which specifically recommends factual, nonstigmatising, neutral language to ensure a respectful, collaborative conversation with patients that does not imply blame for their condition.²

Self-Management

• The report recommends that diabetes self-management education and support (DSMES) programmes are considered to be as important as pharmacological management²
• A patient education approach is also endorsed by NICE.⁵ Both NICE and ADA/EASD recommend ongoing structured education, provided by trained educators, that is tailored to the individual patient’s needs and circumstances—particularly on comorbidities^2,5
• The consensus report explores the key components of DSMES in its first supplementary table;² NICE and the consensus report largely concur on the necessary components of diabetes education, but ADA/EASD often goes into more depth (see Table 2).

Table 2: Comparison of NICE Guidance on Structured Education Versus ADA/EASD Consensus Advice

Personalised Healthcare

• Type 2 diabetes varies significantly between individuals with different symptom profiles, degrees of insulin resistance, comorbidities, complications, age of onset, and personal circumstances²
• The consensus report emphasises the need for person-centred care to account for individual context, risks, and preferences.² Particular mention is made of shared decision making and social determinants of health
• The report also states that ‘providers should evaluate the impact of any suggested intervention in the context of cognitive impairment, limited literacy, distinct cultural beliefs and individual fears or health concerns.’²

Shared Decision Making

• Patients should be empowered to guide their own treatment plan, and fully informed of the risks and benefits of the options presented to them, as well as any contextual benefits (for example, effects on comorbid cardiovascular disease [CVD], heart failure [HF], or chronic kidney disease [CKD]).²

Social Determinants of Health

• The report recommends assessing and addressing social determinants of health (specifically, socioeconomic status, living and working conditions, multisector domains, sociocultural context, and socio-political context) to achieve health equity.²

Glucose Monitoring

• Glycaemic control is typically monitored by glycated haemoglobin (HbA_1c) testing. However, discrepancies between HbA_1c levels and any measured or reported glucose levels from other monitoring methods should prompt consideration of factors that may causing unreliability in HbA_1c or glucose measurements
  • this may include ethnicity, anaemia, end-stage kidney disease, or pregnancy²
• Individualised BGM plans can support self-management and inform dosage of insulin; reviewing self-monitoring data during visits to the practice can reinforce their value in achieving health objectives
• The report does advise that in people with type 2 diabetes not using insulin, routine monitoring may not be as effective
  • however, some individuals may find that such monitoring gives useful insight into the impact of interventions on their blood glucose and symptoms.²

Continuous Glucose Monitoring

• Additional information provided by CGM may be useful, particularly in those taking insulin²
• Standardised, single-page glucose reports can be uploaded from CGM devices. These reports can serve as standard metrics for all CGM devices, and offer healthcare professionals opportunities to review management strategies²
  • they can be used to measure ‘time in range’, defined as the percentage of time that CGM readings are between 3.9 and 10.0 mmol/l (70–180 mg/dl), which is associated with microvascular complications
  • time above and below this range can also be useful to evaluate treatment regimens; minimising the time below range may offer benefit for those unaware when they become hypoglycaemic
• The ambulatory glucose profile⁹ is the only named example of a glucose report in the ADA/EASD recommendations. For this profile, it recommends:²
  • a time in range of over 70% for an HbA1c target of <53 mmol/mol (<7%)
  • a time below range of <4% and less than 1% of time should be spent below a threshold of 3.0 mmol/l (<54 mg/dl).

Treatment Behaviours

• Low rates of adherence, or ‘suboptimal medication-taking behaviour’, can significantly reduce glycaemic and CVD risk factor control²
• The report recommends focusing on ways to facilitate adherence, including social, family, and provider support. Perceived lack of medication efficacy, concerns about hypoglycaemia, and issues with accessibility of medication should be addressed and compensated for when possible²
• When clinical characteristics indicate an intervention based on available evidence, individual preferences may make the choice unsuitable; for example, preferences about route of administration or concerns about side effects²
• The behaviour of physicians is also important to avoid therapeutic inertia. When warranted, treatment should be intensified to meet the goals of therapy, or de-intensified when people are overtreated. Re-evaluate adherence, treatment effectiveness, and side effects at every clinical visit.²

Management of Type 2 Diabetes

Nonpharmacological Management

Nutrition Therapy

• The goal of nutrition in type 2 diabetes should be to promote healthy eating while incorporating individual needs and maintaining enjoyment when eating, including offering support tools²
• Medical nutrition therapy (MNT) provided by a qualified dietitian can, in combination with DSMES, prevent and ameliorate comorbidities²
• No single diet is perfect for every person with type 2 diabetes; selected eating patterns should emphasise food with demonstrable benefit and minimise foods shown to be harmful. Accommodate individual preferences where possible to improve the chances of achieving a sustainable diet²
• Nutrition and energy restriction also play an important role in weight loss (see Weight Management) and, in conjunction with medication and/or surgery, can be considered in order to support glycaemic objectives.²

Physical Health

• Adults with type 2 diabetes should reduce the amount of time they spend sitting or not moving. Every week, this should include:²
  • regular aerobic exercise (more than 150 minutes of moderate-to-vigorous intensity)
  • supplementation with two to three resistance, flexibility, and/or balance training sessions per week (balance training is particularly relevant in older adults or individuals with limited mobility)
• Beneficial effects of exercise extend beyond glycaemic control, and include reduced CV morbidity and all-cause mortality.

Sleep

• Promoting sleep hygiene is an important step in managing type 2 diabetes
• Assess and address comorbid sleep disorders to reduce the impact on sleep quality and quantity
  • obstructive sleep apnoea (OSA) is particularly common in type 2 diabetes, and severity of OSA is associated with impaired blood glucose levels
• Advise patients of the association between time spent sleeping and health outcomes, aiming to sleep neither more nor less than 6–8 hours, and that additional sleep at the weekend does not adequately compensate for lack of sleep.

Weight Management

• Weight reduction helps control HbA_1c and reduces the risk of complications. Although an important factor in glycaemic control, the potential benefits are not limited to diabetes. Risk factors for cardiometabolic disease and quality of life may also be improved by weight loss²
• Type 2 diabetes can be influenced by diet and eating patterns, and this is explored below under Nonpharmacological Management. For weight loss in the context of diet, the report highlights the importance of ‘a net energy deficit that can be maintained’²
• Weight loss of 5–10% can lead to metabolic improvement, and more weight loss (10–15% or more) increases the benefit. It may also lead to remission²
• This aligns with national recommendations for an initial target of 5–10% weight loss for adults with type 2 diabetes who are overweight.⁵

Weight-Loss Medications

• When used alongside lifestyle interventions and healthy weight-management behaviours, medications for weight loss can be effective in increasing control of type 2 diabetes
• Some newer treatments are highly effective for weight management in people with type 2 diabetes, including semaglutide and tirzepatide
  • tirzepatide is not currently approved for weight management in any country¹⁰
• Note that evidence suggests that withdrawing semaglutide treatment results in increased body weight, and that it is essential to acknowledge the chronic nature of weight management.²

Metabolic Surgery

• The consensus report suggests that metabolic surgery can be considered where adults with type 2 diabetes are ‘appropriate candidates’ and:
  • BMI ≥40.0 kg/m² (BMI ≥37.5 kg/m² if Asian ancestry), or
  • BMI 35.0–39.9 kg/m² (32.5–37.4 kg/m² if Asian ancestry) and non-surgical treatment has not achieved durable weight loss or improvement in comorbidities or hyperglycaemia²
• NICE Clinical Guideline 189's recommendations for the criteria for metabolic surgery could guide judgements on appropriate surgical candidates, and include:¹¹
  • a BMI of 40 kg/m² or more, or 35–40 kg/m² and the presence of disease such as type 2 diabetes that could be improved through weight loss
  • no clinically beneficial weight loss has been achieved through nonsurgical measures
  • intensive management in a tier 3 service has been, or will be, provided to the patient
  • there are no clinical concerns about the patient undergoing surgery or anaesthesia
• Metabolic surgery seems to be effective at inducing remission in people whose BMI is greater than or equal to 25 kg/m²
• The longer a patient has been diagnosed with diabetes correlates with reduced likelihood of remission.

Pharmacological Management

The landscape of pharmacological management of diabetes is complex and ever-changing, and influenced by therapeutic priorities, comorbidities, and cost-effectiveness.Competing views on optimal treatment of type 2 diabetes are common. This Guideline Essentials is focused on the views of the ADA/EASD consensus report; for a more comprehensive guide to the differences between ADA/EASD and NICE, consult the Guidelines Primary Care Hack on Comparison of ADA/EASD and NICE recommendations on the pharmacological management of type 2 diabetes in adults.¹²

• The consensus report divides the recommended selection of pharmacological therapy based on whether a patient has a goal to reduce the risk of cardiorenal adverse effects or achieve and maintain glycaemic and weight management goals²
• Whenever possible, reassess and modify treatment every 3–6 months²
• If, after following all of the recommended pharmacological management steps, target HbA_1c has not been maintained, consider:²
  • DSMES referral
  • using technology (for example, CGM) to assess and compensate for gaps in therapy
  • whether any social determinants of health impacting management can be addressed.

Cardiorenal Focus

• Recommendations are further broken down by presenting condition: atherosclerotic cardiovascular disease (ASCVD) or indicators of high CV risk, HF, or CKD²
• Decisions to use appropriate SGLT-2is or GLP-1 RAs in these populations to alleviate cardiorenal risk should not alter any ongoing treatment with metformin for glycaemic control²
• In the presence of confirmed comorbid ASCVD, HF, or CKD, treatment will likely be guided by secondary care.

High CV Risk 

• SGLT-2is and GLP-1 RAs with proven CVD benefit are recommended when indicators of high CV risk are present²
  • at the time of writing, this included canagliflozin and empagliflozin (SGLT-2is) and dulaglutide, liraglutide, or subcutaneous semaglutide (GLP-1 RAs)
• When glycaemic control has not been achieved with monotherapy, an SGLT-2i/GLP-1 RA (whichever was not already prescribed) or a thiazolidinedione (TZD) are recommended
• Indicators of high CV risk include advancing age (≥55 years of age) in combination with two or more additional risk factors, such as:²
  • obesity
  • smoking
  • hypertension
  • albuminuria
  • dyslipidaemia.

Glycaemic and Weight Management Focus

Glycaemic Control

• Offer metformin, or other agents including combination therapy that are sufficiently effective to achieve and maintain treatment goals²
• It is a priority to avoid hypoglycaemia in individuals at high risk of hypoglycaemia²
• See Table 3 for comparative effectiveness of glucose-lowering agents for glycaemic control and weight loss.²

^{Weight management}

• Set individualised weight-management goals and refer to the sections on Nonpharmacological Management and Weight Management for a strategy to achieve them²
• Consider a regimen of pharmacotherapy that has high efficacy in both glycaemic control and weight loss²
• See Table 3 for comparative effectiveness of glucose-lowering agents for glycaemic control and weight loss.²

Table 3: Comparative Effectiveness of Glucose-Lowering Agents for Glycaemic Control and Weight Loss²

Medication-Specific Considerations

In addition to the effects and priorities described above, it is important to consider other factors that may influence therapeutic choice.

SGLT-2is

• Associated with improvements in renal adverse events with comorbid CKD and type 2 diabetes, as well as improved recovery from acute kidney injury²
• At lower eGFR, the efficacy of SGLT-2is at glycaemic control is reduced²
• May increase the risk of diabetic ketoacidosis (DKA)²
• The risk of DKA can be mitigated by:²
  • educating patients on indicators of DKA that should necessitate consulting a healthcare professional
  • temporarily withdrawing SGLT-2is when the risk of DKA is increased by circumstance (such as during fasting, acute illness, or in preparation for surgery).

GLP-1 RAs

• Recommended as a consideration prior to initiating insulin²
• Associated with increased risk of gallbladder and biliary diseases²
• Rapid decrease in HbA_1c from GLP-1 RAs may increase retinopathy complications if the patient already experiences diabetic retinopathy and high glycaemic levels²
• Gastrointestinal side effects are the most common, but tend to diminish after initiation or increased dosage; uptitrate dosage gradually to mitigate side effects, with slow or flexible escalation if intolerant²
• Educate patients who are prescribed GLP-1 RAs in order to:²
  • tell the difference between nausea and satiety
  • encourage helpful eating habits (for example, slower eating, knowing when to stop eating)
  • encourage reduction in meal sizes and reduce intake of fatty or spicy food
  • moderate alcohol consumption and encourage hydration.

Metformin

• Very common first-line monotherapy as a cost-effective treatment with a good safety profile, but other approaches (for example, GLP-1 RAs/SGLT-2is for cardiorenal outcomes) may be considered²
• Should not be used if eGFR is 30 ml/min/1.73 m² or lower²
• Consider reducing dosage if eGFR is 45 ml/min/1.73 m² or lower²
• Monitor and, where appropriate, supplement vitamin B12 levels—particularly if the patient has anaemia or neuropathy.²

Dipeptidyl peptidase-4 Inhibitors (DPP-4is)

• Rare reports of arthralgia and hypersensitivity²
• Increased risk of hypertensive heart failure has been found with saxagliptin²
• Tolerability is generally high and has a neutral effect on CV risk, so are suitable for specific populations and considerations.²

Sulfonylureas

• Associated with increased risk of hypoglycaemia and weight gain²
• Evidence suggests that reduced risk of microvascular complications is associated with use of sulfonylureas; some concerns exist regarding adverse CV outcomes, but all-cause mortality does not appear increased compared with other treatments.²

TZDs

• Pioglitazone associated with benefits in nonalcoholic fatty liver disease and nonalcoholic steatohepatitis²
• Possible side effects include weight gain, fluid retention, bone fracture, and congestive HF.²

Insulin

• When starting insulin, metformin and other therapies being used for their protective benefits should be maintained²
• Lowers glucose in a controllable way based on dose, useful for achieving most blood glucose targets²
• Effectiveness and safety are particularly dependent on patients self-managing properly, so it is particularly important that patients are well informed²
  • for example, on self-monitoring, diet, injection technique, self-titrating of dose, and how to prevent and respond to hypoglycaemia
  • this is a good opportunity to refer for DSMES.
• Insulin therapies vary widely; tailor choices of insulin dose and timing to the individual’s requirements²
• Can lead to weight gain.²

Combination therapy with a GLP-1 RA and insulin

• Compensates in part for the risk of weight gain and hypoglycaemia from higher-dose insulin²
• Better tolerated than GLP-1 RA alone.²

Population-Specific Considerations

As diabetes depends on treating each individual according to their specific needs and circumstances, many factors (including age, gender, and comorbidities) should influence therapeutic choices.

Older Age

• Type 2 diabetes is associated with similar issues to those experienced in older age, particularly frailty and reduced physical capacity, which negatively affects patients’ quality of life and increases demand for healthcare resources²
• It is worth considering recommending withdrawing or lowering the dose of medications to account for reduced benefit from therapies and heightened risks of hypotension or hypoglycaemia.²

^{Areas Requiring Further Evidence}

Type 2 diabetes management is an ever-changing field, and the report acknowledges that several points are in need of further study and in-depth evidence to better understand the exact therapeutic approach to take:²

• more study attention on subgroups, especially vulnerable populations
• direct comparisons between goals focused on weight versus glycaemic management
• further differentiation of data to help select for GLP-1 RA or SGLT-2i in patients with type 2 diabetes and CVD with no HF/CKD
• role and use of CGM
• comorbidities and their effect on treatment, for example, NAFLD and cognitive impairment
• screening (for diabetes, complications, and comorbidities)
• optimal application of new, readily-available technology
• sleep and chronotype.

Expert Commentary on the Guidance

Dr Kevin Fernando
GP Partner, North Berwick and Content Advisor for Medscape Global and UK

The updated ADA/EASD 2022 consensus report is a welcome addition to our expanding international suite of type 2 diabetes guidance for primary and secondary care.

This consensus report places weight management on an equal footing with glycaemic control in the management algorithm. Moreover, the consensus report explicitly states that weight loss of 5–10% can lead to metabolic improvement, and that weight loss of more than 10–15% may lead to remission of type 2 diabetes. Recent, seminal type 2 diabetes remission data have given people living with type 2 diabetes hope that their condition is potentially reversible, and will not inexorably progress to requiring insulin.

More detailed recommendations are provided on lifestyle interventions and healthy behaviours, with a beautifully holistic central figure outlining the importance of 24-hour physical behaviours or the ‘5 Ss’ for type 2 diabetes. We are reminded of the positive cardiometabolic consequences of breaking up prolonged Sitting, moderate to vigorous activity (Sweating), Strengthening exercises, increasing daily Step count and, in an unprecedented recommendation for people living with type 2 diabetes, the significance of good-quality and an adequate quantity of Sleep.

Additionally, the phrase ‘organ protection’ has been introduced with reference to SGLT-2i and GLP-1 RAs, with an overarching management goal of cardiorenal risk reduction in high-risk patients living with type 2 diabetes (for example, those with established ASCVD, HF, or CKD) rather than the gluco-centric approach many previous guidelines and consensus reports have advocated.

SGLT-2is and GLP-1 RAs should be used in individuals at high risk of cardiorenal disease independent of glycaemic control (for instance, even if Hba_1c is within target range) or metformin use. This has workload implications for primary care; however, the compelling and high-quality evidence base for their use supports this approach—these are therapies that can help to narrow the mortality gap in people living with type 2 diabetes compared with the general population.

Notably, initial combination therapy with glucose-lowering agents is recommended in those with high HbA_1c at diagnosis (more than 70 mmol/mol), in younger people living with type 2 diabetes irrespective of their HbA_1c (reflecting their lifetime cardiorenal risk), and in individuals in whom a stepwise approach to glucose-lowering would delay access to cardiorenal protective therapies. Equally importantly, we are reminded to consider deintensification of therapy in frail older adults, especially in those on other antidiabetic agents that may lead to hypoglycaemia, and in people whose HbA_1c is well below target range.

Finally, this updated consensus report reiterates that health technology can be useful to people living with type 2 diabetes, but needs to be part of a holistic management plan supported by self-management education. The consensus report boldly suggests that we consider CGM in all people living with type 2 diabetes on insulin. There are significant cost implications to this approach within the UK, and this strategy will also require further investment in education for both people living with type 2 diabetes and healthcare professionals. However, in my opinion, there is no question about the value CGM can add to the management of type 2 diabetes, as an educational tool and to improve quality of life in people living with type 2 diabetes by helping to prevent hypoglycaemia.

In summary, this updated consensus report ushers in a new era of type 2 diabetes management; we need to think beyond glycaemia, and explore the presence of significant comorbidities such as ASCVD, HF, CKD, and frailty when intensifying or deintensifying therapies. Lifestyle modification remains pivotal to the ongoing successful management of type 2 diabetes, and weight management should be given equal priority to glucose management for all people living with the condition.

Useful Resources

• Davies M, Aroda V, Collins B et al. Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2022; 65: 1925–1966.
• Davies M, D’Alessio D, Fradkin J et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2018; 61: 2461–2498.
• Buse J, Wexler D, Tsapas A et al. 2019 update to: Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2020; 63: 221–228.