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For Primary Care| Key learning points

Key Learning Points: Type 2 Diabetes—ADA/EASD Updates

Dr Roger Henderson | Disclosures

Dr Roger Henderson Provides Six Key Learning Points from an Updated International Consensus Report on Managing Hyperglycaemia in Type 2 Diabetes

Read This Article to Learn More About:
  • the shift in focus of the ADA/EASD consensus report on the management of hyperglycaemia in type 2 diabetes towards person-centred care
  • appropriate nutrition, 24-hour physical behaviours, and weight-management targets for patients with type 2 diabetes
  • new recommendations on initial combination therapy, sodium–glucose co-transporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, and initiation of insulin therapy.

Key points, implementation actions for integrated care systems, implementation actions for future practice written by Dr Kevin Fernando (GP, North Berwick; Content Advisor, Medscape Global and UK), and implementation actions for clinical pharmacists in general practice can be found at the end of the article. 

Also, see the related Theory in Practice Video—The Updated ADA/EASD Consensus Report with Dr Sarah Davies

Reflect on your learning and download our Reflection Record

Diabetes is a global public health problem. In 2021, it was estimated that 537 million adults were living with diabetes, a number that is predicted to rise to 643 million by 2030 and 783 million by 2045.1 In the UK, nearly 5 million people are living with diabetes, around 90% of whom have type 2 diabetes.2 Approximately 850,000 people with diabetes in the UK remain undiagnosed;2 however, to improve quality of life and reduce the risk of long-term complications, this chronic, complex condition requires comprehensive management, not only with pharmacotherapy, but also with multifactorial behavioural changes.

There are many clinical guidelines relevant to primary care practitioners involved in the care of patients with type 2 diabetes. NICE Guideline (NG) 28, Type 2 diabetes in adults: management,3 was updated in February 2022 with new recommendations on drug treatments, and in March 2022 with recommendations on continuous glucose monitoring (CGM). Other useful guidance includes the Primary Care Diabetes Europe (PCDE) position statement on the pharmacological management of type 2 diabetes in primary care,4 which was updated in 2022, and the Scottish Intercollegiate Guidelines Network (SIGN)’s Management of diabetes (SIGN 116).5 Before NG28 was updated, however, many clinicians in the UK followed the American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) consensus report on the management of hyperglycaemia in type 2 diabetes to ensure that their practice was evidence based and up to date.

In September 2022, the ADA and the EASD published an update to their consensus report,6 which adds to the report published in 20187 and its 2019 update.8 The report addresses approaches to the management of blood glucose levels in nonpregnant adults with type 2 diabetes, and is not applicable to people with type 1 diabetes or to children with diabetes. A key change in the latest ADA/EASD consensus report is an increased focus on person-centred care, weight management, and equity of care.6 Box 1 outlines some of the key areas covered by this update.

Box 1: Key Updates to the ADA/EASD Consensus Report6
  • Updated recommendations: 
    • on the use of glucose- and weight-lowering medications for type 2 diabetes, summarised in an algorithm
    • relating to the cardiorenal benefits, termed ‘organ protection’, of SGLT2is and GLP-1 RAs, alongside an updated summary of cardiorenal outcomes studies and meta-analyses comparing the efficacies of different drug classes
  • New guidance on additional clinical considerations—these include age, family background, ethnicity, sex differences, obesity, and weight-related comorbidities (particularly NAFLD and NASH)
  • More detail on the importance of lifestyle and healthy behavioural choices, particularly nutrition therapy, dietary choices, eating patterns, physical activity, and sleep
  • Consideration of the social determinants of health (notably socioeconomic status, living and working conditions, and multisector domains such as housing, sociocultural context, and sociopolitical context) and how they impact treatment for individuals living with type 2 diabetes, with particular emphasis on health systems ensuring equity in the delivery of diabetes care.

ADA=American Diabetes Association; EASD=European Association for the Study of Diabetes; SGLT2i=sodium–glucose co-transporter-2 inhibitor; GLP-1 RA=glucagon-like peptide-1 receptor agonist; NAFLD=nonalcoholic fatty liver disease; NASH=nonalcoholic steatohepatitis

The updated ADA/EASD consensus report6 has implications for several areas of clinical practice. In this article, I will discuss six key learning points from the report for healthcare practitioners working in primary care.

1. Understand the Importance of Diabetes Self-Management Education and Support

In the updated report, the ADA and the EASD stress the importance of diabetes self-management education and support (DSMES) in integrated, holistic, person-centred care for type 2 diabetes, emphasising that it is as important as medication selection in any treatment plan.6,9 DSMES can be provided in various ways; one particular development in this area is the use of technologies, which include mobile apps, simulation tools, digital coaching, and digital self-management interventions.6

Studies have demonstrated greater reductions in glycated haemoglobin (HbA1c) in people with diabetes who are more engaged with its management,6 and DSMES is also associated with improvements in diabetes knowledge, self-care behaviours, quality of life, all-cause mortality risk, and healthcare costs.10 The consensus report therefore recommends that all clinicians should be aware of how to access local DSMES resources, and should offer DSMES to all patients with type 2 diabetes on an ongoing basis.6 Referral to local support services is specifically recommended at diagnosis, annually, and with any changes in social status, health, or life situation.6

Type 2 diabetes and sustained hyperglycaemia are associated with cognitive decline, and this can impact the ongoing management of someone with the condition. The consensus report suggests considering screening for cognitive impairment—such as with a Mini-Mental State Examination, or another suitable screening test—if features of cognitive decline appear.6

2. Recognise the Crucial Roles of Weight Management and Health Behaviour in Type 2 Diabetes Management

The updated consensus report recommends weight loss as a targeted intervention for managing type 2 diabetes.6 This change comes as a result of evidence that weight loss of 5–10% can lead to significant metabolic improvement, and weight loss of 10–15% can have a disease-modifying effect and even induce remission of type 2 diabetes.6,11 Weight loss early in the course of type 2 diabetes may also increase the chance of remission.6,11 Glucose-lowering medications with weight-loss benefits, such as some glucagon-like peptide-1 receptor agonists (GLP-1 RAs), may be beneficial for this purpose.6 It is worth remembering that a successful diet is one that is both realistic and sustainable for the patient, and that an individual’s preferences and contexts are important considerations in the development of any food plan or weight target.6

Indeed, the report emphasises that health behaviour and weight management goals should be agreed between clinicians and their patients on an individual basis, as shared decision making of this kind helps with determining an individual’s best treatment choice.6 Goals that are specific, measurable, attainable, relevant, and time-based (SMART) are particularly effective for achieving behaviour change.6 The ADA and the EASD also recommend that clinicians should remind patients of the importance of blood glucose self-monitoring when working towards their health behaviour goals, and highlight the risk of hypoglycaemia in those taking insulin or sulfonylureas when they are undertaking physical activity or changing their nutritional plan.6

3. Harness the Benefits of 24-Hour Physical Activity Behaviours on Cardiometabolic Health

The updated guidance highlights five areas of appropriate physical behaviour through which people with type 2 diabetes can significantly improve their cardiometabolic health, detailed in Box 2.6

Box 2: 24-Hour Physical Behaviours for People with Type 2 Diabetes6
  • Sitting—frequent activity breaks (every 30 minutes), involving walking or simple exercises, will reduce sedentary time and can improve glucose metabolism
  • Stepping—increasing movement by just 500 steps per day is associated with a 2–9% reduced risk of all-cause mortality and cardiovascular morbidity
  • Sleep—the report emphasises healthy sleep as a key lifestyle component for managing type 2 diabetes; obstructive sleep apnoea affects more than half of people with type 2 diabetes, and both irregular sleep and nightly sleep of <6 hours or >8 hours can have a negative impact on HbA1c
  • Sweating—metabolic profiles are improved by as little as 30 minutes of moderate-intensity physical activity per week; the report recommends encouraging patients to undertake 150 minutes of moderate-intensity physical activity per week, with no more than 2 consecutive days of inactivity
  • Strengthening—glucose levels and insulin sensitivity can be improved by any activity involving the person’s own bodyweight or a form of resistance, such as weights.

HbA1c=glycated haemoglobin

4. Keep Up to Date with the Evidence on Glucose-Lowering Therapies

Metformin remains the first-line medication choice for the treatment of hyperglycaemia in most people with type 2 diabetes, but the report now recommends prioritising the use of organ-protective therapies—GLP-1 RAs, sodium–glucose co-transporter-2 inhibitors (SGLT2is), and thiazolidinediones (TZDs)—if a person has cardiorenal disease or nonalcoholic steatohepatitis (NASH).6 In fact, SGLT2is and GLP-1 RAs are recommended independent of HbA1c level or metformin use for patients with cardiovascular disease (CVD), chronic kidney disease (CKD), or heart failure (HF).6,12,13

Specifically, SGLT2is and GLP-1 RAs with proven cardiovascular benefit are recommended equally for patients with CVD, whereas SGLT2is with proven benefit for HF and primary evidence of reducing CKD progression are recommended for patients with HF and CKD, respectively.6 If SGLT2is are not tolerated or are contraindicated in a person with CKD, a GLP-1 RA with proven cardiovascular benefits can also be considered.6 Consideration of TZDs, specifically pioglitazone, for patients with NASH or nonalcoholic fatty liver disease is suggested, but the guidance notes that benefits must be balanced against possible side effects, and that evidence is still emerging in this area.6

Other considerations for medication use, including risk factors for organ-protective medications, comorbidity-related considerations, and factors such as age, frailty, cognitive impairment, and social determinants of health, should be taken into account when choosing a medication.6

5. Practise Proactive Care to Avoid Therapeutic Inertia

To avoid therapeutic inertia, the updated consensus report recommends evaluating health behaviours, treatment compliance, and side effects of any medications at each clinical visit.6 Initial combination therapy is indicated in certain groups with the aim of preventing this inertia and attaining tighter glucose control than monotherapy allows.6 These groups are:6

  • people with HbA1c levels more than 16.3 mmol/mol higher than their target at diagnosis (greater than 70 mmol/mol in most people)
  • younger people (regardless of HbA1c level)—aiming for an HbA1c target of less than 53 mmol/mol presents the best opportunity to avoid complications in the longer term
  • people for whom a stepwise approach would delay access to cardiorenal protection.

In addition, using fixed-dose combination treatments can help to reduce a patient’s pill burden and improve their adherence.6

The report recommends that clinicians consider deprescribing or reducing medication intensity (if possible and appropriate) in certain groups, such as older adults with frailty or patients for whom their current medication presents a risk of hypoglycaemia.6 Because pharmacological treatment of diabetes often requires intensification, sometimes medication reduction or discontinuation is appropriate, particularly if the medication is ineffective or associated with side effects, or if glycaemic goals have changed.6

6. Initiate Insulin After Appropriate Technological and Pharmacological Considerations

In the updated report, careful consideration is given to the role of insulin for treating hyperglycaemia. It is acknowledged that insulin can be particularly useful because it lowers glucose in a dose-dependent manner, so can address almost any level of blood glucose; however, its safety and efficacy depend on proper education and support.6

Before initiating insulin in anyone with type 2 diabetes, the ADA and the EASD recommend considering GLP-1 RAs (if there is no contraindication to their use), as this class of drugs is insulin sparing.6 GLP-1 RAs help to reduce both hypoglycaemia risk and injection burden, as well as offering some mitigation against weight gain.6

When initiating insulin, a basal type is recommended, with titration in an appropriate way to an agreed fasting target.6 Metformin and organ-protective glucose-lowering medications should be continued, and re-referral for DSMES is advised when starting insulin for the first time or changing to a basal–bolus regimen.6 Patients on insulin may benefit from the use of CGM, as recent evidence suggests that this type of monitoring leads to better glucose control and fewer hyperglycaemic and hypoglycaemic episodes.6,14,15 It is important that clinicians optimise the use of all available technologies to support behaviour change as effectively as possible.6

Summary

The updated ADA/EASD consensus report aims to inform diabetes care in both America and Europe. The report provides detailed guidance on lifestyle interventions and healthy behaviours, as well as an updated algorithm on the use of glucose-lowering medications and updated recommendations on the benefits of SGLT2is and GLP-1 RAs. The report is an extremely useful adjunct to other existing guidelines, such as those produced by NICE, PCDE, and SIGN, and is practice changing for clinicians in primary care managing patients with type 2 diabetes.

Key Points
  • The 2022 update to the ADA/EASD report on managing hyperglycaemia in type 2 diabetes emphasises individualised patient support
  • DSMES is an essential aspect of diabetes care, and proper support is associated with improvements in patients’ HbA1c levels, knowledge, self-care behaviours, quality of life, and all-cause mortality risk, and also in healthcare costs
  • SMART goals are more effective for achieving behaviour change than nonspecific recommendations
  • Weight loss of 5–15% has been shown to induce significant metabolic improvement, and even remission, in patients with type 2 diabetes, and should be considered a targeted intervention for this disease
  • Simple 24-hour physical activity behaviours—including frequent activity breaks, minor improvements in daily steps, better sleep, resistance and bodyweight exercise, and up to 150 minutes of moderate-intensity exercise per week—can lead to significant cardiometabolic improvements
  • Metformin remains the recommended first-line medication for type 2 diabetes, but SGLT2is and GLP-1 RAs can be considered for patients with CVD, CKD, or HF, independent of HbA1c level or metformin use, because of their cardiorenal benefits
  • Avoidance of therapeutic inertia is essential, and is a reason for considering initial combination therapy in patients who are younger (regardless of HbA1c level), whose HbA1c level is greater than 70 mmol/mol, or who require cardiorenal protection
  • Certain individuals may benefit from medication reduction or discontinuation, particularly if they have frailty or if their medication poses a risk of hypoglycaemia
  • Insulin is a useful agent for treating hyperglycaemia, but should be initiated with a basal type, after consideration of GLP-1 RAs
  • CGM should be considered in all patients with type 2 diabetes taking insulin, and technologies should be used effectively to aid self-management.

ADA=American Diabetes Association; EASD=European Association for the Study of Diabetes; DSMES=diabetes self-management education and support; HbA1c=glycated haemoglobin; SMART=specific, measurable, attainable, relevant, time-based; SGLT2i=sodium–glucose co-transporter-2 inhibitor; GLP-1 RA=glucagon-like peptide-1 receptor agonists; CVD=cardiovascular disease; CKD=chronic kidney disease; HF=heart failure; CGM=continuous glucose monitoring

Implementation Actions to Consider for Future Practice

written by Dr Kevin Fernando, GP Partner, North Berwick; Content Advisor, Medscape Global and UK

In light of the 2022 update to the ADA/EASD consensus report, here are some practical actions for primary care clinicians in the UK to consider implementing in their practice:

  • discuss the importance of the five Ss (sitting, stepping, sleep, sweating, and strengthening) with all people living with type 2 diabetes, and reinforce the impact of these 24-hour physical behaviours on their cardiometabolic health
  • regard weight reduction as a targeted intervention for type 2 diabetes, using a weight loss target of 5–15% as a primary focus of management for many people living with the disease. Explain to patients that weight loss of 5–10% results in significant metabolic improvement, whereas weight loss of ≥10–15% can induce remission of type 2 diabetes
  • although metformin remains the first-line pharmacological choice for treating hyperglycaemia in most people living with type 2 diabetes, consider SGLT2is and GLP-1 RAs for those with established or high risk of CVD, HF, or CKD, independent of metformin use and HbA1c level
  • appreciate that type 2 diabetes and sustained hyperglycaemia are associated with cognitive decline that can impact ongoing management, and consider screening patients for cognitive impairment if they have any features of cognitive decline, such as struggling to carry out familiar daily tasks
  • recognise the potential of pioglitazone for those living with NAFLD/NASH and type 2 diabetes and who are at high risk of liver fibrosis, e.g. those with an elevated score on the FIB-4 Index
  • consider CGM for all people living with type 2 diabetes on insulin therapy—technology can be empowering for people living with type 2 diabetes, but needs to be supported with high-quality education.

ADA=American Diabetes Association; EASD=European Association for the Study of Diabetes; SGLT2i=sodium–glucose co-transporter-2 inhibitor; GLP-1 RA=glucagon-like peptide-1 receptor agonist; CVD=cardiovascular disease; HF=heart failure; CKD=chronic kidney disease; HbA1c=glycated haemoglobin; NAFLD=nonalcoholic fatty liver disease; NASH=nonalcoholic steatohepatitis; FIB-4=Fibrosis-4; CGM=continuous glucose monitoring

Implementation Actions for ICSs

The following implementation actions are designed to support ICSs with the challenges involved in implementing new guidance at a system level. Our aim is to help you to consider how to deliver improvements to healthcare within the available resources.

  • Review and discuss the updated ADA/EASD report with local diabetes leads and public health colleagues to identify specific hard-to-reach groups or demographic challenges to address in your area
  • Commission services to reduce any health inequalities
  • Update local formularies and diabetes guidance to ensure that newer antidiabetic agents that provide proven benefits and cardiorenal protection are included and given suitable priority
  • Ensure that a sufficient number of diabetes education programmes are commissioned, accessible, and responsive, including diabetes prevention programmes for those at risk of diabetes but not yet meeting diagnostic thresholds
  • Commission or provide ongoing education programmes for primary care professionals on the management of type 2 diabetes.

ICS=integrated care system; ADA=American Diabetes Association; EASD=European Association for the Study of Diabetes

Implementation Actions for Clinical Pharmacists in General Practice

written by Shailen Rao, Managing Director, Soar Beyond Ltd

The following implementation actions are designed to support clinical pharmacists in general practice with implementing guidance at a practice level.

According to Diabetes UK, one in six people with diabetes have had no contact with their healthcare team since before the pandemic.[A] This statistic emphasises how vital it is that clinical pharmacists in general practice step up and address the backlog of care for people with diabetes. This doesn’t mean that they must do all the work, but by extending their clinical capabilities, practice-based clinical pharmacists can help to address patient need and optimise the MDT skill mix.

Clinical pharmacists in general practice can support these patients by undertaking the following five steps:

  1. Ensure that local guidelines are aligned with current evidence and management options—the updated ADA/EASD consensus report emphasises providing patients with access to the most appropriate treatments, including nonpharmacological management
  2. Treat this as a full QI project—practice-based clinical pharmacists are well placed to drive improvements in care, as they have both the necessary skills and an understanding of the disease and its comorbidities; thus, they can propose a structured QI approach to managing patients within their PCN, and allocate dedicated time to driving this forward and reporting back to their PCN clinical director
  3. Take a stratified approach to managing patients—one in 14 people have diabetes in the UK,[A] which is an unmanageable workload for clinical pharmacists in general practice; stratification tools, such as those produced by the PCDS and i2i Network, will enable them to analyse their list of patients with diabetes and prioritise them into key cohorts
  4. Divide the workload to conquer—utilise the full MDT in the management of patients with diabetes, defining which team members are the best people to deliver aspects of care such as foot checks, medicines optimisation, CGM reviews, and lifestyle advice[B]
  5. Operationalise priority cohorts—break down the number of patients and clinic sessions or appointments by role and time required, and work with the administrative team and practice/PCN manager to turn this into an operational reality.

Soar Beyond Ltd is dedicated to supporting QI and optimisation of the MDT. The i2i Network provides practice-based clinical pharmacists with digital tools and change-management support, via a suite of training and implementation resources. To ensure that you don’t miss out, sign up for free now or find out more about the i2i Network by visiting www.i2ipharmacists.co.uk.

Soar Beyond Ltd’s SMART Workforce tool helps to identify the most appropriate competencies and team members in the ARRS workforce to release clinical capacity. For more information on these services and for case studies in diabetes, visit www.soarbeyond.co.uk.

[A] Diabetes UK. Diabetes is serious. London: Diabetes UK, 2022 (last updated 2023). Available at: diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2022-04/Diabetes is Serious Report Digital_0.pdf

[B] There is a tendency in primary care to rely on practice nurses. In a recent project, Soar Beyond Ltd found that 20 minutes of a 30-minute nurse appointment could be provided by a healthcare assistant and a health and wellbeing coach. The new ARRS workforce provides an opportunity to redistribute workload and increase patient access by drawing on the expertise of different healthcare professionals. Clinical pharmacists may be best placed to oversee treatment intensification, but who can do the rest?

MDT=multidisciplinary team; ADA=American Diabetes Association; EASD=European Association for the Study of Diabetes; QI=quality improvement; PCN=primary care network; PCDS=Primary Care Diabetes Society; CGM=continuous glucose monitoring; ARRS=Additional Roles Reimbursement Scheme

See our related Theory in Practice Video—The Updated ADA/EASD Consensus Report with Dr Sarah Davies

References

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