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