An individualised approach to choosing non-insulin medications for lowering glucose

Decision cycle for person-centred glycaemic management in type 2 diabetes

Type 2 diabetes is far more than just glucose management. It is a chronic complex condition which requires a multifactorial approach to management encompassing evidenced based pharmalogical therapies also behavioural and self-management strategies. The ADA/EASD Consensus Report 2022 offers a comprehensive decision cycle to enable clinicians to deliver person centred care through the use of shared decision making to achieve the primary goals of care; to prevent diabetes related complications and improve quality of life.

 

Glucose lowering therapies

There are several types and classes of glucose lowering therapies available, a summary of which is provided here and is detailed within the ADA/EASD Consensus report 2022.

 

Personalised approach to glucose lowering therapies based on individual characteristics and co-morbidities:

The ADA/EASD 2022 consensus report, glucose lowering algorithm, takes into account clinically important factors to aid decision making when choosing glucose lowering therapies for people living with type 2 diabetes. It focuses on available cardio-renal-metabolic evidence and applies this in a person cantered and holistic way. The left hand side of the algorithm focuses on the goals of cardio-renal risk reduction, it separates out the different risk factors and/or co-morbidities such as ASCVD, HF and CKD and recommends the most appropriate therapy.

The right hand side of the algorithm focuses on the goal of glycaemia and weight management and identifies those glucose lowering agents with high glycaemic and weigh loss efficacy from clinical trial evidence.

Let’s not forget though that healthy lifestyle behaviours, self-management education and social determinants of health are all principles of care that need to be considered as well as and in combination with any glucose lowering therapy.

 

The place of insulin

The ADA/EASD Consensus report suggests that preferred way to initiate insulin in people living with type 2 diabetes is to add basal insulin to existing glucose lowering therapies. It also recommends that the GLP-1 RA therapy should be initiated before insulin and that insulin and GLP-1 RA combination therapy should be considered. In specific circumstances insulin may be the preferred glucose lowering agent In specific circumstances, such as severe hyperglycaemia (HbA1c >86 mmol/mol [>10%]), particularly when associated with weight loss or ketonuria/ketosis and with acute glycaemic dysregulation (e.g., during hospitalization, surgery, or acute illness), in underweight people, or when the diagnosis of type 1 diabetes is suspected.

The infographic below summarises the place of insulin within the management of type 2 diabetes.

 
Michael Bonar