Clinical Question

What are the current recommendations from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) for the treatment of type 2 diabetes mellitus?

Bottom Line

The management of type 2 diabetes continues to move away from glycemic goals and toward a more holistic approach to patient care that considers medications, weight management, attention to cardiovascular risk factors, and kidney protection. Metformin is recommended for most patients, although the new classes of medications that affect the heart and kidneys should be considered for many patients. Sulfonylureas, thiazolidinediones, and insulin, all of which have little effect except to lower blood glucose levels, are distinctly de-emphasized. (Level of Evidence = 5)

Synopsis

The guidelines were developed by a working group composed of members from two professional societies and included endocrinologists and researchers (i.e., no patients or primary care clinicians). Most of the working group members had substantial relationships with the pharmaceutical industry. The group systematically reviewed the evidence and assessed its quality. Rather than strict goals, the guidelines continue to move away from an emphasis on markers of glucose control and toward an emphasis on modifiable risk factors to prevent complications and optimize quality of life. However, they recommend an A1C goal of less than 7% in most adults with a life expectancy of 10 years or more. The authors suggest principles of care that are more holistic, including emphasis on social determinants, psychosocial factors, and shared decision-making. The four categories of care include weight management, medications for glycemia management, attention to cardiovascular risk factors, and kidney protection. Metformin remains a mainstay of treatment, although the authors suggest treatment that controls glycemia and offers cardiorenal protection, such as a sodium-glucose cotransporter-2 inhibitor and a glucagon-like peptide-1 receptor agonist, alone or in combination. Insulin should be used when needed to provide further control of blood sugar.