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2022 ADA/EASD Consensus Statement and T2D
Impact of the 2022 ADA/EASD Consensus Statement on the Management of T2D

Released: April 25, 2023

Expiration: April 25, 2024

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Key Takeaways
  • In addition to counseling people on lifestyle modification, there are 4 major pillars of treatment to focus on: glucose reduction, weight management, cardiovascular risk factor modification, and cardiorenal protection.
  • When treating patients with type 2 diabetes, treat the whole individual by using drugs that are efficacious and safe with other added benefits, where appropriate.

Introduction
In 2022, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) published a joint consensus statement on the management of type 2 diabetes (T2D). The recommendations from this consensus statement also were included in the ADA “Standards of Care in Diabetes—2023.” These continue to be holistic and patient centered. They now also focus on 4 main areas of management.

The first area of focus remains glycemic management. The second area, which was added to the guidelines, is weight management. The third area is cardiovascular risk factor management, including blood pressure, lipid management, and smoking cessation. The fourth area is cardiorenal protection. These 4 areas have been identified to help healthcare professionals (HCPs) treat people with T2D in the most comprehensive way.

Pillars of Therapy
Lifestyle modification remains the cornerstone of care—this includes, of course, diet and exercise. If this fails to control glucose, we then use medications for glycemic management and, where appropriate, weight management. Fortunately, today there are medications that both lower glucose and cause weight loss. In addition, we need to treat all cardiovascular risk factors and use medications that afford cardiorenal protection, where appropriate.

I like that the authors of the consensus statement continue to suggest that metformin may be first-line therapy for glycemic control but reiterate that it may not be the most appropriate initial therapeutic agent. Avoiding hypoglycemia is another emphasis, particularly in individuals at high risk for hypoglycemia.

The guidelines recommend setting weight management goals. There has been an ongoing debate as to whether you “treat the glucose” or “treat the weight” first, but I do not think you can divorce the two. You need to treat both. The guidelines provide a very nice roadmap for weight management. It begins with setting goals and then focuses on lifestyle modification, referral to a structured weight management program, medications for weight loss, and finally—if necessary—metabolic surgery.

When medications for weight loss are discussed, they are divided into categories related to effectiveness, including those that are most effective, those that are moderately effective, and those that are less effective. Tirzepatide and semaglutide are mentioned specifically as being the 2 most effective agents. They are followed by dulaglutide and liraglutide, and then the other glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) and, finally, sodium-glucose cotransporter 2 (SGLT2) inhibitors.

The need to manage cardiovascular risk factors always has been present, but it is once again highlighted and is clearly an important component of managing T2D. In previous guidelines, we have focused on people at high risk for atherosclerotic cardiovascular disease (ASCVD) or those who have established ASCVD. The new guidelines broaden the definition of who is at high risk for ASCVD to include adults aged 40-75 years who have 2 or more additional risk factors for ASCVD, including obesity, hypertension, smoking, dyslipidemia, and the presence of albuminuria. In addition, for patients who have ASCVD or who are at high risk and are not meeting low-density lipoprotein cholesterol goals while receiving maximum-tolerated statin therapy, the recommendation is now to receive an additional agent, such as ezetimibe or a PCSK9 inhibitor.

Heart Failure and Chronic Kidney Disease
Recommendations for heart failure (HF) and chronic kidney disease (CKD) are similar to previous recommendations. As we now know, SGLT2 inhibitors are recommended for people with HF with a reduced or preserved ejection fraction. For people with CKD, the recommendation is either an SGLT2 inhibitor or a GLP-1 RA that has been shown to have CKD benefit, reduce albuminuria, or have cardiovascular risk benefit.

My Recommendations
My personal advice to primary care HCPs who care for people with T2D is to use drugs that are efficacious, safe, and have other added benefits. Metformin is the “go-to” drug for initial treatment for many primary care HCPs. This is appropriate because the drug is safe, effective, and mostly well tolerated. But now we have GLP-1 RAs and a glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA, as well as the SGLT-2 inhibitors; in some circumstances, these medications may be appropriate for initial therapy. The order in which one considers using them depends on the presence of other comorbidities, their adverse event profile, how much glucose lowering or weight loss is needed, and patient preference. It is important to discuss each class of medication with the patient—shared decision-making cannot be overemphasized. In some circumstances, the HCP should direct patients toward one class or another. For example, if you have a patient who has had a myocardial infarction but does not have HF or CKD, that individual should preferably be receiving a GLP-1 RA. On the other hand, if you have someone who has CKD, then an SGLT-2 inhibitor should be considered. Remember that these classes of medications can be used together in people who do not achieve therapeutic goals with just one class of drug. Although both GLP-1 RAs and SGLT2 inhibitors have cardiovascular benefit, we do not know if their combined use improves this benefit any further. We do know that combining these classes of drugs improves A1C and weight loss more than one class alone.

Conclusion
Primary care HCPs who manage T2D should remember that, in addition to counseling people on lifestyle modification, there are 4 major pillars of treatment to focus on: glucose reduction, weight management, cardiovascular risk factor modification, and cardiorenal protection. By focusing on these pillars, we can ensure that patients with T2D are being optimally managed.

Your Thoughts?
In your practice, how are you implementing the new recommendations from the ADA and EASD for the management of T2D? Answer the polling question and join the discussion by posting a comment.

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To what extent do you consider the 4 pillars of treatment for your patients with T2D?

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