Changes in the management of type 2 diabetes (2018 consensus)

Dr Chantal Mathieu is a professor of medicine at KU Leuven (Belgium) and chair in the Division of Endocrinology at UZ Leuven.

What is the most important change in the management of type 2 diabetes according to the 2018 consensus report by the American Diabetes Association (ADA) and the European Association of the Study of Diabetes (EASD)?

Chantal Mathieu, MD, PhD: The 2018 consensus on the management of hyperglycemia in people with type 2 diabetes continued to build on the previous—what was then called—position statement, which was putting the patient at the center of the care. In the previous position statement they already pointed towards the importance of individualized care. We just said it is the patient who needs to come in the center and together with the patient you need to come to a management plan.

There are several things that are important in that management plan. First of all, patient characteristics. We put a lot of emphasis on the presence of atherosclerotic cardiovascular disease, heart failure, or renal disease that will guide the clinician in their choices towards the use of sodium-glucose cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists on top of metformin and on top of lifestyle measures.

Another important point that we introduced in this consensus was the fact that next to these patient characteristics you also need to take into account the characteristics of the agents you need to use and their side effects. For instance, if you want to avoid hypoglycemia, do not put sulfonylurea as second-line to metformin. If you want to avoid weight gain or induce weight loss, again, prefer GLP-1 receptor agonists or SGLT-2 inhibitors.

Another important point in this consensus was the fact that we now clearly said that when oral glucose-lowering agents are not enough to keep glycemic control and you need to think of an injectable, think first of a GLP-1 receptor agonist in people with type 2 diabetes rather than insulin. Except in specific circumstances, like when you have a very high glycated hemoglobin (A_1C), when there are symptoms of polyuria or polydipsia, or when you are not sure that your patient has type 2 diabetes—then prefer insulin. And when you initiate insulin, initiate insulin as a basal insulin. Not only initiate it, but also titrate it to target, to the fasting glycemic target you want to achieve in your patient.

So, there were a few accents put, but really building on previous position statements.