Updates on Type 2 Diabetes

With 1 in 4 persons with diabetes unaware that they even have the disease,¹ type 2 diabetes mellitus (T2DM) is a growing concern for primary care practitioners. Current trends predict that the prevalence of T2DM will nearly double by 2050.¹ As the first stop for most patients, primary care practitioners must be equipped to provide specialized care. Two recent Top Papers^1,2 offer key take-aways:

In the Clinic

In this Top Paper,¹ researchers highlight things I use everyday and put numbers and directions on those clinical interventions. 

1. If a cohort of obese persons have prediabetes and reduce their weight by 5%, what will happen to the incidence of newly diagnosed diabetes in 3 years? It will decrease from 23% to 11%.

2. Not only metformin, but acarbose and a combination of ramipril/rosglitazone can be effective in preventing progression from prediabetes to full blown T2DM.

3. Screening, home blood glucose monitoring, and appropriate HbA1c targets are reviewed.

With the recent explosion of pharmaceutical agents directed at T2DM, practical clinical parameters regarding medications are provided. For example, if a patient exceeds ideal body weight by 20%, metformin is superior to either insulin or sulfonylureas in reducing mortality. The newer glucagon-like peptide-1 (GPL-1) that is used in combination with insulin, dipeptidyl peptidase-4 (DPP-4), and sodium-glucose cotransporter-2 (SGLT2) inhibitors are all placed into context. The question of when to use insulin is answered with evidence as to why. 

AACE/ACE Guidelines

The Clinical Practice Guidelines for Developing Diabetes Mellitus Comprehensive Care Plan from the American Association of Clinical Endocrinologists and American College of Endocrinology is an evidence-based update.² It covers clinical intervention targets and offers practical tips for the practitioner:

1. For patients who present with T2DM and an HbA1c >7.5%, metformin plus a second agent is suggested from the start. For the second agent, preference is given to agents with a low potential for hypoglycemia that are either weight neutral or may lead to weight loss, such as GLP-1 (2-3 kg weight loss), SGLT2 inhibitors, or DPP-4 inhibitors (not the sulfonylureas). If the initial A1c is 9% or greater, insulin is recommended.

2. This Top Paper² has 2 valuable, practical tables that can be referenced by primary care practitioners. These include a breakdown of the recommended steps for the addition of insulin to antihyperglycemic therapy with representative sugar values and dosing suggestions (page 28) and a reference to assist with intensifying insulin for prandial hyperglycemia (page 29).

3. Since this document is meant to be comprehensive, many topics are addressed including managing hypoglycemia and hypertension, and using aspirin, to name a few. 

How should practitioners use these Top Papers? I suggest incorporating Top Paper¹ in your regular readings, to incorporate the clinical advice as part of daily practice. The guidelines² are a handy reference to address any questions on evidence-based, management of T2DM.

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.

References:

1. Vijan S. In the clinic. Type 2 diabetes. Ann Intern Med. 2015;162(5):ITC1-16.
2. Handelsman Y, Bloomgarden Z, Grunberger G, et al. American Association of Clinical Endocrinologists and American College of Endocrinology: clinical practice guidelines for developing diabetes mellitus comprehensive care plan. Endocr Pract. 2015;21(suppl 1):1-87.