Summarize the diabetes medical diagnosis and treatment standards issued by the American Diabetes Association in 2022.👀

Recently, the American Diabetes Association released the Diabetes Medical Diagnosis and Treatment Standards for 2022. With regard to the treatment of type 2 diabetes, the new version of the guidelines has made many updates, weakening the status of metformin as the first-line medication.

1. Recommendations for the treatment of type 2 diabetes.

Initial treatment: Metformin is generally used. For patients with atherosclerotic cardiovascular disease (ASCVD)/high-risk factors, heart failure and/or chronic kidney disease, GLP-1 receptor agonist or SGLT2 inhibitor is recommended as the initial treatment. According to the patient's blood sugar status, metformin is combined or not combined. Unless the patient is contraindicated or intolerant, metformin should be continued after the initial insulin therapy to continuously improve blood sugar and metabolism. 

• Compared with insulin monotherapy, metformin combined with insulin can further reduce HbA1c, reduce insulin dosage, weight gain and the risk of hypoglycemia.

For some patients, early combination therapy can be considered when starting treatment to prolong the time of treatment failure. 

When choosing hypoglycemic drugs, cardiovascular complications, the efficacy of hypoglycemic drugs, the risk of hypoglycemia, the impact on weight, cost, availability, side effects and patient wishes should be considered.

Regardless of whether the HbA1c level is up to standard, if the patient has ASCVD/high-risk factors, kidney disease or heart failure, it is recommended to use SGLT2 inhibitors and/or GLP-1 receptor agonists that have proven cardiovascular benefits.

For patients with type 2 diabetes, GLP-1 receptor agonists are better than insulin.

If insulin is used, it is recommended to combine therapy with GLP-1 receptor agonists to improve the efficacy and durability of the therapeutic effect.

Patients with type 2 diabetes who are not up to the standard should be intensively treated as soon as possible.

The treatment plan should be re-evaluated every 3-6 months, and adjusted according to needs and new influencing factors.

Clinicians should be alert to insulin overtreatment. The following conditions may indicate that there may be excessive insulin consumption. Including the basic dose of more than 0.5IU/kg, the great difference in blood glucose between bedtime and fasting or before and after meals, hypoglycemia (symptomatic or asymptomatic), and high variability. When insulin overtreatment occurs, the next step of individualized treatment should be redesigned.

2. The choice of hypoglycemic drugs for patients with ASCVD, heart failure and chronic kidney disease.

ASCVD/high-risk factors: It is recommended to use GLP-1 receptor agonist or SGLT2 inhibitor. Choose GLP-1 receptor agonists that have proven cardiovascular benefits: dulaglutide, liraglutide and semaglutide. Choose SGLT2 inhibitors that have proven cardiovascular benefits: empagliflozin and canagliflozin.

Heart failure: It is recommended to choose SGLT2 inhibitors that have been proven to be beneficial for heart failure: empagliflozin, canagliflozin, dapagliflozin and ertugliflozin.

Chronic kidney disease: 

• Patients with chronic kidney disease and proteinuria should first choose SGLT2 inhibitors that can delay the progression of chronic kidney disease: canagliflozin, empagliflozin and dapagliflozin. If SGLT2 inhibitors are contraindicated/intolerant, choose GLP1 receptor agonists with cardiovascular benefits: dulaglutide, liraglutide and semaglutide. 
• Patients with chronic kidney disease who do not have proteinuria should choose GLP-1 receptor agonists or SGLT2 inhibitors that have cardiovascular benefits.

3. The main features of hypoglycemic drugs.

Metformin: It has a higher efficacy, no risk of hypoglycemia, and does not have much effect on body weight. There are potential benefits for cardiovascular, but no obvious benefits for the progression of kidney disease and heart failure.

SGLT2 inhibitor: It has a moderate effect, has no risk of hypoglycemia, and can reduce weight. Empagliflozin and canagliflozin have cardiovascular benefits. Empagliflozin, canagliflozin, dapagliflozin and ertugliflozin are beneficial for heart failure. Canagliflozin, dapagliflozin and empagliflozin are beneficial to the progression of kidney disease.

GLP-1 receptor agonist: It has higher efficacy, no risk of hypoglycemia, and can reduce weight. Dulaglutide, liraglutide, and semaglutide have cardiovascular benefits. Neutral to heart failure. Dulaglutide, liraglutide and semaglutide are beneficial for renal endpoints.

DPP-4 inhibitor: It has moderate efficacy, no risk of hypoglycemia, and does not affect body weight. There is no benefit to cardiovascular and the progression of kidney disease. In addition, saxagliptin has a potential risk of heart failure.

Thiazolidinedione: It has a higher efficacy, no risk of hypoglycemia, and will increase weight. Pioglitazone has potential cardiovascular benefits. Thiazolidinediones increase the risk of heart failure and are not beneficial to the progression of kidney disease.

Sulfonylureas: It has a higher efficacy. It has a risk of hypoglycemia and can increase weight. It has no effect on cardiovascular, heart failure and the progression of kidney disease.

Insulin: It has a higher efficacy. It has a risk of hypoglycemia and can increase weight. It has no effect on cardiovascular, heart failure and the progression of kidney disease.

4. Adverse reactions and precautions.

Metformin: Common gastrointestinal reactions (diarrhea, nausea). It may cause vitamin B12 deficiency.

SGLT2 inhibitor: SGLT2 inhibitors need to be stopped before any elective surgery to avoid the risk of DKA (diabetic ketoacidosis). Common side effects include genitourinary system infection, hypovolemia, risk of hypotension, elevated LDL-C, and Fournier gangrene. Canagliflozin has a risk of fracture.

GLP-1 receptor agonist: Common side effects are gastrointestinal reactions (nausea, vomiting, diarrhea). FDA black box warning: risk of thyroid C-cell tumors in rodent studies. However, the relevance to humans is not clear (liraglutide, dulaglutide, exenatide sustained-release agent, semaglutide).

DPP-4 inhibitor: Clinical trials have reported pancreatitis, but the causality has not yet been clarified. If pancreatitis is suspected, the drug should be discontinued. Joint pain is also a common side effect.

Thiazolidinedione: Common side effects include water and sodium retention (edema, heart failure) and the risk of fractures. Pioglitazone and rosiglitazone are at risk of congestive heart failure. Pioglitazone has a risk of bladder cancer. Rosiglitazone may increase LDL-C.

Sulfonylureas: The first generation of sulfonylureas (tolbutamide) has an increased risk of cardiovascular death.

Insulin: Risk of hypoglycemia: human insulin> human insulin analogues.