The American Diabetes Association released their 2022 Diabetes Guidelines update. While I wouldn’t call the changes earth-shattering, there are some items in relation to pharmacotherapy that I feel are really important to note.
The patient population that I work with the most is those who have Type 2 diabetes. The beneficial data in cardiovascular, heart failure, and renal outcomes has been a huge advancement in clinical practice. The updated guidelines have softened their stance slightly on metformin always being the first-line agent. Here’s the exact language from the guidelines “First-line therapy depends on comorbidities, patient-centered treatment factors, and management needs and generally includes metformin and comprehensive lifestyle modification.”
Most will still reach for metformin, but this statement certainly opens the door to start with an SGLT2 inhibitor or a GLP-1 agonist. This is particularly true in the setting of heart failure (SGLT2) or cardiovascular outcomes data (GLP-1 or SGLT2). If you want more details on the pharmacotherapy of diabetes, check out pages 15 and 16 in the 2022 Diabetes Guidelines PDF.
While I am on the topic of cardiovascular outcomes, the guidelines specifically mention the consideration of dual antidiabetic therapy in patients with ASCVD. Of course, the combo agents with the best cardiovascular outcomes data that they are referring to are the GLP-1 agonists and SGLT2 inhibitors.
Another important pharmacotherapy update for the 2022 Diabetes Guidelines is noted in patients with CKD with urine albumin of greater than 300 mg/day. A target goal of a 30% reduction or greater is recommended to slow CKD progression. The drug finerenone is specifically mentioned in the guidelines. Hyperkalemia is a major risk (think similar action to spironolactone) that needs to be monitored. If you are a close follower of the blog, you’ll remember we touched on the clinical pearls with this medication and its use in CKD previously.
Well, there you have my biggest takeaways with the 2022 Diabetes Guidelines. What did I miss to what else would you add to this list?