Among the changes and refinements in the 2023 Standards of Care in Diabetes are the addition of tirzepatide as a glucose-lowering option in obesity management, the use of GLP-1 receptor agonists for achieving prandial control while minimizing the risks of hypoglycemia and weight gain associated with insulin therapy, and updates on agents used for blood pressure control in patients with diabetes. Published recently by the American Diabetes Association (ADA), this document guides health professionals across the spectrum in managing people with all types of diabetes and conditions associated with hyperglycemia.
Sections 8 (obesity), 9 (glycemic treatment), 10 (cardiovascular disease), and 11 (chronic kidney disease) provide the core advice for pharmacotherapy in patients with diabetes. Language in section 8 reinforces the concept of obesity as a chronic disease, and recommendation 8.5 explains that both small and larger weight losses are appropriate treatment goals. “Notably, larger (10% or more) weight loss may have disease-modifying effects, including diabetes remission, and may improve long-term cardiovascular outcomes,” the guideline states. The dual GLP-1/glucose-dependent insulinotropic polypeptide receptor agonist tirzepatide is a newly listed glucose-lowering option with “the potential for weight loss.” Recommendation 9.4d discusses further the importance of weight management in managing glucose lowering in patients with type 2 diabetes.
The treatment plan for type 2 diabetes should include agents that reduce cardiorenal risk when adults also have an established or high risk of atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease, according to recommendation 9.4b. Tables 9.2 and Figure 9.3 provide the “latest consensus report on management of hyperglycemia in type 2 diabetes by the ADA” and the European Association for the Study of Diabetes.
Cardiovascular Disease and Risk Management are the focus of Section 10. A target blood pressure of <130/80 mm Hg is recommended for patients with diabetes (recommendation 10.4), and advice on using high-intensity statin therapy is provided in recommendation 10.20. The addition of ezetimibe or a PCSK9 inhibitor to maximally tolerated statin therapy is discussed in recommendation 10.21, while recommendations 10.22 and 10.23 provide guidance on statin therapy in adults with diabetes who are older than 75 years of age.
“In Recommendation 11.5a, the levels at which a sodium–glucose cotransporter 2 inhibitor could be initiated were changed,” the guidelines notes. “The new levels for initiation are an estimated glomerular filtration rate ≥20 mL/min/1.73 m2 and urinary albumin ≥200 mg/g creatinine,” the report states. “Recommendation 11.5b also recommends that sodium–glucose cotransporter 2 inhibitor might also be effective in people with urinary albumin of normal to ≥200 mg/g creatinine.”