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Diabetes Care 2024: Pharmacologic Approaches to Glycemic Treatment

In the annual update of American Diabetes Association standards for diabetes care, the recommendations for pharmacotherapy now include a preference for insulin analogs or inhaled insulin over injectable human insulins (Recommendation 9.2) and early use of continuous glucose monitoring (CGM) and consideration for automated insulin delivery (AID) systems (Recommendation 9.4) for adults with type 1 diabetes.

Other changes in drug therapy recommendations include the following:

• Recommendation 9.5 was expanded to include educating adults with type 1 diabetes on how to modify their insulin dose based on concurrent glycemia, glycemic trends, and sick day management.

• Recommendation 9.6 was added to suggest prescribing glucagon for individuals taking insulin or at high risk for hypoglycemia.

• Recommendation 9.7 was added to emphasize the importance of regular treatment plan evaluation for individuals with diabetes to ensure individualized goals are met.

• Recommendation 9.14 was updated to highlight the importance of early combination therapy when shortening the time to attainment of individualized treatment goals for adults with type 2 diabetes.

• Recommendation 9.15 was added to reflect that pharmacologic therapies should address both individualized glycemic and weight goals in adults with type 2 diabetes without cardiovascular and/or kidney disease.

• Recommendation 9.16 was added to advise consideration of additional glucose-lowering agents for adults with type 2 diabetes not meeting their individualized glycemic goals.

• Recommendation 9.17 was added to highlight the importance of treatment intensification and a combination of approaches pertaining to weight management and their alignment with glycemic management goals for adults with type 2 diabetes.

• Recommendation 9.18 was updated to reflect prioritizing glycemic management agents that also reduce cardiovascular and kidney disease risk in adults with type 2 diabetes and established/high risk of atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease.

• For adults with type 2 diabetes who have heart failure, Recommendation 9.19 was added to recommend sodium–glucose cotransporter 2 (SGLT2) inhibitors for glycemic management and prevention of heart failure hospitalizations.

• Recommendations 9.20 and 9.21 were added to reflect individualized recommendations for individuals with type 2 diabetes and chronic kidney disease.

• Recommendation 9.22 was updated to reflect that insulin therapy should be considered at any stage irrespective of other glucose-lowering medications in certain circumstances.

glucagon-like peptide 1 (GLP-1) receptor agonists or a dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonist

• Recommendation 9.23 was updated to include a dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide 1 (GLP-1) receptor agonist as an additional option for greater glycemic management that is preferred to insulin, and Recommendation 9.24 was updated to reflect reassessing insulin dosing upon addition or dose escalation of a GLP-1 receptor agonist or a dual GIP and GLP-1 receptor agonist.

• Recommendation 9.25 was broadened to include any glucose-lowering agents if justified for additional benefits (e.g., weight management, cardiometabolic, or kidney benefits) to treatment goals.

• Recommendation 9.26 was added to suggest reassessing the need and/or dosages for other glucose-lowering agents that are associated with a higher risk of hypoglycemia when initiating or intensifying insulin treatment.

• Recommendations 9.28 and 9.29 were added to provide guiding principles of care for people with obstacles that may impede their diabetes management.

• Figure 9.1 was updated to reflect a terminology change from “hybrid closed-loop technology” to “automated insulin delivery systems.”

• Table 9.1 was updated to reflect terminology updates, and Table 9.2 was updated to include counseling people with diabetes about the potential for ileus (subcutaneous semaglutide) and to include that dual GIP and GLP-1 receptor agonist treatment is not recommended for individuals with a history of gastroparesis.

• Tables 9.3 and 9.4 were updated to reflect changes in cost for several agents.

Source: Diabetes Care