The ADA Standards of Care in Diabetes–2024 makes progress in managing type 2 diabetes, but Dr Anne Peters ponders whether it's fast enough.
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For the treatment of type 2 diabetes, the American Diabetes Association (ADA) Standards of Care in Diabetes-2024 place a greater emphasis on the importance of weight management in treating type 2 diabetes, while always advocating for individualized treatment approaches. The 2024 Standards of Care really strengthen the guidelines for pharmacotherapy, frankly, because we now have these great drugs that help patients lose weight and control their diabetes. They state that obesity pharmacotherapy should be considered for people with diabetes and overweight or obesity, along with lifestyle changes.

I'm a big believer in lifestyle change, but I do think that many people need more help, so combining these new therapies that we have for the treatment of overweight and obesity with lifestyle can make a big difference. The Standards of Care now include recommendations that we go beyond body mass index (BMI) in terms of measuring how patients are doing with their weight loss program, and I think this is important because, obviously, people can lose both fat mass and lean body mass. We want to make sure that we're not shifting people toward a less healthy state of being.

The Standards of Care recommend such things as waist circumference measurements, waist-to-hip ratio, and/or waist-to-height ratios. They also talk about monitoring obesity-related anthropometric measurements at least annually to inform treatment considerations. I think we just need to be mindful of patients, and again, encourage lifestyle but really insofar as we're able to monitor how these changes are affecting patients' overall body composition.

The treatment algorithm overall for the management of type 2 diabetes looks at these three basic goals: weight management, glycemic control, and cardiorenal risk reduction. As in every guideline, everything needs to be individualized based on the patient's circumstances — what they have access to and what's right for the patient. I think we need to think, potentially, a bit more aggressively.

The guidelines have been changed to say that early combination therapy should be considered in adults with type 2 diabetes at treatment initiation to shorten time to attainment of individualized treatment targets. I know we've been walking up to this as a possibility and that at times it can be hard to get insurance companies to pay for this, but it does make sense to do the most we can at the outset to get patients down to their treatment goals to help reduce the risk for therapeutic inertia.

It is further stated that, in adults with type 2 diabetes without cardiovascular and/or kidney disease, pharmacologic agents should address both individualized glycemic and weight goals. In individuals who are obese and/or overweight, both glucagon-like peptide-1 (GLP-1) receptor agonists and dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor agonists are preferred to insulin use in managing their type 2 diabetes. Now, obviously, patients may end up on insulin, but if you can, using an incretin hormone is preferred.

For cardiorenal risk reduction and management, the Standards of Care say that adults who have type 2 diabetes, an established or a high risk for atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, treatment regimens should include agents that reduce cardiovascular and kidney disease risk, such as SGLT2 inhibitors or GLP-1 receptor agonists. I think everybody should review section 9 and all the tables and figures within it, because it really talks in detail about how we choose which agents for managing our patients with type 2 diabetes.

In section 10, there is an update following the FDA approval of sotagliflozin, which is the first dual SGLT1/SGLT2 inhibitor. It is recommended for use in patients with type 2 diabetes and established heart failure with either preserved or reduced ejection fraction.

There is a recommendation that was revised to recommend the monitoring of eGFR and serum potassium levels within 7-14 days after initiation of treatment with an ACE inhibitor, ARB, mineralocorticoid receptor agonist, or diuretic, and then at least annually. There were also recommendations added to include screening of adults for asymptomatic heart failure, and they suggested to consider screening adults with diabetes by measuring a natriuretic peptide and an N-terminal proBNP peptide to facilitate prevention of heart failure.

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