New Diabetes Guidelines Fail to Guide

At the beginning of each year, the American Diabetes Association (ADA) releases their new standards of care. In their 2018 Standards of Medical Care in Diabetes,^[1] the real headline is how they have incorporated the cardiovascular (CV) outcome trials data^[2,3,4] into the guidelines.

To summarize, these standards integrate a person's known CV disease status at step two in the treatment algorithm. The first-line therapy for type 2 diabetes is still lifestyle and metformin, but when you go to that second step of adding second-line therapy—the dual-therapy step—the standards of care divide the world into people who have atherosclerotic CV disease and those who do not.

Those who do not have CV disease have a whole world of choice in terms of a second-line agent, but for those who have CV disease, the ADA recommends adding an agent that has been shown to have CV disease benefit, or to reduce CV mortality, or both. The guidelines discuss drugs that improve CV outcomes and reduce mortality, and they include empagliflozin and liraglutide as two agents that do that. Then they describe agents that are known to reduce CV events; canagliflozin is listed as the agent that does that.

In that second step, the ADA recommends that practitioners choose an agent that has CV benefits for patients with known CV disease.