Putting the ADA/EASD Glycemic Management Algorithm to Use

Today I'm going to go through the final American Diabetes Association/European Association for the Study of Diabetes algorithm [for glycemic management] that came out in October 2018.^[1] It's a very complicated algorithm, so I'm going to try to simplify it. I'm not going to go through every different medication but I'll go through the key themes.

Patient-Centered Care

The first theme is patient-centered care. The patient has to be in the center of all of this. It can't be an algorithm that's just applied. Patients have to want to engage with this and want to take the medications. A huge reason that patients don't get to target is that they simply don't take the medications we give them or they start the medications and then stop.

Engaging the patient, individualizing care, and creating a team that's comfortable and works for each patient is incredibly important. I think it's as important as any choice of medicine—engaging the patients and making them feel like their health and their outcomes are what really matter in this setting.

Lifestyle Intervention and Metformin

Once you've done that, foundational therapy includes lifestyle intervention and metformin. Both of those are incredibly important. If you get a patient to take metformin, it's a great drug.

The key to taking metformin is tolerating the gastrointestinal side effects, so I start at a low dose with food and go up slowly. I use extended-release metformin if people develop gastrointestinal side effects to the non–extended-release form. I'll work with patients to see if they can get on the metformin, tolerate it, and then stay on the drug.

Lifestyle change is forever. I don't believe in diets, but I do believe in creating healthy habits. I also don't want people to feel deprived. Working with a good educator or dietitian is great.

People love fad diets and they love magic, but none of that works. It needs to be persistent and something that a patient can really adhere to and fit into their life.

Patients With Cardiovascular or Renal Disease

If, after metformin and lifestyle intervention, the A1c is still elevated, you basically divide the world into two parts. If a patient has established cardiovascular disease, congestive heart failure, or chronic kidney disease (CKD), they go to one side of the algorithm. That's the side of the algorithm where you're going to use preferentially sodium-glucose cotransporter-2 (SGLT2) inhibitors and/or glucagon-like peptide-1 (GLP-1) receptor agonists.

In that group of patients, for those who have predominant heart failure/CKD but don't have CKD so significant that they can't use an SGLT2 inhibitor, you're going to start an SGLT2 inhibitor. If a patient has atherosclerotic cardiovascular disease predominantly, then you can use either an SGLT2 inhibitor or a GLP-1 receptor agonist.

Patients Without Cardiovascular or Renal Disease

The rest of the patients, who don't have CKD, atherosclerotic cardiovascular disease, or congestive heart failure, are divided into three classes. One group has a compelling need to avoid hypoglycemia; that's one algorithm and they give you four different second-line choices.

The next algorithm is a compelling need to lose weight, and that gives you choices of medications that can help with weight loss. Another part of the algorithm basically says that if cost is a major factor, you use these agents preferentially.

With patients who don't have cardiovascular disease or renal disease, you look at hypoglycemia, the need for weight loss, and the cost factor. All of these are important, and as we know, basically all of the drugs that are associated with weight loss are also low-risk medications for hypoglycemia.

There's a lot of blurring of these lines when you look at patients. Nonetheless, you need to think of weight loss, hypoglycemia risk, and cost as you go out on the algorithm for patients who don't have those preexisting risk factors.

One of the other themes is that the first injectable should be a GLP-1 receptor agonist. Again, this isn't the cost side, but for everybody else—even if they can't afford it—you want to try giving them a GLP-1 receptor agonist instead of insulin as a first-line injectable.

Injectable Therapies

There is an entire algorithm that looks at injectable therapies. This is a very complicated algorithm but it can be simplified. Basically, if a patient is on a GLP-1 receptor agonist and the A1c isn't at target, you add in basal insulin. If a patient is on basal insulin and A1c isn't at target, and they can afford it, you add a GLP-1 receptor agonist.

I personally believe, based on a lot of clinical practice, that the combination of a GLP-1 receptor agonist plus basal insulin is much simpler and results in a lot less hypoglycemia and weight gain than if a patient ends up on premeal insulin. [The algorithm addresses] using the combination of insulin and a GLP-1 receptor agonist.

If that doesn't work, consider intensification. If a patient is on analogue insulin—say, basal glargine or degludec—then you would add a rapid-acting analogue insulin before the biggest meal because it tends to be easiest to step patients up.

For many of my patients, that's dinner. Some patients eat a bigger lunch, but you can start adding in premeal insulin before the biggest meal and continuing the basal. I'll generally start with 4 or 6 units, and [the algorithm provides recommendations] for a weight-based approach or to give so many units and then uptitrate.

The key to all of this is minimizing hypoglycemia and weight gain in patients on insulin while also reducing complexity. The simpler the regimen, the more the patients really buy into what they're doing and can do it relatively easily in a way that fits into their life. It works better.

These once-weekly GLP-1 receptor agonists have had a big uptake in my practice. I think the reason is that it's simple. Patients don't have to remember to do it as often, and I end up with reasonably good outcomes.

However, many patients will progress and they'll need insulin. We need to use it in combination with other agents. I always keep people on metformin, and that's what these algorithms suggest. Stopping thiazolidinediones when patients are on insulin and [other recommendations] are also in the algorithm.

Remember the Patient

I would encourage you to read the algorithms. Don't get confused by all of the details because it's really simple. Start with the patient. Use metformin and lifestyle interventions. Determine whether patients have cardiovascular disease/CKD, and treat those patients differently.

For everybody else, use the agents that we have in ways to reduce the risk for hypoglycemia and weight gain. Always keep in mind that cost is a real issue for many patients and that there's a cost-effective way to treat our patients.

In conclusion, this seems complicated—and it is complicated because we have so many choices—but remember the patient. Your goal is to make the choices seem simple for the patient.

In your mind, look at your patient and ask, "Do you have cardiovascular disease or CKD?" If so, give medications that reduce that risk. If not, take into consideration all of these other factors along with the patient.

Consider the concerns about hypoglycemia, weight gain, and the goals for weight loss, and then look at costs. Work with your patients. Try to fit them into these different algorithms and choices.

Remember that your patients may well need insulin at some point, so don't use that as a threat. As patients approach that point, be realistic, practical, and engage them in their care. When you start insulin, a combination of insulin and a GLP-1 receptor agonist often works quite well.

If you need more intensification, work with your patients to figure out which is their biggest meal. Give them insulin, work with them on lifestyle changes, and just keep going back to the patient, their lifestyle, needs, interests, and concerns—and continue to work with them. I think doing it that way and using these guidelines will really help you manage your patients with type 2 diabetes. Thank you.

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