Are there any diabetes management guidelines updated in the past year that change routine care recommendations?

Recent Guideline Updates in Diabetes Management

The most significant recent update to diabetes care is the paradigm shift toward organ-protection-first prescribing, where GLP-1 receptor agonists and SGLT2 inhibitors should be initiated based on cardiovascular disease, heart failure, or chronic kidney disease status—independent of HbA1c levels or glycemic targets. 1

Key Changes in Treatment Selection

Cardiovascular Disease Priority

For patients with established atherosclerotic cardiovascular disease (prior MI, stroke, unstable angina, or revascularization), GLP-1 receptor agonists now have the strongest evidence for reducing major adverse cardiovascular events (MACE), with mortality reductions of 12-26%. 1, 2

• Specifically, semaglutide, liraglutide, or dulaglutide are the only agents with proven MACE reduction and should be prioritized 2, 3
• These agents reduce cardiovascular death and MACE by 14% (HR 0.86,95% CI 0.80-0.93) 2
• The decision to use these agents should be made independently of baseline HbA1c or individualized HbA1c target 1

Expanded Indications Without Established CVD

GLP-1 receptor agonists can now be initiated in patients without established cardiovascular disease if they have high-risk indicators: 1, 3

• Age ≥55 years with coronary, carotid, or lower extremity artery stenosis >50% 1, 3
• Left ventricular hypertrophy 1
• eGFR <60 mL/min/1.73 m² 1
• Albuminuria (urinary albumin-to-creatinine ratio >30 mg/g) 1

Heart Failure Management

SGLT2 inhibitors are now the preferred agents for patients with heart failure, particularly those with heart failure with reduced ejection fraction (HFrEF, EF <45%), to reduce hospitalization for heart failure, MACE, and cardiovascular death. 1, 3

• This recommendation applies regardless of baseline glycemic control 3
• Caution: GLP-1 receptor agonists showed numerically increased risk of death and heart failure hospitalization with liraglutide in patients with recent decompensation, so SGLT2 inhibitors are strongly preferred when heart failure predominates 2

Chronic Kidney Disease Protection

SGLT2 inhibitors are recommended for patients with CKD (eGFR 30-60 mL/min/1.73 m² or urinary albumin-to-creatinine ratio >30 mg/g, particularly >300 mg/g) to prevent CKD progression, hospitalization for heart failure, MACE, and cardiovascular death. 1, 3

• Initiate when eGFR ≥20 mL/min/1.73 m² and continue until dialysis or transplantation 3
• GLP-1 receptor agonists retain glucose-lowering efficacy even with eGFR as low as 15 mL/min/1.73 m² and reduce albuminuria progression 2
• When eGFR <30 mL/min/1.73 m², GLP-1 receptor agonists are preferred due to lower hypoglycemia risk 2

Practical Implementation Changes

Dose Adjustments When Initiating Therapy

When starting SGLT2 inhibitors or GLP-1 receptor agonists in well-controlled patients, proactively reduce other glucose-lowering medications: 3

• Reduce sulfonylurea dose by 50% 3
• Reduce basal insulin dose by 20% 3
• Discontinue DPP-4 inhibitors before starting GLP-1 receptor agonists 3

Obesity Considerations

For patients with BMI >35 kg/m², semaglutide is the preferred GLP-1 receptor agonist due to superior weight loss (2-4 kg in diabetic patients, higher in non-diabetic patients), and GLP-1 receptor agonists should be prioritized over SGLT2 inhibitors. 2, 3

Combination Therapy

GLP-1 receptor agonists are now preferred over insulin when additional glucose-lowering beyond oral agents is needed, as they provide HbA1c reductions of 0.8-1.5% with weight loss of 1.5-3.5 kg and low hypoglycemia risk. 2, 3

• When combining GLP-1 receptor agonists with insulin, the combination provides greater glycemic effectiveness with beneficial effects on weight and reduced hypoglycemia risk 2

Safety Monitoring Updates

SGLT2 Inhibitor Precautions

• Monitor for genital mycotic infections and provide education on genital hygiene 3
• Assess for volume depletion and consider reducing diuretic doses 3
• Use with caution in patients with foot ulcers or high amputation risk, particularly with canagliflozin 3

GLP-1 Receptor Agonist Tolerability

• Start at lowest dose and titrate slowly to mitigate nausea (occurs in 15-20% but typically transient) 2, 3
• Use with caution in patients with history of pancreatitis, gastroparesis, or medullary thyroid cancer 3

Hypoglycemia Definition Update

The definition of clinically significant hypoglycemia has been standardized to level 2 hypoglycemia: <54 mg/dL (3.0 mmol/L). 1

• Patients with level 2 hypoglycemia should have glycemic targets raised to strictly avoid hypoglycemia for several weeks to partially reverse hypoglycemia unawareness 1

Common Pitfalls to Avoid

• Do not wait for HbA1c to be elevated before initiating GLP-1 receptor agonists or SGLT2 inhibitors in patients with cardiovascular disease, heart failure, or CKD 1
• Do not use GLP-1 receptor agonists as first-line in patients with predominant heart failure—use SGLT2 inhibitors instead 2
• Do not forget to reduce insulin or sulfonylurea doses when adding these agents to avoid hypoglycemia 3