Recent Updates to Clinical Practice Guidelines for Diabetes Mellitus

Abstract

Guidelines for the management of patients with diabetes have become an important part of clinical practice that improve the quality of care and help establish evidence-based medicine in this field. With rapidly accumulating evidence on various aspects of diabetes care, including landmark clinical trials of treatment agents and newer technologies, timely updates of the guidelines capture the most current state of the field and present a consensus. As a leading academic society, the Korean Diabetes Association publishes practice guidelines biennially and the American Diabetes Association does so annually. In this review, we summarize the key changes suggested in the most recent guidelines. Some of the important updates include treatment algorithms emphasizing comorbid conditions such as atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease in the selection of anti-diabetic agents; wider application of continuous glucose monitoring (CGM), insulin pump technologies and indices derived from CGM such as time in range; more active screening of subjects at high-risk of diabetes; and more detailed individualization in diabetes care. Although there are both similarities and differences among guidelines and some uncertainty remains, these updates provide a good approach for many clinical practitioners who are battling with diabetes.

Glycemic and Extraglycemic Effects of Metformin in Patients with Diabetes

“…In light of the new evidence and effects of other oral antihyperglycemics on the cardiovascular and renal systems, the Japanese guidelines are the first not to recommend metformin as a first-choice agent, but rather, one of the possible choices for first-line monotherapy. Other guidelines, including Korean and the American Diabetes Associations, recommend including different oral antihyperglycemics earlier than before [61]. Combination therapy of metformin with additional one or two drugs is currently being investigated for longterm safety and glycemic control.…”

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“…When adding a second and maybe third anti-hyperglycemic medicine, the synergy of different combinations and additional interactions were considered. For example, insulin plus metformin and insulin plus thiazolidinediones (TZD) are particularly effective at lowering hyperglycemia, but the latter combination comes with a higher risk of fluid retention 20 .…”

A nationwide cohort study on diabetes severity and risk of Parkinson disease

“…However, it is difficult to assess diabetes severity using single values because these values can change and tend to wax and wane over time. As a general treatment flow in non-insulin-dependent states, such as type 2 DM, if exercise or diet does not improve glycemic control, mono- or dual therapy is started 8 , 9 . Moreover, if treatment control is not possible with monotherapy, patients must be treated with two or more drugs.…”

“…Moreover, if treatment control is not possible with monotherapy, patients must be treated with two or more drugs. Therefore, severity is also evaluated in terms of the number of oral hypoglycemic agents (OHAs) 8 , 9 . Insulin treatment is mostly prescribed for patients with type 2 DM who become insulin-deficient and/or have failed other OHAs, which is referred to as advanced diabetes 10 .…”