Specialists recommend a differential approach in the management of type 2 diabetes

The new statement offers a patient-centered consensus approach to the pharmacological treatment of type 2 diabetes with comorbidity categories.

Type 2 diabetes and its comorbidities are becoming more prevalent and the complexity of optimizing glycemic control is increasing. Photo: Shutterstock.

diabetes Type 2 and its associated comorbidities are becoming more prevalent, and the complexity of optimizing glycemic control is increasing, especially at the front line of patient care.

In many countries, the majority of patients with type 2 diabetes are treated in a primary care setting, according to endocrinologists from Primary Care Diabetes Europe.

However, primary health care professionals face the challenge of the growing plethora of treatment options available to control hyperglycaemia, which makes it difficult to treatment decision making and contributes to therapeutic and treatment inertia.

This position statement offers a decision making model Simple, patient-focused clinics with practical treatment recommendations that can be widely implemented by primary care physicians around the world through shared decision conversations with their patients.

The statement includes

Cardiovascular risk stratification:

-“Very high”: history of cardiovascular disease, multiple disease risk factors uncontrolled cardiovascular disease (ie, hypertension, hyperlipidemia, obesity, smoking, and/or physical inactivity), estimated glomerular filtration rate <60 mL/minute/1.73 m2, albuminuria, and age at diagnosis <40 years.

-“High”: all other patients with type 2 diabetes, including those aged = 65 years.

-Visual graphical patient assessment checklist “What category is your patient with type 2 diabetes in?” with pharmacological recommendations.

Table of glucose-lowering medications listing side effects and prescribing advice.

-Management diabetes type 2 in a virtual consultation environment.

-Risk-stratified treatment recommendations, including information on adherence, lifestyle modification, and metformin.

-Table summarizing drug outcome trials.

-Specific drug treatment recommendations are presented in text and box formats for people with cardiovascular disease, atherosclerotic disease, heart failure, chronic kidney disease, high cardiovascular risk, obesity, and elderly/frail patients.

-Financing: Support from the East Midlands Applied Research Collaboration.

Some general principles, such as avoiding hypoglycemia, focusing on cardiovascular prevention, individualizing control goals, evaluating therapeutic adherence, avoiding therapeutic inertia, recognizing the importance of the results perceived by the patient (eg, weight loss ) and considering patient preferences and values, should be considered when treating patients with T2D.

Side effects are important factors influencing treatment choice and medication adherence.

Patients will have their personal needs, preferences, and tolerances regarding the route of administration (injectable or oral), discomfort, side effects, and the price they are willing to pay out of pocket.

Shared decision making is an approach in which patients and doctors work together and engage in a deliberate dialogue about reasonable treatment options.

In this process, the HCP is the expert in evidence-based medicine and must suggest the safest and most clinically appropriate medications. This approach is feasible in primary care.

On the other hand, the experience during the pandemic also pointed out possible pitfalls of the environment in virtual consultations. The neglect of the essential role of first contact with primary care professionals occurred due to the hegemony of health services in the face of the pandemic.

This led to missed opportunities for preventive care unrelated to COVID-19, as well as an increased post-pandemic chronic disease burden. In addition, safety (eg, effectiveness of physical examination) and equity (eg, insufficient proactive outreach to vulnerable populations) issues were identified in the remote consultation setting.

Therefore, there is a need for a patient-centered telemedicine approach for people with chronic illnesses, including those with T2D, and treatment options should be suitable for this scenario.

Risk-stratified treatment recommendations

1-Adherence to treatment:

Adherence to treatment in patients with T2D is extremely important, since better adherence is associated with better glycemic control, mortality and hospital admissions.

2-Lifestyle modifications:

As part of their first-line therapy, all T2D patients should be offered individualized and comprehensive lifestyle advice, including weight management, physical activity, dietary guidance, and smoking cessation.


In addition to healthy lifestyle management, newly diagnosed T2D patients should also be treated with metformin at the time of diabetes diagnosis as the first-line drug therapy of choice.

4- Risk assessment in patients with T2D:

CVD represents one of the most prevalent comorbidities of T2D, affecting almost a third of all patients worldwide.

5-Justification of the risk stratification criteria:

Established CVD history is one of the most important and widely recognized predictors of future major adverse cardiovascular events (MACE).

6-Patients with very high cardiovascular risk:

The relationship between glucose lowering and cardiovascular disease has been investigated in diabetes.

Recent years have seen an explosion of new treatment options for T2D, and although there are detailed guidelines to guide specialists in the nuances of T2D treatment, few guidelines are aimed at helping primary care physicians navigate the growing number of options.

This updated position statement has been designed to provide practical advice to primary care physicians around the world to provide the best possible care for their full range of T2D patients.

The author group used a consensus approach to arrive at specific treatment recommendations for T2D patients in various comorbidity categories. To help the busy primary care physician, these recommendations have been summarized in a visual tool.

Source consulted here.

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