‘Living’ guideline advises GPs on use of GLP-1 and SGLT-2 drugs in type 2 diabetes
A rapid evolving guideline has recommended two key drugs be prescribed in all patients with type 2 diabetes who are at higher risk of cardiovascular and kidney complications.
Alongside those at most high risk, SGLT-2 inhibitor and GLP-1 receptor agonist drugs should also be prescribed to ‘most’ adults with type 2 diabetes who fall into the moderate risk category, an international expert panel concluded.
But neither drug option should be used routinely in those at lower risk where doctors will need to make more individual decisions, it added.
In the guideline, lower risk was classed as three or fewer cardiovascular risk factors and no established cardiovascular disease.
Higher risk patients are those with established cardiovascular disease or chronic kidney disease or established heart failure, it said.
For adults with diabetes and obesity, tirzepatide is likely to be the drug of choice – irrespective of a patient’s risk of cardiovascular and kidney complications – because of superior effects on weight loss, the guideline published in the BMJ recommended.
But clinicians will want to take into account the higher certainty of cardiovascular and kidney benefits offered by GLP-1 receptor agonists like semaglutide against larger weight loss benefits from tirzepatide based on a patient’s risk profile ‘as well as their values and preferences’.
For adults at higher risk of cardiovascular and kidney complications, the guidance notes tirzepatide should generally not replace drugs that are effective in reducing that risks.
For adults with diabetes and chronic kidney disease at higher risk of complications, the panel recommended finerenone because the benefits are more likely to outweigh the risks.
But they suggested not using finerenone for those at moderate risk of complications.
The recommendations are based on a ‘living’ systematic review and network meta-analysis that includes data from half a million adults with type 2 diabetes across 869 randomised controlled trials, covering 63 medications.
The approach helps clinicians to stay on top of ‘emerging’ evidence from new and updating clinical trials, they noted.
Future versions of the guideline are likely to look at de-prescribing of medicines that are less effective in reducing cardiovascular risk or are associated with serious adverse events as well as further refining prescribing based on risk stratification.
‘This living guideline prioritises the impact of medications on cardiovascular and kidney complications above effects on HbA1c and other markers of glyacemic control, given that complications are of considerable importance to patients and the growing evidence that intensive lowering of blood glucose does not correlate with large reductions in these complications,’ the panel wrote.
Senior author Professor Per Olav Vandvik from the University of Oslo said: ‘All countries struggle to keep up to date with all these drugs and studies coming out.
‘The record-large systematic review that informs these guidelines illustrate why global collaboration on living evidence is needed to inform policy and practice, like we did for Covid-19.’
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