Algorithm for Choosing Antidiabetics in Patients with Type 2 Diabetes
As of June 1, 2020, general practitioners can prescribe antidiabetics from the group of so-called gliptins, inhibitors of the enzyme dipeptidyl peptidase 4 (DPP-4i), in addition to metformin. The cornerstone of type 2 diabetes mellitus treatment remains a comprehensive lifestyle modification (dietary measures, increased physical activity, weight reduction) and metformin as the first-line drug. In selected comorbidities or if these measures do not lead to the desired glycated hemoglobin (HbA1c) level after 3-6 months, the following recommendations can be followed. However, it is essential to remember that the recommendations of professional societies do not always correspond to the prescription limitations of the State Institute for Drug Control (SÚKL).
- Patients without severe comorbidities: SGLT-2 inhibitors, DPP-4 inhibitors, thiazolidinediones, sulfonylurea derivatives, basal insulin.
- Patients with an increased risk of hypoglycemia (elderly individuals, patients with uneven food intake): DPP-4 inhibitors, GLP-1 receptor agonists, SGLT-2 inhibitors, thiazolidinediones; these can be combined with each other or with sulfonylurea derivatives or basal insulin.
- Obese patients: SLGT-2 inhibitors or GLP-1 receptor agonists, subsequently possibly in combination; moreover, these can be combined with DPP-4 inhibitors, sulfonylurea derivatives, thiazolidinediones, basal insulin.
- Patients with heart failure with reduced ejection fraction (left ventricular ejection fraction < 45%) or chronic kidney disease (estimated glomerular filtration 30–60 ml/min = 0.5–1 ml/s, or albumin/creatinine ratio in urine > 30 mg/g): SGLT-2 inhibitors (adequate eGFR required) or GLP-1 receptor agonists; these can also be combined with DPP-4 inhibitors (except saxagliptin), basal insulin, or sulfonylurea derivatives.
- Patients with high CV risk (history of cardiovascular disease – myocardial infarction, stroke, any revascularization; signs of atherosclerosis – transient ischemic attack, unstable angina, limb amputation, NYHA II-III dyspnea, > 50% stenosis of any artery, chronic kidney disease with eGFR < 60 ml/min): GLP-1 receptor agonists or SLGT-2 inhibitors (adequate eGFR required); these can also be combined with DPP-4 inhibitors, basal insulin, thiazolidinediones, or sulfonylurea derivatives.
In the first two cases (CV disease or risk, HFrEF or CKD) we consider therapy intensification, possibly starting combination therapy right away, regardless of the current or target HbA1c level. In other cases, therapy intensification is due to insufficient compensation.
The procedure has been simplified for maximum benefit and practical usability and does not contain exhaustive information.
(epa)
Sources:
1. Davies M. J., D’Alessio D. A., Fradkin J. et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2018; 61: 2461–2498, doi: 10.1007/s00125-018-4729-5.
2. Karen I., Svačina Š. Diabetes mellitus. Novelizace 2020. Doporučené diagnostické a terapeutické postupy pro všeobecné praktické lékaře. Centrum doporučených postupů pro praktické lékaře, Společnost všeobecného lékařství ČLS JEP, 2020. Available at: www.svl.cz/files/files/Doporucene-postupy/2020/DIABETES-MELLITUS-2020.pdf
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