Portuguese-Brazilian evidence-based guideline on the management of hyperglycemia in type 2 diabetes mellitus

• Published in: Diabetology and metabolic syndrome 2020-05, Vol.12 (1), p.45-30, Article 45
• Main Authors: Bertoluci, Marcello Casaccia, Salles, João Eduardo Nunes, Silva-Nunes, José, Pedrosa, Hermelinda Cordeiro, Moreira, Rodrigo Oliveira, da Silva Duarte, Rui Manuel Calado, da Costa Carvalho, Davide Mauricio, Trujilho, Fábio Rogério, Dos Santos Raposo, João Filipe Cancela, Parente, Erika Bezerra, Valente, Fernando, de Moura, Fábio Ferreira, Hohl, Alexandre, Melo, Miguel, Araujo, Francisco Garcia Pestana, de Araújo Principe, Rosa Maria Monteiro Castro, Kupfer, Rosane, Costa E Forti, Adriana, Valerio, Cynthia Melissa, Ferreira, Hélder José, Duarte, João Manuel Sequeira, Saraiva, José Francisco Kerr, Rodacki, Melanie, Castelo, Maria Helane Costa Gurgel, Monteiro, Mariana Pereira, Branco, Patrícia Quadros, de Matos, Pedro Manuel Patricio, de Melo Pereira de Magalhães, Pedro Carneiro, Betti, Roberto Tadeu Barcellos, Réa, Rosângela Roginski, Trujilho, Thaisa Dourado Guedes, Pinto, Lana Catani Ferreira, Leitão, Cristiane Bauermann
• Format: Article
• Language: English
• Subjects: Analysis; Angina pectoris; Antidiabetics; Arteriosclerosis; Atherosclerosis; Blood glucose; Cardiac patients; Cardiovascular disease; Cardiovascular diseases; Cardiovascular risk; Care and treatment; Chronic kidney disease; Chronic kidney failure; Clinical trials; Congestive heart failure; Diabetes; Diabetes mellitus (non-insulin dependent); Diabetes therapy; Diabetes treatment; Diabetics; Disease prevention; Endocrinology; Epidermal growth factor receptors; Evidence-based medicine; Expert evidence; Glomerular filtration rate; Glucose; Guidelines; Health aspects; Heart attacks; Heart diseases; Heart failure; Hyperglycemia; Hypoglycemia; Hypoglycemic agents; Insulin; Ischemia; Kidney diseases; Metformin; Mortality; Patients; Pioglitazone; Practice guidelines (Medicine); Renal failure; Renal function; Review; Stroke; Type 2 diabetes
• ISSN: 1758-5996; 1758-5996
• DOI: 10.1186/s13098-020-00551-1

In current management of type 2 diabetes (T2DM), cardiovascular and renal prevention have become important targets to be achieved. In this context, a joint panel of four endocrinology societies from Brazil and Portugal was established to develop an evidence-based guideline for treatment of hyperglycemia in T2DM. MEDLINE (via PubMed) was searched for randomized clinical trials, meta-analyses, and observational studies related to diabetes treatment. When there was insufficient high-quality evidence, expert opinion was sought. Updated positions on treatment of T2DM patients with heart failure (HF), atherosclerotic CV disease (ASCVD), chronic kidney disease (CKD), and patients with no vascular complications were developed. The degree of recommendation and the level of evidence were determined using predefined criteria. In non-pregnant adults, the recommended HbA target is below 7%. Higher levels are recommended in frail older adults and patients at higher risk of hypoglycemia. Lifestyle modification is recommended at all phases of treatment. Metformin is the first choice when HbA is 6.5-7.5%. When HbA is 7.5-9.0%, dual therapy with metformin plus an SGLT2i and/or GLP- RA (first-line antidiabetic agents, AD1) is recommended due to cardiovascular and renal benefits. If an AD1 is unaffordable, other antidiabetic drugs (AD) may be used. Triple or quadruple therapy should be considered when HbA remains above target. In patients with clinical or subclinical atherosclerosis, the combination of one AD1 plus metformin is the recommended first-line therapy to reduce cardiovascular events and improve blood glucose control. In stable heart failure with low ejection fraction ( 30 mL/min/1.73 m , metformin plus an SGLT-2i is recommended to reduce cardiovascular mortality and heart failure hospitalizations and improve blood glucose control. In patients with diabetes-associated chronic kidney disease (CKD) (eGFR 30-60 mL/min/1.73 m or eGFR 30-90 mL/min/1.73 m with albuminuria > 30 mg/g), the combination of metformin and an SGLT2i is recommended to attenuate loss of renal function, reduce albuminuria and improve blood glucose control. In patients with severe renal failure, insulin-based therapy is recommended to improve blood glucose control. Alternatively, GLP- RA, DPP4i, gliclazide MR and pioglitazone may be considered to reduce albuminuria. In conclusion, the current evidence supports individualizing anti-hyperglycemic treatment