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Hyuk-Sang Kwon

The Catholic University of Korea

page/practice-guidelines-resources https://www.aace.com/pub lications/algorithm

Contents

History of Diabetes Guidelines

A1C, BP & Lipid target goal in diabetes

ADA & EASD Consensus Algorithm

SGLT2 inhibitors and GLP-1 RAs in ASCVD, HF & CKD

Special Focus on Older Adults

Contents

History of Diabetes Guidelines

A1C, BP & Lipid target goal in diabetes

ADA & EASD Consensus Algorithm

SGLT2 inhibitors and GLP-1 RAs in ASCVD, HF & CKD

Special Focus on Older Adults

ADA, American Diabetes Association; EASD, European Association for the Study of Diabetes.

Nathan DM et al. Diabetes Care 2006;29:19632006

ADA, American Diabetes Association; EASD, European Association for the Study of Diabetes.

Nathan DM et al. Diabetes Care 2006;29:19632006

History of ADA/EASD consensus statement

A Consensus Algorithm for the Initiation and Adjustment of Therapy ADA, American Diabetes Association; EASD, European Association for the Study of Diabetes.

Nathan DM et al. 2009 Jan; 32(1): 193ʹ203

2009

History of ADA/EASD consensus statement

A Consensus Algorithm for the Initiation and Adjustment of Therapy ADA, American Diabetes Association; EASD, European Association for the Study of Diabetes.

Inzucchi SE et al. Diabetes Care 2012;35:13642012

History of ADA/EASD consensus statement

ADA, American Diabetes Association; EASD, European Association for the Study of Diabetes.

InzucchiSE et al. Diabetes Care 2015;35:1402015

History of ADA/EASD consensus statement

ADA/EASD consensus report in 2018

20152018

EASD

Sept 2015

ADA

Jun 2016

EASD

Sept 2016

ADA

Jun 2017

EASD

Sept 2017

EASD

Oct 2018

ADA

Jun 2018

Contents

History of Diabetes Guidelines

A1C, BP & Lipid target goal in diabetes

ADA & EASD Consensus Algorithm

SGLT2 inhibitors and GLP-1 RAs in ASCVD, HF & CKD

Special Focus on Older Adults

A1C targetsin various international guidelines

OrganizationTarget of HbA1c

American Diabetes Association(ADA) 2019< 7.0%

American Association of Clinical Endocrinologists & American College of Endocrinology(AACE/ACE) 2019чϲ͘ϱй International Diabetes Federation (IDF) 2017< 7.0%

Japan diabetes society(JDS) 2017< 7.0%

Canadian Diabetes Association(CDA) 2018чϳ͘Ϭй National Institute for Health and Care Excellence (NICE, UK) 2017

KoreanDiabetes Association (KDA) 2019

< 6.5% < 6.5% 11

American Diabetes Association 2019

Data from ref. 1

For individuals with diabetes and hypertension at lower CV risk (10-year ASCVD risk < 15%), treat to a blood pressure target of <140/90 mmHg. A For individuals with diabetes and hypertension at higher CV risk (existing ASCVD or 10-year ASCVD risk > 15%), a blood pressure target of <130/80 mmHg may be appropriate, if it can be safely attained. C

ADA guidelines for lipid control in diabetes 2019

(Moderate-intensity statin may be considered based on risk- benefit profile and presence of ASCVD risk factors)

Contents

History of Diabetes Guidelines

A1C, BP & Lipid target goal in diabetes

ADA & EASD Consensus Algorithm

SGLT2 inhibitors and GLP-1 RAs in ASCVD, HF & CKD

Special Focus on Older Adults

ADA & EASD Treatment algorithm 2019

ADA & EASD Treatment algorithm 2019

ADA & EASD Treatment algorithm 2019

ADA & EASD Treatment algorithm 2019

Published in 31 August 2019

Treatment targets in diabetes

2019 ESC Guidelines on diabetes, pre

diabetes, and cardiovascular diseases

European Heart Journal (2019)

CV = cardiovascular; CVD = cardiovascular disease; DM = diabetes mellitus; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus

a Modified from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice

b Proteinuria, renal impairment defined as eGFR <30 mL/min/1.73 m2, left ventricular hypertrophy, or retinopathy

c Age, hypertension, dyslipidemia, smoking, obesity

Treatment targets in diabetes

2019 ESC Guidelines on diabetes, pre

diabetes, and cardiovascular diseases

European Heart Journal (2019)

CV = cardiovascular; CVD = cardiovascular disease; DM = diabetes mellitus; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus

a Modified from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice

b Proteinuria, renal impairment defined as eGFR <30 mL/min/1.73 m2, left ventricular hypertrophy, or retinopathy

c Age, hypertension, dyslipidemia, smoking, obesity

Contents

History of Diabetes Guidelines

A1C, BP & Lipid target goal in diabetes

ADA & EASD Consensus Algorithm

SGLT2 inhibitors and GLP-1 RAs in ASCVD, HF & CKD

Special Focus on Older Adults

Older Adults:

Standards of Medical Care in Diabetes 2019

Japanese Diabetes Society 2016

Modified from ref. 1

*1 When targets can be attained by appropriate MNT or physical activity/exercise, or during pharmacotherapy without the occurrence of side effects such as hypoglycemia. *2 From the

perspective of preventing complication, HbA1c target value is set at <7%. A fasting blood glucose level <130 mg/dL(7.2 mmol/L) and a 2-h postprandial blood glucose level <180 mg/dL(10.0

mmol/L) can be used as an approximate guideline for the corresponding blood glucose levels. *3 When intensification of treatment is considered difficult due to side effects such as

hypoglycemia or for other reasons.

TargetTarget when aiming for

normal glycemia*1Target when aiming to prevent complication *2Target when intensification of therapy considered difficult *3

HbA1c (%)<6.0< 7.0< 8.0

Patient

background/ health status [1]

Use of drugs

potentially associated with severe hypoglycemia (e.g.insulin, sulfonylureas, glinides)

1. Intact cognitive function

2. No impairment of ADL

For older patients, the glycemic target is to be determined for each patient by taking into account his/her age, duration of diabetes, risk of hypoglycemia, and any support available to the patient, as well

ǯǡȀȋȌǡȀments, while noting the potential risk of hypoglycemia that increases with age in

each patient. and No [2] Yes [3]

1. Moderate or severe dementia

2. Impairment(s) of basic ADL

3. Presence of multiple comorbidities

of functional impairments or or

1.Mild cognitive impairment to

mild dementia or

2. Impairment(s) of instrumental

ADL, no impairment of basic ADL

J Clin Endocrinol Metab 104: 1Ȃ55, 2019

Conceptual Framework for Considering Overall Health and Patient Values in Determining Clinical Targets in Adults Aged 65 y and Older

J Clin Endocrinol Metab 104: 1Ȃ55, 2019

New findings from cardiovascular safety or outcome trial have changed diabetes guideline and it leads the paradigm shift in the concept of anti-diabetes medications. Individualization is the most important thing to be considered in the management of diabetes. Simple approach and less stringent target should be needed in older adults with diabetes. Take

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