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New Type 2 Diabetes Guideline, Expanded Use of Metformin, New Terminology for Obesity

Discussion in 'Endocrinology' started by Dr.Scorpiowoman, Feb 27, 2017.

  1. Dr.Scorpiowoman

    Dr.Scorpiowoman Golden Member

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    New ACP Guideline: Management of Patients With Type 2 Diabetes

    First, in updated guidelines, the American College of Physicians (ACP) reinforces its recommendation that metformin is the best first-line oral therapy for patients with type 2 diabetes.

    This is important because despite the benefits of effective blood glucose lowering, weight loss, less hypoglycemia, and cost, metformin remains underutilized. It's prescribed to only about half of all insured patients with type 2 diabetes.

    If a second agent is required, consider adding one of these four class options:

    • Sulfonylureas

    • Thiazolidinediones

    • SGLT2 inhibitors

    • DPP-4 inhibitors
    They are all supported by moderate-quality evidence from comparative-effectiveness studies.

    Evidence from cardiovascular outcomes trials was not considered in this guideline.

    However, ACP president Nitin Damle, MD, notes that SGLT2 inhibitors and DPP-4 inhibitors may be favored in certain situations.

    It's important to note that these guidelines do not include insulin or other injectables, options that will ideally be addressed as we face the growing epidemic of type 2 diabetes.

    Metformin: Time to Remove Some Restrictions?

    Our next topic continues the conversation about metformin. A new study shows that metformin can benefit many patients who have historically been kept from using it.


    In the past, metformin has not been recommended for those with chronic kidney disease (CKD), congestive heart failure (CHF), and chronic liver disease with hepatic impairment.

    However, an analysis of 17 observational studies found that metformin is associated with lower mortality in type 2 diabetes patients with these comorbidities. It is also associated with fewer CHF hospitalizations and a lower risk for hypoglycemia in patients with CKD. Emerging data suggest that concerns about lactic acidosis in patients with these chronic conditions are largely unfounded.

    In fact, in April, the FDA removed language recommending against use of metformin in patients with mild—and in some cases, moderate—CKD. These new data bolster support for expanded use of metformin in type 2 diabetes.

    Obesity by Any Other Name...

    And finally, clinicians may soon have a new term to use in the medical diagnosis of obesity: adiposity-based chronic disease (ABCD).


    The American Association of Clinical Endocrinologists and the American College of Endocrinology believe that this new terminology may help to better frame obesity as a far-reaching, complications-centric chronic disease. The new terminology is part of a broader effort by the two organizations to create relevant complication-based ICD-10 coding that will facilitate reimbursement, implementation, and quality metrics. They hope to improve processes for evaluation and management of obesity and its complications. Lifestyle medicine is a key focus beyond just a first step in treating obesity.

    Finally, noting the inadequacy of body mass index (BMI) as the only measure of obesity, they hope to spur research into other metrics for measuring the disease.

    So, a heads-up that there may be changes in the not-too-distant future.

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