2023 UPDATE: Luso-Brazilian evidence-based guideline for the management of antidiabetic therapy in type 2 diabetes
Authors: Bertoluci Marcello Casaccia , Silva Júnior Wellington S. , Valente Fernando , Araujo Levimar Rocha , Lyra Ruy , de Castro João Jácome , Raposo João Filipe , Miranda Paulo Augusto Carvalho , Boguszewski Cesar Luiz , Hohl Alexandre , Duarte Rui , Salles João Eduardo Nunes , Silva-Nunes José , Dores Jorge , Melo Miguel , de Sá João Roberto , Neves João Sérgio , Moreira Rodrigo Oliveira , Malachias Marcus Vinícius Bolívar , Lamounier Rodrigo Nunes , Malerbi Domingos Augusto , Calliari Luis Eduardo , Cardoso Luis Miguel , Carvalho Maria Raquel , Ferreira Hélder José , Nortadas Rita , Trujilho Fábio Rogério , Leitão Cristiane Bauermann , Simões José Augusto Rodrigues , dos Reis Mónica Isabel Natal , Melo Pedro , Marcelino Mafalda , Carvalho Davide 
Published: July 2023

Background

The management of antidiabetic therapy in people with type 2 diabetes (T2D) has evolved beyond glycemic control. In this context, Brazil and Portugal defined a joint panel of four leading diabetes societies to update the guideline published in 2020.

Methods

The panelists searched MEDLINE (via PubMed) for the best evidence from clinical studies on treating T2D and its cardiorenal complications. The panel searched for evidence on antidiabetic therapy in people with T2D without cardiorenal disease and in patients with T2D and atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or diabetic kidney disease (DKD). The degree of recommendation and the level of evidence were determined using predefined criteria.

Results and conclusions

All people with T2D need to have their cardiovascular (CV) risk status stratified and HbA1c, BMI, and eGFR assessed before defining therapy. An HbA1c target of less than 7% is adequate for most adults, and a more flexible target (up to 8%) should be considered in frail older people. Non-pharmacological approaches are recommended during all phases of treatment. In treatment naïve T2D individuals without cardiorenal complications, metformin is the agent of choice when HbA1c is 7.5% or below. When HbA1c is above 7.5% to 9%, starting with dual therapy is recommended, and triple therapy may be considered. When HbA1c is above 9%, starting with dual therapyt is recommended, and triple therapy should be considered. Antidiabetic drugs with proven CV benefit (AD1) are recommended to reduce CV events if the patient is at high or very high CV risk, and antidiabetic agents with proven efficacy in weight reduction should be considered when obesity is present. If HbA1c remains above target, intensification is recommended with triple, quadruple therapy, or even insulin-based therapy. In people with T2D and established ASCVD, AD1 agents (SGLT2 inhibitors or GLP-1 RA with proven CV benefit) are initially recommended to reduce CV outcomes, and metformin or a second AD1 may be necessary to improve glycemic control if HbA1c is above the target. In T2D with HF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and mortality and to improve HbA1c. In patients with DKD, SGLT2 inhibitors in combination with metformin are recommended when eGFR is above 30 mL/min/1.73 m2. SGLT2 inhibitors can be continued until end-stage kidney disease.