Portuguese-Brazilian evidence-based guideline on the management of hyperglycemia in type 2 diabetes mellitus
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 
Published: May 2020

Background

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.

Methods

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.

Results and conclusions

In non-pregnant adults, the recommended HbA1ctarget 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 HbA1cis 6.5–7.5%. When HbA1cis 7.5–9.0%, dual therapy with metformin plus an SGLT2i and/or GLP-1RA (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 HbA1cremains 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 (< 40%) and glomerular filtration rate (eGFR) > 30 mL/min/1.73 m2, 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 m2or eGFR 30–90 mL/min/1.73 m2with 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-1RA, DPP4i, gliclazide MR and pioglitazone may be considered to reduce albuminuria. In conclusion, the current evidence supports individualizing anti-hyperglycemic treatment for T2DM.