Where does metformin stand in modern day management of type 2 diabetes?

Metformin is the most commonly used glucose-lowering therapy (GLT) worldwide and remains the first-line therapy for newly diagnosed individuals with type 2 diabetes (T2D) in management algorithms and guidelines after the UK Prospective Diabetes Study (UKPDS) showed cardiovascular mortality benefits in the overweight population using metformin. However, the improved Major Adverse Cardiovascular Events (MACE) realised in some of the recent large cardiovascular outcomes trials (CVOTs) using sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) have challenged metformin’s position as a first-line agent in the management of T2D. Many experts now advocate revising the existing treatment algorithms to target atherosclerotic cardiovascular disease (ASCVD) and improving glycaemic control as a secondary aim. In this review article, we will revisit the major cardiovascular outcome data for metformin and include a critique of the UKPDS data. We then review additional factors that might be pertinent to metformin’s status as a first-line agent and finally answer key questions when considering metformin’s role in the modern-day management of T2D

IDF2022-0579 Post COVID-19 diabetes project: Intensive cardio-renal-metabolic management for people living with type 2 diabetes (T2D)

Background Type 2 diabetes (T2D) increases morbidity and mortality risk related to COVID-19 [1,2]. People with T2D affected by COVID-19 therefore require intensive targeting of metabolic risk factors to mitigate this risk and improve outcomes. Aim The intensive multidisciplinary (MDT) project aimed to improve metabolic risk profile and emotional wellbeing in people with T2D who had severe COVID-19 by adopting a holistic approach. Method The 12-month project, comprised of MDT clinics, development of referral pathways and resource building. Patients were risk-stratified and modifiable risk factors including HbA1c, weight, blood pressure, lipids and the Patient Health Questionnaire-9 depression scale (PHQ-9) were collected at baseline (first clinic appointment) and follow-up (discharge) for patients for whom at least 3-months of data was available. Linear regression assessed change from baseline for all variables. Results Baseline data were collected (N = 61; male 57.4%). 56 had confirmed COVID-19. Median age was 57 years and median T2D duration was 7 years. 52.5% belonged to minority ethnic groups. A significant reduction in HbA1c, weight and PHQ-9 scores were observed at follow-up (Table 1). Use of sodium–glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 agonists (GLP-1RA) was associated with greater reductions in HbA1c and weight. Conclusion Intensive MDT care was beneficial in improving metabolic risk profile and emotional well-being in people with T2D following COVID-19, indicating that holistic approach targeting multiple risk factors improves physical and psychological outcomes for people with T2D.</p

The effects of weight-lowering pharmacotherapies on physical activity, function and fitness: A systematic review and meta-analysis of randomized controlled trials

Weight-lowering pharmacotherapies provide an option for weight management; however, their effects on physical activity, function, and cardiorespiratory fitness are not fully understood. We conducted a systematic review and meta-analysis of randomized controlled trials to investigate the effect of licensed weight loss pharmacotherapies on physical activity, physical function, and cardiorespiratory fitness in individuals with obesity. Fourteen trials met our prespecified inclusion criteria: Five investigated liraglutide, four semaglutide, three naltrexone/bupropion, and two phentermine/topiramate. All 14 trials included a self-reported measure of physical function, with the pooled findings suggesting an improvement favoring the pharmacotherapy intervention groups (SMD: 0.27; 95% CI: 0.22 to 0.32) and effects generally consistent across different therapies. Results were also consistent when stratified by the two most commonly used measures: The Short-Form 36-Item Questionnaire (SF-36) (0.24; 0.17 to 0.32) and the Impact of Weight on Quality Of Life-Lite (IWQOL-Lite) (0.29; 0.23 to 0.35). Meta-regression confirmed a significant association between pharmacotherapy induced weight loss and improved physical function for IWQOL-Lite (p = 0.003). None of the studies reported a physical activity outcome, and only one study reported objectively measured cardiorespiratory fitness. Improvements in self-reported physical function were observed with weight loss therapy, but the effect on physical activity or objectively measured physical function and fitness could not be determined

Recommendations for Management of Diabetes during Ramadan: update 2020, applying the principles of the ADA/EASD Consensus

Fasting the Holy month of Ramadan constitutes one of the five pillars of the Muslim faith.Although there is some evidence that intermittent fasting during Ramadan may be of benefit in losing weight and cardiometabolic risk factors, there is no strong evidence these benefits apply to people with diabetes. The ADA/EASD consensus recommendations emphasize the importance of patient factors and co-morbidities when choosing diabetes medications including the presence of co-morbidities, atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), chronic kidney disease (CKD), hypoglycaemia risk, weight issues and costs.Structured education and pre-Ramadan counselling are key components to successful management of patients with diabetes. These should cover important aspects like glycaemic targets, self-monitoring of blood glucose (SMBG), diet, physical activity including Taraweeh prayers, medication and dose adjustment, side effects and when to break the fast. The Decision Cycle in figure 1 adapted for the specific situation of Ramadan provides an aid for such an assessment.Children with type 1 diabetes should strongly be advised not to fast due to the high risk of acute complications such as hypoglycaemia and probably diabetic ketoacidosis (DKA), although there is very little evidence that DKA is increased in Ramadan. [1]Pregnant women with diabetes or gestational diabetes should be advised to avoid fasting because of possible negative maternal and fetal outcomes.Hypoglycaemia is a common concern during Ramadan fasting. To prevent hypoglycaemic and hyperglycaemic events, we recommend the adoption of diabetes self-management education and support (DSMES) principles.The use of the emerging technology and continuous glucose monitoring (CGM) during Ramadan could help to recognize hypoglycaemic and hyperglycaemic complications related to omission and/or medication adjustment during fasting; however, the cost represents a significant barrier. </p