Oakland Southfield Physicians

OSP News

Treatment Advances in Type 2 Diabetes

Posted: 05/27/2021

New Glycated Hemoglobin (A1c) Targets

Updated goals from the American Diabetes Association

  • Global: <7%
  • Healthy adults ≥ 55: < 7% - 7.5%
  • Complex patients: < 8%
  • Very complex patients: no target (avoid hypoglycemia and symptomatic hyperglycemia)

Chronic Kidney Disease (CKD)

  • A1c accuracy and precision declines with advanced CKD, in dialysis, or when using erythropoietin-stimulating agents
    • Glucose management derived from Continuous Glucose Monitoring (CGM) may be useful
  • Individualize A1c targets from < 6.5% to < 8.0% based on comorbidities
  • Metformin plus a sodium-glucose cotransporter 2 inhibitor (SGLT2i) can be used as a first-line treatment
  • Avoid SGLT2i treatment if the patient has an estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73m2 and stop SGLT2i in dialysis
  • Preferred agents for patients with a low eGFR are a DPP-4 inhibitor, insulin, or a thiazolidinedione
  • Preferred add-on agent for all patients is a long acting GLP-1 receptor agonist


Major risk factors include advancing age, elevated nonhigh-density lipoprotein cholesterol (HDL-C), elevated LDL-C, reduced HDL-C, diabetes, hypertension, CKD, cigarette use, or family history of atherosclerotic cardiovascular disease (ASCVD).

  • High Risk: Diabetes with No Risk Factors
    • LDL-C goal is 100 mg/dL
    • Triglyceride (TG) goal is < 150 mg/dL
    • Recommended treatment is a moderate- to high-intensity statin as needed
  • Very High Risk: Diabetes with 1 or More Risk Factors
    • LDL-C goal is < 70 mg/dL
    • TG goal is < 150 mg/dL
    • Add ezetimibe, a PCKS9 inhibitor, colesevelam, or bempedoic acid, depending on LDL needs
  • Extreme Risk: Diabetes with established clinical ASCVD
    • LDL-C goal is < 55 mg/dL
    • TG goal is < 150 mg/dL
    • Add a PCKS9 inhibitor, ezetimibe, colesevelam, or bempedoic acid, depending on LDL needs
    • For patients with diabetes, 2 or more risk factors and TG 135-499 mg/dL, add icosapent ethyl

Heart Failure

  • For patients with heart failure with reduced ejection fraction (HFrEF), left ventricle ejection fraction less than 45%, the ADA recommends a SGLT2i with proven heart failure benefits
  • Dapagliflozin and Empagliflozin have primary heart failure outcome data
  • Empagliflozin, Canagliflozin, and Dapagliflozin have shown reduction in heart failure and reduction of CKD progression in cardiovascular outcome trials


  • The 2021 ADA guidelines introduced a new concept: overbasalization, which is characterized as an excessive basal dose of insulin
    • Overbasalization is a potential concern anytime the basal dose exceeds 0.5 units/kg/d
    • Any indication of overbasalization should prompt reevaluation of insulin dosing to reduce glucose variability
  • Too much basal insulin can overcorrect fasting glucose levels, which then rebound to excessive levels. Examples include:
    • Elevated bedtime-morning glucose differential, greater than 50 mg/dL
    • Elevated post-preprandial differential, hypoglycemia, and high glucose variability

New Agents in the Pipeline

  • Tirzepatide - a once-weekly “twincretin” combination of a GLP-1 receptor agonist and a glucose-dependent insulinotropic polypeptide, showed solid phase 3 data in T2D. A cardiovascular outcomes trial is ongoing
  • Insulin icodec - a once-weekly basal insulin, showed efficacy and safety profiles similar to once-daily insulin glargine U100 in T2D


  1. https://www.drugtopics.com/view/diabetes-treatment-guidelines-practices-advance-despite-covid-19-focus-in-health-care
  2. Smith JD. New and approved: your annual diabetes update. Presented at: American Pharmacists Association 2021 Annual Meeting and Exposition; March 12-15, 2021; virtual. Accessed March 12, 2021. https://apha2021.pharmacist.com/ 


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