April 21, 2024

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2022 ADA treatment of diabetes: Metformin is no longer the “king”

2022 ADA treatment of diabetes: Metformin is no longer the “king”


2022 ADA treatment of diabetes: Metformin is no longer the “king”. 

Recently, the American Diabetes Association (ADA) released the “American Diabetes Diagnosis and Treatment Standards in 2022”, which provides new guidance on diabetes detection, medication, care, and monitoring.

Especially in terms of blood sugar control, there are more important adjustments. Metformin, known as the “magic drug” and “basic drug” in the diabetes industry, no longer has the “king” status.

This is very meaningful for the prevention and treatment of diabetes worldwide.


We know that controlling diabetes is mainly to reduce the occurrence of complications. Therefore, the guide vividly describes a comprehensive method to reduce the risk of diabetes-related complications.



Basis: lifestyle intervention

Mainly refers to non-drug therapy, starting from impaired glucose tolerance or diagnosis of diabetes, measures include:

1. Prepare a set of measuring cups and kitchen scales at home, and choose the type and quantity of food strictly according to the doctor’s or diabetes recipe.

2. Limit carbohydrate intake, especially those refined carbohydrates, such as cakes, desserts, milk tea, etc., avoid adding sugar in the diet, and reduce high-calorie, high-fat fast food.

3. Eat more fiber-rich non-starchy vegetables, fruits, whole grains, and dairy products, such as carrots, greens, zucchini or tomatoes, and at least 14 grams of fiber for every 1,000 calories ingested. Eat more lean protein like chicken or tofu, and whole grains like brown rice or quinoa.

4. Control weight. It is recommended that overweight and obese people lose 5%-10% of their current body weight, so that insulin can lower blood sugar levels more effectively. Obesity not only increases the risk of diabetes, but also increases the risk of severe COVID-19.

5. Proper exercise and exercise can promote the muscles to absorb sugar from the blood and help your blood sugar level drop faster after a meal.



Key 1: Blood glucose management


Diabetes patients need to check and monitor blood glucose values ​​regularly, and do regular hemoglobin glycated checks.

Unlike immediate blood glucose indicators, glycosylated hemoglobin can reflect the average blood glucose level of the past three months, so that doctors can know whether the patient’s control is good or bad.


The guideline recommends that under the premise of not causing hypoglycemia, it is recommended to control the glycated hemoglobin value of adults below 7%.

If we can take active and effective measures to keep the glycosylated hemoglobin within a healthy range, then the risk of complications for patients with diabetes, such as nerve damage, eye problems, or heart disease, can be greatly reduced.


First, reduce A1C through diet and exercise. If you do not control well, you must start medication, such as metformin and insulin.


But it should be noted that there is currently no medical evidence that certain foods or health products can reduce the level of glycosylated hemoglobin in diabetic patients.






Key 2: Use drugs that benefit the heart and kidneys


In the past, once drug treatment was started, most patients would be recommended to use metformin because of its good effect and low side effects, and it was widely used as a basic drug.


However, the new guidelines weaken the first-line status of metformin to a certain extent. If diabetes is combined with atherosclerotic cardiovascular diseases, such as coronary heart disease, myocardial infarction, cerebral infarction, cerebral hemorrhage, peripheral arteriosclerosis, etc., or combined with cardiovascular disease For high-risk factors, such as hypertension, hyperlipidemia, obesity, etc., you can first choose GLP-1 receptor agonists or SGLT-2 inhibitors with cardiovascular benefits; if diabetes is complicated by chronic kidney disease, you can first choose to have kidneys A beneficial SGLT-2 inhibitor.


If injection is needed, GLP-1 receptor agonist is preferred instead of insulin, or a combination of the two can be used.


According to statistics, 70% of diabetic patients in some countries have cardiovascular disease or high cardiovascular risk factors.

In other words, most patients with type 2 diabetes should use the two new drugs as first-line hypoglycemic drugs instead of metformin.


Of course, if there is no cardiovascular and renal disease, metformin can still be the first choice.

Metformin should also continue to be used after insulin therapy is started, which is beneficial for controlling blood sugar and metabolism.





Key 3: Blood pressure management


Hypertension is one of the common complications or concomitant diseases of diabetes. About 30% of patients with type 2 diabetes in outpatient clinics in some countries have hypertension.


The coexistence of diabetes and hypertension can significantly increase the risk of occurrence and progression of cardiovascular disease, stroke, nephropathy and retinopathy, and also increase the mortality rate of diabetic patients. Conversely, controlling high blood pressure can significantly reduce the risk of diabetes complications.


Generally speaking, if the blood pressure of diabetic patients is ≥140/90mmHg, it is necessary to consider starting drug antihypertensive treatment; if it is ≥160/100mmHg, antihypertensive drug treatment must be started immediately, and blood pressure should be controlled to <140/90mmHg.


Five types of antihypertensive drugs (ACEI, ARB, diuretics, calcium antagonists, β-blockers) can be used for diabetic patients, of which ACEI or ARB is the first choice and the basic drug in the combined antihypertensive program.




Pillar 4: Blood Lipid Management


Type 2 diabetes is an independent risk factor for atherosclerotic cardiovascular disease, and the incidence of dyslipidemia is significantly higher than that of non-diabetic patients.

The proportion of type 2 diabetes patients with dyslipidemia in some countries is high, but the treatment rate and compliance rate are low. Therefore, patients with type 2 diabetes should strengthen blood lipid management.


Accompanied by multiple cardiovascular risk factors (male ≥40 years old or female after menopause, smoking, obesity, family history of ischemic cardiovascular disease, etc.), blood lipids should be monitored every 3 months after the diagnosis of type 2 diabetes.

For patients with type 2 diabetes with dyslipidemia, under lifestyle intervention and drug therapy, blood lipids are monitored every 4 to 12 weeks, and blood lipids are monitored every 3 to 12 months thereafter.




SGLT-2 and LP-1


SGLT-2 inhibitors inhibit the reabsorption of glucose by the kidneys and promote urinary glucose excretion, thereby achieving the effect of lowering blood sugar without increasing the risk of hypoglycemia.

Studies have shown that it can significantly reduce the risk of major cardiovascular adverse events and renal events, and patients with moderate renal insufficiency can also use it in a reduced amount.

Currently, the approved SGLT-2 inhibitors for clinical use in some countries include dapagliflozin, enpagliflozin and canagliflozin.


GLP-1 receptor agonists can enhance insulin secretion, inhibit glucagon secretion, and delay gastric emptying, reduce food intake through central appetite suppression, significantly reduce body weight, improve blood lipids and blood pressure, without increasing Risk of hypoglycemia.

The GLP-1 receptor agonists currently on the market in China include exenatide, liraglutide, risnaglutide, and benaglutide, all of which require subcutaneous injection.






2022 ADA treatment of diabetes: Metformin is no longer the “king”

(source:internet, reference only)

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