New international recommendations for type 2 diabetes – consequences for treatment practice in Norway?

New international recommendations for the use of anti-hyperglycaemic drugs in patients with type 2 diabetes are at odds with current practice in Norway and the Norwegian Directorate of Health's national clinical guidelines.

New knowledge indicates that changes are needed in the traditional treatment of patients with type 2 diabetes. Anti-hyperglycaemic drugs that belong to the SGLT2 inhibitor groups (sodium-glucose cotransporter-2 inhibitors) and GLP-1 receptor agonists (glucagon-like peptide-1 receptor agonists) have been shown to reduce cardiovascular events, progression of kidney disease and mortality (1–3). Weight reduction as a result of intensive caloric restriction or bariatric surgery can lead to remission of diabetes in a significant number of patients (4, 5), and is proposed as a new primary treatment goal (6). In addition, new medications will soon be available in Norway which show a documented reduction in blood glucose levels and, in particular, a reduction in body weight that far surpasses previous findings (7, 8).

Weight reduction as a result of intensive caloric restriction or bariatric surgery can lead to remission of diabetes in a significant number of patients, and is proposed as a new primary treatment goal

Several international clinical guidelines with relevance for doctors and patients in Norway have now been revised based on this knowledge (9–12). The European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) recently published updated consensus recommendations for the management of type 2 diabetes (9). The aim of the treatment is to prevent complications and optimise quality of life. The recommendations emphasise a holistic, person-centred approach to managing type 2 diabetes and the importance of good communication between healthcare professionals and patients and of using language that is non-stigmatising and based on facts (e.g. not using words such as diabetic and non-compliant). Emphasis is placed on combating health inequalities and promoting universal access to treatment. The recommendations also have a strong focus on the importance of weight reduction as a cornerstone of treatment, and a summary is given of new knowledge generated from several cardiorenal outcome studies.

The most important changes in the pharmacological treatment of hyperglycaemia include the recommendation that SGLT2 inhibitors or GLP1 receptor agonists 'should' be prescribed for people with established cardiovascular disease and 'could' be prescribed for patients at high risk of such disease, regardless of their HbA1c level and of whether they are already using metformin. About one-third of patients with type 2 diabetes have a diagnosed cardiovascular disease. However, the number in the risk group depends on the criteria applied.

For patients with obesity, a weight reduction of 10–15 % is recommended as an important part of the treatment (the current recommendation is 5–10 %). This can normalise blood glucose levels without the need for medication in a significant proportion of patients, but will mean that many patients will require more intensive intervention than they currently receive. The DiRECT study showed that 46 % of patients with established type 2 diabetes were normoglycaemic without medication one year after participating in an intensive low-calorie weight management programme within primary care (4). Several studies, including a randomised controlled trial conducted in Norway (5), have shown remission in 60–70 % of patients after bariatric surgery for morbid obesity. Recently published studies using semaglutide 2.4 mg/week (7) and tirzepatide (8), which are expected to be available in Norway soon, show an average weight reduction of around 10 %, and a large proportion of patients achieved a weight reduction in excess of 15 %. We believe that a broad and open debate is now needed on the use of and funding for such medication, involving users, GPs, specialists and the authorities. It is now three years since the European Society of Cardiology (ESC), in collaboration with the EASD, published its guidelines on diabetes, pre-diabetes and cardiovascular diseases (10). These guidelines obviously have a different and broader approach to cardiovascular diseases than the aforementioned recommendations, but they are largely consistent with them. However, they go further than the EASD and ADA's guidelines in omitting metformin as the medication of first choice for treating hyperglycaemia in people with established or a high risk of cardiovascular disease. They also include more patients in the latter category.

We believe that a broad and open debate is now needed on the use of and funding for such medication (semaglutide and tirzepatide)

Heart failure and chronic kidney disease are common major complications of type 2 diabetes and lead to increased mortality and high costs (13, 14). Consequently, the guidelines for these conditions have also been updated (11, 15). Perhaps the most important recommendation in the guidelines for chronic kidney disease is the clear advice to screen for the condition through regular measurements of the urinary albumin/creatinine ratio (UACR) in addition to estimated glomerular filtration rate (eGFR) in all patients with type 2 diabetes. In relation to pharmacological treatment, the Kidney Disease: Improving Global Outcomes (KDIGO) organisation draws attention to new evidence related to the use of SGLT2 inhibitors and non-steroidal mineralocorticoid receptor antagonists in addition to standard treatment with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor antagonists.