WHO issues guidelines for T2D and T1D treatment intensification

  • Ann Intern Med

  • curated by Miriam Tucker
  • Clinical Essentials
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Takeaway

  • WHO guidelines are aimed at adults with either type 1 diabetes (T1D) or type 2 diabetes (T2D) in low-resource settings worldwide and disadvantaged populations in high-income countries.

Key recommendations

  • Give a sulfonylurea to patients with T2D who do not achieve glycemic control with metformin alone or who have metformin contraindications.
  • Introduce human insulin to patients with T2D who do not achieve glycemic control with metformin and/or a sulfonylurea.
  • If insulin is unsuitable, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium-glucose cotransporter-2 inhibitor (SGLT-2i), or a thiazolidinedione (TZD) may be added.
  • Use human insulin in adults with T1D and with T2D for whom insulin is indicated.
  • Consider long-acting insulin analogues in adults with T1D or T2D who have frequent severe hypoglycemia with human insulin.

American College of Physicians editorial commentary

  • “Although sulfonylureas have been used for decades and their long-term safety has been established, we…worry about the cumulative effect of hypoglycemia.”
  • “The decision to name sulfonylureas as the single best second-line agent largely reflects the prioritization of cost and the recognition that WHO guidelines must apply to low-resource settings.”
  • “Another consideration…is emerging evidence of potential additional benefits for some agents” such as cardiovascular benefit with some SGLT-2is.  

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