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2024 ADA Guideline Recommendation: Latest Insights on the Pharmacological
Management of Obesity in Type 2 Diabetes Obesity is a chronic, often relapsing
disease with multiple metabolic, physical, and psychosocial complications,
including a significantly increased risk for type 2 diabetes mellitus (T2DM).
Among patients with T2DM and overweight or obesity, modest weight loss has been
shown to improve glycaemia and reduce the requirement for glucose-lowering
medications, whereas larger weight loss can significantly minimise glycated
haemoglobin (HbA1c) and fasting glucose and may promote sustained diabetes
remission. 2024 ADA Guideline Update on Obesity Pharmacotherapy in Type 2
Diabetes • Medications for comorbid conditions which are associated with weight
gain should be reduced whenever possible. • Medications with beneficial effects
on weight should be considered when selecting glucose-lowering medications for
patients with T2DM and overweight or obesity. • Obesity pharmacotherapy should
be considered for patients with diabetes and overweight or obesity, along with
lifestyle modifications. Potential benefits and risks must be considered. • The
preferred pharmacotherapy for patients with diabetes and overweight or obesity
should include a GLP-1RA (glucagon-like peptide 1 receptor agonist) or dual
GIP/GLP-1RA [glucose-dependent insulinotropic polypeptide and glucagon-like
peptide 1 receptor agonist] with greater weight loss efficacy (i.e., Semaglutide
or Tirzepatide), especially considering their added weight-independent benefits
(e.g., glycaemic and cardiometabolic). • For those who have not achieved goals,
weight management therapies should be reassessed, and the treatment should be
intensified with additional approaches (e.g., metabolic surgery, additional
pharmacologic agents, and structured lifestyle management programs) to prevent
therapeutic inertia. Approved Obesity Pharmacotherapy The U.S. Food and Drug
Administration (FDA) has approved several medications for weight management as
adjuncts to reduced calorie diet and increased physical activity in individuals
with a BMI of ?30 kg/m2 or ?27 kg/m2 with ?1 obesity-associated comorbid
conditions (e.g., T2DM, hypertension, and/or dyslipidaemia). Nearly all
FDA-approved obesity drugs have been shown to improve glycaemia in T2DM patients
and delay progression to type 2 diabetes in at-risk people, and some of these
agents (e.g., Liraglutide and Semaglutide) have an indication for glucose
lowering in addition to weight management. FDA-approved obesity
pharmacotherapies1 Short-term treatment (12 weeks) Phentermine Long-term
treatment (52 or 56 weeks) Orlistat Phentermine/Topiramate ER
Naltrexone/Bupropion ER Liraglutide Semaglutide Tirzepatide Abbreviations: ER:
Extended-release. Reference: 1. American Diabetes Association Professional
Practice Committee. 8. Obesity and Weight Management for the Prevention and
Treatment of Type 2 Diabetes: Standards of Care in Diabetes-2024. Diabetes Care.
2024;47(Suppl 1):S145-S157. doi:10.2337/dc24-S008.
https://diabetesjournals.org/care/article/47/Supplement_1/S145/153942/8-Obesity-and-Weight-Management-for-the-
Prevention

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Novel pharmacological treatment approaches for adults with type 2 diabetes:
insights from 2024 American College of Physicians guideline Type 2 diabetes
represents a multifactorial condition, which can lead to disturbed glucose
homeostasis. Lifestyle interventions along with pharmacological treatment are
imperative to achieve successful management of patients with type 2 diabetes.1
The prime treatment goals for patients with type 2 diabetes encompass adequate
glycaemic control along with primary and secondary prevention of atherosclerotic
cardiovascular and kidney diseases. The American College of Physicians (ACP)
guideline, 2024, has laid down the following novel pharmacological treatment
approaches for adults with type 2 diabetes2: • The addition of a sodium-glucose
cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist to
Metformin and appropriate lifestyle interventions is recommended for adults with
type 2 diabetes who have inadequate glycaemic control. o The use of an SGLT-2
inhibitor can reduce the risk of all-cause mortality, progression of chronic
kidney disease, major adverse cardiovascular events, and hospitalisation due to
congestive heart failure. o The use of a GLP-1 agonist can mediate a reduction
in all-cause mortality, major adverse cardiovascular events, and stroke. • The
addition of a dipeptidyl peptidase-4 (DPP-4) inhibitor to Metformin and
lifestyle interventions is not recommended for adults with type 2 diabetes and
inadequate glycaemic control in order to reduce all-cause mortality and
morbidity. References: 1. Borse SP, Chhipa AS, Sharma V, et al. Management of
Type 2 Diabetes: Current Strategies, Unfocussed Aspects, Challenges, and
Alternatives. Med Princ Pract. 2021;30(2):109-121. doi:10.1159/000511002
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114074/ 2. Qaseem A, Obley AJ,
Shamliyan T, et al. Newer Pharmacologic Treatments in Adults With Type 2
Diabetes: A Clinical Guideline From the American College of Physicians. Ann
Intern Med. Published online April 19, 2024. doi:10.7326/M23-2788
https://www.acpjournals.org/doi/10.7326/M23-2788#:~:text=Newer pharmacologic
treatments include glucagon,) inhibitors (canagliflozin, dapagliflozin,

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ALL CONTENTS

2024 AMERICAN DIABETES ASSOCIATION (ADA) GUIDELINE: LATEST DEVELOPMENTS IN TYPE
2 DIABETES MANAGEMEN

Aug 02, 2024

2024 American Diabetes Association (ADA) Guideline: Latest Developments in Type
2 Diabetes Management T2DM is one of the most common metabolic diseases
globally. A holistic, multifaceted, person-centred approach, taking into account
the complexity of managing T2DM and its complications, is recommended across the
lifespan. 2024 ADA guideline on newer updates for T2DM management • At the
initiation of treatment, early combination therapy might be considered for
adults with T2DM to expedite the achievement of individualised treatment goals.
• For adults with T2DM without cardiovascular and/or kidney disease,
pharmacologic agents should address both the individualised glycaemic and weight
goals. • For adults with T2DM who have not achieved their individualised
glycaemic goals, the choice of subsequent glucose-lowering agents should
consider the individualised glycaemic and weight goals, along with the presence
of other metabolic comorbidities and the risk of hypoglycaemia. • For adults
with T2DM who have not attained their individualised weight goals, additional
weight management interventions, such as intensification of lifestyle
modifications, structured weight management programmes, pharmacologic agents, or
metabolic surgery, as appropriate, are recommended. • For adults with T2DM and
established or high risk of ASCVD, HF, and/or CKD, the treatment regimen should
include agent(s) that lower cardiovascular and kidney disease risk [e.g., SGLT2
inhibitors and/or GLP-1 RA] for glycaemic management and comprehensive
cardiovascular risk reduction, irrespective of A1C and in consideration of
person-specific factors. • An SGLT2 inhibitor is recommended for adults with
T2DM who have HF (with either reduced or preserved ejection fraction) for
glycaemic management and the prevention of HF hospitalisations. • For adults
with T2DM who have CKD [with confirmed eGFR of 20–60 mL/minute/1.73 m2 and/or
albuminuria], an SGLT2 inhibitor is recommended to lower the progression of CKD,
cardiovascular events, and hospitalisations for HF; however, it is important to
note that the glycaemic benefits of SGLT2 inhibitors are decreased at eGFR
<45>10% (>86 mmol/mol) or blood glucose ?300 mg/dL (?16.7 mmol/L)]. • For adults
with T2DM, a GLP-1 RA, including a dual glucose-dependent insulinotropic
polypeptide (GIP) and GLP-1 RA, is preferred over insulin. • When insulin is
used, combination therapy with a GLP-1 RA, including a dual GIP and GLP-1 RA, is
suggested for greater glycaemic effectiveness and beneficial effects on weight
and hypoglycaemic risk for adults with T2DM. Insulin dosing must be reevaluated
upon addition or dose escalation of a GLP-1 RA or dual GIP and GLP-1 RA. • In
adults with T2DM, glucose-lowering agents might be continued upon initiation of
insulin therapy (unless contraindicated or not tolerated) for ongoing glycaemic
and metabolic benefits (i.e., weight, cardiometabolic, or kidney benefits). •
When starting insulin therapy in adults with T2DM, the reassessment of need for
and/or dose of glucose-lowering agents with higher hypoglycaemia risk (i.e.,
sulphonylureas and meglitinides) is recommended to lower the risk of
hypoglycaemia and treatment burden. • For adults with diabetes experiencing
cost-related barriers, lower-cost medications, such as Metformin,
sulphonylureas, thiazolidinediones, and human insulin, should be considered for
glycaemic management. This decision should be made in the context of their
associated risks for hypoglycaemia, weight gain, cardiovascular and kidney
events, and other potential adverse effects.1 References: 1. American Diabetes
Association Professional Practice Committee. 9. Pharmacologic Approaches to
Glycemic Treatment: Standards of Care in Diabetes-2024. Diabetes Care.
2024;47(Suppl 1):S158-S178. doi:10.2337/dc24-S009.
https://diabetesjournals.org/care/article/47/Supplement_1/S158/153955/9-Pharmacologic-Approaches-to-Glycemic-Treatment

SCREENING FOR PREDIABETES AND TYPE 2 DIABETES: AN UPDATE FROM 2024 ADA GUIDELINE

Aug 02, 2024

Screening for prediabetes and type 2 diabetes: an update from 2024 ADA guideline
Prediabetes is used to describe the individuals whose glucose/haemoglobin A1c
levels do not meet the criteria for diabetes, but have an abnormal carbohydrate
metabolism, which leads to an elevated glucose level (dysglycaemia) intermediate
between normoglycaemia and diabetes. Type 2 diabetes accounts for substantial
cases of diabetes and encompasses patients with relative insulin deficiency and
peripheral insulin resistance. Prediabetes and type 2 diabetes are often
detected by measuring the fasting plasma glucose or haemoglobin A1c levels or
with an oral glucose tolerance test (OGTT).1 The American Diabetes Association
(ADA) guideline, 2024, recommendations on screening for prediabetes and type 2
diabetes2: • Screening for prediabetes and type 2 diabetes must be done through
an assessment of risk factors or a validated risk calculator in asymptomatic
adults. • Testing for prediabetes or type 2 diabetes in asymptomatic patients
must be considered in adults of any age who are overweight or obese with one or
more risk factors. For other individuals, screening must begin at the age of 35
years. • If the tests show normal results, repeat screening is recommended at a
minimum of 3-year intervals, or sooner if symptoms arise or there is a change in
the risk (weight gain). • In order to screen for prediabetes and type 2
diabetes, fasting plasma glucose (FPG), 2-hour plasma glucose (PG) during 75-g
OGTT, and A1c tests are deemed appropriate. • When OGTT is used to screen for
prediabetes or diabetes, adequate carbohydrate intake (at least 150 g/day) must
be ensured three days before testing. • Risk-based screening for prediabetes or
type 2 diabetes must be considered after the onset of puberty or after the age
of 10 years, whichever is earlier, in adolescents and children who are
overweight [body mass index (BMI) ? 85th percentile] or obese (BMI ? 95th
percentile) with one or more risk factors for diabetes. • Screening patients for
diabetes or prediabetes should be considered if they are on certain medications,
such as statins, glucocorticoids, thiazide diuretics, certain medications for
human immunodeficiency virus (HIV) infection, and second-generation
antipsychotics, as such drugs can increase the risk of prediabetes or diabetes.
• For patients who are prescribed with second-generation antipsychotics,
prediabetes and diabetes must be screened at baseline and should be repeated 12
to 16 weeks after the initiation of medications or sooner, if clinically
indicated, and on an annual basis. • Patients with HIV must be screened for
diabetes and prediabetes via an FPG test before the initiation of antiretroviral
therapy, during switching antiretroviral therapy, and 3 to 6 months after the
initiation or switching of antiretroviral therapy. If the initial screening
tests demonstrate normal results, FPG must be checked annually. References: 1.
US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Screening for
Prediabetes and Type 2 Diabetes: US Preventive Services Task Force
Recommendation Statement. JAMA. 2021;326(8):736-743. doi:10.1001/jama.2021.12531
https://jamanetwork.com/journals/jama/fullarticle/2783414 2. American Diabetes
Association Professional Practice Committee. 2. Diagnosis and Classification of
Diabetes: Standards of Care in Diabetes-2024. Diabetes Care. 2024;47(Suppl
1):S20-S42. doi:10.2337/dc24-S002.
https://diabetesjournals.org/care/article/47/Supplement_1/S20/153954/2-Diagnosis-and-Classification-of-Diabetes

2024 AMERICAN DIABETES ASSOCIATION (ADA) GUIDELINES: ADVANCEMENTS IN YOUTH-ONSET
TYPE 2 DIABETES MAN

Aug 02, 2024

2024 American Diabetes Association (ADA) Guidelines: Advancements in Youth-Onset
Type 2 Diabetes Management With the burgeoning obesity epidemic, there is an
increasing incidence of youth-onset T2DM.1 The approach to treating youth-onset
T2DM begins with lifestyle intervention and pharmacological management.2 2024
American Diabetes Association (ADA) guideline: An update on managing youth-onset
T2DM • In addition to behavioural counselling for healthy nutrition and physical
activity changes, pharmacological therapy should be initiated upon diagnosis of
T2DM. • For youth with incidentally diagnosed or metabolically stable diabetes
[A1C <8.5% (<69 mmol/mol) and asymptomatic], Metformin is the preferred initial
pharmacological treatment, provided renal function is normal. • In youths
experiencing marked hyperglycaemia [BG ?250 mg/dL (?13.9 mmol/L), A1C ?8.5% (?69
mmol/mol)] without acidosis at diagnosis who are symptomatic with polyuria,
nocturia, polydipsia, and/or weight loss, the initial treatment approach
involves the use of long-acting insulin while Metformin is initiated and
titrated. • Subcutaneous or intravenous insulin should be initiated in youth
with ketosis/ketoacidosis to rapidly correct hyperglycaemia and metabolic
derangement. Following the resolution of acidosis, Metformin should be initiated
while subcutaneous insulin therapy is continued. • An assessment for
hyperglycaemic hyperosmolar nonketotic syndrome should be conducted for
individuals presenting with severe hyperglycaemia [BG ?600 mg/dL (?33.3
mmol/L)]. • If glycaemic goals are not achieved with Metformin (with or without
long-acting insulin), GLP-1 receptor agonist and/or Empagliflozin is recommended
for children aged ?10 years. • It is important to consider medication-taking
behaviour and the medications’ effect on weight while choosing glucose-lowering
or other medications for youth with overweight or obesity and T2DM. • In cases
where youth fail to achieve glycaemic goals, noninsulin therapies (Metformin, a
GLP-1 receptor agonist, and Empagliflozin) should be maximised before initiating
and/or intensifying the insulin therapy regimen. • For individuals initially
treated with insulin and Metformin and/or other glucose-lowering medications who
have achieved glucose goals based on blood glucose monitoring or continuous
glucose monitoring, insulin can be tapered over 2–6 weeks by reducing the
insulin dose by 10–30% every few days.3 References: 1. Chang N, Yeh MY, Raymond
JK, et al. Glycemic control in youth-onset type 2 diabetes correlates with
weight loss. Pediatr Diabetes. 2020;21(7):1116-1125. doi:10.1111/pedi.13093.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8629030/ 2. Rodriquez IM,
O'Sullivan KL. Youth-Onset Type 2 Diabetes: Burden of Complications and
Socioeconomic Cost. Curr Diab Rep. 2023;23(5):59-67.
doi:10.1007/s11892-023-01501-7.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10037371/ 3. American Diabetes
Association Professional Practice Committee. 14. Children and Adolescents:
Standards of Care in Diabetes-2024. Diabetes Care. 2024;47(Suppl 1):S258-S281.
doi:10.2337/dc24-S014.
https://diabetesjournals.org/care/article/47/Supplement_1/S258/153946/14-Children-and-Adolescents-Standards-of-Care-in

2024 ADA GUIDELINE RECOMMENDATIONS ON PHARMACOLOGICAL INTERVENTIONS FOR ADULTS
AT HIGH RISK FOR TYPE

Aug 02, 2024

2024 ADA guideline recommendations on pharmacological interventions for adults
at high risk for type 2 diabetes Diabetes ranks among the prime causes of severe
health complications and also remains a chief reason for mortality on a global
scale. It is thought that type 2 diabetes arises due to an interaction between
several lifestyle factors, medical conditions, hereditary risk factors,
psychosocial and demographic risk factors, quantity or quality of sleep,
depression, cardiovascular disease, hypertension, dyslipidaemia, ageing,
ethnicity, a family history of diabetes, physical inactivity, and presence of
obesity.1 As weight loss via behavioural interventions in physical activity and
diet can be a difficult approach to maintain on a long-term basis, patients at
high risk of type 2 diabetes might benefit from additional support and
pharmacotherapeutic approaches. The American Diabetes Association (ADA) 2024 has
laid down the following recommendations on pharmacological interventions for
adults at high risk for type 2 diabetes2: • For the prevention of type 2
diabetes, Metformin should be considered in adults at high risk of type 2
diabetes, as indicated by the Diabetes Prevention Program (DPP), especially in
the following cases: o Individuals aged 25 to 59 years with a body mass index
(BMI) of ? 35 kg/m2, higher fasting plasma glucose level [for instance, ? 110
mg/dl (? 6 mmol/L)], and higher levels of haemoglobin A1C [for instance, ? 6.0%
(? 42 mmol/mol), and o Individuals with prior gestational diabetes mellitus. •
The long-term use of Metformin might be associated with vitamin B12 deficiency.
Hence, periodic assessment of vitamin B12 levels in individuals treated with
Metformin should be considered, especially in patients with anaemia or
peripheral neuropathy. References: 1. Ismail L, Materwala H, Al Kaabi J.
Association of risk factors with type 2 diabetes: A systematic review. Comput
Struct Biotechnol J. 2021;19:1759-1785. Published 2021 Mar 10.
doi:10.1016/j.csbj.2021.03.003
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050730/ 2. American Diabetes
Association Professional Practice Committee. 3. Prevention or Delay of Diabetes
and Associated Comorbidities: Standards of Care in Diabetes-2024. Diabetes Care.
2024;47(Suppl 1):S43-S51. doi:10.2337/dc24-S003
https://diabetesjournals.org/care/article/47/Supplement_1/S43/153945/3-Prevention-or-Delay-of-Diabetes-and-Associated

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