Therapy of Type 2 Diabetes

UPDATES TO CONTENT COMPARED TO THE PREVIOUS YEAR'S VERSION

Part 1 of the clinical practice guideline

Change 1: An additional section on the prevalence and incidence of type 2 diabetes in Germany has been added.
Reason: These current figures highlight the medical, psychosocial and health policy significance of this complex disease.

Change 2: On the basis of current data, the various risk factors and their structured assessment (including the increasing importance of fatty liver) for the development of cardiovascular and renal complications are again highlighted.
Reason: For an individual therapy decision, the in-depth risk assessment is very helpful Supporting reference: [6] [7]

Change 3: The short diagnostics section has been brought forward
Reason: More logical order of sections

Change 4: The section on plasma glucose self-measurement was supplemented to include the possibilities and possible necessity of using CGM in people with type 2 diabetes
Reason: The treatment of people with type 2 diabetes is becoming more individual and therefore more complex. Temporary information about TiR and TuR can at minimum be helpful in the treatment decision.

Change 5: In the section on nutritional therapy, current literature citations were introduced and new evidence on the benefits of moderate coffee consumption in many chronic diseases, including type 2 diabetes, was mentioned. Hypocaloric nutrition, intermittent fasting, etc. play an important role
Reason: Evidence from the cited literature

Change 6: A section on fatty liver disease and its treatment options has been added.
Reason: Fatty liver disease as an important risk disease for chronic liver disease and as a risk factor for cardiovascular and renal complications in people with type 2 diabetes still plays a subordinate role in screening. The regular determination of the FIB-4 index is simple and prognostically significant.
Supporting references: Updated S2K Guideline Non-Alcoholic Fatty Liver Disease; Diabetes and Fatty Liver section in this supplement Part 2 of the clinical practice guideline

Change 7: In contrast to the ESC guideline (avoidance of metformin), the DDG, the National Treatment Guideline on type 2 diabetes as well as the ADA/EASD consensus recommendations, the section on metformin emphasizes that SGLT-2 inhibitors and/or GLP-1RAs (usually with metformin) should be used in high-risk patients and in people with already manifest cardiovascular (including heart failure) and renal diseases.
Reason: RCTs and their meta-analyses

Change 8: In new analyses of RCTs, sulfonylureas (SHs) were associated with a significantly higher rate of severe hypoglycaemia and cardiovascular events, including all-cause mortality. On the other hand, a large Scottish cohort study showed that no higher rates of cardiovascular events, including mortality, were observed for sulfonylureas as the 2nd antidiabetic agent after metformin compared to DPP4 inhibitors or pioglitazone. From this, the authors concluded that SHs continue to be recommended as second-line medications, especially in health systems that cannot afford more expensive antidiabetic drugs.
Supporting reference: [67]

Change 9: A recent meta-analysis of 82 studies showed that DPP4 inhibitors were significantly associated with a higher risk (22%) of gallbladder and biliary tract disease.
Supporting reference: [104]

Change 10: In the SGLT inhibitors section, the new [Tab. 4] on the approval and (contra)indications of dapagliflozin, empagliflozin and ertugliflozin for type 2 diabetes, nephropathy and heart failure (HF pEF, HFmEF, HFrEF).
Reason: New approvals and indications
Supporting references: Current instructions for use

Change 11: A large number of new clinical studies and their meta-analyses on the use of SGLT-2 inhibitors approved in Germany and their effects on cardiovascular and renal endpoints are discussed.
Reason: An update was necessary

Change 12: Section on the effect of SGLT-2 inhibitors on the liver
Reason: An update was necessary

Change 13: Updates in the GLP-1 receptor agonists section as a whole and in the discussion of the individual substances. In most cases, the newer data were added at the end of the discussion of the respective active ingredient.
Reason: An update was necessary.

Change 14: [Tab. 6] in Part 2 (Additional informations) on cardiovascular and renal benefits (absolute risk reduction and hazard ratios) of SGLT-2 inhibitors and GLP-1 RAs based on a recent meta-analysis
Supporting reference : [318

Change 15: The Basal insulins section describes a head-tohead comparison of injectable incretin-based drugs IBGLMs (short- and long-acting GLP-1 RAs and tirzepatide) vs. basal insulin therapy (NPH, glargine, detemir, degludec). In all studies (n = 20) with a total of 11843 patients, there was a reduction in HbA1c of 0.48% (0.45–0.52) more with IBGLMs than with basal insulins. This effect was particularly evident with the long-acting GLP-1 RAs and tirzepatide (pooled doses: ΔHbA1c –0.90% [−1.06; −0.75]). Short-acting GLP-1 RAs were comparably effective compared to basal insulin (p = 0.90). All IBGLM subgroups resulted significantly in lower body weight (−4.6 [−4.7; −4.4] kg), in particular tirzepatide (−12.0 [−13.8–10] kg). Based on the analyses, the authors again underline that in the event of therapy escalation to injectable drugs, IBGLMs should be considered first instead of basal insulins.
Supporting reference: [353]
Change 16: icodec insulin is described
Reason: Current data

The Clinical Practice Guidelines of the German Diabetes Society/Deutsche Diabetes Gesellschaft (DDG) are based on the contents of the National Healthcare Guideline (Nationale VersorgungsLeitlinie (NVL)) “Type 2 Diabetes” [1]. The modifications in therapy and their justifications made in the present Clinical Practice Guidelines were largely updated on the basis of new randomized controlled trials (RCTs) and meta-analyses.

In order to improve the work with the extensive clinical practice guideline in daily practice, the authors have decided to move the individual glucose-lowering pharmaceuticals and some algorithms in the current clinical practice guideline to a detailed appendix. The corresponding list of references can also be found in the appendix.

Publication History

Article published online:
10 April 2024

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