Recommendations for Early and Comprehensive Management of Type 2 Diabetes and Its Related Cardio-Renal Complications

Abstract

Type 2 diabetes (T2D) is a global health problem accompanied by an elevated risk of complications, the most common being cardiac and renal diseases. In Lebanon, the prevalence of T2D is estimated at 8-13%. Local medical practice generally suffers from clinical inertia, with gaps in the yearly assessment of clinical manifestations and suboptimal screening for major complications. The joint statement presented here, endorsed by five Lebanese scientific medical societies, aims at providing physicians in Lebanon with a tool for early, effective, and comprehensive care of patients with T2D. Findings from major randomized clinical trials of antidiabetic medications with cardio-renal benefits are presented, together with recommendations from international medical societies. Optimal care should be multidisciplinary and should include a multifactorial risk assessment, lifestyle modifications, and a regular evaluation of risks, including the risks for cardiovascular (CV) and renal complications. With international guidelines supporting a shift in T2D management from glucose-lowering agents to disease-modifying drugs, the present statement recommends treatment initiation with metformin, followed by the addition of sodium-glucose cotransporter 2 inhibitors or glucagon-like peptide-1 receptor agonists due to their CV and renal protection properties, whenever possible. In addition to the selection of the most appropriate pharmacological therapy, efforts should be made to provide continuous education to patients about their disease, with the aim to achieve a patient-centered approach and to foster self-management and adherence to the medical plan. Increasing the level of patient engagement is expected to be associated with favorable health outcomes. Finally, this statement recommends setting an achievable individualized management plan and conducting regular follow-ups to monitor the patients' glycemic status and assess their risks every 3-6 months.

Keywords: Cardiovascular risk; Chronic kidney disease; Diabetic complications; Early management; Glycemic control; Nephropathy risk; Treatment; Type 2 diabetes.

Fig. 1

Pillars for optimal management of patients with type 2 diabetes. BP Blood pressure, DMDs Disease modifying drugs, GLP-1 RA glucagon-like peptide-1 receptor agonists, SGLT2i sodium-glucose cotransporter type 2 inhibitors

Fig. 2

Lebanese consortium for pharmacological treatment of hyperglycemia recommendation. Single asterisk: For patients at high risk (e.g., atherosclerotic cardiovascular disease, multiple risk factors, HF, or chronic kidney disease) or if treatment with metformin is contraindicated, DMDs could be initiated first. Double asterisks: For patients with established HF or CKD, SGLT2i remain the DMD with the highest proven benefit. Dagger: For patients who cannot tolerate or afford DMDs, then other antidiabetic medications (dipeptidyl peptidase-4 inhibitor, thiazolidinediones, sulfonylureas or insulin) remain viable options for effective glycemic control, although they do not offer cardio-renal protection. HbA1c Glycated hemoglobin A1

Fig. 3

Lebanese consortium recommendations for an effective management of T2D patients. Single asterisk: With evidence of kidney impairment and if UACR ≥ 300 mg/g or eGFR < 60 mL/min/1.73 m², testing is recommended every 3 months. Double asterisks: Other cardiac tests could be ordered for a complete heart health assessment based on the patient condition. Single cross: eGFR declines with age, even in people without kidney disease. BNP Brain natriuretic peptide, DBP diastolic blood pressure, ECG electrocardiography, LDL-C low-density-lipoprotein-cholesterol, NT-ProBNP N-terminal prohormone of BNP, SBP systolic blood pressure, T2D type 2 diabetes, UACR urinary albumin to creatinine ratio