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CPG – Management of Type 2 Diabetes

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CPG – Management of Type 2 Diabetes 210112_MEMS_T2DM CPG_6th-COVER_OL.pdf 1 12/01/2021 1:14 PM C M Y CM MY CY CMY K CLINICAL PRACTICE GUIDELINES MANAGEMENT OF TYPE 2 DIABETES MELLITUS (6th Edition) DECEMBER 2020 MOH/P/PAK/447.20(GU)-e Malaysia Endocrine Ministry of Health Academy of Medicine Diabetes Malaysia Family Medicine Specialists & Metabolic Society Malaysia Malaysia Association of Malaysia MOH/P/PAK/447.20(GU)-e CLINICAL PRACTICE GUIDELINES MANAGEMENT OF TYPE 2 DIABETES MELLITUS (6TH EDITION) 2 This is the revised and updated Clinical Practice Guidelines (CPG) on Management of Type 2 Diabetes Mellitus (T2DM). The recommendations in this 6th edition CPG supersedes the 5th edition Clinical Practice Guidelines on Management of Type 2 Diabetes Mellitus 2015. STATEMENT OF INTENT This guideline is meant for the clinical management of T2DM, based on the best available evidence at the time of development. Adherence to this guideline may not necessarily guarantee the best outcome in every case. Every healthcare provider is responsible for the individualised management of his/her patient based on patient presentation and management options available locally. REVIEW OF THE GUIDELINES These guidelines issued in December 2020, will be reviewed in 5 years (2025) or sooner if new evidence becomes available. CPG Secretariat Health Technology Assessment Section Medical Development Division Ministry of Health Malaysia Level 4, Block E1, Precinct 1 62590 Putrajaya Electronic version is available on the following websites: http://www.acadmed.org.my http://www.diabetes.org.my http://mems.my/ http://www.moh.gov.my FOREWORD by Tan Sri Dato' Seri Dr Noor Hisham Abdullah, Director General of Health, Malaysia Management of any chronic disease requires a concerted effort with the participation of all stake holders starting with the patients themselves and, clinical healthcare professionals as well as public health policymakers. This is 3 even more important in the management of Type 2 diabetes mellitus (T2DM). An optimum result can only be achieved with a holistic approach and active patient participation with the support of appropriate diabetes education and lifestyle modification. In addition to its negative impact on the quality of life and health care costs, diabetes also increases the economic burden of individuals, families and communities and, affects national productivity. I note that there has been a recent explosion of advances made in the management of diabetic complications. The use of new technology and findings from landmark trials have changed clinical pathways and recommendations in the way T2DM is managed. This has been reflected in the latest Clinical Practice Guidelines (CPG) for the Management of T2DM (6th Edition). These guidelines also focus on preventing and reducing diabetes-related complications, thereby improving clinical outcomes. This CPG will form a valuable resource for healthcare professionals from primary to tertiary care levels, to deliver the best possible care for their patients, from disease prevention to treatment of complications. In this networked age, we should no longer be working in silos and I would like to reaffirm the importance and recognition of a multidisciplinary approach in managing T2DM. I have been a champion for embracing technology and innovation – and note that there is emphasis on the potential to use mobile apps and other forms of technological advances / telemedicine to improve diabetes self-management. The importance of this is even greater now in the context of the new norm forced on everyone by the Covid-19 pandemic. The breadth and depth of material covered reflects the commitment and the dedication of the CPG committee, despite the difficulties encountered during the Covid-19 pandemic. I would like to congratulate the chairs and the members for their hard work and it is my sincere wish that this document will further elevate the standard of diabetes care and reduce the burden of T2DM in our country. Tan Sri Dato' Seri Dr Noor Hisham Abdullah FOREWORD by Chairpersons of T2DM Clinical Practice Guidelines, 6th edition taskforce These are exciting times for the treatment of Type 2 diabetes mellitus (T2DM) and a time for concern. The past 5 years have seen amazing breakthroughs that 4 give hope for people with T2DM. Several Cardiovascular Outcome trials (CVOTs) from 2 new classes of glucose-lowering agents have shown cardiovascular (CV) protection, beyond glucose. On the other hand, prevalence of diabetes in Malaysia continues to rise unabated. The 2019 National Health and Morbidity Survey (NHMS) shows a prevalence of 18.3% (for adults >18 years of age), a 4% increase from 2015; 48.6% were undiagnosed. In addition, ~5.0% of our young Malaysians between 18-29 years are also diabetic. It is worrying to see this trend. The frequent co-existence with other well-known comorbidities, e.g. hypertension, dyslipidaemia, overweight/ obesity further complicates the situation. The 5th edition of our Clinical Practice Guidelines (CPG) for the Management of T2DM 2015, was detailed and comprehensive. Our aspiration was to build on the previous CPG. Since then, there have been major advances; in therapeutics, nutrition, technology as well as, digital health. The landmark CVOTs have consistently demonstrated positive beneficial CV outcomes in those with either established or at high risk for cardiovascular disease (CVD). Another exciting advance has been the discovery of a 2nd therapeutic class of agent, apart from the renin-angiotensin system blockers, to directly reduce progression of diabetic kidney disease (DKD). DKD remains the largest contributor of new patients requiring dialysis in Malaysia and, recent renal outcome trials definitively show positive outcomes for prevention of progression to end-stage renal failure and reduction of albuminuria. More exciting data may be forthcoming with ongoing dedicated trials investigating effects of these glucose-lowering agents, on heart failure and prevention of kidney disease not only in people with diabetes but also, in nondiabetic individuals. These results have led to paradigm shifts, changing practices as we move forward. The objective of these guidelines is to reflect the uptake of this new data in clinical decision making and therefore, provide evidence-based recommendations to assist healthcare providers in identifying, diagnosing and managing our patients with T2DM. Some of the other notable updates, include additional sections on current hot topics; e.g. non-alcoholic fatty liver disease (NAFLD) and periodontal disease. The landmark CVOTs have been consolidated and summarised in Appendix 8. T2DM is not a stand-alone disease instead reaching across a spectrum of other non-communicable diseases. Hence, in this updated guideline, we expanded our taskforce to include colleagues from other specialities; including nephrology, neurology, gastroenterology-hepatology, cardiology, ophthalmology, psychiatry and dental surgery. The committee hopes that this combination of expertise has enhanced the recommendations in this CPG to further improve clinical 5 decision making. by Chairperson of T2DM Clinical Practice Guidelines, 6 Foreword The development of these guidelines extended into an extraordinary situation caused by the COVID-19 pandemic. Through it, the hardworking committee members of the taskforce, including our reviewers, persevered with continuous and timely discussions to reach consensus where required through use of technology/remote communication, enabling its completion. To this, we extend our appreciation and gratitude, and commend their unwavering commitment to deliver the best evidence-based standard of care to our patients with T2DM. th edition taskforce Dr Chan Siew Pheng Chairperson Dato’ Paduka Professor Dr Wan Datuk Dr Zanariah Hussein Mohamad Wan Bebakar Co-chair Co-chair TERMS OF REFERENCE Guidelines development 6 The guidelines development task force consisted of endocrinologists, paediatric endocrinologists, family medicine specialists, public health physicians, general physicians and dietitians. Where relevant, experts from different specialties were also included to review and update certain sub-sections within these guidelines. These included a nephrologist, neurologist, gastroenterologist- hepatologist, cardiologist, ophthalmologist, psychiatrist, dental surgeon, pharmacist and diabetes educator. The previous edition of the CPG on Management of T2DM 2015 was used as the basis for the development of this present guideline. Literature search was carried out at the following electronic databases: PUBMED, Medline, Cochrane Databases of Systematic Reviews (CDSR) and Journal full text via OVID search engine. In addition, the reference lists of all relevant articles retrieved were searched to identify further studies. Reference was also made to the lastest edition of other guidelines on the management of T2DM including guidelines developed by the American Diabetes Association (ADA) Standards of Medical Care in Diabetes, American Association of Clinical Endocrinologists’, American College of Endocrinology, International Diabetes Federation (IDF) Global Guideline for Type 2 Diabetes, the European Association for the Study of Diabetes (EASD), National Institute For Health and Care Excellence (NICE); Malaysian CPG on Management of Obesity, Canadian Diabetes Association, The Royal Australian College of General Practitioners and Diabetes Australia, Malaysian Dietitians’ Association, Trafford NHS Healthcare Trust and Joint British Diabetes Societies Inpatient Care Group. These
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