## The 2024 ADA/EASD Consensus: Patient-Centred Care The 2024 joint ADA/EASD consensus update emphasised individualisation of glycaemic targets rather than a universal HbA1c goal. The appropriate target depends on: - Duration of diabetes and life expectancy. - Presence of established CVD, CKD, or heart failure. - Hypoglycaemia awareness and risk. - Patient preference and socioeconomic factors. ## Glycaemic Targets | Patient Profile | HbA1c Target | |---|---| | Newly diagnosed, low comorbidity | < 6.5% | | Most adults with T2DM | < 7.0% | | Established CVD or CKD | < 7.0–7.5% | | Frail elderly, limited life expectancy | < 8.0–8.5% | | Pregnancy (pre-existing T2DM) | < 6.5% | ## Drug Sequencing ### At Diagnosis (Metformin ± Second Agent) Metformin remains the preferred initial agent in the absence of contraindications (eGFR < 30 is a contraindication; use with caution at eGFR 30–45). However, if the patient has established atherosclerotic CVD, heart failure, or CKD at diagnosis, the 2024 consensus recommends initiating an **SGLT-2 inhibitor** and/or **GLP-1 receptor agonist** alongside or instead of metformin, because of their proven cardiovascular and renal benefits beyond glycaemic control. ### Second-Line Addition - **SGLT-2 inhibitor**: empagliflozin, dapagliflozin, canagliflozin — favoured in heart failure and CKD. - **GLP-1 RA**: semaglutide, liraglutide, dulaglutide — favoured in established CVD and in patients needing significant weight reduction. - **DPP-4 inhibitor**: saxagliptin, sitagliptin — weight-neutral, well tolerated, but no CV benefit (saxagliptin associated with HF hospitalisation — avoid in HF). - **Sulfonylurea**: low cost, effective, but hypoglycaemia risk and weight gain limit use. ## Monitoring Schedule ### At Every Visit - BP, weight, BMI. - Foot inspection (10-g monofilament for neuropathy screening annually). - Medication adherence and tolerance. - Hypoglycaemic episodes. ### Every 3 Months - HbA1c (until at target, then every 6 months). - Fasting glucose review if on insulin. ### Annually - Fasting lipid profile. - Urine ACR and eGFR (renal function). - Dilated fundus examination (diabetic retinopathy screening). - ECG if cardiovascular risk is high. ## Hypoglycaemia Recognition & Management Hypoglycaemia (< 70 mg/dL) is a medical emergency risk in patients on insulin or sulfonylureas. Educate patients on the rule of 15: 15 g of fast-acting carbohydrate, recheck in 15 minutes. For severe hypoglycaemia: 1 mg glucagon IM or SC (or intranasal), call emergency services. ## Documenting Diabetes in ClinIT ClinIT's structured chronic-disease note template includes HbA1c trend charts, medication titration history, foot exam findings, and annual review checklist. Automated flags alert the doctor when a patient's annual renal or eye check is overdue.