The effect of nurse prescribers on glycaemic control in type 2 diabetes: A systematic review and meta-analysis

The effect of consultations performed by specialised nurses or advanced nurse practitioners on patient and organisational outcomes in patients with complex health conditions: An umbrella review

BACKGROUND

Policymakers and researchers often suggest that nurses may play a crucial role in addressing the evolving needs of patients with complex conditions, by taking on advanced roles and providing nursing consultations. Nursing consultations vary widely across settings and countries, and their activities range from complementing to substituting traditional physician-led consultations or usual care.

OBJECTIVE

This study was aimed at describing the effects of nursing consultations with patients with complex conditions in any setting on patient outcomes (quality of life, physical status, psychosocial health, health behaviour, medication adherence, mortality, anthropometric and physiological outcomes, and patient satisfaction) and organisational outcomes (health resource use and costs).

DESIGN

Umbrella review.

METHODS

We followed the Joanna Briggs Institute method for umbrella reviews. We searched PubMed, Embase, Cochrane Database of Systematic Reviews and CINAHL to identify relevant articles published in English, Dutch, French, Spanish or German between January 2013 and February 2023. We included systematic literature reviews, with or without meta-analyses, that included randomised controlled trials conducted in high-income countries. Reviews were eligible if they pertained to consultations led by specialised nurses or advanced nurse practitioners. Article selection, data extraction and quality appraisal were performed independently by at least two reviewers.

RESULTS

We included 50 systematic reviews based on 473 unique trials. For all patient outcomes, nursing consultations achieved effects at least equivalent to those of physician-led consultations or usual care (i.e., non-inferiority). For quality of life, health behaviour, medication adherence, mortality and patient satisfaction, more than half the meta-analyses found statistically significant effects in favour of nursing consultations (i.e., superiority). Cost results must be interpreted with caution, because very few and heterogeneous cost-related data were extracted, and the methodological quality of the cost analyses was questionable. Narrative syntheses confirmed the overall conclusions of the meta-analyses.

CONCLUSIONS

The effects of nursing consultations on patients with complex health conditions across healthcare settings appear to be at least similar to physician-led consultations or usual care. Nursing consultations appear to be more effective than physician-led consultations or usual care in terms of quality of life, health behaviour, mortality, patient satisfaction and medication adherence. Further analysis of the primary data is necessary to determine the patient populations and settings in which nursing consultations are most effective. Moderate study quality, diversity amongst and within systematic reviews, and quality of reporting hamper the strength of the findings.

Content of medicine prescription and clinical practice training for haematology advanced practice nurses in China: A modified Delphi study

AIM

To explore the scope and form of prescriptions for blood and hematopoietic drugs that future advanced practice nurses (APNs) in the Department of Haematology and to establish a medicine prescription training content in China.

BACKGROUND

Because the increasing number of doctors cannot meet the increasing demand for medical care with the population growth, many countries have begun to explore the medical team structure and practice areas, among which nurse prescribing rights have been the most effective. However, China's higher nursing education system still lacks education and training on nurse prescription.

DESIGN

On the basis of literature research and semi-structured interviews, a set of nursing prescription content, education, training and practice system suitable for Chinese nurses was jointly created.

METHODS

Two rounds of expert consultation between 23 haematology nursing experts and clinical experts determined the training content of blood system drugs and medicine prescriptions. Additionally, on the basis of the 23 experts，13 experts engaged in clinical and education, teaching and training experts were involved. Two rounds of expert consultation with 36 experts identified a general clinical practice training program for advanced practice nurses in China.

RESULTS

Regarding contents and forms of hematopoietic drugs, the study concluded that advanced practice nurses in haematology department can prescribe anti-anemia drugs, anti-coagulant drugs and anti-thrombotic drugs in 2 categories and 16 drugs. Of these, four kinds of drugs should be prescribed in the form of protocol prescription. One kind of drug should be prescribed in the form of extended prescription and 11 drugs should be prescribed in the form of independent/extended or agreed/extended prescription. Regarding training content, the study obtained the training content of nurses' medicine prescriptions in eight clinical circumstances and the medicine prescription training content for common diseases of the blood system. The required specifications and the medicine prescription decision skills of nurses were sorted out according to different prescription types.

CONCLUSIONS

The degrees of expert authority were both higher in consultations. Moreover, the results after consultation were reliable. It was recommended that haematology APNs could prescribe anti-anaemic drugs and anti-coagulation and anti-thrombotic drugs. Furthermore, most drugs should be prescribed in the form of independent/extended or agreed/extended prescriptions. The establishment of a medicine prescription training content for haematology APNs is expected to provide a reference for clinical practice education and training for drug prescriptive authority applicants for blood and hematopoietic system nurses in China.

The Influence of Nurse-Led Interventions on Diseases Management in Patients with Diabetes Mellitus: A Narrative Review

The global prevalence of people with diabetes mellitus (PWD) is rapidly increasing. Nurses can provide diabetes care for PWD in several areas. Interventions led by nurses can support PWD for effective management of diabetes, which can positively improve clinical outcomes. Nurse-led diabetes self-management education (DSME) is an effective strategy to manage diabetes mellitus (DM) since it improves self-care practice and knowledge regarding diabetes. PWD often need to stay in hospitals longer, which involves poorer patient satisfaction and clinical outcomes. Nurse-led clinics for DM management are a new strategy to possibly ameliorate the disease management. Diabetes specialist nurses can play an important role in improving diabetes care in inpatient settings. Various studies have revealed that nurses can independently provide care to PWD in collaboration with various other healthcare providers. Studies also demonstrated that the nurse-led education-receiving group showed a significantly reduced level of average glycosylated haemoglobin A1c level. Moreover, nurse-led interventions often result in significant improvements in diabetes knowledge, psychological outcomes, self-management behaviours, and physiological outcomes. The purpose of this literature review was to identify the impact of nurse-led interventions on diabetes management. Moreover, in this review, a number of nursing interventions and the nurses' roles as educators, motivators as well as caregivers in DM management have been extensively discussed. This article also summarises the outcomes that are measured to evaluate the impact of nursing interventions and the strategies to overcome the existing and emerging challenges for nurses in diabetes care.

Examining nursing processes in primary care settings using the Chronic Care Model: an umbrella review

BACKGROUND

While there is clear evidence that nurses can play a significant role in responding to the needs of populations with chronic conditions, there is a lack of consistency between and within primary care settings in the implementation of nursing processes for chronic disease management. Previous reviews have focused either on a specific model of care, populations with a single health condition, or a specific type of nurses. Since primary care nurses are involved in a wide range of services, a comprehensive perspective of effective nursing processes across primary care settings and chronic health conditions could allow for a better understanding of how to support them in a broader way across the primary care continuum. This systematic overview aims to provide a picture of the nursing processes and their characteristics in chronic disease management as reported in empirical studies, using the Chronic Care Model (CCM) conceptual approach.

METHODS

We conducted an umbrella review of systematic reviews published between 2005 and 2021 based on the recommendations of the Joanna Briggs Institute. The methodological quality was assessed independently by two reviewers using the AMSTAR 2 tool.

RESULTS

Twenty-six systematic reviews and meta-analyses were included, covering 394 primary studies. The methodological quality of most reviews was moderate. Self-care support processes show the most consistent positive outcomes across different conditions and primary care settings. Case management and nurse-led care show inconsistent outcomes. Most reviews report on the clinical components of the Chronic Care Model, with little mention of the decision support and clinical information systems components.

CONCLUSIONS

Placing greater emphasis on decision support and clinical information systems could improve the implementation of nursing processes. While the need for an interdisciplinary approach to primary care is widely promoted, it is important that this approach not be viewed solely from a clinical perspective. The organization of care and resources need to be designed to support contributions from all providers to optimize the full range of services available to patients with chronic conditions.

PROSPERO REGISTRATION

CRD42021220004.

Effectiveness of nurse-led clinics on healthcare delivery: An umbrella review

BACKGROUND

Healthcare provision remains challenging leading to a focus on health service redesign including the development of nurse-led clinics. While there is a belief that nurse-led services positively impact on healthcare delivery, it is necessary to inform development through examination of the evidence.

METHODS

A search was conducted of Cumulative Index of Nursing and Allied Health Literature, MEDLINE, EMBASE, Scopus and the Cochrane Library for systematic reviews evaluating the effectiveness of nurse-led clinics when compared with usual care published between 2015 and 2020. Outcomes of interest were clinical outcomes, patient satisfaction and patient access to health care. Study quality was appraised using the AMSTAR 2 tool (A MeaSurement tool to Assess Systematic Reviews). A narrative analysis was conducted.

RESULTS

From 681 identified studies, nine were included, with reporting quality rated from very low to high quality. Patient clinical outcomes were reported as equal to or better than usual care across all studies included. There was evidence of high levels of patient satisfaction with nurse-led clinics across the included systematic reviews. While access to health care was the least reported variable, there were reports that access to health care increased or patient reliance on other healthcare providers reduced due to nurse-led clinics.

CONCLUSIONS

Despite the heterogeneous nature of the systematic reviews, along with some quality issues in reporting, there was evidence that nurse-led services provided comparable or superior care to usual care with high levels of patient satisfaction. There was a lack of reporting on the impact of nurse-led clinics on patient access to health care; further research is required on this area. Health service managers should consider nurse-led clinics an effective innovation in health service provision.

Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycaemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional healthcare team providing diabetes care in the USA and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the healthcare system and physical activity behaviours including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional health care team providing diabetes care in the U.S. and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the health care system, and physical activity behaviors, including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Inequal distribution of nursing personnel: a subnational analysis of the distribution of nurses across 58 countries

BACKGROUND

Nursing personnel are critical for enabling access to health service in primary health care. However, the State of the World's Nursing 2020 report showed important inequalities in nurse availability between countries.

METHODS

The purpose of this study/analysis was to describe the differences in nurse-to-population density in 58 countries from six regional areas and the relationship between differences in access to nurses and other indicators of health equity.

RESULTS

All countries and income groups showed subnational inequalities in the distribution of nursing personnel with Gini coefficients ranging from 1 to 39. The latter indicated situation such as 13% of the population having access to 45% of nurses in a country. The average max-to-min ratio was on average of 11-fold. In our sample, the African region had the highest level of subnational inequalities with the average Gini coefficient of 19.6. The European Region had the lowest level of within-country inequalities with the average Gini coefficient being 5.6. A multivariate analysis showed a clustering of countries in three groups: (1) high Gini coefficients comprised mainly African countries; (2) moderate Gini coefficients comprised mainly South-East Asian, Central and South American countries; (3) low Gini coefficients comprised mainly Western countries, Japan, and Korea. The analysis also showed that inequality in distribution of nurses was correlated with other indices of health and inequality such as the Human Development Index, maternal mortality, and life expectancy.

CONCLUSIONS

This study showed that there is a high level of geographic inequality in the distribution of nurses at subnational level. Inequalities in nursing distribution are multifactorial, to improve access to nurses, policies should be bundled, tailored to the local context and tackle the various root causes for inequalities.

Expanding nurses' authority - Physicians' and nurses' attitudes

AIM

To examine and compare the attitudes of physicians and registered nurses regarding extending nurses' authority.

DESIGN

This was a comparative quantitative study, which used a questionnaire that examined the attitudes of nurses and physicians regarding expanding nurses' authority.

METHODS

The study comprised a sample of 134 nurses (62.7%) and physicians (37.3%), who filled out the self-report questionnaire that included sociodemographic data and questions designed to examine the participants' attitudes and perceptions on expanding nurses' authority. The general reliability of the questionnaire was Cronbach's α = 0.931. Participants were sampled through the convenience-snowball method.

RESULTS

Differences were found between the attitudes of physicians and nurses to expanding nurses' authority. Nurses tended to be in favor, whereas physicians tended to be against (t(86.29) = 7.713; p < 0.05). Nurses' attitudes are also more positive specifically to procedures related to drug administration (t(132) = 6.894; p < 0.05) and resuscitation (t(132) = 2.974; p < 0.05), compared to physicians.

CONCLUSIONS

Nurses have more positive attitudes toward expanding nurses' authority than physicians do, specifically toward drug administration and resuscitation. Further study is proposed to identify factors which affect the physician-nurse relationship and attitudes on a large scale through a qualitative study.

Variation in the achievement of HbA1c , blood pressure and LDL cholesterol targets in type 2 diabetes in general practice and characteristics associated with risk factor control

AIMS

To identify population, general practitioner, and practice characteristics associated with the achievement of HbA_1c , blood pressure and LDL cholesterol targets, and to describe variation in the achievement of risk factor control.

METHODS

We conducted a cross-sectional survey of 9342 people with type 2 diabetes, 281 general practitioners and 77 general practices in Norway. Missing values (7.4%) were imputed using multiple imputation by chained equations. We used three-level logistic regression with the achievement of HbA_1c , blood pressure and LDL cholesterol targets as dependent variables, and factors related to population, general practitioners, and practices as independent variables.

RESULTS

Treatment targets were achieved for HbA_1c in 64%, blood pressure in 50%, and LDL cholesterol in 52% of people with type 2 diabetes, and 17% met all three targets. There was substantial heterogeneity in target achievement among general practitioners and among practices; the estimated proportion of a GPs diabetes population at target was 55-73% (10-90 percentiles) for HbA_1c , 36-63% for blood pressure, and 47-57% for LDL cholesterol targets. The models explained 11%, 5% and 14%, respectively, of the total variation in the achievement of HbA_1c , blood pressure and LDL cholesterol targets. Use among general practitioners of a structured diabetes form was associated with 23% higher odds of achieving the HbA_1c target (odds ratio 1.23, 95% confidence interval (CI) 1.02-1.47) and 17% higher odds of achieving the LDL cholesterol target (odds ratio 1.17, 95% CI 1.01-1.35).

CONCLUSIONS

Clinical diabetes management is difficult, and few people meet all three risk factor control targets. The proportion of people reaching target varied among general practitioners and practices. Several population, general practitioner and practice characteristics only explained a small part of the total variation. The use of a structured diabetes form is recommended.

Views of People with Diabetes Regarding Their Experiences of the Facilitators and Barriers in Type 1 Diabetes Inpatient Care: An Interpretative Phenomenological Analysis

BACKGROUND

The aim of this study was to comprehend how people with diabetes view their experiences of the possible barriers and facilitators in inpatient care for type 1 diabetes from non-specialized nurses.

DESIGN

An interpretative phenomenology analysis (IPA) was conducted.

METHODS

The sample consisted of people with type 1 diabetes 1 (n = 24) who use the services of the state hospitals in Cyprus. The data were collected in two phases: firstly, focus groups with people with diabetes (n = 2) were conducted and analysed, and then individual semi-structured interviews with people with diabetes (n = 12) were conducted.

RESULTS

It is evident from the findings that people with diabetes experienced several barriers in diabetes inpatient care, which is concerning since this can have adverse effects on patients' outcomes. No facilitators were reported.

CONCLUSION

Significant results were found in relation to the barriers to diabetes inpatient care. Crucially, the findings demonstrate that all these factors can negatively affect the quality of care of patients with diabetes, and most of these factors are related not only to diabetes care but also generally to all patients who receive inpatient care. Interestingly, no participant reported any facilitators to their care, which further affected the negative perceptions of the care received.

Nurse Prescribing-Readiness of Polish Nurses to Take on New Competencies-A Cross-Sectional Study

From January 2016, nurses in Poland received new competencies for prescribing. The work is the first in Poland to elaborate on the subject of nurses' readiness to learn and develop in the context of new nursing rights regarding autonomous prescription of medication and continuation of the prescription for medication. The aim of the study is to analyze the readiness of Polish nurses to learn and develop in the context of new competencies to write prescriptions. The research was conducted among 756 nurses. The standardized questionnaire (Readiness of Employees for Learning and Development) was used. For all subscales of readiness for learning and development, average scores prevailed. The readiness to write prescriptions was significantly related to the level of openness to changes in the work environment (A1 scale), self-evaluation of past educational development (C5 scale) and educational and professional goals alignment- employee and company (scale D2) and increasing the readiness of nurses to practice all of the aforementioned agents, in particular medical devices. The readiness of nurses to learn and develop at all levels of the subscales was on an average level. Younger nurses, with a shorter seniority, having higher education and additional qualifications had a higher readiness to prescribe medications and write prescriptions. The higher readiness for learning and development was matched by a greater readiness to prescribe. The results obtained can be used to plan training and courses, as well as to create special pro-development programs, which may increase the nurses' involvement in personal and professional development.

Reprint of: Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention: JACC Health Promotion Series

The primary objective of this study was to analyze the most up-to-date evidence regarding whether and how blood sugar regulation influences cardiovascular health promotion and disease prevention by carrying out an umbrella review. Three separate, systematic literature searches identified 2,343 papers in total. Overall, 44 studies were included for data extraction and analysis. The included systematic reviews and meta-analyses published between January 1, 2016, and December 31, 2017, were of good to very good quality (median Overview Quality Assessment Questionnaire score = 17). Identified evidence suggests that cardiovascular disease (CVD) prevention services should consider regulation of blood glucose as a key target for intervention. Furthermore, the recommendations for effective intervention and service development/training described here for prevention of CVD should be adopted into evidence-based practice guidelines. Multidisciplinary teams should be formed to deliver multicomponent interventions in community-based settings. There may be substantial opportunities for integrating CVD and diabetes prevention services.

Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention: JACC Health Promotion Series

The primary objective of this study was to analyze the most up-to-date evidence regarding whether and how blood sugar regulation influences cardiovascular health promotion and disease prevention by carrying out an umbrella review. Three separate, systematic literature searches identified 2,343 papers in total. Overall, 44 studies were included for data extraction and analysis. The included systematic reviews and meta-analyses published between January 1, 2016, and December 31, 2017, were of good to very good quality (median Overview Quality Assessment Questionnaire score = 17). Identified evidence suggests that cardiovascular disease (CVD) prevention services should consider regulation of blood glucose as a key target for intervention. Furthermore, the recommendations for effective intervention and service development/training described here for prevention of CVD should be adopted into evidence-based practice guidelines. Multidisciplinary teams should be formed to deliver multicomponent interventions in community-based settings. There may be substantial opportunities for integrating CVD and diabetes prevention services.

Impacts of nurse-led clinic and nurse-led prescription on hemoglobin A1c control in type 2 diabetes: A meta-analysis

BACKGROUND

To evaluate the impacts of nurse-led clinic and nurse-led prescription on hemoglobin A1c (HbA1c) control in type 2 diabetes.

METHODS

We searched relevant publications in English and Chinese database and conducted meta-analysis by Stata 12.0. We divided the case groups of included studies into 2 categories according to the role of nurse: nurse-led clinic and nurse-led prescription. Nurse-led clinic was implemented on the basis of standard diabetes care provided by doctor, and control group also receive the standard diabetes care but without nurse-led clinic. The doctor mentioned above might work alone or in a health care team. Nurse-led prescription was prescribed by nurse independently and compared with that of doctor.

RESULTS

The meta-analysis shown that, compared with the standard diabetes care, nurse-led clinic significantly decreases HbA1c level (standard mean difference [SMD] = -0.767; 95% confidence interval [CI]: -1.062, -0.471; P < .001). In subgroup analysis, nurse-led clinic also had positive impacts on controlling HbA1c level, no matter in developed countries (SMD = -0.353; 95% CI: -0.6, -0.106; P = .005) or developing countries (SMD = -1.114; 95% CI: -1.498, -0.73; P < .001). Additionally, there was no significant difference between nurse-led prescription and doctor prescription in controlling HbA1c levels (SMD = -0.203; 95% CI: -0.434, 0.029; P = .086).

CONCLUSION

The nurse-led clinic had positive significance for HbA1c control. Meanwhile, the impact of nurse-led prescription on controlling HbA1c is comparable to that of doctor. It is valuable to provide nurse-led clinic on the basis of standard diabetes care provided by doctor to better control HbA1c, and nurse-led prescription should be provided when doctor-led service is limited.

Person-Centered Primary Care and Type 2 Diabetes: Beyond Blood Glucose Control

With an estimated 9% of persons in the United States diagnosed with diabetes, primary care providers such as midwives and nurse practitioners are increasingly working with persons who have diabetes and are seeking primary care services. This article reviews the current literature with regard to the initial evaluation of individuals who are diagnosed with diabetes, and what is entailed in comprehensive continuing management of care. A person-centered interprofessional approach to care of the person with diabetes is presented. Recommendations are given that address dietary habits, activities of daily living, medication regimens, and potential alternative therapies. Social constructs related to effective care of individuals with diabetes also are addressed. Knowledge of current research that has identified effective care practices for individuals with diabetes is imperative to ensuring their well-being, and promoting a person-centered and interprofessional approach is best for offering optimal care to those diagnosed with diabetes.

The Effects of Nurse-Led Multidisciplinary Team Management on Glycosylated Hemoglobin, Quality of Life, Hospitalization, and Help-Seeking Behavior of People with Diabetes Mellitus

AIM

To evaluate the effect of community-nurse-led multidisciplinary team management on glycosylated hemoglobin (HbA1c), quality of life (QOL), hospitalization, and help-seeking behavior in people with type 2 diabetes mellitus (DM).

METHODS

A quasi-experimental trial was conducted among people with type 2 DM from two community centers in China. The intervention group (n = 88) received community-nurse-led multidisciplinary team management for 2 years, while the control group (n = 91) received usual care. Data regarding HbA1c, QOL (assessed by the SF-36), hospitalization, and help-seeking behavior were collected at baseline and at 6, 12, and 24 months.

RESULTS

During the 24-month project, the intervention group demonstrated 1.08% reduction in HbA1c, whereas the control group achieved an increase of 0.45%. The differences between the two groups were statistically significant (P < 0.001). The intervention group showed greater increased in QOL scores (from 66.43 to 70.47, P < 0.001), more decrease in hospitalization (OR = 2.981, 95% CI: 1.016, 8.752 versus OR = 1.189, 95% CI: 0.411, 3.444; P = 0.028) when compared with the control group. The percentage increase of seeking help from nurses in the intervention group (from 12.5% to 57.3%, P < 0.001) was significantly greater than that in the control group after the intervention.

CONCLUSIONS

Nurse-led multidisciplinary team management is an effective intervention for improving glycemic control, QOL, hospitalization, and help-seeking behavior for people with DM in a community.

Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.

Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication, and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.