The usefulness and relevance of diabetes clinical guidelines are beyond doubt. Their use is widespread among internal medicine clinicians, though they have a weakness: “The most relevant information they rely on comes from clinical trials, and these underrepresent certain groups — women, pediatrics, individuals aged 65 or older, etc. Therefore, we cannot simply use the guidelines; we have to adapt them based on patient characteristics, and when these do not allow us to use the guidelines, we must know how to proceed,” said Javier Ena, MD, of the Department of Internal Medicine at Marina Baixa Hospital in Villajoyosa, Spain, and former coordinator of the Diabetes, Obesity, and Nutrition Working Group of the Spanish Society of Internal Medicine (SEMI), in an interview with Univadis Spain, part of the Medscape Professional Network.

This was precisely the focus of the session “Updates to Diabetes Mellitus Management Guidelines” at the 46th National Congress of SEMI, held on November 26-28 in Córdoba, Spain, together with the 39th Congress of the Andalusian Society of Internal Medicine. Participants included Marta Fernández Toral, from the Service of Internal Medicine, Hospital Universitario Clínico San Cecilio in Granada, Spain, who addressed the role of clinical guidelines in comprehensive diabetes management, and Ena, who addressed diabetes treatment in older adults.

Comprehensive Diabetes Management

The most relevant current guidelines include the annual consensus of the American Diabetes Association; the KDIGO guidelines for managing diabetes in chronic kidney disease; European Society of Cardiology guidelines for managing cardiovascular disease in diabetes; and documents from SEMI’s Diabetes, Obesity, and Nutrition Working Group, which adapt global evidence to the reality of Spain’s health system.

For appropriate use, patients should be phenotyped from the outset to tailor therapy. To support this task, SEMI’s Diabetes, Obesity, and Nutrition Working Group produces an annual treatment algorithm adjusted to different profiles: cardiorenal patients, those with severe obesity, or frail older adults — in whom safety and hypoglycemia prevention are priorities, among others. This approach enables “made-to-measure” choices of organ-protective drugs. “The reason this algorithm is updated each year is because diabetes is a very active field, with frequent new drugs that rapidly change the landscape,” Ena explained.

Barriers to Implementation

Two obstacles stand out. First, limited time in clinic: Modern diabetes care requires reviewing renal and cardiac protection, lipid control, and blood pressure, as well as educating patients on new technologies and injection devices. Second, bureaucratic and access barriers: Evidence can move faster than reimbursement. For example, even when guidelines recommend SGLT2 inhibitors for heart failure with preserved ejection fraction in patients without diabetes, administrative restrictions or prior authorization may limit use.

For Ena, access is the bigger problem: “Many of the new diabetes drugs also treat obesity. They are not covered by the National Health System because obesity is not considered a disease. Some patients who could benefit are not receiving them because these drugs are expensive and they cannot afford them. To get around this, some companies market the same drug under different names for obesity vs other indications to improve chances of public reimbursement.”

How Treatment Is Evolving

Diabetes treatment has undergone three major shifts in recent years. First, a move from a glucocentric to an organ-centric approach: For decades, diabetes care focused almost exclusively on lowering blood glucose. The priority was glycemic control, and it was assumed that if glucose was well controlled, everything else would be fine; drugs were chosen by how much they reduced glucose. The problem is that lowering glucose does not always reduce cardiovascular or renal complications or mortality. With an organ-centric approach, the goal is not just glucose but also protecting key organs affected by diabetes — the heart, kidneys, liver, etc. — because diabetes is a multiorgan disease, not just a glucose problem. This is where SGLT2 inhibitors and GLP-1 receptor agonists have become pillars beyond glycemic control.

The second shift is the arrival of dual glucose-dependent insulinotropic polypeptide/GLP-1 receptor agonists, which mark a new era of high efficacy in weight loss and metabolic control.

Finally, new technologies have changed how diabetes is assessed and managed: Continuous glucose monitoring at frequent intervals without finger stick is now possible, along with tracking “time in range,” the percentage of time a patient keeps glucose within the target range.

Diabetes Care in Older Adults

Adults aged 65 years or older with diabetes are the most important group for whom clinical guidelines fall short. This is because “most have some level of functional frailty, which requires setting less stringent glycemic targets and adapting diabetes medications, prioritizing safety over treatment efficacy,” Ena emphasized. In Spain, an estimated 20% of those aged 65 years or older have diabetes, rising to 25% among those aged 75 years or older, underscoring the magnitude of the issue in this population.

Therefore, “it is essential to stratify this population by functional capacity, cognitive status, and life expectancy to decide the most appropriate management for each patient. This is done with simple assessments that define three categories: Robust patients who, although older than 65, can be considered clinically middle-aged, have no functional limitations, and thus can be managed per clinical practice guidelines to avoid diabetes-related complications and maintain excellent glycemic control; prefrail patients with some limitations who can still be treated with selected guideline-recommended drugs depending on their characteristics; and frail patients — those with physical or psychological dependence, limited life expectancy, cognitive impairment, and multiple comorbidities such as kidney failure, heart failure, dementia, obesity, etc. In these cases, the goal is usually to avoid diabetes-related symptoms, not strict glycemic control, because that would require drugs whose side effects would overshadow clinical benefits. This last group accounts for 70% of hospitalized patients with diabetes,” Ena concluded.

Ena reported having no conflicts of interest. 

This story was translated from Univadis Spain.