https://www.acpjournals.org/doi/10.7326/M20-2470 Pharmacologic Approaches to Glycemic Treatment of Type 2 Diabetes: Synopsis of the 2020 American Diabetes Association's Standards of Medical Care in Diabetes Clinical Guideline FREE Which is as the artciel suggest in a sypnopsis of the 2020 ADA guidelines metformin is still universal fist line but now the guideline says The choice of agent to add to metformin therapy should be individualized on the basis of patient characteristics, preferences, and drug-specific effects. The big rec from this paper is Among patients with type 2 diabetes who have established ASCVD or established kidney disease, or heart failure, a sodium–glucose cotransporter-2 (SGLT2) inhibitor or glucagon-like peptide-1 receptor agonist (GLP-1 RA) with demonstrated cardiovascular disease benefit is recommended (Grade A recommendation). they go on to say maybe one of the key lines--------The addition of these medications should be considered independent from HbA1c level in this patient population. You might remember dapaggliflozin – the article last year that I said was one of the top articles of the year because it changed how we practice for both diabetes and heart failure!! Well now---I give you--- https://www.nejm.org/doi/10.1056/NEJMoa2022190 Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure in the NEJM EMPEROR-Reduced trial recently out which looked to see if empagliclozin could join dapagliflozin for risk reduction in heart failure!! This was a double-blind, randomized, placebo-controlled, using empagliflozin (10 mg daily) At a mean follow-up of 16 months, patients receiving empagliflozin had a lower risk for the primary endpoint of cardiovascular death or hospitalization for worsening HF than placebo recipients with a shocking NNT of 20 although this was mainly driven by heart failure hospitalizations these numbers are similar to dapagliflozin -- (19.4% vs. 24.7%). –AND THIS was INDEPENDENT OF DIABETIC DIAGNOSIS!! AND when you looked at the change in A1C at the end of the trial—there was no difference, just maybe these SGLT2 inhibitors really are people drugs, not diabetic drugs which has to make everyone question the relevance of the surrogate marker we use for diabetes, A1C. not to go on too much of a rant but if we look at A1C and say this is the standard by which all drugs should be measured and some drugs DO NOT CHANGE THE A1C or at least not with any clinical significance but they do prevent death, MI and hospisitliations while other drugs dont change any of the hard outcomes but they change the A1C we have to say maybe just maybe A1C is not the marker we should care about. and as excited as I am abou the rush of evidence around SGLT2 inhibitors. Sadly the best medication is likely still prevention, with healthy lifestyle- these drugs are still around $500 a month so we are talking at least 6grand a year for a drug that 95 out of 100 people will never benefit from. Which means we are talking roughly 120,000$ per event saved! So I grant you this is a really impressive article and empagliflozin is now joining dapagliflozin to prevent heart failure hospitalistizations, and I still think the SGLT-2 inhibitors are quickly becoming king of the castle for diabetes treatment—I also think they will never truly take the thrown till they are $4 a month like metformin. next article And while talking guidelines Synopsis of the 2020 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: The Diagnosis and Management of Hypertension in the Primary Care Setting FREE Also in annals of internal medicine but had a couple interesting or new recommendations like we suggest using attended or unattended, fully automated blood pressure measurement. A fully automated BP programmed to wait 5 minutes and recod the average of threee measurements separated by at least 30 seconds(continued)