Palabras clave
guía de práctica clínica
terapia combinada
iSGLT2
AR GLP-1
finerenona
control glucémico
Colombia
Cómo citar
Resumen
Contexto: la Asociación Colombiana de Endocrinología, Diabetes y Metabolismo (ACE) desarrolló esta guía de práctica clínica con el propósito de emitir recomendaciones
actualizadas para el manejo y seguimiento de las personas que viven con diabetes mellitus tipo 2 (DM2) en Colombia. Esta actualización responde a la necesidad de revisar las directrices establecidas en la guía nacional publicada en 2016, a la luz de la evidencia científica reciente y robusta disponible a nivel mundial, la cual ha generado cambios sustanciales en la
aproximación terapéutica.
Objetivo: la guía enfatiza el enfoque preventivo de desenlaces cardiovasculares y renales, así como la integración de intervenciones en el estilo de vida y la incorporación de la tecnología como parte esencial del abordaje holístico de la persona con DM2.
Metodología: la guía fue elaborada mediante la metodología GRADE, en concordancia con los lineamientos de AGREE II e Institute of Medicine. El proceso incluyó la formulación de nueve preguntas PICO, búsquedas sistemáticas, evaluación crítica de la evidencia y formulación de recomendaciones en un panel interdisciplinario con participación de
pacientes. La transparencia se garantizó con gestión de conflictos de interés y revisión
externa internacional.
Principales recomendaciones: se recomienda iniciar terapia combinada con metformina e inhibidor del cotransportador sodio-glucosa tipo 2 (iSGLT2) o inhibidor de la dipeptidil peptidasa-4 (iDPP-4) en pacientes con niveles significativamente elevados de HbA1c, desaconsejándose las combinaciones con sulfonilureas.
En pacientes que no alcanzan la meta glucémica con monoterapia con metformina, se sugiere añadir un iSGLT2 o un agonista del receptor de GLP-1 (AR GLP-1), ´éste último especialmente en presencia de sobrepeso, obesidad o HbA1c marcadamente elevada.
En caso de control glucémico inadecuado pese al uso de antidiabéticos orales, se recomienda como primera opción la adición de un AR GLP-1, particularmente en pacientes con índice de masa corporal (IMC) > 27 kg/m². La adición de insulina basal se sugiere cuando no se logra el control con AR GLP-1.
En el contexto de diabetes tipo 2 asociada a sobrepeso u obesidad, se aconseja el uso de
AR GLP-1 o agonistas duales GLP-1/GIP. En personas con obesidad grado 2 o superior,
puede considerarse la cirugía metabólica o bariátrica, siempre que esté acompañada de educación, evaluación individual del riesgo-beneficio y sea realizada en centros de referencia especializados.
Las terapias cardiorrenoprotectoras (iSGLT2, AR GLP-1, finerenona) deben priorizarse e
iniciarse de manera independiente al grado de control glucémico o a la terapia concomitante, en personas con enfermedad cardiovascular aterosclerótica, insuficiencia cardíaca o enfermedad renal crónica, según el perfil clínico individual.
Se recomienda el uso de sistemas de monitoreo continuo de glucosa (MCG en tiempo real) en pacientes que reciben múltiples dosis de insulina y presentan hipoglucemias o control glucémico inadecuado.
Finalmente, se enfatiza la importancia de la educación diabetológica continua y del enfoque multidisciplinario en el manejo integral de todas las personas con diabetes tipo 2.
Conclusiones: esta guía constituye una herramienta práctica y rigurosa para la atención integral de la DM2 en Colombia, con recomendaciones adaptadas al contexto nacional y con alto potencial para mejorar la calidad de vida y reducir la carga de la enfermedad.
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