ADA Releases Standards of Medical Care in Diabetes 2019
The American Diabetes Association has recently released new and revised clinical practice recommendations in 2019 Standards of Medical Care in Diabetes. The updated standards, published in the journal Diabetes Care, also reflect a collaboration between the American College of Cardiology and the American Heart Association to align goals for optimal CVD management. For the first time this year, the updated ADA standards are endorsed by the ACC.
The 2019 Standards of Care provide the latest in comprehensive, evidence-based recommendations for the diagnosis and treatment of children and adults with type 1, type 2, or gestational diabetes, strategies to prevent or delay type 2 diabetes, and therapeutic approaches that can reduce complications and improve health outcomes.
The guidance puts the patient at the center of care. With more treatment algorithms that provide decision support for individualized care, the 2019 Standards of Care create a roadmap for therapeutic approaches and medication selection based on each patient’s overall health status. The Standards of Care’s cardiovascular recommendations include updates that aim to reduce heart attacks, strokes, heart failure, and other manifestations of cardiovascular disease; cardiovascular disease is the leading cause of death and disability for people with diabetes.
Diabetes technology is now more thoroughly discussed in its own section and includes new recommendations on insulin delivery, blood glucose meters, continuous glucose monitors, automated insulin delivery devices (such as the artificial pancreas) and insulin injection technique.
The document contains recommendations on the following:-
• Improving Care and Promoting Health in Populations
• Classification and Diagnosis of Diabetes
• Prevention or Delay of Type 2 Diabetes
• Comprehensive Medical Evaluation and Assessment of Comorbidities
• Lifestyle Management
• Glycemic Targets
• Diabetes Technology
• Obesity Management for the Treatment of Type 2 Diabetes
• Pharmacologic Approaches to Glycemic Treatment
• Cardiovascular Disease and Risk Management
• Microvascular Complications and Foot Care
• Older Adult
• Children and Adolescents
• Management of Diabetes in Pregnancy
• Diabetes Care in the Hospital
• Diabetes Advocacy
Important updates and changes to the 2019 Standards of Care include:
Personalizing diabetes care
• A new Goals of Care graphic decision cycle details the need for ongoing assessment and shared decision-making to achieve care goals, help reduce therapeutic inertia and improve patient self-management.
• New text guides health care professionals’ use of language to communicate about diabetes with people with diabetes and professional audiences in an informative, empowering, and educational style.
• To address the unique nutritional and physical activity needs and considerations for older adults (>65 years) with diabetes, a new recommendation on lifestyle management is included.
• A new treatment algorithm provides a path for simplifying insulin treatment plans, as well as a new table to help guide providers considering medication simpliﬁcation and deintensiﬁcation in older adults (>65 years) with diabetes.
• Treatment recommendations for children and adolescents with type 2 diabetes are signiﬁcantly expanded to incorporate ADA guidance on youth published in 2018, and recommendations now include screening and diagnosis, lifestyle management, pharmacologic treatment, psychosocial factors for consideration, cardiac function and more.
• A new graphic provides guidance on the management of new-onset diabetes in overweight youth.
Diabetes cost and advocacy
• The ADA statement on the rising cost of insulin, Insulin Access and Affordability Working Group: Conclusions and Recommendations, is referenced in the Standards of Care advocacy section to reinforce ADA’s focus on making sure cost is not a barrier to successful diabetes management.
• Additional information is also included in the Standards of Care focusing on the ﬁnancial costs of diabetes to individuals and society.
Cardiovascular disease and diabetes
• For the first time, the cardiovascular disease management chapter of the Standards of Care is endorsed by the American College of Cardiology.
• The section includes new language to acknowledge heart failure as a major cause of cardiovascular morbidity and mortality in people with diabetes and the need to consider heart failure when determining optimal diabetes care.
• Updated recommendations detail the use of sodium–glucose cotransporter 2 (SGLT-2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists, diabetes medications that have proven cardiovascular beneﬁt for people with type 2 diabetes and diagnosed CVD, with and without heart failure.
• A new recommendation outlines the benefits of GLP-1 receptor agonists and SGLT-2 inhibitors for people with type 2 diabetes and chronic kidney disease.
• The ADA now endorses the use of ACC’s atherosclerotic cardiovascular disease (ASCVD) risk calculator, the ASCVD Risk Estimator Plus, for the routine assessment of 10-year ASCVD risk in people with diabetes.
Technology and diabetes
• A new section focused on diabetes technology includes new recommendations on insulin delivery (syringes, pens and insulin pumps), blood glucose meters, continuous glucose monitors (real-time and intermittently scanned), and automated insulin delivery devices (such as the artificial pancreas).
• Telemedicine is becoming more widely available and has the potential to increase access to care for patients with diabetes. The Standards of Care addresses remote delivery of health-related services and clinical information via telemedicine
• To ensure that insulin is delivered into the proper tissue in the right way for optimal glucose management and safety, discussion on insulin injection technique is included
Medical nutrition therapy (diet)
• Extending the patient-centered care focus, the Standards of Care acknowledge that there is no one-size-fits-all eating pattern, and that a variety of eating patterns can help manage diabetes. It is recommended for patients to be referred to and work with a registered dietitian to create a personalized nutrition plan.
• A recommendation is updated to emphasize the benefits of consuming more water and fewer beverages sweetened with either nutritive (caloric) or nonnutritive (noncaloric) sweeteners.
Pharmacologic approaches and glycemic targets
• The recommended pharmacologic treatment for type 2 diabetes is signiﬁcantly updated to align with and reflect the new ADA-EASD Consensus Report, specifically consideration of important comorbidities, such as ASCVD, chronic kidney disease and heart failure and key patient factors, such as hypoglycemia risk, body weight, costs and patient preference.
• The approach to injectable medication therapy is also revised: for patients who require the additional glucose-lowering efficacy of an injectable medication, a GLP-1 receptor agonist is now recommended as the ﬁrst choice before insulin for most patients with type 2 diabetes.
• Gabapentin is included as a new medication to be considered for the treatment of neuropathic pain in people with diabetes based on the latest data that indicates strong efﬁcacy and the potential for cost savings.
• A new table aids in the assessment of hypoglycemia risk details factors that increase the risk of treatment-associated hypoglycemia.
About the ADA
Founded in 1940, the American Diabetes Association (ADA) is the nation’s leading voluntary health organization whose mission is to prevent and cure diabetes, and to improve the lives of all people affected by diabetes. The ADA drives discovery by funding research to treat, manage and prevent all types of diabetes, as well as to search for cures; raises voice to the urgency of the diabetes epidemic; and works to safeguard policies and programs that protect people with diabetes.
Note: This list is a brief compilation of some of the key recommendations included in the Guidelines and is not exhaustive and does not constitute medical advice. The complete 2019 Standards of Care is available here: https://pxmd.co/Vz6g8