Annual care standards published by ADA
The American Diabetes Association (ADA) has published its annual care recommendations to reflect the latest advances in evidence-based research.
Notable new recommendations in the 2018 edition of Standards of Medical Care in Diabetes (Standards of Care) include advances in cardiovascular disease risk management including hypertension and an updated, patient-focused care.
The integration of new technology into diabetes management as well as routine screening for type 2 diabetes in high-risk youth (BMI >85th percentile plus at least one additional risk factor) are also included.
The document provides evidence-based recommendations for the diagnosis and treatment of children and adults with type 1, type 2 or gestational diabetes, strategies to improve the prevention or delay of type 2 diabetes, and therapeutic approaches that reduce complications and positively affect health outcomes.
Beginning in 2018, the ADA will update and revise the online version of the Standards of Care throughout the year with necessary annotations if new evidence or regulatory changes merit immediate incorporation.
Dr William T. Cefalu, ADA’s chief scientific, medical and mission officer, said: “The Standards of Care are the primary resource for the optimal management of diabetes, and include updated guidelines for diabetes diagnosis, and for evidence-based prevention of diabetes and diabetes-related complications. We are especially proud of the new recommendations for patients with diabetes and cardiovascular disease.
“Since 1989, the American Diabetes Association has provided annual updates to the Standards of Care, and the Standards are accepted as the global standard for diabetes care. As new technology, research and treatments continue to improve and emerge, we are pleased that we will have the capacity to provide real-time updates to the Standards of Care throughout the year.”
The Standards of Care incorporate comprehensive information based upon current research findings and an extensive body of literature. Significant changes and updates in the 2018 edition are:
Cardiovascular disease and diabetes
- Based upon the results of multiple cardiovascular outcome trials (CVOT), there are new treatment recommendations for adults with type 2 diabetes, suggesting a pathway for people with heart disease that, after lifestyle management and metformin, should include a medication validated to improve heart health. A new table outlines the data from recent CVOT studies, and a new figure details our recommendations based on those CVOT studies. (Section 8, page S76, Table 9.4 and Figure 8.1, respectively)
- Four major, randomized controlled trials that compared intensive versus standard hypertension treatment strategies are summarized and outlined in a new table, providing support for the ADA’s recommendations that most adults with diabetes and hypertension should have a target blood pressure of <140/90 mmHg and that risk-based individualization to lower targets, such as 130/80 mmHg, may be appropriate for some patients. The studies highlighted include the Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD BP) trial; the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation—Blood Pressure (ADVANCEBP) trial; the Hypertension Optimal Treatment (HOT) trial; and the Systolic Blood PressureIntervention Trial (SPRINT). (Section 9, page S88, Table 9.1)
- A new algorithm illustrating the recommended antihypertensive treatment approach for adults with diabetes and confirmed hypertension (blood pressure ≥140/90 mmHg) has been added. (Section 9, page S90, Figure 9.1)
- Also new this year is the recommendation that all hypertensive patients with diabetes monitor their blood pressure at home to help identify potential discrepancies between office vs. home blood pressure, and to improve medication-taking behavior. (Section 9, page S87)
Screening youth for type 2 diabetes
- Updated recommendations emphasize that testing for prediabetes and type 2 diabetes should be considered in children and adolescents younger than 18 years of age who are overweight or obese (BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height), and have one or more additional risk factors for diabetes such as (1) maternal history of diabetes or gestational diabetes during the child’s gestation; (2) family history of type 2 diabetes in first- or second-degree relative; (3) race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander; and/or (4) signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight). (Section 2, page S19, Table 2.5)
Health technology and diabetes management
- The ADA recommends including technology-based methods, along with individual and group settings, for the delivery of effective diabetes self-management education and support. (Section 4, page S38)
- As continuous glucose monitoring (CGM) technology continues to evolve, the ADA adjusted its recommendations to align with recent data showing that CGM helps improve glycemic control for adults with type 1 diabetes starting at age 18 (previous recommendations were for those ages 25 and older). (Section 6, page S55)
- Federal regulatory changes prompted the ADA to include language describing CGM devices that don’t require confirmation from finger sticks to make treatment decisions, and a new type of “flash” CGM that doesn’t have any alarms and only provides “on demand” glucose readings. (Section 6, page S56)
A1C test considerations
- Additional language and recommendations have been added to help ensure appropriate use of the A1C test to diagnose diabetes and for monitoring glycemic control in people with diabetes. The A1C can give skewed results in people with certain conditions that alter the lifespan of red blood cells in the body (the ability of the A1C test to provide a measure of average blood glucose over time is based on the lifespan of red blood cells), as well as in people with certain genetic traits that alter the molecules in their red blood cells. Age, ethnicity and pregnancy can also affect A1C results. The ADA emphasizes that health care providers need to be aware of these limitations, to use the correct type of A1C test and to consider alternate diagnostic tests (fasting plasma glucose test or oral glucose tolerance test) if there is disagreement between A1C and blood glucose levels. (Section 2, page S14)
Diabetes management in specific groups
- Three new recommendations were added to highlight the importance of individualizing pharmacologic therapy for older adults with diabetes to reduce the risk of hypoglycemia, avoid overtreatment and simplify complex regimens while maintaining personalized blood glucose targets. (Section 11, page S122)
- A new guideline recommends all pregnant women with preexisting type 1 or type 2 diabetes should consider daily low-dose aspirin starting at the end of the first trimester in order to reduce the risk of pre-eclampsia. (Section 13, page S140)
Patient-centered care and acknowledging cost-of-care impact
- A new table summarizes drug-specific and patient factors that may impact diabetes treatment. The chart includes the most relevant considerations, such as risk of hypoglycemia, weight effects, kidney effects and costs for all preferred diabetes medications, in one location to guide the choice of antihyperglycemic agents as part of patient-provider shared decision-making. (Section 8, page S77, Table 8.1)
- The guidelines recommend increased awareness and screening for social determinants of health such as financial ability to afford medication; access to healthy foods and food insecurity; and community support. (Section 1, page S9)
Additional important updates
- The immunization needs for people with diabetes were clarified and updated to more closely align with recommendations from the Centers for Disease Control and Prevention. (Section 3, page S29-31)
- A new section describes emerging evidence that speciﬁc glucose-lowering medications delay the onset and progression of kidney disease. (Section 10, page S108)
- A detailed table highlighting the components of a comprehensive medical evaluation has been redesigned and reorganized. It incorporates information about the recommended frequency of the components of care at both initial and follow-up visits, including regular screening for mental health. (Section 3, page S30, Table 3.1)