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US care standards updated by American Diabetes Association

By Editor
18th December 2018
Clinical guidance

The American Diabetes Association (ADA) has included several new and revised clinical practice recommendations in its 2019 Standards of Medical Care in Diabetes.

The ADA say the changes are designed to put the person with diabetes at the centre of care, including efforts to reduce therapeutic inertia, improve language and expanded recommendations for children and adolescents with type 2 diabetes.

Published online in the journal Diabetes Care on Monday, December 17, the 2019 version is a collaboration between the American College of Cardiology and the American Heart Association.

It provides 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.

Professor William T. Cefalu, ADA’s Chief Scientific, Medical and Mission Officer, said: “The latest evidence-based research continues to provide critical information that can optimise treatment options and improve patient outcomes and quality of life. The new 2019 Standards of Care emphasise a patient-centered approach that considers the multiple health and life factors of each person living with diabetes.

“We are also pleased about our close collaboration with the American College of Cardiology, aligning the ADA’s CVD recommendations with the ACC for the first time ever, and also complements our new Know Diabetes by Heart initiative with the American Heart Association. These updated CVD guidelines can help to significantly reduce mortality from CVD, the leading cause of death for people living with diabetes. The 2019 Standards of Care affirm the ADA’s commitment to providing rapid release of evidence-based recommendations that can yield improved patient outcomes and reduce complications and health care costs, and we hope providers will continue to download and use the mobile App for easy access to the Standards of Care at the point of care.”

Important updates and changes to the 2019 Standards of Care include:

Personalising 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. (Section 4, page S35, Figure 4.1)
  • 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. (Section 4, page S34, Recommendation 4.1)
  • 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. (Section 12, page S141, Recommendation 12.10)
  • 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. (Section 12, pages S143 – S144, Figure 12.1, and Table 12.2, respectively)
  • 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. (Section 13, pages S148 – S164)
  • A new graphic provides guidance on the management of new-onset diabetes in overweight youth. (Section 13, page S157, Figure 13.1)

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. (Section 16, page S182)
  • Additional information is also included in the Standards of Care focusing on the financial costs of diabetes to individuals and society. (Section 1, pages S7–S12)

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. (Section 10, pages S103 – S123)
  • 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. (Section 10, pages S103–S123)
  • 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. (Section 10, page S114, Recommendations 10.39 and 10.40). 
  • 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. (Section 11, page S124, Recommendation 11.3)
  • 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. (Section 10, page S104) 

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). (Section 7, pages S71 – S80)
  • 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. (Section 1, pages S8 – S9)
  • 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. (Section 9, page S91)

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. (Section 5, page S47-48)
  • A recommendation is updated to emphasize the benefits of consuming more water and fewer beverages sweetened with either nutritive (caloric) or nonnutritive (noncaloric) sweeteners. (Section 5, page S49, Recommendation 5.23 in Table 5.1)

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. (Section 9, pages S95 – S96, Figures 9.1 and 9.2) 
  • 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. (Section 9, page S95, Figure 9.2)
  • 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. (Section 11, S131, Recommendation 11.31)
  • A new table aids in the assessment of hypoglycemia risk details factors that increase the risk of treatment-associated hypoglycemia. (Section 4, page S39, Table 4.3)

Updates to the Standards of Care are established and revised by the ADA’s Professional Practice Committee (PPC). The committee is a multidisciplinary team of 15 leading US experts in the field of diabetes care and includes physicians, diabetes educators, registered dietitians and others whose experience includes adult and paediatric endocrinology, epidemiology, public health, lipid research, hypertension, preconception planning and pregnancy care.

To access 2019 Standards of Medical Care in Diabetes, click here.

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