For 2019, ADA and ACC Align Their Diabetes Recommendations

For the first time in its annual diabetes management guidelines, the American Diabetes Association (ADA) has aligned its recommendations with those of the American College of Cardiology (ACC) for cardiovascular risk reduction in people with type 2 diabetes.

The 2019 Standards of Medical Care in Diabetes, published online December 17 in Diabetes Care (and updated in real-time) also incorporate the recently published joint consensus guidelines by the ADA and European Association for the Study of Diabetes (EASD), which emphasize patient-centered decision-making about the treatment of hyperglycemia in type 2 diabetes.

And in all areas of diabetes management, the 2019 Standards "strengthen the ADA stance on patient-centered care and involving the individual in the decision-making pathway," ADA Professional Practice Committee Chair Joshua J. Neumiller, PharmD, CDE, told Medscape Medical News.

According to Neumiller, who is vice chair and Allen I. White Distinguished Associate Professor in the Department of Pharmacotherapy at Washington State University, Spokane, "A one-size-fits all approach doesn't really work for anybody with diabetes."

"We've acknowledged that throughout and tried to provide practitioners with some tools and decision pathways and algorithms to help them reach a treatment approach that is appropriate for a given person."

Other notable changes in 2019 involve the diagnosis of diabetes, foot exams, managing older adults and youth with diabetes, use of diabetes technology, and a greater emphasis on the cost of medications as a major factor in clinical decision-making.

Neumiller encourages primary care clinicians in particular to consult the abridged version of the Standards, now published online in Clinical Diabetes, and to download the Standards app, both of which include the key algorithms and decision pathways.

"Some of this individualization can really be aided through these tools," he stressed.

Aligning With ACC

The "expert consensus decision pathway" in the cardiovascular disease management section of the new ADA Standards aligns with that published by the ACC in November 2018, aimed at educating cardiologists on the use of two major new diabetes drug classes — sodium-glucose cotransporter type 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor (GLP-1) agonists — both of which have been shown to reduce adverse cardiovascular outcomes in patients with cardiovascular disease and diabetes.

That document was formally endorsed by the ADA and now the ACC has reciprocated for this one, with each of the writing panels including liaisons from the other organization.

"We're very excited to have that endorsement from ACC in the cardiovascular section...There's a really strong collaboration coming out of both organizations...I think this is very important, so that the information going out to providers is consistent," Neumiller said.

Along with the guidance on use of SGLT2 inhibitors and GLP-1 agonists, the cardiovascular chapter also recommends consideration of heart failure and chronic kidney disease as major factors in determining optimal care, and endorses the ACC's Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator Plus for routine assessment of 10-year ASCVD risk in people with diabetes.

Changing Old Paradigms: Diagnosis, SMBG, Technology, and Feet

Based on new data, ADA now says that diabetes can be diagnosed based on two abnormal test results — such as fasting blood glucose and HbA_1c — from the same blood sample, so the patient doesn't have to return before the diagnosis can be made.

The Professional Practice Committee made the change "to increase efficiency so people are diagnosed earlier," Neumiller said, noting that "one of the concerns with the old approach is if you saw a positive blood sample it might be months before they get back in for a follow-up," whereas the new approach should help in identifying people with diabetes earlier and initiating treatment sooner.

A new section on diabetes technology has also been added, with recommendations on insulin delivery devices, glucose monitoring, "artificial pancreas" systems, and telemedicine.

Some of the information was previously included in separate chapters, but now "we thought it was important to have a central hub addressing technology," Neumiller said.

In the technology section, the ADA has added new language acknowledging that self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes who aren't at risk for hypoglycemia (ie, not taking insulin or sulfonylureas) is of limited benefit and doesn't appear to affect outcomes.

"We still emphasize the importance of SMBG for giving a lot of information on impact of lifestyle and medications, but we're backing off a little bit, saying that if their hypoglycemia risk is low, take a close look at the appropriate frequency of SMBG and the impact on their self-management capabilities," Neumiller explained.

In another clinical paradigm shift, ADA no longer advises clinicians examine the feet of all patients with diabetes at every office visit.

Rather, such routine foot examinations should be reserved for patients at high risk for ulceration, and yearly foot exams are advised for everyone else.

Diabetes Across the Ages

In keeping with the patient-centered approach, new information now addresses care for older adults with diabetes and youth with type 1 or type 2 diabetes.

In particular, the older adult section provides recommendations on lifestyle management, nutrition, and medication de-intensification, including a new table and algorithm to aid clinicians on simplification and de-prescribing of insulin and other medication regimens in people with limited life expectancy.

Discussions of type 2 diabetes in youth have been significantly expanded in the section on children and adolescents, with new recommendations in several areas, including screening and diagnosis, lifestyle management, pharmacologic management, and transition of care to adult providers.

The chapter now incorporates ADA statements published in the past year on type 1 diabetes and type 2 diabetes in youth.

Cost Considerations

The 2019 Standards address costs of diabetes care in several chapters.

The first chapter on population health advises assessing patients' social contexts including food insecurity, housing stability, and financial barriers, and referring them to community resources when available.

And a concluding section on advocacy incorporates the ADA "Insulin Access and Affordability Working Group: Conclusions and Recommendations" statement that was published in May 2018.

"The Professional Practice Committee felt addressing cost was very important...to make sure providers keep it in mind and ask patients about it," Neumiller said.

Although newer type 2 diabetes drugs may offer benefits over older agents such as greater efficacy, less hypoglycemia and weight gain, and cardiovascular benefits, "if the individual with diabetes can't afford the drug and doesn't take it, it's all for naught, so we have to consider that very early in our decision-making process."

Neumiller has reported no relevant financial relationships.

Diabetes Care. Published online December 17, 2018. Full text

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