Every year since 1989, the American Diabetes Association has published guidelines that reflect the most up-to-date information about diabetes management. Let’s review some of the new updates.
The revisions include an emphasis on health promotion and health literacy, and the role of the community health worker was detailed. In the section for diabetes diagnosis and classification, more information about the effects of hemoglobinopathies/race/ethnicity were included. Also, the diagnosis of gestational diabetes was clarified specifically regarding the glucose tolerance test. Screening for prediabetes and diabetes was expanded for all adults at age 35.
In the section for comorbidity management, an important emphasis was placed on patients with nonalcoholic fatty liver disease (NFALD) and nonalcoholic steatohepatitis (NASH). The American Gastroenterological Association guidelines, particularly for managing these conditions, were summarized. And vaccination information for coronavirus disease 2019 (COVID-19) was included.
This year, there have been some important updates regarding the use of technology that will have direct impact on primary care practices since most people with diabetes are managed by their primary care providers. Early use of technology was emphasized, and the choice of device was based on individual and caregiver preferences. The Freestyle Libre and Dexcom 6 were detailed and the use of the AGP (ambulatory glucose profile) was recommended, with particular emphasis on hypoglycemia detection and prevention.
The section on continuous glucose monitors also included “connected insulin pens” along with associated evidence to support them. These are important updates that primary care providers will need to pay attention to since our patients will ask us for them. We need to be familiar with how to order them, how to apply to the patient, and how to interpret the data.
Insulin pumps and automated insulin delivery systems were detailed in the same section. The revisions also included a recommendation to allow people to use their diabetes devices during outpatient or inpatient visits (when safe to use them and they can be properly supervised). This update arose as people with diabetes were hospitalized with COVID-19; the staff needed to rely on these devices for real-time data as they managed insulin infusions as an example. It helped maintain safe distances while patients were in ICUs or other isolated environments.
In the pharmacology sections, approved obesity medications were added to include newly approved (new indication at higher doses) semaglutide. Multiple pharmacology updates were made to reflect emerging evidence, and the revisions emphasize the selection of specific agents based on comorbid conditions, patient factors, and efficacy.
In the cardiovascular disease and risk management sections, endorsement by the American College of Cardiology was highlighted for the 4th year in a row. To further reflect this collaborative approach with the ACC, an entire section regarding clinical approaches to the patient was reproduced from the ACC’s “2020 Expert Consensus Decision Pathway on Novel Therapies Cardiovascular Risk Reduction in Patients with Type 2 Diabetes.” (https://doi.org/10.1016./j.jacc.2020.05.037)
The overall theme in this section is the comprehensive approach to reducing diabetes-related risk factors. Some of the specific pharmacological agent “call-outs” include:
- ACE Inhibitors and ARBs use for chronic kidney disease
- Evolocumab therapy and stroke reduction
- Bempedoic acid was added in the statin section
- Discussions of specific SGLT2i and GLP1ra agents with demonstrated CV benefit were added:
- Dapagliflozin (DAPA-CKD trial)
- Sotogliflozin (SOLOIST-WHF trial)
- Efpeglenatide (AMPLITUDE-O trial)
- Dapagliflozin (DAPA-HF trial)
- Ertugliflozin (VERTIS CV trial)
- Sotagliflozin (SCORED trial)
There are many other updates in this documents that were not mentioned. One important theme is for healthcare providers to regard diabetes management as an opportunity to appreciate and specifically target the patient’s overall risks for CV disease. This calls for less focus on “just lowering the glucose numbers” so we can give more attention to all other risk factors: blood pressure and cholesterol, weight, activity, and smoking status.
Piqued by this preview? Join us for robust discussions of these and many other topics in our internal medicine section under diabetes management in the ThriveAP program! Learn more about the program.
Dr. Jane Kapustin, PhD, CRNP is a class leader at ThriveAP.