Every year the American Diabetes Association publishes its Standards of Medical Care in Diabetes, updated recommendations for health care providers to use when treating people with diabetes, in a supplement to the January issue of Diabetes Care. It provides guidelines on everything from how to diagnosis diabetes to treatment for children with cystic fibrous.
This year the Standards are largely similar to the recommendations published last year but there have been some changes in a few categories because of new evidence or a change in the strength of the evidence in the medical literature. In addition to providing guidelines, the Standards rate the strength of the evidence for each recommendation and review the literature that supports the evidence. Below are some highlights of the new recommendations for adults this year. (Recommendations for children will be covered separately next Wednesday.)
Criteria for Diagnosis Types of diabetes
The terminology for risk of future diabetes was changed to prediabetes to acknowledge this specific new category of condition. This is a good thing because it sets the stage for coverage of pre-diabetes by insurance companies.
Screening women with gestational diabetes (GDM) postpartum was clarified to mean an oral glucose tolerance test (OGTT) and non-pregnancy diagnostic criteria which now includes A1C. Using A1C means that women don’t need to be fasting to be diagnosed.
The Standards now include specific recommendations for when patients using multiple daily injections of insulin or insulin pump therapy should check blood glucose levels; namely prior to meals and snacks, occasionally post-prandially, at bedtime, prior to exercise and driving, and with symptoms of low blood glucose. This gives providers and patients clear guidelines for evaluating treatment plans.
Insulin analogs (Novolog®, Humalog® and Apdira®) were recognized as the treatment of choice for most people with type 1 diabetes as a way to reduce hypoglycemia risk. This acknowledges that these types of insulins are more closely related to how the body’s own insulin works and provide better therapeutic results. Although most patients should be steered toward these insulins, patient preference and other socioeconomic and/or cognitive needs may predispose a patient to use regular or mixed dose insulin.
A big change occurred in the target guidelines for hypertension–they were relaxed. Previously people with diabetes who were hypertensive had goals for blood pressure of less than 130/80 mg/hg. Citing the lack of evidence for the benefit of tighter control and possible increased risk, the Standards now recommend a more lenient less than 140/80mg/hg.
The Standards added a recommendation that the choice of medications should be patient-centered and include consideration of costs, efficacy, potential side effects, and effects on weight, co-morbidities, hypoglycemic risk and patient preferences. This was based on the evidence that aside from metformin and insulin no other hypoglycemic agent outperformed any other as a second-tier choice of drug.
An acknowledgement was added to the effect that insulin therapy would be needed for many people with type 2 diabetes due to the progressive nature of the disease. This acknowledges to both health providers and patients that weight loss and exercise therapy are effective up to only a certain point in patients with long-standing type 2 diabetes.
Diabetes Self Management Education
Diabetes Self Management Education programs were identified as an appropriate venue for those with pre-diabetes to receive education and support to develop behaviors that can delay or prevent diabetes. (Recommendations in the Standards of Care by the American Diabetes Association does not automatically translate to insurance coverage by the Centers for Medicare Services, but it is a beginning.) At present pre-diabetes is not a covered benefit for Medicare beneficiaries.
A line was added to indicate that hypoglycemia unawareness or episodes of severe hypoglycemia (those requiring assistance) should trigger reassessment of the current treatment regimen emphasizing the burden of severe hypoglycemia on the patient and potentially others and underlining the importance eliminating its occurrence as possible.
Over the past year there has been a lot of discussion as to the appropriate treatment goals, including A1C for people with diabetes. There was a small change in the wording of the recommendations, but a big change in the meaning. The ADA’s guidelines recognize the needs of older adults with diabetes as being different than those of the rest of the adult population and acknowledge the need for individualization
The full document runs to 167 pages and can be accessed here.
Changes to guidelines for pediatrics and young adult patients will be posted on the blog next Wednesday.