Every year, with the January issue of Diabetes Care, the Standards of Medical Care in Diabetes is released by the American Diabetes Association (ADA). This document is the output of the ADA’s multidisciplinary Professional Practice Committee that systematically searches MEDLINE to revise or clarify recommendations. Feedback from the larger clinical community is also incorporated, and changes are made to reflect new advances that will improve the care of people with diabetes.
I will focus on selected key 2018 updates. The full 2018 Standards of Care (available at the professional.diabetes.org/soc) will incorporate any changes made throughout the year. The images and recommendations discussed in this article are correct at the time of publication.
What is new and different in the Standards of Care for 2018?
1. The guidelines provide expanded recommendations for comprehensive evaluation and management
Table 3.1 provides a checklist of the components of the comprehensive medical evaluation (history, physical exam, laboratory assessment, etc.), including the timing and frequencies for each component. This checklist is very useful for busy primary care providers who are managing patients who often have numerous conditions.
Table 3.1 Components of the comprehensive diabetes medical evaluation at initial and follow-up visits (view a larger version of Table 3.1 here).
View a larger version of Table 3.1 here.
© 2018 American Diabetes Association® Diabetes Care 2018 Jan; 41 (Supplement 1). Reprinted with permission from the American Diabetes Association®.
2. Pharmacologic management of type 2 diabetes
The 2018 Standards of Care recommendations for pharmacologic therapy for adults with type 2 diabetes have been changed to reflect recent cardiovascular outcome trials data (summarized in Table 8.1). The new recommendations suggest that people with newly diagnosed type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD) should begin treatment with lifestyle management and metformin, but then, should hemoglobin A1c (A1C) targets not be met, incorporate an agent with proven cardiovascular benefit based on evidence from the recent trials. As with all medications, drug-specific and patient factors should be considered.
Table 8.1 Drug-specific and patient factors to consider when selecting antihyperglycemic treatment in adults with type 2 diabetes (view a larger version of Table 8.1 here).
†FDA approved for CVD benefit. CVD, cardiovascular disease; DKA, diabetic ketoacidosis; DKD, diabetic kidney disease; NASH, nonalcoholic steatohepatitis; RAs, receptor agonists; SQ, subcutaneous; T2DM, type 2 diabetes.
© 2018 American Diabetes Association® Diabetes Care 2018 Jan; 41 (Supplement 1). Reprinted with permission from the American Diabetes Association®.
The algorithm for antihyperglycemic treatment also highlights that the intensity of treatment is based upon A1C at diagnosis. If the A1C is <9%, then pharmacologic monotherapy with metformin should be added to lifestyle management. If the A1C is ≥9.0%, then consider dual pharmacologic therapy plus lifestyle management. Finally, if the A1C is ≥10.0% or if the blood glucose is ≥300 mg/dL, or if the patient is symptomatic (polyuria, polydipsia) then consider combination injectable therapy (insulin and/or GLP-1 receptor agonist; see Figure 8.2).
Figure 8.2 Combination injectable therapy (view a larger version of Figure 8.2 here).
Combination injectable therapy for type 2 diabetes. FBG, fasting blood glucose; hypo, hypoglycemia. View a larger version of Figure 8.2 here.
© 2018 American Diabetes Association® Diabetes Care 2018 Jan; 41 (Supplement 1). Reprinted with permission from the American Diabetes Association®.
The ADA recommends that providers assess their patients with diabetes at 3 months. If patients are not at goal, consider intensifying therapy. If the patient has achieved the shared treatment goal, then A1C should be monitored at least twice a year.
Table 8.1 highlights the differences between the agents in terms of efficacy, cost, hypoglycemia and important cardiovascular and renal effects.
3. Cardiovascular risk factor management
Hypertension
A new recommendation was added that all patients with diabetes and hypertension should monitor their blood pressure at home to help identify discrepancies between office and “true” blood pressure, as well as to improve medication-taking behavior. If the initial blood pressure is 140/90–159/99 mmHg, pharmacologic therapy should start with one agent. If the initial blood pressure is ≥160/100, pharmacologic therapy should start with two agents. As with previous recommendations, if the patient has albuminuria, use of an angiotensin-converting-enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) is the initial preferred therapy but these should not be used simultaneously. Figure 9.1 illustrates the recommended antihypertensive treatment approach for adults with diabetes and hypertension.
Figure 9.1 Recommendations for the treatment of confirmed hypertension in people with diabetes (view a larger version of Figure 9.1 here).
Recommendations for the treatment of confirmed hypertension in people with diabetes. *An ACE inhibitor (ACEi) or ARB is suggested to treat hypertension for patients with UACR 30–299 mg/g creatinine and strongly recommended for patients with UACR ≥300 mg/g creatinine. **Thiazide-like diuretic; long-acting agents shown to reduce cardiovascular events, such as chlorthalidone and indapamide, are preferred. ***Dihydropyridine calcium channel blocker. BP, blood pressure. This figure can also be found in the ADA position statement “Diabetes and Hypertension”. View a larger version of Figure 9.1 here
© 2018 American Diabetes Association® Diabetes Care 2018 Jan; 41 (Supplement 1). Reprinted with permission from the American Diabetes Association®.
Dyslipidemia
The lipid management recommendations have been modified to stratify risk based on two broad categories: those with documented ASCVD and those without. The recommendations for statin and combination treatment in adults with diabetes have been updated as shown in Table 9.2.
Table 9.2 Recommendations for statin and combination treatment in adults with diabetes (view a larger version of Table 9.2 here).
View a larger version of Table 9.2 here
© 2018 American Diabetes Association® Diabetes Care 2018 Jan; 41 (Supplement 1). Reprinted with permission from the American Diabetes Association®.
4. Type 2 diabetes in children and adolescents
This section has been expanded in response to the significant increase in rates of type 2 diabetes in children. Type 2 diabetes in youth has increased over the past 20 years and recent estimates suggest an incidence of ~5000 new cases per year in the US. Type 2 diabetes in youth has more rapidly progressive β-cell function decline and an accelerated development of diabetes complications.
Distinguishing between type 1 and type 2 diabetes in youth has become more complicated due to the prevalence of obesity. Risk-based screening for prediabetes and/or type 2 diabetes should be considered in children and adolescents in the following scenarios:
- After the onset of puberty or ≥10 years of age, whichever occurs earlier;
- In the overweight (BMI >85th percentile) or obese (BMI >95th percentile);
- In individuals with one or more additional risk factors for diabetes.
Several recent studies suggest the oral glucose tolerance test (OGTT) or fasting plasma glucose (FPG) as more suitable diagnostic tests than A1C in the pediatric population, especially among certain ethnicities. The ADA acknowledges the limited data supporting A1C for diagnosing type 2 diabetes in children and adolescents, but continues to recommend the A1C test for the diagnosis of type 2 diabetes in this cohort.
5. Prediabetes
The 2018 Standards of Care continues to remind people that those with an A1C of 5.7–6.4% are at increased risk of diabetes and cardiovascular disease. Those people who have prediabetes should consider an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program. This is particularly helpful for the following populations:
- Obese adults with hypertension;
- Pregnant women with gestational diabetes;
- Individuals from an at-risk ethnic group (Hispanic, African American, Native American, Asian);
- Individuals with truncal obesity or who are sedentary.
The ADA recommends the addition of metformin to patients with a history of gestational diabetes, who are under 60 years old, or have a BMI >35.
Resources
- Download the complete American Diabetes Association Standards of Medical Care in Diabetes, or the abridged version for primary care providers.
- Learn more about the 2018 Standards of Care and earn up to 0.75 credit hour by taking the free webcast with the American Diabetes Association’s Chief Scientific Medical and Mission Officer, Dr. William T. Cefalu.
- Visit professional.diabetes.org/soc.