Standards of Medical Care in Diabetes: A 2020 Update from the American Diabetes Association
The Standards of Medical Care in Diabetes are released annually by the American Diabetes Association (ADA) and updated throughout the year. Diabetes professionals from across the world look to the document as a framework for good clinical practice. In this commentary, I will address what has changed in the 2020 edition.
A renewed focus on unique presentations
In their latest update, the ADA has acknowledged the heterogeneity of dysglycemia. Sections on prediabetes, cystic fibrosis-related diabetes, gestational diabetes mellitus, preconception care, diabetes in migrant and seasonal agricultural workers, and type 1 diabetes in older adults, have been added, edited, and improved. Furthermore, special emphasis is given to the need for diabetes screening in people with hepatitis C and autoimmune disease.
A broader scope for management and monitoring
Emphasis on behavior change, wellbeing, nutrition therapy, tobacco avoidance (including e-cigarettes), and psychosocial screening/management makes the 2020 update to the Standards of Medical Care a more comprehensive document.
In a major addition to the previous edition, this update features the ADA’s recommendations on use of the ambulatory glucose profile and time in range to evaluate glycemic control in patients using continuous glucose monitoring devices. Supplementing these calls to action are reinforced messages on the need to avoid clinical inertia in the provision of care for hyperglycemia and cardiovascular disease.
Tools for treatment
The use of sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP‑1RAs) is recommended not only for their glucose-lowering efficacy, but now also for cardiovascular benefit. At the same time, the ADA has used the document to sensitize readers to the need to screen patients receiving glucose-lowering medications for hypoglycemia unawareness. In this vein, the availability of intranasal glucagon and subcutaneous glucagon solutions are cited as tools for the management of hypoglycemia.
Pharmacologic therapy in diabetes is complex, and the 2020 Standards of Medical Care provides simple algorithms and guidance to assist in the initiation and intensification of treatment. Along these lines, multiple approaches to management with insulin are discussed; the role of cardiovascular and renal dysfunction in deciding which glucose-lowering therapy is also highlighted; and SGLT2 inhibitors and GLP‑1RAs are now considered the therapies of choice to add on to metformin, in individuals with atherosclerotic cardiovascular disease and renal impairment, respectively. A full section on obesity management for the treatment of type 2 diabetes includes guidance on clinical examination and interviewing. Liraglutide’s approval in children aged 10 years and over also receives attention.
Complications in the spotlight
While the prevention and management of all vascular complications is discussed in the 2020 Standards of Medical Care, the kidney receives significant focus. Enhanced sections on staging, management, and monitoring of renal function are prominent within the document. Further to these, sections on hypertension, dyslipidemia, and cardiovascular disease management have also been supported with updates.
Overall, the freely accessible 2020 Standards of Medical Care in Diabetes is a welcome addition to every diabetes care professional’s e-library, providing crisp, yet complete, coverage of the screening, diagnosis, management, and monitoring of diabetes and its complications.
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