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A Summary of ADA’s New 2018 Standards of Medical Care in Diabetes

Dec 16, 2017
 

Comprehensive recommendations feature notable new recommendations for people with cardiovascular disease and diabetes.

New recommendations in the 2018 edition of the American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes (Standards of Care) include advances in cardiovascular disease risk management, including hypertension; an updated care algorithm that is patient-focused; the integration of new technology into diabetes management; and routine screening for type 2 diabetes in high-risk youth (BMI >85th percentile plus at least one additional risk factor). The Standards of Care provide the latest in comprehensive, evidence-based recommendations for the diagnosis and treatment of children and adults with type 1, type 2, or gestational diabetes, strategies to improve the prevention or delay of type 2 diabetes, and therapeutic approaches that reduce complications and positively affect health outcomes. The Standards of Care have been published  in advance of a supplement to the January 2018 print issue of Diabetes Care.

The Standards of Care are the primary resource for the optimal management of diabetes, and include updated guidelines for diabetes diagnosis, and for evidence-based prevention of diabetes and diabetes-related complications.

A summary of the important changes in the 2018 edition are:

Cardiovascular disease and diabetes

  • Based upon the results of multiple cardiovascular outcome trials (CVOT), there are new treatment recommendations for adults with type 2 diabetes, suggesting a pathway for people with heart disease that, after lifestyle management and metformin, should include a medication validated to improve heart health. (Section 8, page S76, Table 9.4 and Figure 8.1, respectively)
  • Four major, randomized controlled trials that compared intensive versus standard hypertension treatment strategies are summarized and outlined in a new table, providing support for the ADA’s recommendations that most adults with diabetes and hypertension should have a target blood pressure of <140/90 mmHg and that risk-based individualization to lower targets, such as 130/80 mmHg, may be appropriate for some patients. (Section 9, page S88, Table 9.1)
  • A new algorithm illustrating the recommended antihypertensive treatment approach for adults with diabetes and confirmed hypertension (blood pressure ≥140/90 mmHg) has been added. (Section 9, page S90, Figure 9.1)
  • Also new this year is the recommendation that all hypertensive patients with diabetes monitor their blood pressure at home to help identify potential discrepancies between office vs. home blood pressure, and to improve medication-taking behavior. (Section 9, page S87)

Screening youth for type 2 diabetes

  • Updated recommendations emphasize that testing for prediabetes and type 2 diabetes should be considered in children and adolescents younger than 18 years of age who are overweight or obese (BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height), and have one or more additional risk factors for diabetes such as (1) maternal history of diabetes or gestational diabetes during the child’s gestation; (2) family history of type 2 diabetes in first- or second-degree relative; (3) race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander; and/or (4) signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight). (Section 2, page S19, Table 2.5)

Health technology and diabetes management

  • The ADA recommends including technology-based methods, along with individual and group settings, for the delivery of effective diabetes self-management education and support. (Section 4, page S38)
  • As continuous glucose monitoring (CGM) technology continues to evolve, the ADA adjusted its recommendations to align with recent data showing that CGM helps improve glycemic control for adults with type 1 diabetes starting at age 18. (Section 6, page S55)
  • Federal regulatory changes prompted the ADA to include language describing CGM devices that don’t require confirmation from finger sticks to make treatment decisions, and a new type of “flash” CGM that doesn’t have any alarms and only provides “on demand” glucose readings. (Section 6, page S55)

A1C test considerations

  • Additional language and recommendations have been added to help ensure appropriate use of the A1C test to diagnose diabetes and for monitoring glycemic control in people with diabetes. The A1C can give skewed results in people with certain genetic traits that alter the molecules in their red blood cells. The ADA emphasizes that health care providers need to be aware of these limitations, to use the correct type of A1C test, and to consider alternate diagnostic tests (fasting plasma glucose test or oral glucose tolerance test) if there is disagreement between A1C and blood glucose levels.  (Section 2, page S14)

Diabetes management in specific groups

  • Three new recommendations were added to highlight the importance of individualizing pharmacologic therapy for older adults with diabetes to reduce the risk of hypoglycemia, avoid overtreatment and simplify complex regimens while maintaining personalized blood glucose targets. (Section 11, page S122)
  • A new guideline recommends all pregnant women with pre-existing type 1 or type 2 diabetes should consider daily low-dose aspirin starting at the end of the first trimester in order to reduce the risk of pre-eclampsia. (Section 13, page S140)

Patient-centered care and acknowledging cost-of-care impact

  • A new table summarizes drug-specific and patient factors that may impact diabetes treatment. The chart includes the most relevant considerations, such as risk of hypoglycemia, weight effects, kidney effects and costs for all preferred diabetes medications, in one location to guide the choice of antihyperglycemic agents as part of patient-provider shared decision-making. (Section 8, page S77, Table 8.1)
  • The guidelines recommend increased awareness and screening for social determinants of health such as financial ability to afford medication; access to healthy foods and food insecurity; and community support. (Section 1, page S9)

Additional important updates

  • The immunization needs for people with diabetes were clarified and updated. A new section describes emerging evidence that specific glucose-lowering medications delay the onset and progression of kidney disease.  (Section 3, page S29-31)
  • A new section describes emerging evidence that specific glucose-lowering medications delay the onset and progression of kidney disease. (Section 10, page S108)
  • A table highlighting the components of a comprehensive medical evaluation has been redesigned and reorganized.  (Section 3, page S30, Table 3.1)
  • The complete supplement is published online at http://care.diabetesjournals.org/content/41/Supplement_1