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ADA’s New Focus on Total Patient

What does it mean when we say we need to focus on the total or whole patient?

It comes down to focusing on the things that affect the patient’s ability to self-manage their diabetes so they can have a normal life while improving their quality of life, which can include the psychological, financial, and social circumstances in their lives.

The ADA’s 2017 142-page document, “Standards of Care” published December 15th in a supplement to Diabetes Care also addresses the antibody screening of asymptomatic first-degree relatives of patients with type 1 diabetes to help prevent DKA, including the use of a standard number to determine hypoglycemia and using empagliflozin or liraglutide in patients with type 2 diabetes to help prevent cardiovascular disease, and also monitoring patients for B12 deficiency when taking metformin.

The standards also contain new advice or updates related to gestational diabetes follow-up, inclusion of sleep assessment in diabetes management, use of fat and protein in insulin-dosing calculations, interruption of sitting every 30 minutes with short exercise bouts, and consideration for use of metabolic (formerly bariatric) surgery down to body mass index 30 kg/m2.

ADA Chief Scientific and Medical Officer Robert E Ratner, MD, added that, “The ADA is the only group that revises practice guidelines annually. The new changes also advises assessment of nonmedical factors that influence patients’ abilities to self-manage their diabetes, including issues around access to care, financial barriers, and food insecurity, along with psychological or psychiatric disorders. Plus, there is a new chapter on Promoting Health and Reducing Disparities in Populations,” which provides guidance for promoting patient-centered care aligned with the Chronic Care Model, team-based care, and referral to local community resources for further support.

“You need to be aware of issues that impact self-management.…It doesn’t do the patient or clinician any good if the clinician writes a prescription for an expensive branded medication and the patient can’t afford it,” Dr Ratner noted in his press conference.

“We need to keep reminding ourselves as medical professionals that we’re not just managing glucose, we are managing a human being who’s just trying to live a normal life.”

This also includes evaluation for symptoms of diabetes distress, depression, anxiety, and disordered eating and of cognitive capacities, using appropriate standardized tools at initial visits, periodic intervals, or if the patient experiences any changes that merit concern, with the inclusion of family members when appropriate. Any problems found should be addressed via follow-up visit or referral.

We also need to realize that depression is extremely common in both type 1 and type 2 diabetes and doubles the cost of care if left untreated, Dr. Ratner said.  “The idea is that we’re not just managing glucose, we’re managing a human being who’s trying to live a normal life, and it’s hard. Ultimately, the person with diabetes is their own primary caregiver, and we need to be able to support them in doing that very difficult job,” he said.

The standards now also recommend that first-degree relatives of people with type 1 diabetes be screened for islet autoantibodies. Closer monitoring is advised for those relatives who are positive for two or more antibodies on two separate occasions, since they have a greater than 95% probability of developing type 1 diabetes.  By identifying individuals at the stage of persistent positive antibodies, we have the research opportunity to intervene and prevent the progression, but more important, we know who’s at risk and can begin therapy before DKA. “This is a huge and fundamental change in our understanding of T1D,” Ratner said.

Another new recommendation, initially published in a separate position statement on November 21, calls for “serious, clinically significant” hypoglycemia to be officially defined as a value less than 54 mg/dL (< 3.0 mmol/L), with a “glucose-alert value” designating need for action set at 70 mg/dL (3.9 mmol/L) or lower. Symptoms have been removed from the definition.  Actually having definite numbers to define hypoglycemia will make it much more standardized.

The new guidelines can recognize the fact that a lot of people have hypoglycemic unawareness. “If you have a confirmed value of 50, that’s serious hypoglycemia even without symptoms. What we’re saying is individuals and their caregivers should strive to never have a glucose value less than 54.”  The 70-mg/dL value is not considered hypoglycemia, but rather a level suggesting that a therapeutic adjustment be made, such as adjusting insulin dose, eating, or suspending the patient’s insulin pump.  “Our therapeutics aren’t that good, so we need a buffer zone between a potentially dangerous level and where we’re going to intervene,” Dr Ratner explained.

Also included in the pharmacologic chapter is a new evidence-based recommendation to consider periodic measurement of vitamin B12 levels in patients on long-term metformin use and use supplementation as needed, following reports regarding an association between metformin use and vitamin B12 deficiency.

And, in light of the overall emphasis on real-life circumstances, for the first time this year the standards provide median cost information for glucose-lowering medications, including insulins.

Practice Pearls:

  • First-degree relatives of those with type 1 diabetes need to be tested for antibodies and watched more closely.
  • Using empagliflozin or liraglutide in patients with type 2 diabetes can help in preventing cardiovascular disease.
  • We need to focus on the things that affect the patient’s ability to self-manage their diabetes so they can have a normal life.

Diabetes Care. Published online December 15, 2016. Standards of Care