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New ADA Standards Highlighted by Sections Part 2 (Sections 6-14)

Clinically significant hypoglycemia redefined, bariatric surgery renamed.

Section 6. Glycemic Targets

Based on recommendations from the International Hypoglycaemia Study Group, serious, clinically significant hypoglycemia is now defined as glucose <54 mg/dL (3.0 mmol/L), while the glucose alert value is defined as ≤70 mg/dL (3.9 mmol/L) (Table 6.3). Clinical implications are discussed.

Section 7. Obesity Management for the Treatment of Type 2 Diabetes

To be consistent with other ADA position statements and to reinforce the role of surgery in the treatment of type 2 diabetes, bariatric surgery is now referred to as metabolic surgery.

To reflect the results of an international workgroup report endorsed by the ADA and many other organizations, recommendations regarding metabolic surgery have been substantially changed, including those related to BMI thresholds for surgical candidacy (Table 7.1), mental health assessment, and appropriate surgical venues.

Section 8. Pharmacologic Approaches to Glycemic Treatment

The title of this section was changed from “Approaches to Glycemic Treatment” to “Pharmacologic Approaches to Glycemic Treatment” to reinforce that the section focuses on pharmacologic therapy alone. Lifestyle management and obesity management are discussed in separate chapters.

To reflect new evidence showing an association between B12 deficiency and long-term metformin use, a recommendation was added to consider periodic measurement of B12 levels and supplementation as needed.

A section was added describing the role of newly available biosimilar insulins in diabetes care.

Based on the results of two large clinical trials, a recommendation was added to consider empagliflozin or liraglutide in patients with established cardiovascular disease to reduce the risk of mortality.

Figure 8.1, antihyperglycemic therapy in type 2 diabetes, was updated to acknowledge the high cost of insulin.

The algorithm for the use of combination injectable therapy in patients with type 2 diabetes (Fig. 8.2) has been changed to reflect studies demonstrating the noninferiority of basal insulin plus glucagon-like peptide 1 receptor agonist versus basal insulin plus rapid-acting insulin versus two daily injections of premixed insulin, as well as studies demonstrating the noninferiority of multiple dose premixed insulin regimens versus basal-bolus therapy.

Due to concerns about the affordability of antihyperglycemic agents, new tables were added showing the median costs of noninsulin agents (Table 8.2) and insulins (Table 8.3).

Section 9. Cardiovascular Disease and Risk Management

To better align with existing data, the hypertension treatment recommendation for diabetes now suggests that, for patients without albuminuria, any of the four classes of blood pressure medications (ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics, or dihydropyridine calcium channel blockers) that have shown beneficial cardiovascular outcomes may be used.

To optimize maternal health without risking fetal harm, the recommendation for the treatment of pregnant patients with diabetes and chronic hypertension was changed to suggest a blood pressure target of 120–160/80–105 mmHg.

A section was added describing the cardiovascular outcome trials that demonstrated benefits of empagliflozin and liraglutide in certain high-risk patients with diabetes.

Section 10. Microvascular Complications and Foot Care

A recommendation was added to highlight the importance of provider communication regarding the increased risk of retinopathy in women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who are pregnant.

The section now includes specific recommendations for the treatment of neuropathic pain.

A new recommendation highlights the benefits of specialized therapeutic footwear for patients at high risk for foot problems.

Section 12. Children and Adolescents

Additional recommendations highlight the importance of assessment and referral for psychosocial issues in youth.

Due to the risk of malformations associated with unplanned pregnancies and poor metabolic control, a new recommendation was added encouraging preconception counseling starting at puberty for all girls of childbearing potential.

To address diagnostic challenges associated with the current obesity epidemic, a discussion was added about distinguishing between type 1 and type 2 diabetes in youth.

A section was added describing recent nonrandomized studies of metabolic surgery for the treatment of obese adolescents with type 2 diabetes.

Section 13. Management of Diabetes in Pregnancy

Insulin was emphasized as the treatment of choice in pregnancy based on concerns about the concentration of metformin on the fetal side of the placenta and glyburide levels in cord blood.

Based on available data, preprandial self-monitoring of blood glucose was deemphasized in the management of diabetes in pregnancy.

In the interest of simplicity, fasting and postprandial targets for pregnant women with gestational diabetes mellitus and preexisting diabetes were unified.

Section 14. Diabetes Care in the Hospital

This section was reorganized for clarity.

A treatment recommendation was updated to clarify that either basal insulin or basal plus bolus correctional insulin may be used in the treatment of noncritically ill patients with diabetes in a hospital setting, but not sliding scale alone.

The recommendations for insulin dosing for enteral/parenteral feedings were expanded to provide greater detail on insulin type, timing, dosage, correctional, and nutritional considerations.
The American Diabetes Association. Standards of Medical Care in Diabetes—2017: Summary of Revisions Diabetes Care. 2017;40(1):S4-S5. doi: 10.2337/dc17-S003.