Translating the 2019 ADA Standards of Care in Diabetes

The 204-page Guidelines behemoth features a new comprehensive look at all things diabetes - with 16 chapters.

What is new?

1. Insulin is no longer the first-line therapy for most Type 2 diabetic patients. GLP-1 or SGLT2 inhibitors are recommended for patients with established ASCVD (atherosclerotic cardiovascular disease) or CKD (chronic kidney disease), or for those who need to lose weight and are included in first-line treatment options for patients without ASCVD or CKD (along with either DPP-4i or TCD).

2. The Treatment Roadmap layout is new. Treatment paths follow down two branches:

A.  Main Path (Go here first.)  Think about each of these five conditions or concerns. The treatment road map may vary accordingly for each.  Does the patient have:
·         An established ASCVD predominate
·         Heart failure or a CKD predominate
·         No ASCVD
·         A compelling need to limit weight gain or promote weight loss
·         Cost as an issue – interestingly, the monthly costs of agents are included (note, this is actually addressed in a separate publication)

B.  A1C Path (Go here after you have thought about the Main Path.)

3. The ADA’s “bromance” with the ACC (American College of Cardiology) and concordance of diabetes management recommendations for patients with ASCVD. There has long been some disconnect between various associations and their biometric level recommendations. For example, blood pressure recommendations would vary depending on which professional association is publishing it. Not too long ago, there would be 4 different sets of guidelines based on who published it. In a nutshell:

·       The ADA & ACC share the same recommended diabetes management algorithm for patients who have established ASCVD, Heart Failure or Kidney Disease.

·       Our team believes that in general, it is a good idea to share common management philosophies

·       However, we believe the ADA erred in using the ACC’s ASCVD Risk algorithm. Here is why:

a)     The ASCVD Risk model is not specific to diabetes (Type 1 or Type 2) patients. The UKPDS is specific to Type 2 Diabetes and is defensible. The Swedish National Diabetes Register (as published by Cedarholm,et al.) has a 5-year CV (cardiovascular) outcome model specific to Type 1 Diabetes. Both seem to be more appropriate algorithms than the ASCVD risk model.

b)      The ASCVD Risk model is not specific to gender

c)       The ASCVD Risk model does not take into account the patient’s duration of diabetes

d)      The ASCVD Risk model does not include microvascular outcome predictions

e)      ASCVD itself is defined as CHD (coronary heart disease), cerebrovascular disease or peripheral arterial disease presumed to be of atherosclerotic origin. It does not address microvascular complications.

·       The ADA should have continued recommending the UKPDS outcomes model that takes into account a patient’s age, duration of diabetes, gender and common biometrics that are also used in the ASCVD model (BP, lipids, smoking, comorbid conditions). Our team ran the same patients’ set of risk factors through all 3 models, and were surprised to see the ASCVD risk calculator show HIGHER risk than the UKPDS. Likely because diabetes is classified the same as prior heart attack, stroke, etc.

·        Interestingly, the 2018 ADA Standards downplayed the usefulness of the ASCVD Risk Calculator because diabetes itself is a risk factor for ASCVD, primarily because it does not take diabetes duration into account.

4. Granularity. One could say that the ADA Standards have always been granular, but they take it to a whole new level with this publication. The document itself is a treasure trove for source content, but really needs to be “dummied down” to make educational applications (hardcopy or digital) possible for doctors to be able to use with their patients.

5. Screening for Prediabetes. We were impressed with the content and “flyer” for “Are You At Risk For Type 2 Diabetes?”. Special kudos to the ADA for including this! It would be even better if the ADA also included a similar 1-page reusable tool for lifestyle management, another for physical activity, nutrition, simpler treatment algorithms, comorbidities, etc.

6. Hypoglycemia discussion. While there is no separate chapter, hypoglycemia is identified as the major limiting factor in glycemic management of both Type 1 and Type 2 diabetics. Hypoglycemia is addressed in nearly every page when treatment is discussed.  There is a table on page s39 that identifies known hypoglycemia risks, although they are not weighted or prioritized.

7. Technology in Diabetes. This is a whole new chapter that thoroughly provides the rationale and use of technology in diabetes.

8. Hypertensive Patients. There is a fantastic, easy-to-read flow-chart for how to manage diabetes in patients with confirmed hypertension. We are presuming this should be the treatment flowchart when hypertension is suspected to be the highest priority/causation.

9. Goals of Care. This is more of an opinion piece that describes how diabetes care should be personalized. It’s sort of a random, “check the box” bit of content. There is an updated physical activity recommendation for older adults that has good content.

10. Alignment with the EASD-ADA Consensus Report for Pharmacologic Treatment. The ADA is wisely consolidating recommendations with their cross-Atlantic partner, the EASD – which makes sense.

In summary, the ADA continues to solidify its leadership in diabetes management and education with the 2019 Standards of Medical Care in Diabetes. While we do not agree with all of the publication, the ADA still deserves kudos for setting the bar.

Fitzpatrick Translational Science, Inc. is a leader in the design and development of endocrinology patient, provider and payer online tools; particularly within the cardio metabolic arena.

Kevin Fitzpatrick, Fitzpatrick Translational Science
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