The 204-page Guidelines
behemoth features a new
comprehensive look at all things diabetes - with 16 chapters.
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.)
each of these five conditions or concerns. The treatment road map may vary
accordingly for each.
Does the patient
An established ASCVD predominate
Heart failure or a CKD predominate
A compelling need to limit weight gain or promote
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
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:
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.
The ASCVD Risk model is not specific to gender
The ASCVD Risk model does not take into account
the patient’s duration of diabetes
The ASCVD Risk model does not include
microvascular outcome predictions
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.
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.
We were impressed with the content and “flyer” for “Are You At Risk For Type 2 Diabetes?”.
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.
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.
This is a whole new chapter that thoroughly provides the rationale
and use of technology in diabetes.
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
9. Goals of
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
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.
Translational Science, Inc. is a leader in the design and development of
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Fitzpatrick Translational Science