Spotlight on guidelines

The American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) and the American Diabetes Association (ADA) each released new guidance in the past month, the former updating its algorithm for treatment of type 2 diabetes and the latter focusing on management of diabetes in long-term care and skilled nursing facilities.

The AACE/ACE's comprehensive type 2 diabetes management algorithm was first published in 2013. The update covers lifestyle therapy (a new section in 2016), obesity, prediabetes, glucose control with noninsulin antihyperglycemic agents and insulin, management of hypertension, and management of dyslipidemia. The principles of the 2016 document are similar to the 2013 version but place more emphasis on lifestyle therapy, including medically supervised weight loss, and stress the importance of a comprehensive management plan for lipids, blood pressure and related comorbidities. The update also includes guidance on all obesity, antihyperglycemic, lipid-lowering, and antihypertensive medications approved by the FDA through December 2015. The algorithm and an executive summary of the AACE/ACE's related consensus statement were published in the January Endocrine Practice and are available free of charge online.

The ADA position statement, which appeared in the February Diabetes Care, stressed the importance of avoiding hypoglycemia and remembering the ultimate goal is to improve the quality of life of patients with type 2 diabetes. The position statement noted that diabetic adults in long-term care and skilled-nursing facilities are a heterogeneous population with differing comorbid conditions and overall health status, making establishment of individual goals and treatments critical. Risk of hypoglycemia is of particular concern, the statement said, and simplified treatments are preferred. Sliding-scale insulin as a sole therapy should be avoided.

During care transitions, the ADA recommends revisiting diabetes management targets, performing medication reconciliation, providing patient and caregiver education, reevaluating patients' ability to perform diabetes self-care, and ensuring close communication between transferring and receiving care teams. A detailed transitional care plan covering current meals, activity levels, previous treatment regimens and self-care education, laboratory tests, hydration status, and previous hypoglycemia episodes is also recommended. The ADA also noted that because patients in long-term care facilities are not seen by a clinician every day, successful care depends on the presence of a dedicated interprofessional team.

In patients at end of life, the ADA recommends focusing diabetes management goals on promoting comfort, controlling distressing symptoms, avoiding dehydration, preserving dignity and quality of life, and avoiding ED visits, hospital admissions, and institutionalization. The statement said that decreasing treatment complexity and instituting a higher threshold for additional diagnostic testing should be considered. The ADA also stressed the importance of respecting a patient's right to refuse and withdraw treatments during end-of-life care.