ADA updates medical care standards for diabetes

Areas of the standards that were changed include classifying type 1 diabetes, setting thresholds for metabolic surgery, and emphasizing lifestyle management.

The American Diabetes Association (ADA) recently updated its “Standards of Medical Care for Diabetes,” with changes to several areas including classifying type 1 diabetes, setting thresholds for metabolic surgery, and emphasizing lifestyle management.

Some of the changes are as follows:

Section 2, “Classification and Diagnosis of Diabetes,” now reflects new consensus on staging and classifying type 1 diabetes. Language clarifying advice on diabetes screening and testing was also added, and the timing of recommended testing for gestational diabetes in pregnant women was modified so results would be available to discuss at the routine postpartum visit. A new section was also added on post-transplant diabetes.

Section 3, “Comprehensive Medical Evaluation and Assessment of Comorbidities,” is a new section and highlights the importance of assessing comorbidities in the context of a patient-centered comprehensive evaluation. Specifically, the section outlines the goals of clinician-patient communication, expands the list of diabetes comorbidities, and adds a recommendation for sleep assessment.

Section 4 is renamed “Lifestyle Management,” reflecting its new focus. Nutrition therapy recommendations for patients who are prescribed flexible insulin therapy were modified to include fat and protein counting, not just carbohydrate counting. Interruption of prolonged sitting every 30 minutes with short bouts of physical activity is now recommended, as is balance and flexibility training in older patients.

Section 5, “Prevention or Delay of Type 2 Diabetes,” was revised to emphasize the importance of screening for prediabetes using assessment tools and diagnostic tests when appropriate. The standards now suggest clinicians consider checking B12 levels in patients on long-term metformin.

Section 6, “Glycemic Targets,” defines serious, clinically significant hypoglycemia as a glucose level below 54 mg/dL (3.0 mmol/L) and defines the glucose alert value as ≤70 mg/dL (3.9 mmol/L).

Section 7, “Obesity Management for the Treatment of Type 2 Diabetes,” contains substantially revised recommendations about thresholds for metabolic surgery (formerly called “bariatric surgery”).

Section 8 has been renamed “Pharmacologic Approaches to Glycemic Treatment.” Changes include a new section on biosimilar insulins, recommendations on specific pharmacotherapies (empagliflozin or liraglutide) to reduce the risk of death, an updated algorithm for use of injectable therapy beyond just basal-bolus therapy, and cost information about insulin and noninsulin agents.

Section 9, “Cardiovascular Disease and Risk Management,” contains updated information on choice of antihypertensive medications, treatment of pregnant woman with diabetes and hypertension, and cardiovascular outcome trials in high-risk diabetic patients.

Section 14, “Diabetes Care in the Hospital,” recommends that either basal insulin or basal plus bolus correctional insulin may be used in non-critically ill hospitalized patients with diabetes but not sliding scale alone.

“Standards of Medical Care in Diabetes—2017” was published by Diabetes Care on Jan. 1 and is available online. A summary of the revisions is also available.