Updated ADA standards of diabetes care include focus on cardiovascular issues

The American Diabetes Association (ADA) recommends assessment of 10-year atherosclerotic cardiovascular disease (ASCVD) risk in patients with diabetes and discusses appropriate use of the ASCVD calculator.

The American Diabetes Association's (ADA) 2019 update of its Standards of Medical Care in Diabetes states that overall diabetes risk assessment and determination of optimal treatment should include assessment of 10-year risk for atherosclerotic cardiovascular disease (ASCVD).

The section on cardiovascular disease and risk management was endorsed for the first time by the American College of Cardiology, the ADA said. Blood pressure recommendations have been modified to emphasize individualizing targets according to cardiovascular risk, and the revised section also discusses appropriate use of the ASCVD risk calculator, the ADA said. Heart failure was included in the ASCVD recommendations, which said heart failure should be considered when determining optimal diabetic treatment. New recommendations also advised using medications with proven cardiovascular benefit in patients with diabetes and known ASCVD.

The updated standards were published Dec. 17, 2018, by Diabetes Care and appear as a supplement to the January issue.

Some other new or revised recommendations include the following:

The ADA updated the nutrition section to highlight the importance of weight loss in patients at high risk and added recommendations on tobacco use and cessation. Patients with diabetes should be encouraged to increase intake of water and decrease intake of beverages sweetened with sugar or with artificial sweeteners, the ADA said.

Regarding glycemic targets, the ADA added a recommendation to reevaluate glycemic targets over time, in order to emphasize that risks and benefits of such targets can change as patients age. The ADA modified a previous recommendation to acknowledge the benefits of tracking weight and activity in those aiming to achieve and maintain a healthy weight, in addition to noting that medical devices for weight loss are not currently recommended in patients with diabetes because data are limited.

The section on pharmacologic approaches to glycemic treatment was changed substantially in accordance with the joint consensus report from the ADA and the European Association for the Study of Diabetes (EASD), which was released in October 2018. For patients with type 2 diabetes who require an injectable medication, a glucagon-like peptide-1 receptor agonist should be the first choice rather than insulin, the ADA said. The ADA also added a new section on insulin injection technique that emphasized its importance to appropriate dosing and avoidance of complications.

For patients with type 2 diabetes and chronic kidney disease, agents that benefit renal outcomes should be considered, the ADA recommended. For patients with diabetes and neuropathic pain, the ADA added gabapentin to potential treatments, due to data on efficacy and cost savings. Foot inspection is now recommended at every visit only in patients with diabetes who are at high risk for ulceration, the ADA said, while annual foot examinations continue to be recommended for all patients.

A summary of these and other revisions to the Standards of Medical Care in Diabetes is available from Diabetes Care.