Spotlight on the 2024 Standards of Care

The American Diabetes Association (ADA) updated its Standards of Care in Diabetes last month.

The updates include significant changes to the guidance on obesity, among other topics. Glucagon-like peptide 1 (GLP-1) receptor agonists and combination glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonists are added as preferred pharmacotherapies for obesity management. The updates also call for reducing therapeutic inertia regarding weight management, emphasize the growing evidence of the long-term benefits of bariatric surgery, stress the importance of monitoring weight loss progress, and provide a list of accredited centers for surgery. The standards also recommend clinicians personalize obesity care and use measurements beyond body mass index (i.e., waist circumference, waist-to-hip ratio, and/or waist-to-height ratio).

Updated screening recommendations call for measuring a natriuretic peptide level in adult diabetes patients with no symptoms of heart failure (to facilitate the prevention of progression to symptomatic stages of heart failure) and conducting ankle-brachial index testing in patients who are age 50 years or older, have microvascular disease in any location, have foot complications, or have any end-organ damage from diabetes. Peripheral artery disease screening should also be considered in anyone who has had diabetes for 10 years.

Regarding medications, the updates also newly recommend monitoring patients' serum creatinine/estimated glomerular filtration rate and potassium seven to 14 days after starting an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, mineralocorticoid receptor agonist, or diuretic. They recommend bempedoic acid for patients with diabetes intolerant of statins even without cardiovascular disease and recommend either an sodium-glucose cotransporter-2 (SGLT2) inhibitor or an SGLT1/2 inhibitor for patients with diabetes and heart failure (either reduced or preserved ejection fraction) to decrease risk of worsening heart failure or death.

The section on bone health was substantially revised and now recommends regular evaluation and treatment of bone health. A table lists general and diabetes-specific risk factors for fracture.

There are also updates to the standards' guidance on the diagnosis and classification of diabetes, emphasizing the importance of differentiating which form of diabetes a patient has and refining the diagnostic criteria for type 1 diabetes.

Recommendations on hypoglycemia prevention and management are updated, too. New recommendations clarify the clinical scenarios where de-intensifying diabetes medications is appropriate and highlight the benefits of continuous glucose monitoring (CGM) for hypoglycemia prevention. Multiple changes focus on diabetes technology, including new recommendations that people with diabetes be offered diabetes devices (e.g., insulin pens, connected pens, glucose meters, and CGM or automated insulin delivery systems) and that clinicians master the use of these tools.

Other updates address new vaccines, emphasize culturally sensitive, inclusive, and person-centered care, and provide guidance on screening for diabetes distress, among many other topics.

The standards of care are updated annually by the ADA's Professional Practice Committee of 21 global experts from diverse professional backgrounds. Relevant sections of the 2024 updates are endorsed by the American College of Cardiology, the American Society of Bone and Mineral Research, and the Obesity Society. The full standards and a summary of revisions were published as a supplement to the January 2024 Diabetes Care.