The Committee also sought to further define hypoglycemia. The update indicates that a level of lower than 54 mg/dL (3.0 mmol/L) should be considered serious, clinically important hypoglycemia, even in the absence of symptoms. It is recommended that values below this level be reported in clinical trials and practice. Previous recommendations defined hypoglycemia in hospitalized patients as blood glucose levels <70 mg/dL (3.9 mmol/L) and severe hypoglycemia as levels <40 mg/dL (2.2 mmol/L). Severe hypoglycemia is now defined as “that associated with severe cognitive impairment regardless of blood glucose level,” and a level ≤70 mg/dL “is considered an alert value and may be used as a threshold for further titration of insulin regimens,” according to the Standards.
“Also, and perhaps most important, is the Standards’ acknowledgment and addressing of the socioeconomic aspects of diabetes management: medication cost and self-management support,” Dr Pantalone added. “These areas had been inadequately addressed by earlier versions of the guideline.”
The new version includes 2 detailed tables that provide the estimated monthly cost of various glucose-lowering medications, and the section on reducing disparities in diabetes care states that community health workers, peers, and lay leaders can facilitate the delivery of diabetes self-management education (DSME) and support services. “Strong social support leads to improved clinical outcomes, a reduction in psychosocial issues, and adoption of healthier lifestyles,” the Committee noted.
Other notable additions include recommendations pertaining to screening and mental health referrals for patients with depression, anxiety, diabetes distress, eating disorders, and other psychological issues; greater emphasis on assessing comorbidities in patients with diabetes, and an expanded list of such comorbidities, including mental disorders as well as autoimmune disease and HIV; a new physical activity recommendation to break up sedentary behavior every 30 minutes to reduce associated behaviors illuminated by recent research; and increased options for both glucose management and hypertension treatment.
“The ADA has done a fantastic job of remaining on top of the new advances in diabetes management, incorporating new findings and recommendations into the guidelines in a timely manner, but doing so only after a thorough and vigorous review of the recently published medical literature,” said Dr Pantalone.
- American Diabetes Association. Standards of medical care in diabetes–2017. Diabetes Care. 2017;40(Suppl. 1):S6-S10.
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- Marso SP, Daniels GH, Brown-Frandsen K, et al.; LEADER Steering Committee; LEADER Trial Investigators. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375:311-322.