ADA’s 2019 Standards of Medical Care in Diabetes Focus on Patient-Centered Care

The American Diabetes Association (ADA) published its 2019 Standards of Medical Care in Diabetes, an evidence-based document intended to provide clinicians, educators, and other stakeholders in the diabetes treatment landscape with up-to-date recommendations, treatment goals, and best practices for improving health outcomes in patients with diabetes.¹ For this annual update, a multidisciplinary committee of 15 leading experts in diabetes care reviewed evidence from studies published in MEDLINE since October 15, 2017, to update, strengthen, and clarify prior ADA recommendations.^1,2

Major updates to the 2019 guidelines focus on individualized care, cardiovascular disease (CVD) in diabetes, and diabetes technology.

Editor’s note: to view all figures and tables, please see the guidelines published online here.

Patient-centered, personalized care: Patient-centered care is an increasingly important theme in clinical practice recommendations. There are several additions to the ADA Standards of Care that encourage the personalization of diabetes treatment, including an emphasis on shared decision making and consideration of social context (eg, food insecurity, housing stability) in treatment decisions. Patient-centered communication — actively listening, eliciting patient preferences, and assessing literacy and other potential barriers to understanding information — should be utilized by all members of a diabetes management team to improve patient health outcomes.¹

• For older adults with diabetes, the guidelines now include a lifestyle management section. Medical, psychological, functional, and social assessments may be necessary to determine the best approach to diabetes management in this population. A treatment algorithm (Figure 12.1) for simplifying insulin therapy in older patients with type 2 diabetes (T2D) is included in the updated document.¹
• New recommendations are incorporated for young patients with T2D. Information about risk-based screening, psychosocial factors in treatment, and pharmacologic treatment options aligns with ADA guidelines for youth-onset T2D published in 2018. A graphic (Figure 13.1) outlining lifestyle management/weight loss in overweight youth is included in the new Standards of Care.¹
• Because risks and benefits associated with glycemic targets change over the course of a patient’s life, a recommendation was added to reevaluate targets over time.

Cardiovascular disease: Endorsed by the American College of Cardiology (ACC) for the first time, this section includes recommendations for reducing CVD risk in patients with diabetes. Of note, the guidelines encourage the individualization of blood pressure targets based on cardiovascular risk and recommend the use of the ACC’s risk calculator for atherosclerotic cardiovascular disease in diabetes.

The use of aspirin as a preventative therapy for CVD in diabetes is also addressed. Based on trial data, aspirin can reduce ischemic vascular events to a modest extent and may be considered for primary prevention in the context of high cardiovascular risk and low bleeding risk; however, this is unlikely for older adult patients. In patients with a history of atherosclerotic CVD, aspirin is recommended for secondary prevention.¹

In patients diagnosed with both CVD and diabetes, the guidelines recommend using medications with proven cardiovascular benefits, including sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists.^1,2

Based on results of a study published in January 2019, the Standards of Care recommend the use of icosapent ethyl in patients with diabetes and atherosclerotic CVD taking statins who have persistently elevated triglyceride levels.³

Diabetes technology: For the first time, the Standards of Care include a dedicated ‘Diabetes Technology’ section, focused on devices that deliver insulin and monitor glucose levels. The new guidelines do not recommend self-monitoring of blood glucose for patients with diabetes not using insulin, as evidence shows that this practice has little clinical benefit in this population. Information about telemedicine and the remote delivery of clinical services was incorporated as their use grows in diabetes treatment, particularly for the management of blood sugar levels and medication adherence.¹

In future versions of the Standards of Care, this section will expand to cover other topics and issues in technology-enabled diabetes care.

Pharmacologic treatment: Significant changes to this section were made to align with the ADA and European Association for the Study of Diabetes (EASD) 2018 consensus statement.¹ Considerations should be made for comorbidities, body weight, risk for hypoglycemia, and patient preference when choosing pharmacologic agents in diabetes treatment. For patients with T2D who need additional glucose-lowing effects in medication, a glucagon-like peptide 1 receptor agonist is recommended as the first choice before insulin.¹

• The Standards of Care include a table to aid in assessing hypoglycemia risk associated with treatment; use of insulins, impaired kidney function, long duration of diabetes, and several other risk factors are listed as key considerations when choosing a pharmacologic agent.¹
• Based on results from a large randomized controlled trial, dapagliflozin has been associated with beneficial effects in reducing heart failure and chronic kidney disease progression in patients with T2D.³ These benefits are reflected in the Standards of Care recommendations.

Microvascular complications: Aligning with the ADA-EASD consensus report, pharmacologic treatments with proven benefits for renal outcomes should be considered in patients with T2D and kidney disease. Several new treatment options and screening recommendations were added in the 2019 Standards of Care for other microvascular complications, including neuropathic pain, gastroparesis, and foot ulcers in diabetes.¹

Advocacy: The new document includes information about affordability and access to insulin, an issue the ADA previously addressed in a position statement.¹

Lifestyle management: The importance of weight loss in the prevention of diabetes in high-risk patients with overweight or obesity has been emphasized in the 2019 Standards of Care. Considerations for eating patterns, macronutrient distribution, and meal planning were also added, with particular attention given to low-carbohydrate diets. Encouraging reduced consumption of sugar-sweetened beverages, increased water intake, and leisure-time physical activities is recommended in the new guidelines. “There is not a one-size-fits-all eating pattern for individuals with diabetes, and meal planning should be individualized,” stated the guideline authors.¹

The 2019 Standards of Care are available in a mobile application and in an abridged version for primary care physicians.² Although updated annually, the recommendations are a “living” document updated in real time throughout the year with relevant new evidence and regulatory changes as they become available.¹

“Generally, these recommendations have the best chance of improving outcomes when applied to the population to which they are appropriate,” wrote the authors. “Of course, evidence is only one component of clinical decision making. Clinicians care for patients, not populations; guidelines must always be interpreted with the individual patient in mind.”¹

Editor’s note: This article was updated on April 3, 2019, to reflect additions to the Standards of Care announced in March 2019. Updates to the article include the addition of recommendations for icosapent ethyl and dapagliflozin use based on newly available data.

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References

1. American Diabetes Association. 2019 Standards of Medical Care in Diabetes. http://care.diabetesjournals.org/content/42/Supplement_1. Published December 17, 2018. Accessed December 17, 2018.

2. American Diabetes Association. Patient-centered Care is the Focus and Priority of the 2019 Standards of Medical Care in Diabetes, published Today by the American Diabetes Association [press release]. December 17, 2018. Accessed December 17, 2018.

3. American Diabetes Association. American Diabetes Association Issues Critical Updates to the 2019 Standards of Medical Care in Diabetes [press release]. March 27, 2019. Accessed April 2, 2019.