The 2023 Update to the American Diabetes Association’s Standards of Care in Diabetes

The American Diabetes Association (ADA) just published their yearly updated guidelines for the “Standards of Care in Diabetes” in Diabetes Care.

As new research and treatment options for patients with diabetes emerge, the standard of care for these patients continues to evolve. As such, the ADA releases annual updates to their standards of care, so as to improve the health and quality of life of these patients. With the 2023 update to the guidelines, the ADA honed in on patient empowerment. They wrote, “The 2023 Standards of Care includes revisions to incorporate person-first and inclusive language. Efforts were made to consistently apply terminology that empowers people with diabetes and recognizes the individual at the center of diabetes care.”

Vaccinations

In line with the Centers of Disease Control and Prevention (CDC) recommendations, the ADA recommends COVID-19 vaccinations for all adults and some children. Refer to manufacture information for dosing and frequency based on patient age and comorbidity.

Highly recommended immunizations for adults with diabetes include:

• Hepatitis B: 2- or 3-dose series for individuals younger than 60
• Human papilloma virus: 3-dose series over 6 months for individuals 26 or younger
• Influenza: annually for all individuals with diabetes. Avoid live attenuated influenza vaccine
• Pneumonia: 1 dose of PPSV23 for individuals who have previously received 1 dose of PCV13 or at least 1 year after PCV15. If PPSV23 is an individual’s first dose of pneumonia vaccination, individual may receive PCV15 or PCV20 at least 1 year after their first dose. Do not administer PPSV23 after 1 dose of PCV20.
• Tetanus, diphtheria, pertussis: Booster recommended every 10 years for all adult individuals. Individuals who are pregnant should receive an extra dose.
• Zoster: 2-dose series of Shingrix for individuals over the age of 50, even if the individual has been vaccinated previously

Diabetes Prevention, Delay of Type 2 Diabetes and Associated Comorbidities

Adults who are overweight or obese at high risk of diabetes should be referred to an intensive lifestyle behavior change program. Treatment goals include a weight reduction of at least 7% (up to 15%) of initial body weight along with a healthy reduced-calorie diet and at least 150 minutes of moderate intensity physical exercise per week.

New recommendations include:

• Individuals receiving statin therapy and who are at high risk of developing type 2 diabetes should regularly monitor glucose status. It is not recommended to discontinue statin therapy.
• Pioglitazone can be considered in individuals with a history of stroke and evidence of insulin resistance or prediabetes to lower the risk of stroke or myocardial infarction. Begin with a low dose to mitigate risk of adverse effects, including weight gain, edema, and fracture.
• Pharmacotherapy can be considered to support person-centered care goals.
• Consider more intensive preventive approaches in individuals at high risk of progression to diabetes. This includes individuals with a BMI of at least 35 kg/m², higher glucose level, and history of gestational diabetes.

Glycemic Goals (6.6)

For individuals who are frail or at high risk for hypoglycemia, glucose levels should be in range over 50% of the time and below range less than 1% of the time. For other nonpregnant adults, glucose levels should be in range over 70% of the time, below range less than 4% of the time, and less than 54 mg/dL less than 1% of the time.

Older adults with few chronic illnesses and intact cognitive function should have a lower glycemic goal (A1c <7.0%-7.5%) while older adults with multiple chronic conditions, cognitive impairment, or functional dependence should have a less-stringent glycemic goal (A1c <8%). Glycemic goals for some older adults may be relaxed, but hyperglycemia leading to symptoms or risk of acute hyperglycemia complications should be avoided.

Children and adolescents should have individualized A1c goals that are reassessed over time. An A1c goal of less than 7% is appropriate, and more stringent A1c goals of less than 6.5% could be reasonable for individuals if they can be achieved without significant hypoglycemia or negatively impacts on well-being. Less stringent A1c goals of less than 7.5% may be appropriate for children and adolescents who cannot communicate symptoms of hypoglycemia, have hypoglycemia unawareness, lack access to analog insulins or advanced insulin delivery technology, cannot check blood glucose regularly, or have nonglycemic factors that raise A1c. Even less stringent A1c goals of less than 8% could be appropriate for children and adolescents with a history of severe hypoglycemia or limited life expectancy.

Individuals who are pregnant have an A1c target of less than 6%. If this cannot be achieved without significant hypoglycemia, A1c target can be relaxed to less than 7%.

Pharmacologic Approaches to Glycemic Treatment and Diabetes Technology

To help reach glycemic goals, it is now recommended that all patients with diabetes who use basal insulin be monitored with a continuous glucose monitoring (CGM) device. The ADA has included a new table describing known substance interference with CGM devices, which provides a list of specific CGM systems that are affected.

Selection of pharmacologic therapy should be guided by patient-centered treatment factors, including comorbidities and treatment goals. Adults with type 2 diabetes and established or high risk of atherosclerotic cardiovascular disease (ASCVD), heart failure, and/or chronic kidney disease should have agents that reduce cardiorenal risk in their treatment regimen. A patient’s treatment regimen should support weight management goals.

In adults with type 2 diabetes, a glucagon-like peptide-1 (GLP-1) receptor agonist is preferred to insulin to minimize risks of hypoglycemia and weight gain associated with insulin therapy. If insulin is used, combination therapy with a GLP-1 receptor agonist is recommended for great efficacy and durability of treatment effect.

Cardiovascular Disease, Risk Management

Blood pressure target goals for individuals with diabetes were revised to a target blood pressure of less than 130/80 mmHg. Anti-hypertensive drug therapy should be initiated when blood pressure is persistently greater than 130/80 mmHg with a target blood pressure goal of less than 130/80 mmHg.

In pregnant individuals, a blood pressure of greater than 140/90 mmHg requires initiation of anti-hypertensive drug therapy or titration of current therapy, with a target systolic blood pressure of 110 to 135 mmHg and diastolic blood pressure of 85 mmHg to reduce the risk for accelerated maternal hypertension.

High intensity statin is recommended for individuals with diabetes aged 40 to 75 at higher cardiovascular risk (defined as 1 or more ASCVD risk factors), with a goal to reduce LDL cholesterol at least 50% of baseline and a target LDL of less than 70 mg/dL. In individuals with multiple ASCVD risk factors, consider adding ezetimibe or a PCSK9 inhibitor to maximum tolerated statin therapy. In individuals older than 75, it is reasonable to continue statin treatment or initiate moderate-intensity statin.

In individuals with type 2 diabetes and established heart failure with either preserved or reduced ejection fraction, a sodium-glucose cotransporter 2 (SGLT-2) inhibitor is recommended to reduce risk of worsening heart failure and improve symptoms, physical limitations, and quality of life.

In individuals with type 2 diabetes and chronic kidney disease with albuminuria treated with maximum tolerated doses of an ACE inhibitor or ARB, addition of finerenone is recommended.

Chronic Kidney Disease, Risk Management

In patients with diabetes and diabetic kidney disease, SGLT2 inhibitors are to be initiated when patients reach an estimated glomerular filtration rate (eGFR) of at least 20 mL/min/1.73 m² and urinary albumin of at least 200 mg/g creatinine; GLP-1 agonists or a nonsteroidal mineralocorticoid receptor antagonist can also be considered in this population if eGFR is at least 25 mL/min/1.73 m².

Mineralcorticoid receptor antagonists are effective in individuals with chronic kidney disease (CKD) and albuminuria at risk of cardiovascular events or chronic kidney disease progression.

Retinopathy, Neuropathy, Foot Care

Treatments of other modifiable risk factors, including lipids and blood pressure, can aid in the prevention of diabetic peripheral neuropathy progression in patients with type 2 diabetes and may reduce disease progression in diabetes.

Autonomic neuropathy should be assessed in individuals with diabetes at time of diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes, then annually thereafter. Screening for autonomic neuropathy includes asking about orthostatic dizziness, syncope, or dry cracked skin in the extremities.

For the treatment of neuropathic pain in patients with diabetes, gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers are recommended as first-line treatments.

The conference that covers these updates, Clinical Update Conference, will be held February 10-12, 2023, in Tampa, Florida and virtually.