Updated 2017 American Diabetes Association Standards of Care

The American Diabetes Association (ADA) publishes the Standards of Medical Care in Diabetes annually, based on the latest medical research. The following narrative provides a summary of the 2017 updated recommendations that have been developed for clinical practice. The ADA guidelines are not intended to aid or preclude clinical judgment. The full guidelines can be accessed at ADA’s Diabetes Pro website.

Tailoring Treatment to Reduce Disparities: Updated guidelines focus on improving outcomes and reducing disparities in populations with diabetes such as:

• Ethnic/Cultural/Sex/Socioeconomic Differences and Disparities: Provide structured interventions that are tailored to ethnic populations and integrate culture, language, religion, and literacy skills.
• Food Insecurity: Evaluate hyperglycemia and hypoglycemia in the context of food insecurity (FI), which is defined as the unreliable availability of nutritious food. Recognize that homelessness and poor literacy and numeracy often occur with FI. Propose solutions and resources accordingly.

 Comprehensive Medical Evaluation and Assessment of Comorbidities: The clinical evaluation should include conversation about lifestyle modifications and healthy living. PAs should address barriers including patient factors (e.g., remembering to obtain or take medications, fears, depression, and health beliefs), medication factors (e.g., complex directions, cost) and system factors (e.g., inadequate follow up). Simplifying treatment regimens may improve adherence. This section highlights the elements of a patient-centered comprehensive medical exam, including the importance of assessing comorbidities such as:

• Cognitive Dysfunction: Tailor glycemic therapy to avoid significant hypoglycemia. Cardiovascular benefits of statin therapy outweigh any risk of cognitive dysfunction.
• Mental Illness: The prevalence of type 2 diabetes is higher in patients with schizophrenia, bipolar and schizoaffective disorder. Annually screen for diabetes among patients taking psychotropic medications. Carefully monitor changes in weight, glycemic control and cholesterol levels if second-generation antipsychotic medications are prescribed and reassess the need for treatment periodically.
• Cancer: Diabetes is associated with an increased risk of certain types of cancer (liver, pancreas, endometrium, colon/rectum, breast, and bladder). Recommend patients undergo age and sex-appropriate cancer screenings and reduce modifiable cancer risk factors, such as obesity, physical inactivity, and smoking.
• Psychosocial/Emotional Disorders: People with diabetes may be at increased risk of psychosocial/emotional disorders such as anxiety, depression, and disordered eating behavior. Monitor patients for symptoms and refer to a mental health provider when appropriate.

Lifestyle Management: This new section reinforces the importance of optimizing lifestyle management throughout the entire lifespan of care for patients with diabetes. The team-based approach to care addresses all aspects of lifestyle management including nutrition, physical activity, smoking, and psychosocial care. All patients with diabetes should participate in diabetes self-management education and support activities both at diagnosis and as needed thereafter to learn knowledge and skills necessary for implementing quality, long-term diabetes self-care and management.

Pharmacologic Approach to Glycemic Treatment: For patients who have been on metformin for a long time, periodically measure their vitamin B12 levels, since long-term use may be associated with a vitamin B12 deficiency.  Based on the results of two large clinical trials, the new standards include a recommendation to consider empagliflozin or liraglutide in patients with established cardiovascular disease to reduce the risk of mortality.

Two new tables are included showing the median costs of noninsulin agents and insulins, so providers and patients can be more informed about the affordability of antihyperglycemic agents.

Hypertension treatment: The new Standards of Care state that for patients without albuminuria, any of the four classes of blood pressure medications (ACE inhibitors, angiotensin receptor blockers, diuretics, or calcium channel blockers) have shown to be effective in reducing cardiovascular events.

 Glycemic treatment

The ADA’s antihyperglycemic therapy in type 2 diabetes figure was updated along with the algorithm for the use of combination injectable therapy in patients with type 2 diabetes. Metformin is still the preferred initial therapy in treating type 2 diabetes. Add a second oral agent or basal insulin if monotherapy at the maximum tolerated dose is ineffective at achieving the targeted A1C goal.

Use a patient-centered approach to guide the choice of pharmacological agents. Considerations include efficacy, cost, potential side effects, weight, comorbidities, hypoglycemia risk, and patient preferences.

 Obesity Management for the Treatment of Type 2 Diabetes:  Modest weight loss (5% total body weight) has been shown to improve glycemic control and triglycerides as well as reduce the need for diabetic medications. The updated guidelines recommend a tiered approach to treating overweight/obesity with behavior modifications, pharmacotherapy, and metabolic surgery. See Table 1.

Table 1 –Treatment for Overweight and Obesity in Type 2 Diabetes

	BMI category (kg/m2)
Treatment	23.0* or 25.0–26.9	27.0–29.9	27.5* or 30.0–34.9	35.0–39.9	³40
Diet, physical activity, and behavioral therapy	┼	┼	┼	┼	┼
Pharmacotherapy		┼	┼	┼	┼
Metabolic surgery			┼	┼	┼

┼Treatment may be indicated for selected motivated patients.

*Cutoff points for Asian-American individuals.

Screening:

Consider screening for type 2 diabetes and prediabetes in asymptomatic adults with an informal assessment of risk factors or a validated tool.

Classification and diagnosis of diabetes

PAs should test to detect type 2 diabetes in overweight or obese adults of any age if they have any additional risk factors (family history, dyslipidemia, hypertension, etc.). All patients should be tested beginning at age 45. Women with gestational diabetes should be screened for persistent diabetes at 4-12 weeks postpartum. Patients with normal results should be tested every three years.

 Table 2: Criteria for the Diagnosis of Prediabetes and Diabetes

	Prediabetes	Diabetes
A1C	5.7–6.4%	≥6.5%**
FPG	100–125 mg/dL (5.6-6.9 mmol/L)	≥126 mg/dL (7.0 mmol/L)**
OGTT*	140–199 mg/dL (7.8-11.0 mmol/L)	≥200 mg/dL (11.1 mmol/L)**
RPG		≥200 mg/dL (11.1 mmol/L)***

*2-hour plasma glucose value after a 75-g OGTT

**Confirm results with repeat testing.

***Diagnostic in patients with established symptoms of hyperglycemia

A1C, glycated hemoglobin; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test, RPG, random plasma glucose

Vaccinations

Children and adults with diabetes should receive age-appropriate vaccinations as recommended for the general public. All unvaccinated adults with diabetes between the age of 19 and 59 should receive the hepatitis B vaccine.

Prevention or delay of type 2 diabetes

PAs should refer patients with prediabetes for intensive diet and physical activity behavioral counseling. The Diabetes Prevention Program (cdc.gov/diabetes) targets a 7 percent loss in body weight and 150 minutes of moderate-intensity physical activity such as brisk walking, per week. Consider metformin use in patients with prediabetes who have a BMI >35 kg/m², those aged <60 years, and women with prior gestational diabetes. Cardiovascular risk factors in patient with prediabetes should be assessed and treated appropriately. Technology can be used to change behavior and prevent or delay the onset of type 2 diabetes.

Aspirin therapy: Consider low-dose aspirin therapy (75-162 mg/day) as a primary prevention strategy in patients with type 1 or type 2 diabetes who are at increased cardiovascular risk. Aspirin therapy should be used in all patients with atherosclerotic cardiovascular disease (ASCVD). Patients with ASCVD and a documented aspirin allergy should take clopidogrel (75 mg/day). Dual antiplatelet therapy with both agents is reasonable for up to one year after an acute coronary syndrome.

Lipid management: The guidelines provide recommendations regarding the use of moderate-to-high dose statin therapy. Lifestyle modification focusing on weight loss, reduction of saturated fat consumption, and increased fiber intake to improve the lipid profile is recommended.  See Table 3.

TABLE 3. Recommendations for Statin and Combination Treatment in People with Diabetes

Age	Risk factors	Recommended statin intensity*
<40 years	None ASCVD risk factor(s)** ASCVD	None Moderate or high High
40–75 years	None ASCVD risk factors ASCVD ACS and LDL cholesterol ≥50 mg/dL (1.3 mmol/L) or in patients with a history of ASCVD who cannot tolerate high-dose statins	Moderate High High Moderate plus ezetimibe
>75 years	None ASCVD risk factors ASCVD ACS and LDL cholesterol ≥50 mg/dL (1.3 mmol/L) or in patients with a history of ASCVD who cannot tolerate high-dose statins	Moderate Moderate or high High Moderate plus ezetimibe

*In addition to lifestyle therapy.

**ASCVD risk factors include LDL cholesterol ≥ 100 mg/dL (2.6 mmol/L), high blood pressure, smoking, chronic kidney disease, albuminuria, and family history of premature ASCVD. ASCVD atherosclerotic cardiovascular disease; ACS, acute coronary syndrome.

 Children and adolescents: The treatment goals for youth with type 2 diabetes are generally the same as those for youth with type 1 diabetes. ADA recommends setting a target A1C of < 7.5% in all children with diabetes. The benefit of A1C control should be balanced against the potential risk of hypoglycemia when implementing intensive treatment regimens. Children with diabetes are encouraged to engage in 60 minutes of physical activity each day. Blood pressure should be measured at each routine visit.

A fasting lipid panel, assessment for albumin excretion, and dilated eye exams are recommended at the time of diagnosis in type 2 diabetes.

Older adults: PAs should screen for hypoglycemia and, if present, manage it by adjusting glycemic targets and medications appropriately. Strict blood pressure control and lipid management may not be warranted in patients needing palliative care, and in some instances treatment may be withdrawn if clinically warranted. Depression screening should be a priority.

Diabetes and pregnancy: Preconception counseling with emphasis on the importance of glycemic control in reducing the risk of congenital anomalies is recommended. Family planning and a discussion about effective contraception until the woman is prepared for pregnancy should be conducted. Eye exams should be done before pregnancy or in the first trimester, and each trimester depending on the degree of existing retinopathy. Insulin is the preferred medication in treating preexisting diabetes in pregnancy and gestational diabetes. Metformin and glyburide may be used in gestational diabetes, but both cross the placenta. The A1C target in pregnancy is 6-6.5%, with tighter control (<6%) in the absence of hypoglycemia and more relaxed control (<7%) in the context of significant hypoglycemia.

Microvascular complications

Optimize glucose control to reduce the risk or slow the progression of diabetic kidney disease. To screen for diabetic retinopathy and macular edema, patients should receive a dilated eye exam by an optometrist or ophthalmologist at diagnosis with type 2 diabetes, and five years after being diagnosed with type 1 diabetes, then every two years thereafter or more frequently if retinopathy is detected.

PAs should assess urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and eGFR at least annually in patients with type 1 diabetes of five years or more, and all type 2 patients with hypertension.

Patients should have an annual comprehensive foot exam. PAs should assess for diabetic peripheral neuropathy starting at diagnosis of type 2 diabetes and five years after the diagnosis of type 1 diabetes and annually thereafter. The foot exam should include a visual skin inspection, 10-g monofilament test, pin-prick or vibratory sense assessment and pulse checks in the legs & feet.

 Diabetes care in the hospital

PAs should review the hospital policy for treating patients with blood glucose levels <70 mg/dL in an effort to reduce the incidence of hypoglycemia. Special attention and provisions should be given to patients during the perioperative period.  Insulin therapy should be started in patients with persistent hyperglycemia (>180 mg/dL). Glucose target range for critically ill patients should be 140-180 mg/dL. Sole use of sliding-scale insulin in the inpatient setting is strongly discouraged.

 Key Points:

• Individualize care to address patient’s life circumstances.
• Utilize the entire multidisciplinary care team for behavioral, lifestyle, dietary, and pharmaceutical interventions.
• Set glycemic goals based on duration of diabetes, age/life expectancy, co-morbid conditions, hypoglycemia unawareness, or other patient considerations.
• Reduce cardiovascular disease risk factors with lifestyle changes, blood pressure control, statin, and aspirin therapy.
• Screen and treat microvascular disease early to reduce complications.

Adjust glycemic targets and therapies for special populations including older adults, youth, pregnant women, and hospitalized patients.

Authors: Billy Collins, DHSc, PA-C; Joy Dugan, MPH, PA-C; Amy Butts, MPAS, CDE, PA-C; Jay Shubrock, DO

Conflicts of Interest and Source of Funding: BC, JD, and AB have nothing to declare. JS has served as a consultant to Novo Nordisk and Lilly Diabetes and has research support from Lilly Diabetes, Astra Zeneca, Takeda and Novo Nordisk.