2023 ADA updates advise weight loss, lower BP and lipid goals for people with diabetes
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Notable updates to the American Diabetes Association’s 2023 Standards of Care address the role of weight loss in diabetes management and cardiovascular risks and now advise lower targets for blood pressure and LDL cholesterol.
The 2023 updates are published online and as a supplement to the January issue of Diabetes Care.
“ADA’s mission is to prevent and cure diabetes, a chronic illness that requires continuous medical care, and the release of ADA’s Standards of Care is a critical part of that mission,” Charles D. “Chuck” Henderson, ADA CEO, said in a related press release. “This year’s annual report provides necessary guidance that considers the role health inequities play in the development of diabetes, particularly for vulnerable communities and communities of color disproportionately impacted by the disease. This guidance will ensure health care teams, clinicians and researchers treat the whole person.”
Obesity and type 2 diabetes
The updates recommend that weight loss be considered a goal of treatment on an individual basis. Weight loss of more than 10% has the potential to remit type 2 diabetes, the authors note, and improve CV risks.
The updates added tirzepatide (Mounjaro, Lilly), a dual GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonist approved in May, as a recommended glucose-lowering therapy that can lead to weight loss.
CVD risk management
The updates include a strong focus on CVD and risk management. The recommendations advise the use of drug therapies that reduce cardiorenal risk for adults with type 2 diabetes and established or high risk for atherosclerotic CVD, heart failure (HF) or chronic kidney disease.
The 2023 Standards update the definition of hypertension for people with diabetes as a systolic blood pressure at least 130 mm Hg or diastolic BP at least 80 mm Hg, which is the definition used by the American College of Cardiology and the American Heart Association. Blood pressure below 130/80 mm Hg is the recommended treatment goal, with drug therapies considered for people with diabetes and hypertension.
The use of high-intensity statin therapy is recommended for people with diabetes aged 40 to 75 years who have elevated risk for CVD to reduce LDL cholesterol by 50% or more from baseline. Continuing statin therapy beyond age 75 years for those who currently receive it or initiating moderate-intensity statin therapy in this age group is also advised to meet the new LDL treatment goal of less than 70 mg/dL.
High-intensity statin therapy is also recommended for those with established atherosclerotic CVD to target LDL reductions of 50% or more from baseline and an LDL goal of less than 55 mg/dL. The addition of ezetimibe or a PCSK9 inhibitor is recommended if goals are not achieved on maximum statin therapy.
The recommendations also support SGLT2 inhibitor therapy for those with established HF with preserved or reduced ejection fraction.
Kidney disease in diabetes
For people with type 2 diabetes and chronic kidney disease, the addition of finerenone (Kerendia, Bayer) is recommended for those with albuminuria treated with the maximum tolerated dose of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.
SGLT2 inhibitor initiation levels were changed to an estimated glomerular filtration rate of 20 mL/min/1.73 m2 or more and urinary albumin of at least 200 mg/g creatinine. The Standards also state that SGLT2 inhibitors may be considered for those with urinary albumin of normal to at least 200 mg/g creatinine, but notes that study evidence has not yet been published.
Along with other medications, mineralocorticoid receptor antagonists are recommended for CV and kidney protection when other treatments were not effective.
Diabetes care in underserved areas, social determinants of health
The 2023 updates added a recommendation to utilize community health workers to support diabetes management and the management of CV risk factors, particularly among underserved communities and health care systems. The authors also recommend utilizing point-of-care HbA1c testing for diabetes screening and diagnosis.
Regarding social determinants of health, the Standards recommend guiding the design and delivery of diabetes self-management education and support along with telehealth delivery and other digital health solutions.
Treating older adults
For older adults with type 2 diabetes on multiple doses of insulin, continuous glucose monitoring should be considered to improve glycemic outcomes and decrease glucose variability. Based on two small randomized controlled trials of older adults, a new recommendation was added to consider automated insulin delivery system use and other advanced insulin delivery devices, such as connected pens, to reduce the risk for hypoglycemia.
Additionally, simplification of complex treatment plans is now recommended to reduce hypoglycemia and polypharmacy risk and decrease disease burden if it can be achieved within the individualized HbA1c target. Clinicians should consider CGM use to assess hypoglycemia risk for older adults using sulfonylureas or insulin.
“Evidence-based recommendations drive better care for all people with diabetes, including vulnerable communities and those at high risk. ADA’s Standards of Care are the gold standard for diabetes care and prevention that allows clinicians around the world to remain abreast of the rapidly changing health care landscape,” Robert A. Gabbay, MD, PhD, FACP, chief scientific and medical officer for the ADA, said in the release.
Reference:
- American Diabetes Association Releases 2023 Standards of Care in Diabetes to Guide Prevention, Diagnosis, and Treatment for People Living with Diabetes. diabetes.org/newsroom/press-releases/2022/american-diabetes-association-2023-standards-care-diabetes-guide-for-prevention-diagnosis-treatment-people-living-with-diabetes. Published Dec. 12, 2022. Accessed Dec. 13, 2022.
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