Q&A: American Diabetes Association's updated standards

The American Diabetes Association recently updated its Standards of Medical Care in Diabetes to underscore new drug recommendations for patients with diabetes, cardiovascular outcomes trials, psychosocial health and bariatric surgery.

Jim Chamberlain, MD, medical director for diabetes services at St. Mark’s Hospital and St. Mark’s Diabetes Center, Salt Lake City, spoke with Healio Internal Medicine to discuss the new and important changes to the standards and how they will impact practice and patients.

Question: What is new in the guidelines?

Answer: The 2017 American Diabetes Association's Standards of Medical Care in Diabetes include several important additions that will impact all practitioners providing care to people with diabetes. The Standards of Care has been updated to address screening for diabetes and prediabetes, psychosocial and mental health issues in patients with diabetes, diabetes self-management and lifestyle considerations, complications, comorbidities and obesity management, medical management in the inpatient and outpatient settings, and cardiovascular disease risk management.

Question: What do primary care doctors need to know about the update?

Answer: Screening guidelines for diabetes and prediabetes in both children and adults have been updated. A downloadable 'Diabetes Risk Test' is included and practitioners should strongly consider utilizing this tool in the office setting. With respect to mental health, providers should be screening for mental health disorders such as depression, ‘diabetes distress,’ anxiety, and eating disorders. Patients should be referred to mental health experts when necessary.

The Standards of Care also recommends evaluating sleep patterns and duration of sleep as part of the medical evaluation based on evidence showing a relationship between sleep quality and glucose control. The section on complications of diabetes includes new recommendations to emphasize the importance of providers communicating the increased risk for retinopathy in women with type 1 or type 2 diabetes who are planning pregnancy or who are pregnant. New specific recommendations for the treatment of neuropathic pain are included as is a new recommendation for consideration of specialized therapeutic footwear for patients at high risk for foot complications.

Diabetes comorbidities have been expanded to include autoimmune diseases, HIV, anxiety disorders, depression and serious mental illness. These should be addressed as part of a comprehensive diabetes evaluation and management plan. Bariatric surgery should be a consideration that providers discuss with patients with inadequately controlled type 2 diabetes and a BMI of 30 kg/m² or greater (27.5 kg/m² for Asian-Americans).

Question: How will the updated standards affect patients?

Answer: Diabetes self-management recommendations have been revised and patients should now be encouraged to increase physical activity by interrupting prolonged sitting every 30 minutes with ‘short bouts’ of physical activity. In addition, providers are encouraged to discuss and help patients on flexible insulin regimens understand the effects of fat and protein on mealtime insulin doses.

Question: What are the important changes to the guidelines?

Answer: Two specific medications, the SGLT-2 inhibitor Jardiance (empagliflozin, Boehringer-Ingelheim) and the GLP-1 receptor agonist liraglutide should now be considered in certain high-risk patients with diabetes to lower the risk for death based on recent cardiovascular outcomes trials. In the hospital setting, providers should use either basal insulin or basal plus bolus correctional insulin when treating noncritically ill patients with diabetes, but not sliding scale insulin alone. Cardiovascular risk management was updated to include the recommendation that for patients with diabetes and hypertension without albuminuria, ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics or dihydropyridine calcium channel blockers are all options for first-line therapy for hypertension based on positive cardiovascular outcomes trials. Lastly, the recommendation for the treatment of pregnant patients with diabetes and chronic hypertension was updated to suggest a BP target of 120–160/80–105 mm Hg to optimize maternal health without risking harm to the fetus.