Q&A: Updated diabetes guidelines focus on screening, treating comorbidities

The American Diabetes Association recently published its annual Standards of Medical Care in Diabetes report. It provides new and updated practice guidelines, including recommendations for screening and treatment based on comorbidities.

Almost 122 million Americans have diabetes or prediabetes, according to the American Diabetes Association. The CDC has previously published data that show 21.4% of those with diabetes have yet to be diagnosed with the condition.

“The evidence for the prevention and treatment of diabetes and its complications is constantly evolving,” Robert Gabbay, MD, PhD, chief scientific and medical officer for the American Diabetes Association and a co-author of the new report, said in a press release. “It is crucial we do our best to keep medical professionals informed on best practices and medical advances in the field of diabetes.”

In an interview with Healio, Gabbay discussed some of the key takeaways of the report for primary care physicians.

Healio: What does the guidance say about determining first-line therapies based on a patient’s comorbidities? Why was this change made?

Gabbay: The specific comorbidities that we talk about in the guidelines regarding first-line therapy is based on the presence of: No. 1, atherosclerotic cardiovascular disease; No. 2, congestive heart failure; and No. 3, diabetic kidney disease. If people have one of those comorbidities, that helps to dictate what initial therapy may be effective. We usually recommend metformin as the first-line therapy, but for people with one of those comorbidities, one may consider first-line therapy being medications that have been demonstrated to reduce morbidity and mortality from those specific comorbidities.

The Standards of Medical Care in Diabetes is based on an exhaustive review of the literature and the evidence base by the professional practice committee and the American Diabetes Association staff. As we went through those sources, it became clear that there are treatments for those three comorbidities that transcend anything else and, in fact, may have benefits beyond just the lowering of blood glucose. That is why we have the emphasis of individualized therapy for people with one of those comorbidities.

Healio: Why was the age to start screening for prediabetes and diabetes lowered to 35 years? How much of an impact will this change have?

Gabbay: No. 1, we are missing many people and delaying the diagnosis of type 2 diabetes, which can have long asymptomatic periods. No. 2, there are a large number of people who are going undiagnosed, and we need to address that. Although the guidelines put the cutoff point at age 35, PCPs should screen earlier if a person has risk factors for the disease.

I am not familiar with specific numbers on how much of an impact this change will have, but we do know that it will certainly include more people than were being diagnosed previously.

Healio: Who should now be tested for gestational diabetes? When should this testing occur?

Gabbay: This is a really exciting part of the updated Standards of Medical Care in Diabetes that some people have not picked up on because of the other things we have talked about. We still recommend testing at 24 to 28 weeks for gestational diabetes. We now also recommend screening people who are less than 15 weeks pregnant to see if they might have preexisting diabetes. In the absence of this recommendation, many people who had preexisting diabetes did not know until their third trimester.

Healio: Regarding other guideline updates, which ones are most important for PCPs to be aware of and why?

Gabbay: Everyone needs to think more holistically about the individualizing therapy for comorbidities, screening more people for prediabetes and diabetes and testing for gestational diabetes. They also need to start thinking more holistically about bringing high levels of blood pressure and cholesterol levels under control and using appropriate medications to lower cardiovascular and renal disease risk. The underpinning of this is lifestyle management and diabetes education, not just controlling glucose levels.

Another important takeaway is to have more discussions around liver disease. Things like [nonalcoholic steatohepatitis] and [nonalcoholic fatty liver disease] are rapidly becoming a more common complication of diabetes.

Changes to the guideline from a technology standpoint lead to a broader statement about the value of continuous glucose monitoring in people with either type 1 diabetes or type 2 diabetes remotely. The American Diabetes Association is developing educational programs for primary care providers around how to obtain and use that information remotely.

Healio: Is there anything else you would like to add?

Gabbay: The American Diabetes Association has created a number of resources and ways to access the information we have.

We have an abridged version of the Standards of Medical Care in Diabetes, an app and a free webcast that covers everything that is new. We are also working on a variety of infographics and other visuals that will make the information contained within the Standards of Medical Care in Diabetes more actionable.

We will also continue to amend the Standards of Medical Care in Diabetes between the yearly updates, because, as you can appreciate, there is just so much happening in diabetes that sometimes you cannot wait a full year to have the most up-to-date information possible.

References:

CDC. National diabetes statistics report. Accessed Jan. 10, 2022.

Latest ADA annual Standards of Care includes changes to diabetes screening, first-line therapy, pregnancy, and technology. https://www.diabetes.org/newsroom/press-releases/2021/latest-ada-annual-standards-of-care-includes-changes-to-diabetes-screening-first-line-therapy-pregnancy-technology. Printed Dec. 20, 2021. Accessed Jan. 10, 2022.