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Updated clinical practice guidelines for diabetes

06/05/2019

Once a year we review and update the clinical practice guidelines for some chronic conditions. We have updated our guidelines for diabetes based on the information the American Diabetes Association published in the Standards of Medical Care in Diabetes — 2019 report.*

Highlights of the changes are:

  • Based on new data, criteria for the diagnosis of diabetes was changed to include two abnormal test results from the same sample (i.e., fasting plasma glucose and A1C from same sample).
  • Because smoking may increase the risk of type 2 diabetes, a section on tobacco use and cessation was added. Discussion about e-cigarettes was expanded to include more on public perception and how their use to aid smoking cessation was not more effective than “usual care.”
  • Based on a new consensus report on diabetes and language, new text was added to help health care professionals communicate with people with diabetes and professional audiences in an informative, empowering and educational style.
  • A new table was added listing factors that increase risk of treatment-associated hypoglycemia.
  • The fatty liver disease section was revised to include updated text and a new recommendation regarding when to test for liver disease.
  • A recommendation was modified to encourage people with diabetes to decrease consumption of both sugar-sweetened and nonnutritive-sweetened beverages and use other alternatives, with an emphasis on water intake.
  • The sodium consumption recommendation was updated for those with both diabetes and hypertension. The guidelines do not recommend restricting sodium intake below 1,500 mg per day.
  • A recommendation was added to reevaluate glycemic targets over time to emphasize glycemic targets can change as diabetes progresses and patients age.
  • The recommendation to use self-monitoring of blood glucose in people who are not using insulin was changed because routine glucose monitoring has limited additional clinical benefit in this population.
  • To align with the ADA-EASD consensus report, the approach t injectable medication therapy was revised. A recommendation was made that, for most patients who need the greater efficacy of an injectable medication, a glucagon-like peptide 1 receptor agonist should be the first choice, ahead of insulin.
  • For the first time, the American College of Cardiology endorsed the section acknowledging heart failure is an important cardiovascular disease that needs to be considered when determining optimal diabetes care.
  • A discussion of the appropriate use of the ASCVD risk calculator was included, and recommendations were modified to include assessment of 10-year ASCVD risk as part of overall risk assessment and in determining optimal treatment approaches.
  • The recommendation and text regarding the use of aspirin in primary prevention was updated with new data.
  • Gabapentin was added to the list of agents to be considered for the treatment of neuropathic pain in people with diabetes based on data on efficacy and the potential for cost savings.
  • The recommendation for patients with diabetes to have their feet inspected at every visit was modified to only include those at high risk for ulceration. Annual examinations remain recommended for everyone.
  • Within the pharmacologic therapy discussion, deintensification of insulin regimes was introduced to help simplify insulin regimen to match individual’s self-management abilities. The report included new figures and table to help guide providers considering medication regimen simplification and deintensification/deprescribing in older adults with diabetes.
  • The discussion of type 2 diabetes in children and adolescents was significantly expanded, with new recommendations in several areas, including screening and diagnosis, lifestyle management, pharmacologic management and transition of care to adult providers.
  • Women with preexisting diabetes are now recommended to have their care managed in a multidisciplinary clinic to improve diabetes and pregnancy outcomes.
  • Greater emphasis has been placed on the use of insulin as the preferred medication for treating hyperglycemia in gestational diabetes mellitus as it does not cross the placenta to a measurable extent. It also notes how metformin and glyburide should not be used as first-line agents because both cross the placenta to the fetus.

*Source: American Diabetes Association. Standards of Medical Care in Diabetes — 2019. (last accessed 14 May 2019)