The American Diabetes Association (ADA) has released the 2017 update to its Standards of Medical Care in Diabetes (Standards).1 The document is reviewed each year by a multidisciplinary committee of experts in diabetes care, which examines relevant research that informs the revisions.
“The most recent update to the ADA Standards of Medical Care addresses many new and important issues regarding the management of patients with diabetes,” said Kevin M. Pantalone, DO, staff endocrinologist and director of clinical research at the Cleveland Clinic Foundation. The 2017 Standards contain the usual guidelines pertaining to type 2 diabetes prevention and the diagnosis and treatment of type 1, type 2, and gestational diabetes. Additionally, Dr Pantalone identified several of the most notable updates.
One recommendation suggests considering metabolic surgery for patients with obesity and uncontrolled type 2 diabetes who have a body mass index (BMI) as low as 30 kg/m2 (27.5 kg/m2for Asian Americans). This update is based on a growing body of research showing that metabolic surgery — previously referred to as bariatric surgery — leads to improved glycemic control and reduced cardiovascular disease (CVD) risk in this patient population compared with other medical and lifestyle interventions.2 The committee also noted that the safety of metabolic surgery has significantly improved in the past 2 decades: Related mortality rates are 0.1% to 0.5%, which are similar to the rates associated with hysterectomy or cholecystectomy.2
Another update recommends considering 2 specific glucose-lowering therapies (glucagon-like peptide-1 [GLP-1] receptor agonists or sodium-glucose cotransporter-2 [SGLT2] inhibitors) for high-risk patients with CVD who have type 2 diabetes, which is in line with the findings of recently published clinical trials, including the EMPA-REG OUTCOME (ClinicalTrials.gov identifier: NCT01131676) and LEADER (ClinicalTrials.gov identifier: NCT01179048) trials.
The EMPA-REG OUTCOME study examined the effects of the SGLT2 inhibitor empagliflozin vs placebo and usual care in high-risk patients with CVD who have diabetes.3 The findings show that the drug led to a 14% reduction in the composite outcome of myocardial infarction (MI) and stroke, and a 38% reduction in CV death over a median follow-up period of 3.1 years.3 As a result, the US Food and Drug Administration (FDA) added a new indication for empagliflozin to reduce CV mortality risk in adults with type 2 diabetes and heart disease.4 In a similar manner, results from the LEADER trial showed that the GLP-1 receptor agonist liraglutide resulted in fewer MI, stroke, or CV deaths compared with placebo (13% vs 14.9%) over a median follow-up period of 3.8 years.5
The committee also sought to further define hypoglycemia. The update indicates that a level of lower than 54 mg/dL (3.0 mmol/L) should be considered serious, clinically important hypoglycemia, even in the absence of symptoms. It is recommended that values below this level be reported in clinical trials and practice. Previous recommendations defined hypoglycemia in hospitalized patients as blood glucose levels <70 mg/dL (3.9 mmol/L) and severe hypoglycemia as levels <40 mg/dL (2.2 mmol/L). Severe hypoglycemia is now defined as “that associated with severe cognitive impairment regardless of blood glucose level,” and a level ≤70 mg/dL “is considered an alert value and may be used as a threshold for further titration of insulin regimens,” according to the Standards.
“Also, and perhaps most important, is the Standards’ acknowledgment and addressing of the socioeconomic aspects of diabetes management: medication cost and self-management support,” Dr Pantalone added. “These areas had been inadequately addressed by earlier versions of the guideline.”
The new version includes 2 detailed tables that provide the estimated monthly cost of various glucose-lowering medications, and the section on reducing disparities in diabetes care states that community health workers, peers, and lay leaders can facilitate the delivery of diabetes self-management education (DSME) and support services. “Strong social support leads to improved clinical outcomes, a reduction in psychosocial issues, and adoption of healthier lifestyles,” the committee noted.
Other notable additions include recommendations pertaining to screening and mental health referrals for patients with depression, anxiety, diabetes distress, eating disorders, and other psychological issues; greater emphasis on assessing comorbidities in patients with diabetes, and an expanded list of such comorbidities, including mental disorders as well as autoimmune disease and HIV; a new physical activity recommendation to break up sedentary behavior every 30 minutes to reduce associated behaviors illuminated by recent research; and increased options for both glucose management and hypertension treatment.
“The ADA has done a fantastic job of remaining on top of the new advances in diabetes management, incorporating new findings and recommendations into the guidelines in a timely manner, but doing so only after a thorough and vigorous review of the recently published medical literature,” said Dr Pantalone.
- American Diabetes Association. Standards of medical care in diabetes–2017. Diabetes Care. 2017;40(Suppl. 1):S6-S10.
- Rubino F, Nathan DM, Eckel RH, et al. Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations. Diabetes Care. 2016;39(6):861-77.
- Zinman B, Wanner C, Lachin JM, et al; EMPA-REG OUTCOME Investigators. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015; 373:2117-2128.
- FDA approves Jardiance to reduce cardiovascular death in adults with type 2 diabetes [news release]. Silver Spring, MD: FDA; December 2, 2016. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm531517.htm. Accessed January 18, 2017.
- Marso SP, Daniels GH, Brown-Frandsen K, et al.; LEADER Steering Committee; LEADER Trial Investigators. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375:311-322.