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Saturday, December 22, 2018

Patient-centered Care is the Focus and Priority of the 2019 Standards of Medical Care in Diabetes, Published Today by the American Diabetes Association®

With the evidence from the latest, high-quality diabetes research, the American Diabetes Association’s 2019 Standards of Medical Care in Diabetes (Standards of Care) include new and revised clinical practice recommendations that put the patient at the center of care. With more treatment algorithms that provide decision support for individualized care, the 2019 Standards of Care create a roadmap for therapeutic approaches and medication selection based on each patient’s overall health status. The Standards of Care’s cardiovascular recommendations, which have been endorsed for the first time by the American College of Cardiology, include updates that aim to reduce heart attacks, strokes, heart failure, and other manifestations of cardiovascular disease; cardiovascular disease is the leading cause of death and disability for people with diabetes. Diabetes technology is now more thoroughly discussed in its own section and includes new recommendations on insulin delivery, blood glucose meters, continuous glucose monitors, automated insulin delivery devices (such as the artificial pancreas) and insulin injectiontechnique.

The 2019 Standards of Care provide the latest in comprehensive, evidence-based recommendations for the diagnosis and treatment of children and adults with type 1, type 2, or gestational diabetes, strategies to prevent or delay type 2 diabetes, and therapeutic approaches that can reduce complications and improve health outcomes. The Standards of Care are available online today, December 17, at 2:00 p.m. ET in Diabetes Care, and will be published as a supplement to the January 2019 print issue of Diabetes Care. The online version of the Standards of Care, or the living Standards of Care, will continue to be updated in real-time throughout the year with necessary annotations if new evidence or regulatory changes merit immediate incorporation. This ensures that the Standards of Care provide all stakeholders (i.e. providers, patients, researchers, health plans, policymakers, etc.) with the most up-to-date components of diabetes care, general treatment goals and tools to evaluate the quality of care.
“The latest evidence-based research continues to provide critical information that can optimize treatment options and improve patient outcomes and quality of life. The new 2019 Standards of Care emphasize a patient-centered approach that considers the multiple health and life factors of each person living with diabetes,” said ADA’s Chief Scientific, Medical and Mission Officer William T. Cefalu, MD. “We are also pleased about our close collaboration with the American College of Cardiology, aligning the ADA’s CVD recommendations with the ACC for the first time ever, and also complements our new Know Diabetes by Heart initiative with the American Heart Association. These updated CVD guidelines can help to significantly reduce mortality from CVD, the leading cause of death for people living with diabetes. The 2019 Standards of Care affirm the ADA’s commitment to providing rapid release of evidence-based recommendations that can yield improved patient outcomes and reduce complications and health care costs, and we hope providers will continue to download and use the mobile App for easy access to the Standards of Care at the point of care.”

Important updates and changes to the 2019 Standards of Care include:

Personalizing diabetes care:

  • A new Goals of Care graphic decision cycle details the need for ongoing assessment and shared decision-making to achieve care goals, help reduce therapeutic inertia and improve patient self-management(Section 4, page S35, Figure 4.1)
  • New text guides health care professionals’ use of language to communicate about diabetes with people with diabetes and professional audiences in an informative, empowering, and educational style. (Section 4, page S34, Recommendation 4.1)
  • To address the unique nutritional and physical activity needs and considerations for older adults (>65 years) with diabetes, a new recommendation on lifestyle management is included. (Section 12, page S141, Recommendation 12.10)
  • A new treatment algorithm provides a path for simplifying insulin treatment plans, as well as a new table to help guide providers considering medication simplification and deintensification in older adults (>65 years) with diabetes. (Section 12, pages S143 – S144, Figure 12.1, and Table 12.2, respectively)
  • Treatment recommendations for children and adolescents with type 2 diabetes are significantly expanded to incorporate ADA guidance on youth published in 2018, and recommendations now include screening and diagnosis, lifestyle management, pharmacologic treatment, psychosocial factors for consideration, cardiac function and more. (Section 13, pages S148 – S164)
  • A new graphic provides guidance on the management of new-onset diabetes in overweight youth. (Section 13, page S157, Figure 13.1)   
Diabetes cost and advocacy

  • The  ADA statement on the rising cost of insulin, Insulin Access and Affordability Working Group: Conclusions and Recommendations, is referenced in the Standards of Care advocacy section to reinforce ADA’s focus on making sure cost is not a barrier to successful diabetes management. (Section 16, page S182)
  • Additional information is also included in the Standards of Care focusing on the financial costs of diabetes to individuals and society. (Section 1, pages S7–S12)

Cardiovascular disease and diabetes

  • For the first time, the cardiovascular disease management chapter of the Standards of Care is endorsed by the American College of Cardiology. (Section 10, pages S103 – S123)
  • The section includes new language to acknowledge heart failure as a major cause of cardiovascular morbidity and mortality in people with diabetes and the need to consider heart failure when determining optimal diabetes care. (Section 10, pages S103–S123)
  • Updated recommendations detail the use of sodium–glucose cotransporter 2 (SGLT-2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists, diabetes medications that have proven cardiovascular benefit for people with type 2 diabetes and diagnosed CVD, with and without heart failure. (Section 10, page S114, Recommendations 10.39 and 10.40). 
  • A new recommendation outlines the benefits of GLP-1 receptor agonists and SGLT-2 inhibitors for people with type 2 diabetes and chronic kidney disease. (Section 11, page S124, Recommendation 11.3)
  • The ADA now endorses the use of ACC’s atherosclerotic cardiovascular disease (ASCVD) risk calculator, the ASCVD Risk Estimator Plus, for the routine assessment of 10-year ASCVD risk in people with diabetes. (Section 10, page S104) 

“The American College of Cardiology and the American Diabetes Association share a goal to reduce the burden of cardiovascular disease that too often follows a diabetes diagnosis,” said American College of Cardiology Vice President Richard Kovacs, MD, FACC. “ACC is proud to stand behind this important document that will provide a roadmap for clinicians to effectively assess and manage cardiovascular disease in patients with diabetes and, in turn, save lives.”

Technology and diabetes 

  • A new section focused on diabetes technology includes new recommendations on insulin delivery (syringes, pens and insulin pumps), blood glucose meters, continuous glucose monitors (real-time and intermittently scanned), and automated insulin delivery devices (such as the artificial pancreas). (Section 7, pages S71 – S80)
  • Telemedicine is becoming more widely available and has the potential to increase access to care for patients with diabetes. The Standards of Care addresses remote delivery of health-related services and clinical information via telemedicine. (Section 1, pages S8 – S9)
  • To ensure that insulin is delivered into the proper tissue in the right way for optimal glucose management and safety, discussion on insulin injection technique is included. (Section 9, page S91)
Medical nutrition therapy (diet)

  • Extending the patient-centered care focus, the Standards of Care acknowledge that there is no one-size-fits-all eating pattern, and that a variety of eating patterns can help manage diabetes. It is recommended for patients to be referred to and work with a registered dietitian to create a personalized nutrition plan. (Section 5, page S47-48)
  • A recommendation is updated to emphasize the benefits of consuming more water and fewer beverages sweetened with either nutritive (caloric) or nonnutritive (noncaloric) sweeteners. (Section 5, page S49, Recommendation 5.23 in Table 5.1)

Pharmacologic approaches and glycemic targets 

  • The recommended pharmacologic treatment for type 2 diabetes is significantly updated to align with and reflect the new ADA-EASD Consensus Report, specifically consideration of important comorbidities, such as ASCVD, chronic kidney disease and heart failure and key patient factors, such as hypoglycemia risk, body weight, costs and patient preference. (Section 9, pages S95 – S96, Figures 9.1 and 9.2)  
  • The approach to injectable medication therapy is also revised: for patients who require the additional glucose-lowering efficacy of an injectable medication, a GLP-1 receptor agonist is now recommended as the first choice before insulin for most patients with type 2 diabetes. (Section 9, page S95, Figure 9.2)
  • Gabapentin is included as a new medication to be considered for the treatment of neuropathic pain in people with diabetes based on the latest data that indicates strong efficacy and the potential for cost savings. (Section 11, S131, Recommendation 11.31)
  • A new table aids in the assessment of hypoglycemia risk details factors that increase the risk of treatment-associated hypoglycemia. (Section 4, page S39, Table 4.3)
Updates to the Standards of Care are established and revised by the ADA’s Professional Practice Committee (PPC). The committee is a multidisciplinary team of 15 leading U.S. experts in the field of diabetes care and includes physicians, diabetes educators, registered dietitians and others whose experience includes adult and pediatric endocrinology, epidemiology, public health, lipidresearch, hypertension, preconception planning and pregnancy care. For the 2019 Standards of Care, two designated representatives from the American College of Cardiology (ACC) reviewed, provided feedback and endorsed the recommendations for cardiovascular disease and risk management on behalf of the ACC. The PPC performs an extensive, global clinical diabetes literature search each year for the annual Standards of Care update, supplemented with input from ADA leaders and staff and the medical community at-large. The online and mobile versions of the Standards of Care will include any research updates or policy changes that are approved throughout 2019; they are tagged and updated in overlays as the living Standards of Care. Members of the PPC must disclose potential conflicts of interest with industry and/or relevant organizations; these disclosures are available on page S184 of the 2019 Standards of Care. The complete 2019 Standards of Care and the 2019 Abridged Standards of Care, which focuses on the key recommendations for primary care physicians, are all available online at http://care.diabetesjournals.org/content/42/Supplement_1on December 17, 2018, at 2:00 p.m. ET.

About Diabetes Care®

Diabetes Care, a monthly journal of the American Diabetes Association (ADA), is the highest-ranked, peer-reviewed journal in the field of diabetes treatment and prevention. Dedicated to increasing knowledge, stimulating research and promoting better health care for people with diabetes, the journal publishes original articles on human studies in clinical care, education and nutrition; epidemiology, health services and psychosocial research; emerging treatments and technologies; and pathophysiology and complications. Diabetes Care also publishes the ADA’s recommendations and statements, clinically relevant review articles, editorials and commentaries. Topics covered are of interest to clinically oriented physicians, researchers, epidemiologists, psychologists, diabetes educators and other health care professionals.

About the American Diabetes Association
Approximately every 21 seconds, someone in the United States is diagnosed with diabetes. Nearly half of the American adult population has diabetes or prediabetes, and more than 30 million adults and children are living with the disease. The American Diabetes Association (ADA) is the nation’s leading voluntary health organization on a mission to prevent and cure diabetes, as well as improve the lives of all people affected by the disease. For nearly 80 years, the ADA has driven discovery by funding research to treat, manage and prevent all types of diabetes, while working relentlessly for a cure. Magnifying the urgency of this epidemic, the ADA works to safeguard policies and programs that protect people with the illness, those at risk of developing diabetes and the health care professionals who serve them by initiating programs, advocacy and education efforts that can lead to improved health outcomes and quality of life. 


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