The American Diabetes Association (ADA) Standards of Medical Care in Diabetes was recently updated. Major updates include recommendations for cardiovascular disease (CVD) risk reduction, pharmacologic treatments and glycaemic targets.

For the first time in its 80-year history, ADA held virtual scientific sessions from June 12 to June 16 2020. The ADA session – the world’s largest meeting dedicated to diabetes - hosted more than 12,500 participants from around the globe and included scientific advances and groundbreaking research presentations from eminent speakers.

The ADA Standards of Medical Care in Diabetes was also recently updated which included recommendations for CVD risk reduction, pharmacologic treatments and glycaemic targets. Let us swift through the major updates to the ADA Standards of Medical Care in Diabetes.

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Time in range (TIR) for assessment of glycaemic management (vs HbA1c)

New recommendations were added on use of time in range (TIR) for assessment of glycaemic management.

As per the recommendation, TIR is associated with the risk of microvascular complications and should be an acceptable end point for clinical trials and can be used for assessment of glycaemic control. Additionally, time below target (<70 and <54 mg/dL [3.9 and 3.0 mmol/L]) and time above target (>180 mg/dL [10.0 mmol/L]) are useful parameters for reevaluation of the treatment regimen.

The ADA acknowledges that for TIR to be fruitful, more people with diabetes should be given access to continuing glucose monitoring (CGM) technology. Reports generated from CGM will enable evaluation of TIR and help assess hypoglycaemia, hyperglycaemia, and glycaemic variability.

*To read more on this new metric, read Dr. Jothydev Kesavadev's article. Click here.

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Pharmacologic approaches to glycaemic treatment

The ADA has elaborated numerous approaches to treatment with insulin analog, which can enable patient safety by avoiding diabetic ketoacidosis and significant hypo- or hyperglycemia.

The ADA recommends early combination therapy in some patients at treatment initiation to extend the time to treatment failure. The recommendation is based on results from the VERIFY trial. In trial, study subjects receiving the initial combination of metformin and the dipeptidyl peptidase 4 (DPP-4) inhibitor vildagliptin had a slower decline of glycaemic control compared to metformin alone and to vildagliptin added sequentially to metformin.

With respect to individual drug classes, evidence from latest studies on sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) suggests that these drugs can be an option for patients when atherosclerotic cardiovascular disease (ASCVD), heart failure, or chronic kidney disease predominates independent of A1C.

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Cardiovascular disease and risk management

The cardiovascular disease and risk management section of the ADA’s Standards of Care has been endorsed by the American College of Cardiology.

SGLT2 inhibitors and GLP-1 receptor agonists are recommended for patients with type 2 diabetes and ASCVD and the recommendations are individualised based on additional comorbidity burden.

To align with newer study findings and consensus guidelines, the use of statin therapy to reduce ASCVD risk have also been updated. The ADA recommends use of moderate-intensity statins in patients with diabetes aged 40 to 75 years who do not have established ASCVD. In cases with established ASCVD and comorbid diabetes, patients of all ages should receive high-intensity statins.

In patients with ASCVD or other CVD risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL), the addition of icosapent ethyl is recommended to reduce cardiovascular risk.

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Microvascular complications

As per the new recommendations, patients with urinary albumin >30 mg/g creatinine and/or an eGFR <60 mL/min/1.73 m² should be monitored twice annually to guide therapy. SGLT2 inhibitors and GLP-1 receptor agonists can be considered in patients with type 2 diabetes and diabetic kidney disease.

• For patients with type 2 diabetes and diabetic kidney disease, the use of a SGLT2 inhibitors should be considered in patients with an estimated glomerular filtration rate ≥30 mL/min/1.73 m² and urinary albumin >30 mg/g creatinine, particularly in those with urinary albumin >300 mg/g creatinine, to reduce risk of chronic kidney disease (CKD) progression, cardiovascular events, or both.
• In patients with CKD who are at increased risk for cardiovascular events, use of a glucagon-like peptide 1 receptor agonist may reduce risk of progression of albuminuria, cardiovascular events, or both.

As per ADA, it is not suggested to discontinue renin-angiotensin system blockade for minor increases in serum creatinine (<30%) in the absence of volume depletion.

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All forms of diabetes mediated by autoimmune β-cell destruction are included under the rubric of type 1 diabetes

The dilemma if the slowly progressive autoimmune diabetes with an adult onset should be tagged latent autoimmune diabetes in adults is now acknowledged by the ADA. As per the update, all forms of diabetes mediated by autoimmune β-cell destruction are included under the rubric of type 1 diabetes.

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Testing for prediabetes and/or type 2 diabetes for women who are planning a pregnancy

As per the new recommendation, high-risk women (overweight or obesity or those who have one or more additional risk factors) who are planning a pregnancy should be tested for prediabetes and/or type 2 diabetes.

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A variety of eating patterns are acceptable for people with prediabetes

On the basis of a consensus report published in April 2019, a variety of eating patterns may be appropriate for patients with prediabetes including Mediterranean and low-calorie, low-fat eating patterns.