Top 5 Changes to the ADA Standards of Care in Diabetes
Discussion with James J. Chamberlain, MD and Annie Neuman, PA-C
A synopsis of the 2016 American Diabetes Association (ADA) Standards of Medical Care in Diabetes was published online ahead of print in the Annals of Internal Medicine. EndocrineWeb spoke with the synopsis authors James J. Chamberlain, MD and Annie Neuman, PA-C about the top 5 changes in the guidelines that endocrinologists, primary care providers, and other health care practitioners should know about.
Dr. Chamberlain is Medical Director for Diabetes Services at St. Mark’s Hospital and St. Mark’s Diabetes Center in Salt Lake City, Utah. Ms. Neuman is a physician assistant in the Department of Internal Medicine at St. Mark’s Hospital and St. Mark’s Diabetes Center.
Q: What are the top 5 changes to the ADA Standards of Medical Care in Diabetes that endocrinologists and primary care physicians (PCPs) should know about?
A: First, we believe it is important for PCPs to continue to stress lifestyle modification, including diet control and increased physical activity. New phone apps and referrals to diabetes education can help achieve these goals.
We would stress the importance of using multiple oral agents, especially at diagnosis, for patients with hemoglobin A1C levels >9%. Most patients in this category will require at least two medications to achieve satisfactory glycemic control.
Aggressive atherosclerotic cardiovascular disease treatment and control is imperative to reduce morbidity and mortality. Patients with diabetes over the age of 40 years need to be treated with statin therapy if tolerated.
We are now encouraging earlier referrals to nephrology for diabetes patients with declining kidney function and/or increasing or severe albuminuria. Earlier evaluation and treatment may slow the rate of progression to end-stage renal disease.
Lastly, it is important to understand that each patient and their goals should be individualized, especially in the elderly and other vulnerable populations. Newer evidence has indicated that the elderly may not require as strict glycemic control or targets. The risks of hypoglycemia often outweigh the risks of microvascular complications in this population.
Q: How may these changes improve outcomes in people with diabetes?
A: We hope that these changes are incorporated into all practices treating patients with diabetes and result in the following outcomes:
- The screening of all adults for diabetes beginning at age 45 years (regardless of weight) to reduce the number of undiagnosed patients with diabetes in the United States
- Individualized and tailored treatment by providers to all patients, especially vulnerable populations with diabetes
- Use of the comprehensive new section entitled “Obesity Management for the Treatment of Type 2 Diabetes” so patients are treated aggressively for weight loss if appropriate
- Improved diabetes care in the hospital
- Recognition of the nuances of diabetes care in the older adult population
- Earlier referral to diabetic kidney specialists to reduce the chances of progressing to end-stage kidney disease
- More aggressive preventive therapies for atherosclerotic cardiovascular disease, including the recommendation that in all patients with diabetes aged >40 years, moderate-intensity statin treatment should be considered (strongly encourage use of the table titled “Recommendations for Statin and Combination Treatment in People With Diabetes”) to reduce the risks of heart attack and stroke
- Use of new technology such as apps and text messaging to improve lifestyle and behavioral modiﬁcation and to help treat and prevent diabetes
- Continued access to continuous glucose monitoring and insulin pumps after patients turn 65 years of age.
Q: Is there anything else about the Standards of Medical Care in Diabetes that you would like to emphasize to health care providers?
A: It is imperative to get the ADA Standards of Medical Care in front of as many health care providers as possible, including PCPs, diabetologists, and endocrinologists. The Annals article has allowed us to “get the word out” to the internal medicine community worldwide, and we hope they will use the review to help provide the most current and evidence-based care to their patients with diabetes.
We encourage providers to visit the ADA website (professional.diabetes.org) and to take advantage of a tremendous amount of free content, including webcasts (CME credits are available), access to journals, abridged versions of the Standards of Care, meeting information (2016 Scientific Sessions June 10-14 in New Orleans, and the single-day option for primary care providers called Diabetes is Primary on Saturday June 11, 2016), and to consider ADA professional membership. We want providers to recognize that ADA is committed to collaborating with American Association of Clinical Endocrinologists, American College of Physicians, American Academy of Family Physicians, and all professional organizations affiliated with providers treating people with diabetes!
March 15, 2016