ADA’s 2021 Standards of Care: What To Know Now

The updated recommendations from the America Diabetes Association focus on evolving evidence, upgraded technology and individualized care

With Boris Draznin MD, PhD, Marie E. McDonnell MD and Scott Isaacs MD, FACP, FACE

American Diabetes Association's 2021 GuidelinesWhat's changed since last year in the ADA guidelines for the treatment of diabetes.

The 2021 update of the American Diabetes Association’s Standards of Medical Care in Diabetes focuses on evolving evidence, updated technology and individualized care at any age.

“Each section has updates,” says Boris Draznin, MD, PhD, professor of medicine at the University of Colorado and chair of the Professional Practice Committee of the ADA, the committee responsible for updating the standards.

The standards have been updated annually, he says, since 1989.

“We meet several times a year, as a committee, and we discuss the potential changes on an ongoing basis.” The committee also updates the standards on an as-needed basis throughout the year.

Endocrine Web asked Dr. Draznin to recap what he sees as the most important changes for endocrinologists, primary care physicians and other healthcare providers who care for those with diabetes to be aware of. We also asked two other experts who treat patients with diabetes to weigh in.

An overview of the ADA update

Dr. Draznin focused on several changes he viewed as important. 

Social determinants of health

Physicians are encouraged to consider economic, environmental, social and other factors that impact on their disease. The recommendation is not only to identify and recognize those social factors, he says, but also ‘’to find out what we can do to improve those determinants of health in a positive way.”

For instance, some populations might have food insecurity, he says, even as high as 20%. “If we don’t discuss with our patients the ability to secure food, and good quality food,” he says, medical treatment will suffer. Housing security must also be evaluated, especially important in these economically difficult times. “All of that relates eventually to the ability to treat diabetes,” Dr. Draznin says.

Knowing about a patient’s situation isn’t enough, he says, “but also being knowledgeable about social services in the community that might help this patient, to know where social workers are. That is a very important aspect. I would consider it critically important.”

Glycemic control

“Previously we relied on a measure of blood sugar, with self-measurements and evaluating 1,2,3 times a day, depending on needs,” Dr. Draznin says. “Now we put much more emphasis on time-in-range goal.”

That’s attainable with continuous glucose monitoring (CGM). As Dr. Draznin says, the consensus is that it is important; what is not yet scientifically affirmed is if the time in range results in fewer complications.

CGM is viewed as ideal for those who need multiple daily injections of insulin or who are on continuous infusion to manage their diabetes. It’s no longer viewed as only for those with type 1 diabetes, he says.

The update includes information on the possible benefit of systems that combine technology and online coaching.

Treatment of cardiovascular disease that occurs with diabetes

Managing the cardiovascular disease that often accompanies diabetes continues to be crucial. “We are proud to say that section has also been endorsed by the American College of Cardiology for the third year in a row,” Dr. Draznin says.

The advice is supported by evidence from clinical trials in its recommendation on how to use medication in those with coexisting diabetes and CVD. “I would encourage everyone to review that section,” Dr. Draznin says.

Treatment of chronic kidney disease in patients with diabetes

Paralleling the need to manage CVD is the need to manage kidney issues in those with diabetes, including chronic kidney disease (CKD). “CKD is so prevalent, every primary care provider probably has a patient with this,” Dr.  Draznin says.

Over the years, he says, GLP-1 receptor agonists and SGLT-2 inhibitors have been shown to help those who either have diabetes with CVD or CKD, he says, yet the use of these medications lags greatly. “We clearly recommend greater attention to prescribing these drugs,” he says.

In fairness, he adds, physicians may face barriers to prescribing these due to the need for preauthorization, or due to costs.

Treatment of older adults with diabetes

Older age, by itself, is probably not a reason to not prescribe the newer medications, Dr. Draznin says. “One should not relax their therapy just because patients reach the age of 70, or whatever. There are plenty of very functional older people. They should be treated as vigorously as anyone else.”

Treatment of children and adolescents with diabetes

Assessing food insecurity is also important when caring for children and teens, Dr. Draznin says. Doctors should also be careful to thoroughly assess children to determine if the diabetes is type 1 or 2, he says. “We need to remember that obese children can have type 1, and not make assumptions,” Dr. Draznin says.

Expert Perspectives

“This is a welcomed update to the ADA standards of care, addressing several newer topics in diabetes management,” says Scott Isaacs, MD, FACP, FACE, an Atlanta endocrinologist. “Important topics like the management of chronic kidney disease and heart failure are highlighted. The section of diabetes technology is very informative, as this is an area that is constantly changing.”  Also noteworthy he says, is information about vaccines for people with diabetes, including the COVID-19 vaccine. For the vaccines, the standards defer to the CDC’s recommendations.

The standards do a good job of linking out to other useful guidelines, says Marie E. McDonnell, MD, chief of diabetes in the division of endocrinology, diabetes and hypertension at Brigham and Women’s Hospital in Boston. For instance, they link out to Social Determinants of Health, a consensus report just updated by the ADA.  If a doctor needs more information, it’s easy to access it from the Standards.

The greater emphasis on the characterization of diabetes is also welcome, Dr. McDonnell says. When healthcare providers focus on factors leading to the need for insulin or other therapies, the focus can be on therapy-driven classification—that is, what does this patient need to control the diabetes?

Dr. McDonnell would point healthcare providers to read the list of conditions for which they should not use hemoglobin A1C to screen for diabetes, such as in patients with cystic fibrosis-related diabetes. “I think that list is handy and people need to have it in their heads.”

Also worth reviewing are the updates on lower bounds on glucose targets in pregnancy, she says.

While it’s almost old news, ‘’When we see the patient with diabetes now, we think more about the heart and the kidneys than we used to and preserving the health of those organs, too," Dr. McDonnell says. 

"It’s also crucial," she says, "that endocrinologists and primary care providers caring for those with diabetes also be aware of what medications other specialists, such as nephrologists and cardiologists who are caring for those patients are prescribing."

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