Wholistic Approach to Care Leads Changes in 2019 Diabetes Guidelines

The need to step-up efforts to prevent progression of diabetes, and to place patients front and center in their own care are featured prominently in the newly revised edition of the American Diabetes Association Standards of Medical Care in Diabetes.

With Joshua J. Neumiller, PharmD, CDE

Evolving with the times and key research findings particularly in cardiovascular disease, there are four significant changes in diabetes management of note for clinicians in the newly released Standards of Medical Care in Diabetes 2019,which Joshua J. Neumiller, PharmD, CDE, FASCP, vice chair and Allen I. White Distinguished Associate Professor in the College of Pharmacy at Washington State University in Seattle who chaired the American Diabetes Association (ADA) Primary Practice Committee, discussed with EndocrineWeb.

Progressive Recommendations Reflect Future Diabetes Management  

In commenting on the changes of note in the 2019 ADA Standards of Care, Dr. Neumiller identified four areas that may be particularly valuable to healthcare providers who manage adult patients with diabetes:

  • Evolving care to a practice of Shared Decision Making
  • Aligning cardiovascular disease recommendations with diabetes care
  • Emphasizing the role of diabetes technology in enhancing glucose control
  • Drawing attention to need for less intervention in seniors

Shared decision-making has been an evolving model of care that places an equal value on the clinical guidance of the provider—informed by evidence-based research and patient history and current needs— and the necessity of active, patient self-management. It is timely that the American Diabetes Association begins the Standards of Care 2019,1 with an urgency that all clinicians adopt a patient-centered approach to practice.

1.  Address Individual Needs Guided By Consensus Recommendations

The 2019 standards led off with a new practice guideline that emphasizes the need to manage patients individually, accounting for all related and interrelated comorbidities at the outset and ongoing, as much as to steward patients to take responsibility for their own care. In this way, healthcare providers and patients will be better able to meet agreed-upon medical recommendations and to achieve the desired outcomes and to the ability, according to Dr. Neumiller.

“We’re taking a more global view of diabetes in these Standards of Care in that we are emphasizing the need for clinicians to fully embrace a patient-centered approach and looking at diabetes management more wholistically,” Dr. Neumiller told EndocrineWeb.

Patient empowerment is crucial if clinical outcomes are to be achieved, and occurs when individuals accept personal responsibility for his or her health. By enabling patients to recognize the benefits gained by self-management, the will be better positioned to learn how to solve their own problems—understanding how glucose data matches to their personal food choices, for example, and always with support from their healthcare team.1

Another notable recommendation is the need to adopt language with patients that “plays into the sensitivity of patient-centered care. We want to move away from labeling patients with a disease or leaving them feeling judged for their failures, such as controlling their hemoglobin A1c levels,” he said.

An effective treatment approach will be one that fosters discussion rather than perpetuates the traditional way of talking to or at the patient (eg, the more traditional clinical delivery). This will mean engaging more actively with our patients—“it’s about interacting with individuals to elicit good changes, and using open language to encourage discussion.”

Active Engagement Needed to Reverse Rising Rates of Type 2 Diabetes

“With an emphasis on the Decision Cycle, the new Goals of Care (Figure 4.1, page S35), we are putting clinicians on level ground with their patients to increase the emphasis on the individual and caregivers,” said Dr. Neumiller. “It’s just as important to determine what motivates our patients and extends to our need to use patient-friendly language so as to engage them. That means employing motivational interviewing techniques as a key tactic in promoting patient-centered care. This is stressed in the section on older adults and their caregivers (Section 12).1

“Prevention, particularly lifestyle strategies, is reflected in the newest treatment algorithm, which remains the cornerstone of cardiovascular management and obesity intervention,” said Dr. Neumiller. There is, for example, as much a focus on careful consideration of the impact of prescribing weight-inducing drugs and for prescribing medications to support weight loss in these updated recommendations.

As for weight management, the guidelines do not go into depth here, he said. “While there is a nod to the potential value of intermittent fasting for some patients, a more comprehensive assessment of newer evidence-based strategies will be provided in the forthcoming Nutrition Consensus Report (anticipated publication in March 2019).”

2.  Cardiovascular Disease Gain Prominence as a Care Strategy

Addressing cardiovascular disease (CVD) took a major turn this past year following publication of several randomized trials that substantiated the clear benefits of reducing cardiovascular comorbidity and morbidity in patients with type 2 diabetes. Treating CVD is no longer a matter for cardiologists, as endocrinologists, diabetologists, and primary care practitioners have the tools at their disposal—two novel antidiabetic medications: sodium-glucose co-transporter-2 inhibitors (SGLT2i and glucagon-like peptide-1 receptor agonists (GLP-1RA)—to initiate prescribed therapy.2

Of particular note, a specific recommendation has been added to reflect the substantial burden arising from the increased risk of heart failure in patients with diabetes.1

Finally, for the first time, the chapter dedicated to managing patients at risk for cardiovascular disease (Section 10),has gained the endorsement of the American College of Cardiology (ACC), to acknowledge that these treatment recommendations are aligned with the ACC guidance.3

3.  Embrace Opportunities Introduced by Growth in Diabetes Technology 

Given the growing range and array of devices approved and studied to enhance glucose management and insulin delivery, there are new recommendations on the use of these products such as injectable pens, continuous glucose monitors (CGMs) and automated insulin delivery devices,1 said Dr. Neumiller.

“The significant developments in insulin delivery and glucose data capture has been on my mind,” said Dr. Neumiller. “In recognizing the growing importance of diabetes technologies, this is our first pass at providing a more formal examination of these advances in diabetes management. As such, we addressed the pros and cons of CGMs, insulin pumps, injectable pens, and blood glucose sensors in streamlining glycemic management.”

This is particularly important in terms of patient-centeredness; there is a need to properly identify individuals who are the best candidates for these diabetes devices, taking into consideration various patient factors such as the faculties, vision, and dexterity of the individual to be capable of managing a CGM or an insulin pump, he said.

“Most of the updates pertain to improving the care of people with type 2 diabetes; however, the addition of a section dedicated to diabetes devices is directed to the management of type 1 diabetes,”Dr. Keumiller said.

“And while not new, we’ve attempted to better articulate monitoring techniques of the hybrid system, particularly as concerns children and adolescents with type 1 diabetes,” he said.


4.  Aging Requires a Different Focus on Diabetes Care

“Interesting changes in the section on managing diabetes in older adults (Section 12).1  The committee noted that older adults are likely to have a greater tendency toward hypoglycemia, yet it may be more judicious to approach management to meet quality of life concerns by deescalating blood glucose levels,” Dr. Neumiller said.  

Our recommendation in more senior patients is to recommend loosening hemoglobin A1c targets, and take a step further in goal-setting to account for both comorbidities and a capacity for care, he said. 

For example, in patients with diabetes and established CVD, it may be warranted to deescalate blood glucose management to reduce treatment burdens. In fact, the goal has evolved to deintensify medication regimens to keep these patients safe; the answer may be to remove meds so as to lessen the greater risks in more fragile patients.1

Involvement of caregivers also necessitates a simplification of care. “As life situations change, our patients may be better off emphasis with deintensification versus intensification of their diabetes management,” Dr. Neumiller said.

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