ADA 2020 Standards of Care Incorporate CVD Risk Stratification, New Medications

The 2020 update to the American Diabetes Association (ADA) Standards of Medical Care in Diabetes has been published in Diabetes Care.¹ For the annual update of this comprehensive clinical guide, which provides the most up-to-date recommendations from the ADA for optimal management of type 1 diabetes (T1D) and type 2 diabetes (T2D), a multidisciplinary committee made up of 16 physicians, educators, and other experts simplified elements of the document to improve ease of use.^1,2 Major changes to the 2020 iteration involve recommendations for cardiovascular disease (CVD) risk reduction, pharmacologic treatments, glycemic targets, and recommendations for individualized patient care.²

Accompanying the publication of the 2020 Standards of Care in Diabetes Care is an update to the consensus report by the ADA/European Association for the Study of Diabetes on management of hyperglycemia in type 2 diabetes.³ This consensus report and the 2020 Standards of Care now incorporate findings from major cardiovascular outcome trials published in 2019.² These large-scale research projects that explored CVD in diabetes have been central to building on the theme of patient-centered care, a major focus of the ADA’s 2019 Standards of Care that is echoed in the 2020 update.²

Key updates to the Standards of Care are highlighted below:

Cardiovascular Disease

For the second consecutive year, the American College of Cardiology has endorsed the Cardiovascular Disease and Risk Management section of the ADA’s Standards of Care.¹

Sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists have been recognized as recommended therapies for patients with T2D and atherosclerotic cardiovascular disease (ASCVD).¹ In the 2020 update, these recommendations have been individualized based on additional comorbidity burden:

• SGLT2 inhibitors with demonstrated cardiovascular benefits are recommended for patients with T2D plus ASCVD, ASCVD risk factors, or diabetic kidney disease to reduce the risk for cardiovascular events and heart failure hospitalization.¹
• GLP-1 receptor agonists with demonstrated cardiovascular benefits are recommended for patients with T2D plus ASCVD or associated risk factors to reduce the risk for cardiovascular events.¹
• SGLT2 inhibitors may be considered for patients with T2D and established heart failure to reduce the risk for heart failure hospitalization.¹

Recommendations for use of statin therapy to reduce ASCVD risk have also been revised to align with newer consensus guidelines.⁴ For primary prevention, it is recommended to use moderate-intensity statins in patients with diabetes aged 40 to 75 years who do not have established ASCVD. In cases of established ASCVD with comorbid diabetes, patients of all ages should receive high-intensity statins.¹

For patients with ASCVD or other CVD risk factors whose low-density lipoprotein cholesterol levels are controlled with statin therapy but for whom persistent hypertriglyceridemia (135-499 mg/dL) is an issue, isocapent ethyl can be considered to reduce CVD risk.¹

Pharmacotherapy

The 2020 Standards of Care also incorporate updates for medical therapy in diabetes based on decisions made by the United States Food and Drug Administration (FDA) in 2019.

• Oral semaglutide was approved by the FDA in September 2019 and is now discussed in the Standards of Care.² Data suggest oral semaglutide has a noninferior cardiovascular safety profile compared with placebo, but more long-term studies are needed to better understand its cardiovascular effects.¹
•  Liraglutide was approved by the FDA in June 2019 for use in pediatric patients.² A new recommendation is included in the updated Standards of Care for this indication: liraglutide should be considered in children aged ≥10 years when glycemic targets are not met with metformin, barring a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2.¹

With the goal of simplification, an updated guide to intensification of injectable glucose-lowering therapies has also been incorporated into the 2020 Standards of Care (Section 9, page S104).²

Glycemic Targets

An international panel convened in 2019 to address formal adoption of continuous glucose monitoring (CGM) metrics in clinical practice.⁵ Use of CGM is beneficial in diabetes management with regard to convenience and accuracy, but lack of clear guidance on targets has led to low uptake in routine practice.⁵ The recommendations produced by this panel have been included in the latest Standards of Care:

• A standardized single-page report of CGM data (eg, the Ambulatory Glucose Profile) should be considered when using CGM devices and can be used as a component in the clinical decision making process.^1,5
• Time in range (70-180 mg/dL) is an indicator of glycemic control.¹ Time spent above or below range can be used to inform treatment decisions.

Relating to hypoglycemia, the FDA approved intranasal glucagon and injectable glucagon solution in 2019. These agents have been included in the 2020 Standards of Care as alternatives to traditional glucagon injection powder, which must be reconstituted.¹ Special attention should be given to expiration dates on glucagon products.¹

Personalized Diabetes Care

The 2020 update to the Standards of Care emphasizes several aspects of individualized care in diabetes, including considerations for use of technology, older patients, lifestyle management, and prevention of diabetes.²

• The section outlining recommendations for diabetes technology has been updated to emphasize that there is no “one-size-fits-all” approach to use of technology in diabetes care.¹ Utilization of technology should be tailored to the patient’s needs and skill level and access to devices should be considered.¹
• Specific considerations for older patients with T1D have been outlined in a new section of the Standards of Care to address social issues that may affect diabetes management.¹
•  The “Lifestyle Management” section has been renamed to “Facilitating Behavior Change and Well-being to Improve Health Outcomes” to emphasize the importance of improving behaviors and psychological wellbeing in diabetes care.¹ Additions include personalization of nutrition therapy based on consensus report findings and guidance on e-cigarettes based on evidence from the Centers for Disease Control and Prevention. Patients with diabetes who use either tobacco or e-cigarettes should receive smoking cessation counseling and use of either should be discouraged.¹
•  In the Diabetes Prevention Program Outcomes Study, metformin was shown to be less effective than lifestyle modification for diabetes prevention.¹ However, metformin was likely the more cost effective option and in analyses based on 15-year follow-up data, patients with higher baseline fasting glucose and women with a history of gestational diabetes experienced higher reductions in risk for diabetes with metformin vs placebo. The 2020 Standards of Care recommend metformin as an option for individuals at high risk for diabetes.¹

The 2020 iteration of the Standards of Care, a “living” document that is updated as evidence and regulatory changes become available, will be published in the January 2020 issue of Diabetes Care.² Also available to clinicians are the abridged Standards of Care for primary care providers, Standards of Care mobile application, and pocket chart version of the document.²

References

1. American Diabetes Association. Standards of Medical Care in Diabetes—2020. Diabetes Care. 2020;43(suppl 1):S1-S212.

2. Cardiovascular disease, technology and personalized care highlighted in ADA’s 2020 Standards of Medical Care in Diabetes [news release]. Arlington, VA: American Diabetes Association; December 20, 2019. Accessed December 20, 2019.

3. Buse JB, Wexler DJ, Tsapas A, et al. 2019 update to: management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2020;43:1-7.

4. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;73(24):3168-3209.

5. Battelino T, Danne T, Bergenstal RM, et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diabetes Care. 2019;42(8):1593-1603.2

This article originally appeared on Endocrinology Advisor