ADA guidelines for diabetes

ADA Standards of Medical Care in Diabetes

The 2020 American Diabetes Association (ADA) Standards of Medical Care in Diabetes is an important resource tool used by health professionals in caring for people with diabetes. The document caters to clinicians, patients, researchers, payers, and other interested individuals. In addition, it includes recommendations on general treatment goals and the tools to evaluate the quality of care given.

The Professional Practice Committee (PPC) of the ADA makes it a priority to continuously improve and update the resources used in the Standards of Medical Care in Diabetes. They do this by publishing important and relevant updates such as drug approvals and label changes online.

(1) Improving Care and Promoting Health in Populations

The recommendations under this position statement ensure that decisions are timely, evidence-based, align with the Chronic Care Model and comply under the appropriate and reliable data metrics.

(2) Classification and Diagnosis of Diabetes

Diabetes can be classified into the following general categories:

1. Type 1 (due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency)
2. Type 2 (due to a progressive loss of adequate β-cell insulin secretion frequently on the background of insulin resistance)
3. Gestational diabetes mellitus (diabetes diagnosed in the second or third trimester of pregnancy)
4. Specific types of diabetes due to other causes (e.g. monogenic diabetes syndromes, diseases of the exocrine pancreas, and drug-or-chemical-induced diabetes)

Misdiagnosis among patients with type 1 or patients with type 2 diabetes is common because it is not easily identifiable. This becomes more apparent over time.

According to the ADA, these are the criteria for diagnosis:

• FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*
• 2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.*
• A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*
• In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L).

DCCT, Diabetes Control and Complications Trial; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; WHO, World Health Organization; 2-h PG, 2-h plasma glucose.

(3) Prevention or Delay of Type II Diabetes

According to the ADA, patients with prediabetes are recommended at least annual monitoring for the development of type II diabetes. Included in this section are guidelines on lifestyle interventions (such as nutrition and weight loss), pharmacologic interventions, prevention of cardiovascular disease, and diabetes self-management education and support.

(4) Comprehensive Medical Evaluation and Assessment of Comorbidies

Adopting a patient-centered approach to care requires a close working relationship between the patient and clinicians involved in the treatment planning, making medical evaluation successful.

(5) Facilitating Behavior Change and Well-Being to Improve Health Outcomes

Diabetes self-management education and support (DSMES), medical nutrition therapy (MNT), routine activity for weight loss, smoking cessation counseling when needed, and psycho-social care, are factors which may help reach a person’s target goals to improve his or her health outcomes.

(6) Glycemic Targets

Glycemic management is primarily assessed with the A1C test, which was the measure studied in clinical trials demonstrating the benefits of improved glycemic control. For people with type 2 diabetes, assessment of glycemic control can be done through patient self monitoring of blood glucose (SMBG). Under this position statement include recommendations on A1C testing, glucose assessment, A1C goals, hypoglycemia, and intercurrent illnesses.

(7) Diabetes Technology

This refers to the hardware, devices and software used by people to help manage their condition through either insulin administration (via syringe, pen or pump) or blood glucose monitoring. An example of this is a basal (rapid-acting) insulin which patients with type 2 diabetes commonly used for long acting stabilization of glucose levels during the day and night.

(8) Obesity Management for the Treatment of Type 2 Diabetes

There is strong evidence that obesity management can delay the progression from prediabetes to type 2 diabetes, and is beneficial in the treatment for patients. Diet, physical activity and behavioral activity, pharmacotherapy are some ways to track obesity management. Glucagon-like peptide 1 receptor agonist medications, for example, are approved by the Food and Drug Administration (FDA) for the treatment of obesity.

(9) Pharmacologic Approaches to Glycemic Treatment

Insulin therapy is essential among people with Type 1 diabetes. This involves the multiple injections of prandial or basal insulin, or continuous subcutaneous insulin infusion to reduce hypoglycemia risk. A pharmacologic therapy for type 2 diabetes includes combination therapy, which makes maintenance of glycemic targets possible due to the progressive nature of type 2 diabetes.

(10) Cardiovascular disease and Risk Management

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality for people with diabetes. ASCVD is defined as coronary heart disease (CHD), cerebrovascular disease, or peripheral arterial disease. Here includes a risk calculator (determining whether you are considered high risk or not), hypertension and blood control, and other risk factors one may have to inform themselves on.

(11) Microvascular Complications and Foot Care

Under this involves information on microvascular complications (such as chronic kidney disease, neuropathy), its evidences for treatment (clinical trial, meta-analysis, randomized controlled studies, etc.) as well as foot care.

(12) Older Adults

Older adults are more at risk for illnesses such as hypertension, heart failure, stroke, chronic kidney disease, etc. Because of this, diabetes management among older adults require regular assessment of medical, psychological, functional, and social domains because there are many complications that come with older age.

(13) Children and Adolescents

Management among children and adolescents cannot be derived from the management of adults due to the difference in epidemiology, pathophysiology, developmental considerations, and response to therapy. Included under this are guidelines for children in terms of glucose lowering, glucose control in patients and diabetes complications.

(14) Management of Diabetes in Pregnancy

Diabetes is prevalent among women of reproductive age and women that are pregnant. This section discusses the risk factors of having diabetes in pregnancy and provides recommendations for the following aspects: preconception counseling, preconception care, glycemic targets in pregnancy, management guidelines, pregnancy and drug considerations and postpartum care.

(15) Diabetes Care in Hospital

Recommendations under this are on hospital care delivery standards, glycemic targets in hospitalized patients and other components of diabetes care in the hospital. A recommendation under the hospital care delivery standards is:

• Perform an A1C test on all patients with diabetes or hyperglycemia (blood glucose >140 mg/dL [7.8 mmol/L]) admitted to the hospital if not performed in the prior 3 months. B
• Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations.

(16) Diabetes Advocacy

This section emphasizes the rights for those who have diabetes at all levels. The ADA does this by establishing guidelines which prohibit discrimination.

For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction found in the ADA website https://care.diabetesjournals.org/ or thru https://doi.org/10.2337/dc20-SINT