patient care perspectives

Incorporating the American Diabetes Association Standards of Medical Care in Diabetes in Clinical Practice

by Rita Rastogi Kalyani, MD, MHS, FACP

Overview

The American Diabetes Association (ADA) Standards of Medical Care in Diabetes—2021 is rooted in evidence-based data. These clinical practice recommendations have evolved over time to include higher-grade evidence and emphasize the importance of both lifestyle modifications and glucose-lowering therapies in the management of diabetes.

Expert Commentary

Rita Rastogi Kalyani, MD, MHS, FACP

Editor in Chief, Johns Hopkins Diabetes Guides
Director, Diabetes Management Service
Johns Hopkins Total Pancreatectomy Islet Auto Transplant Program
Associate Professor of Medicine
Johns Hopkins University School of Medicine
Baltimore, MD

“These guidelines have incorporated the expanding knowledge base year after year, as the evidence emerges.”

Rita Rastogi Kalyani, MD, MHS, FACP

There are currently more noticeable trends toward higher-level, evidence-based recommendations being presented over time and as described within the ADA Standards of Medical Care in Diabetes—2021 (also referred to as Standards of Care). These higher-level recommendations (ie, based on clinical trial data) now comprise a much larger proportion of the recommendations and reflect the current state of knowledge as more evidence emerges. Further, Standards of Care reflects the most up-to-date research, and, although there are still some expert consensus–based recommendations in areas where research gaps continue to exist, there are much fewer compared with the past. 

These guidelines have incorporated the expanding knowledge base year after year, as the evidence emerges. It was only a few years ago that the new chapter dedicated to obesity was added, where previously this had only been a subsection within another chapter. This came about because of the growing evidence on the importance of obesity management and the benefits observed from advancements in both the medical treatment of obesity and metabolic surgery in patients with type 2 diabetes. Newer classes of drugs, such as glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter-2 inhibitors, are now recommended as adjunct therapies for patients with type 2 diabetes who have accompanying cardiovascular or renal comorbidities. Additionally, a new chapter on diabetes technology was added 2 years ago, reflecting the plethora of technologies, including continuous glucose monitoring, that are now available. The standards of medical care truly reflect the comprehensive care of patients with diabetes, recognizing the different comorbidities and the impact of diabetes—not only at the population level but also at individual and societal levels. The recommendations reflect and reiterate the existing evidence, and they add new elements from the expanding knowledge base.

With regard to anticipated future editions of Standards of Care, there will likely be an increased focus on currently available glucose-lowering agents that are effective for the management of obesity at higher doses. As more of these therapies are approved by the US Food and Drug Administration, they will likely be integrated within the ADA Standards of Care. Similarly, the rising role of type 2 diabetes pharmacotherapies in lowering cardiovascular risk and reducing the progression of nephropathy is a prime example of future considerations, as it will be necessary to examine the long-term effectiveness of these therapies. These anticipated new areas reflect the ability of the ADA Standards of Care to evolve as the evidence evolves.

References

American Diabetes Association. 4. Comprehensive medical evaluation and assessment of comorbidities: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021;42(suppl 1):S40-S52. doi:10.2337/dc21-S004

American Diabetes Association. 7. Diabetes technology: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42(suppl 1):S71-S80. doi:10.2337/dc19-S007

American Diabetes Association. 7. Obesity management for the treatment of type 2 diabetes: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018;41(suppl 1):S65-S72. doi:10.2337/dc18-S007

American Diabetes Association. Summary of revisions: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021;44(suppl 1):S4-S6. doi:10.2337/dc21-Srev

Chukir T, Shukla AP, Saunders KH, Aronne LJ. Pharmacotherapy for obesity in individuals with type 2 diabetes. Expert Opin Pharmacother. 2018;19(3):223-231. doi:10.1080/14656566.2018.1428558

Riise HKR, Igland J, Sulo G, et al. Casual blood glucose and subsequent cardiovascular disease and all-cause mortality among 159 731 participants in Cohort of Norway (CONOR). BMJ Open Diabetes Res Care. 2021;9(1):e001928. doi:10.1136/bmjdrc-2020-001928

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