Each year the American Diabetes Association (ADA) updates its evidence-based clinical practice guidelines, Standards of Medical Care in Diabetes. The current version of the guidelines is published each January as a supplement to the journal Diabetes Care and an abridged version for primary care in the journal Clinical Diabetes. The Standards (over 200 published pages) have 16 sections and even the abridged version for primary care is over 25 pages. The ADA has free online resources explaining the Standards, including a slide deck, apps for online and mobile use, and a half-hour CE webcast on the key updates and highlights from the 2021 Standards of Medical Care in Diabetes by ADA’s Chief Scientific and Medical Officer, Robert Gabbay, MD, PhD. The ADA had an annual CME program “Diabetes Is Primary” designed to update primary care practitioners on the Standards but there were no presentations in 2020, and there is currently no posting of upcoming presentations.
Detection and optimal management of diabetes is particularly important now because diabetes not only substantially increases the risk of morbidity and mortality from Coronavirus SARS2 infection, but infection is associated with an increased incidence of new diabetes of both Types 1 and 2.
The intention of this article is not to summarize the entire Standards but review the annual update with emphasis on those changes most relevant to primary care practice.
- Improving Care and Promoting Health in Populations
Social determinants of health may have a greater influence on outcomes in diabetes than medical interventions. Involving agencies outside the treatment team may prevent “cost-related medication non-adherence”.
- Classification and Diagnosis of Diabetes
Routine screening for diabetes and pre-diabetes should begin at age 45 and be repeated at 3-year intervals unless there are risk factors including obesity, hypertension, pregnancy, HIV, family history, or the use of chronic medications that affect glucose tolerance that warrant earlier screening.
- Prevention or Delay of Type 2 Diabetes
Individuals with pre-diabetes may need at least 7% body weight loss and 150 minutes of exercise per week to prevent progression to diabetes. Obese adolescents should get an hour of exercise including both strength training and aerobics.
- Comprehensive Medical Evaluation and Assessment of Comorbidities
Because of the pandemic, there is increased emphasis on keeping all vaccines current, careful evaluation for complications and comorbidities, and discussion with documentation of an advanced care plan including designation of surrogates for medical decisions.
- Facilitating Behavior Change and Well-Being to Improve Health Outcomes
Providers should facilitate participation in diabetes self-management and education systems (DSMES) and medical nutrition therapy (MNT). Providers should encourage physical activity tailored to any microvascular complications, smoking cessation, and “mindful self-compassion”.
- Glycemic Targets
A1C targets and frequency of measurement are unchanged, but there is increased emphasis on “diabetes technology” including interpretation of several indices from continuous glucose monitoring (CGM) devices. Primary care providers will increasingly see standardized ambulatory glucose profile (AGP) reports from these devices including not just average glucose and glucose variability but now targeted “glucose management indicators” (GMI) and “time in range” (TIR).
- Diabetes Technology
Because of the proliferation of CGM technology and the increased reliability of transcutaneous sensors, the trend in data gathering is shifting from self-monitored blood glucose (SMBG) reporting to “professional” CGM where a patient gets a device from the provider’s office (like arrhythmia monitoring), wears it for 14 days, and returns it with professional interpretation of the results against the glycemic targets mentioned above. CGM is increasingly used in patients with multiple daily injections or those with insulin pumps (especially during pregnancy).
- Obesity Management for the Treatment of Type 2 Diabetes
Providers are cautioned to use “patient-centered non-judgmental language” to foster collaboration and to measure BMI at least annually to guide therapy. Behavioral counseling, nutritional counseling, and physical activity coaching require frequent visits to be most effective.
- Pharmacologic Approaches to Glycemic Treatment
For both T1 and T2DM, sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce mortality and progression of both congestive heart failure (CHF) and chronic kidney disease (CKD). For patients without CHF or CKD but with increased cardiovascular risk, either glucagon-like peptide-1 receptor agonists (GLP-1RA) or SGLT2i with proven cardiovascular benefit is recommended. For T2DM, if injectable therapy is needed, GLP-1RA is preferred over insulin if the patient can afford it.
- CVD and Risk Management
Lifestyle modification focusing on weight loss (if indicated); application of a Mediterranean style or DASH (Dietary Approaches to Stop Hypertension) eating pattern; reduction of saturated fat and trans fat; increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity should be recommended to improve the lipid profile and reduce the risk of developing ASCVD in patients with diabetes. Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) are preferred for treatment of hypertension. Statins with at least moderate low density lipoprotein reducing capability are preferred for prevention of hyperlipidemia. Aspirin (75-162mg/d) is recommended for high risk or established atherosclerotic disease but not for primary prevention.
- Microvascular Complications and Foot Care
Spot urinary albumin-to-creatinine ratio, screening for peripheral neuropathy, dilated retinal examination, and foot examinations should be done annually in patients with T2DM.
- Older Adults
Annual screening for neurocognitive functioning, depression, vision, fall risk, incontinence, and polypharmacy is recommended. Older adults on medications for diabetes should be asked about symptoms of hypoglycemia at every visit.
- Children and Adolescents
Treatment of youth-onset type 2 diabetes should include lifestyle management, diabetes self-management education, and pharmacologic treatment by a multidisciplinary team. Current pharmacologic treatment options for youth-onset type 2 diabetes are limited to three approved drugs: insulin, metformin, and liraglutide.
- Management of Diabetes in Pregnancy
Insulin is the preferred medication for treating hyperglycemia in gestational diabetes. Women with preexisting diabetes who are planning a pregnancy should ideally be managed beginning in preconception in a multidisciplinary clinic including an endocrinologist, maternal-fetal medicine specialist, RD/RDN, and CDCES, when available.
- Diabetes Care in the Hospital
Use of only a sliding-scale insulin regimen in the inpatient hospital setting is strongly discouraged. If oral medications are held in the hospital, there should be a protocol for resuming them 1–2 days before discharge.
- Diabetes Advocacy
ADA has many public position statements and advocacy groups including a group petitioning pharmaceutical manufacturers to improve insulin access and affordability.
- American Diabetes Association. Standards of Medical Care in Diabetes-2021. Diabetes Care 2021 Jan; 44(Supplement 1): S1-222. https://doi.org/10.2337/dc21-Sint
- American Diabetes Association. Standards of Medical Care in Diabetes-2021 Abridged for Primary Care Providers. Clinical Diabetes 2021 Jan; 39(1): 14-43. https://doi.org/10.2337/cd21-as01
- American Diabetes Association. Practice Guidelines Resources. https://professional.diabetes.org/content-page/practice-guidelines-resources (accessed Feb 13, 2021)
- American Diabetes Association. Diabetes Is Primary. https://professional.diabetes.org/diabetes-primary (accessed Feb 13, 2021)
- Kumar A, Arora A, Sharma P, Anikhindi SA, Bansal N, Singla V, Khare S, Srivastava A. Is diabetes mellitus associated with mortality and severity of COVID-19? A meta-analysis. Diabetes Metab Syndr. 2020 Jul-Aug;14(4):535-545. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7200339/
- Rubino F, Amiel SA, Zimmet P, Alberti G, Bornstein S, Eckel RH, Mingrone G, Boehm B, Cooper ME, Chai Z, Del Prato S, Ji L, Hopkins D, Herman WH, Khunti K, Mbanya JC, Renard E. New-Onset Diabetes in Covid-19. N Engl J Med. 2020 Aug 20;383(8):789-790. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7304415/
Charles A. Sneiderman, MD, PhD, DABFM
Medical Director, Culmore Clinic
Bailey’s Crossroads, VA
Published on 3/24/2021