The American Diabetes Association’s updated clinical recommendations for 2022 call for wider population screening, along with furthering the trends towards individualization of care use of diabetes technology.
The summary of changes from 2021 spans four pages. “Diabetes is a really dynamic field so there is a lot to update which is good. It means progress,” ADA Chief Science & Medical Officer Robert A. Gabbay, MD, PhD, told Medscape Medical News.
The American Diabetes Association Standards of Medical Care in Diabetes ─ 2022 was published December 20, 2021, online as a supplement to Diabetes Care.
Screening Widened by Age, in Pregnancy, and for Type 1 Diabetes
One dramatic change is a drop in age to begin screening all people for prediabetes and diabetes from 45 years to 35 years, regardless of risk factors such as obesity.
“Sadly, there are increasing numbers of people with diabetes and developing diabetes younger,” Gabbay said.
In August 2021, the US Preventive Services Task Force dropped its recommended age of diabetes screening from 40 to 35 years for people with overweight or obesity, but not universally, as ADA now has.
The ADA made its recommendation independently, Gabbay noted.
The recommendation for testing pregnant women early in gestation (<15 weeks) for preexisting diabetes was also expanded, from just those with risk factors to consideration of testing all women for undiagnosed diabetes at the time they’re planning pregnancy, and if not then, at the first prenatal visit. Screening for gestational diabetes is then performed at 24-28 weeks.
Again, this is due to increasing diabetes onset at younger ages, Gabbay said. “We’re well aware that the number of women who have diabetes and don’t know it and become pregnant is significant and therefore screening early on is important.”
New guidance regarding autoantibody screening in adults suspected of having type 1 diabetes and genetic testing for those who don’t fit typical criteria for either of the two main types are based on the ADA/European Association for the Study of Diabetes joint consensus statement on type 1 diabetes in adults published in October 2021.
Individualization of Care Based on Comorbidities, Other Factors
The concept of individualization of care in diabetes has been emphasized for several years now, but continues to be enhanced with new data and newly available management tools.
Regarding management of type 2 diabetes, several charts have been included to help guide decision-making.
One lists drug-specific and patient factors, including comorbidities, to consider when selecting glucose-lowering medications. A new table depicts a building with four “pillars,” for complication risk reduction, including management of blood pressure, lipids, glucose, and use of agents with cardiovascular and kidney benefit.
“On the type 2 side, the choice of therapy is really guided by several factors. We lay them out in a nice diagram…. A lot of useful information there compares classes of drugs in order to help clinicians make decisions on what would be the appropriate therapy for a given individual,” Gabbay said.
An algorithm for pharmacologic treatment includes considerations of weight, hypoglycemia, and cost. Tables are also provided listing average wholesale prices (AWPs) of insulins and noninsulin medications.
A section now entitled “Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes” has added content regarding the importance of addressing obesity in diabetes, particularly in the context of the COVID-19 pandemic, and the addition of semaglutide as an approved obesity treatment.
“What we hope is that this engenders a shared decision-making process with the patient to identify what the goals are and then choose the appropriate therapy for those goals,” Gabbay said.
New information has also been added about management of nonalcoholic fatty liver disease (NAFLD). “I think that’s one of the unrecognized and unaddressed complications of diabetes that we’ll see in the future, particularly as new therapies come out,” Gabbay predicted.
The section on cardiovascular disease and risk management, endorsed for the fourth year in a row by the American College of Cardiology (ACC), includes several new recommendations, including diagnosis of hypertension at a single visit if blood pressure is 180/110 mm Hg or greater, and individualization of blood pressure targets.
Chronic kidney disease (CKD) management has now been separated from other microvascular complications into a stand-alone section, with several new updates. Retinopathy, neuropathy, and foot care remain combined in one section.
Diabetes Technology: Rapidly Evolving, Access an Issue
The new technology section “doubles down on the time in [normal glucose] range (TIR) concept,” but also emphasizes the importance of time below range.
“When we see that, we need to make a therapeutic change. We were concerned that as there’s more and more information and numbers, users might not pick up on what’s important,” Gabbay noted.
The new Standards also provides greater affirmation of the value of continuous glucose monitoring (CGM) for people with both type 1 and type 2 diabetes at any age, with individualized choice of devices.
Access to technology is a “big issue, and something the ADA has really been fighting for, particularly in terms of health disparities,” Gabbay said, noting that ADA has a new Health Equity Now platform, which includes a “bill of rights” calling for all patients with diabetes to have access to state-of-the-art technologies, including CGM.
Overall, he said, “I think the big picture is diabetes continues to evolve and advance. After careful review of the literature, the Standards of Care identifies at least four big areas where there are some changes that clinicians need to know about: screening, how to individualize treatment, considerations of comorbidities, and the important role that technology plays.”
Gabbay is an employee of the American Diabetes Association.
Miriam E. Tucker is a freelance journalist based in the Washington DC area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR’s Shots blog, and Diabetes Forecast magazine. She is on Twitter @MiriamETucker.