ADA Revises Standards of Diabetes Care

Clinical Context

In the United States, diabetes has been diagnosed in nearly 19 million people. It is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk for long-term complications. The American Diabetes Association (ADA) has provided annual diabetes recommendations that include screening, diagnostic, and therapeutic actions that may affect health outcomes in people with diabetes.

The aim of the Standards of Medical Care in Diabetes—2012 recommendations was to provide clinicians, patients, researchers, payers, and other interested individuals with components of diabetes care, general treatment goals, and tools to evaluate the quality of care. The summary of revisions for the 2012 report is provided.

Study Synopsis and Perspective

A new standards of care statement from the ADA addresses screening, diagnostic, and treatment interventions known or thought to improve health outcomes of patients with diabetes. The new recommendations are published in a supplement to the January issue of Diabetes Care.

"Diabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications," the statement notes. "Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes."
The new ADA recommendations aim to describe the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. They address clinicians, patients, researchers, payers, and other interested individuals. They are not intended to replace clinical judgment or to prevent more extensive assessments and interventions by additional specialists, should these be required in the opinion of the treating clinician.
The guidelines offer targets that are suitable for most patients with diabetes, while acknowledging that goals may need to be modified to accommodate individual preferences, comorbid conditions, and other patient-specific factors.
Separate sections cover specific needs and recommendations for children with diabetes, pregnant women, and persons with prediabetes. The new guidelines include screening, diagnostic, and therapeutic actions that have been shown or thought by consensus opinion to improve outcomes of diabetic patients. Many of these guidelines have been shown to be cost effective.
The evidence base for these recommendations was updated from a Medline search of pertinent human studies published since January 1, 2010, and each recommendation was graded on the corresponding level of evidence using an ADA grading system. These standards of care were reviewed and approved by healthcare professionals, scientists, and lay people comprising the Executive Committee of the ADA's Board of Directors. A separate statement has addressed driving and diabetes.
Specific Recommendations
A few highlights of the ADA standards of diabetes care include the following:

• Criteria to diagnose diabetes include a hemoglobin A1c (A1c) level of 6.5% or higher, a fasting plasma glucose level of 126 mg/dL (7.0 mmol/L) or higher, a 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during an oral glucose tolerance test, or a random plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis.
• Screening for type 2 diabetes and for future diabetes risk in asymptomatic people, using the A1c, fasting plasma glucose, or 2-hour 75-g oral glucose tolerance test should be considered in adults of any age who are overweight or obese and who have at least 1 additional risk factor for diabetes. Testing should begin at age 45 years in those without these risk factors. Subsequent testing at least during 3-year intervals is reasonable in those with initial normal test results.
• Patients using multiple insulin injections or insulin pump therapy should perform self-monitoring of blood glucose levels at least 3 times daily. Self-monitoring of blood glucose levels may be useful in other patients with diabetes. Continuous glucose monitoring used with intensive insulin regimens may help lower A1c levels in selected adults at least 25 years old with type 1 diabetes.
• Glycemic goals in adults are to lower A1c levels to less than or approximately 7%, which has been associated with fewer microvascular complications and (if started early) with long-term reduction in macrovascular disease. More stringent A1c goals may be suitable for selected individual patients, if these can be achieved without significant hypoglycemia or other adverse effects of treatment. Less-stringent A1c goals may be suitable for some patients, such as those with a history of severe hypoglycemia or limited life expectancy.
• Type 2 diabetes treatment should begin with metformin therapy and lifestyle interventions. Insulin therapy may be needed for patients who are markedly symptomatic and/or have elevated blood glucose or A1c levels. If noninsulin monotherapy fails to reach the A1c target during 3 to 6 months, a second oral agent, a glucagon-like peptide-1 receptor agonist, or insulin may be needed.

The authors of the ADA position statement have disclosed no relevant financial relationships.

Diabetes Care. 2012;35(Suppl 1):S11-S63.

Related Link
The National Diabetes Information Clearinghouse provides educational materials for both patients and healthcare professionals, including links to diabetes-related topics, patient organizations, and the National Diabetes Education Program.

Study Highlights

• For detection and diagnosis of gestational diabetes mellitus (GDM), an additional recommendation was that women with a history of GDM found to have prediabetes should receive lifestyle interventions or metformin to prevent diabetes (A).
• Metformin therapy for the prevention of type 2 diabetes may be considered in patients with impaired glucose tolerance (A), impaired fasting glucose (E), or an A1c level of 5.7% to 6.4% (E). Also, metformin may be especially useful for those with a body mass index of more than 35 kg/m², age younger than 60 years, and women with prior GDM.
• For glycemic goals in adults, a new recommendation was that providers might reasonably suggest more stringent A1c goals (such as < 6.5%) for selected individual patients, if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, long life expectancy, and no significant cardiovascular disease.
• Regarding immunizations, an added recommendation was to administer hepatitis B vaccination to adults with diabetes per recommendations by the US Centers for Disease Control and Prevention (C).
• For hypertension or blood pressure control, the statement recommends administration of 1 or more antihypertensive medications at bedtime (A).
• For diabetes care in specific populations, in children and adolescents, additional recommendations were added regarding the transition from pediatric to adult care:
  • As teens make the transition into emerging adulthood, healthcare providers and families must recognize many vulnerabilities in these teens (B) and prepare the developing teen, beginning in early to mid adolescence and at least 1 year before the transition. (E)
  • Both pediatricians and adult healthcare providers should assist in providing support and links to resources for the teen and emerging adult. (B)
• Additional recommendations were also added regarding patients with cystic fibrosis-related diabetes (CFRD):
  • Annual screening for CFRD with an oral glucose tolerance test should begin by age 10 years in all patients with cystic fibrosis who do not have CFRD. (B) Use of A1c levels as a screening test for CFRD is not recommended. (B)
  • During a period of stable health, the diagnosis of CFRD can be made in patients with cystic fibrosis according to usual diagnostic criteria. (E)
  • Patients with CFRD should be treated with insulin to attain individualized glycemic goals. (A)
  • Annual monitoring for complications of diabetes is recommended beginning 5 years after the diagnosis of CFRD. (E)
• Additional recommendations for diabetes care in specific settings (ie, diabetes and employment, diabetes and driving, and diabetes management in correctional institutions) were added:
  • Any person with diabetes, whether insulin treated or noninsulin treated, should be eligible for any employment for which he or she is otherwise qualified. A healthcare professional with expertise in treating diabetes should perform an individual assessment if questions arise about the medical fitness of a person with diabetes for a particular job.
  • The ADA position statement on diabetes and driving recommends against blanket restrictions based on the diagnosis of diabetes and urges individual assessment by healthcare providers if restrictions on licensure are being considered.
  • People with diabetes in correctional facilities should receive care that meets national standards.
• The following recommendations were added regarding strategies to improve diabetes care:
  • Care should be aligned with components of the Chronic Care Model to ensure productive interactions between a prepared proactive practice team and an informed, activated patient. (A)
  • When feasible, care systems should support team-based care, community involvement, patient registries, and embedded decision support tools to meet patient needs. (B)
  • Treatment decisions should be timely and based on evidence-based guidelines that are tailored to individual patient preferences, prognoses, and comorbidities. (B)
  • A patient-centered communication style should be used that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care. (B)

Clinical Implications

• According to the ADA position statement on standards of care in diabetes, metformin may be considered in women with a history of GDM found to have prediabetes and for prevention of type 2 diabetes, especially in those with impaired glucose tolerance, impaired fasting glucose, or an A1c level of 5.7% to 6.4%.
• New recommendations were added to the ADA position statement on standards of care in diabetes regarding diabetes and employment, diabetes and driving, and diabetes management in correctional institutions.