COMMENTARY

ADA 2018 Abridged Standards of Medical Care in Diabetes: Update for Primary Care

Jay H. Shubrook, DO; Eric L. Johnson, MD

Disclosures

December 08, 2017

Jay H. Shubrook, DO: Good morning. This is Jay Shubrook, family physician and diabetologist at Touro University, California. We are continuing our series on Everyday Diabetes: Practical Management for Primary Care.

I am delighted to have with me today Eric Johnson, associate professor in family medicine at the University of North Dakota School of Medicine, and assistant director of the Altru Diabetes Center. We are talking about the 2018 "Abridged Standards of Care" from the American Diabetes Association (ADA). Eric, who is the incoming chair of the Primary Care Advisory Group of the ADA, is responsible for this document. Welcome, Eric. We're glad to have you onboard.

Eric L. Johnson, MD: Thank you, Jay. It's great to be here with you today.

Dr Shubrook: Eric, what is the "Abridged Standards of Care" and why is it important for primary care?

Dr Johnson: The "Abridged Standards of Care" is a document prepared by the Primary Care Advisory Group. The idea is to take the full "Standards," a very large document with all current and pertinent information, and boil it down into a 20-page document that is more useful for a primary care practitioner. This seems to be a very usable and popular format.

Dr Shubrook: It is a very important document; it's like the Cliffs Notes of the "Standards of Care." This is the meat, the things that would be most important to primary care. Is that correct?

Dr Johnson: I think that's a good description.

Dr Shubrook: Where can we find the "Abridged Standards of Care"?

Dr Johnson: They are published and released on the same day as the larger, complete "Standards of Care" document, and both are available in full text on the ADA website.

Key Changes for 2018

Dr Shubrook: What are some of the key changes or key content that you think are important in the 2018 "Abridged Standards of Care"?

Dr Johnson: I think what will be of interest to most people is the change in the algorithm for pharmacologic management of type 2 diabetes. There are some new data reflecting results of the cardiovascular (CV) outcome trials,[1,2,3,4,5] which are incorporated directly into the algorithm. When considering dual therapy with metformin, consider agents that have positive CV outcomes. Those include the SGLT2 inhibitors, empagliflozin, and canagliflozin, as well as the GLP-1 agonist liraglutide. I think that this is very important, because these have been shown to reduce the incidence of CV endpoints in those with CV disease (CVD).

Dr Shubrook: There may now be some preferential recommendations based upon medications that have benefits for CV outcomes.

Dr Johnson: That is right, Jay. Back in 2008, the US Food and Drug Administration said that manufacturers of all new diabetes medications must complete CV safety studies, and these are the outgrowth of that. We have three agents that have shown benefit for reducing CVD.

Dr Shubrook: That's important, because it seems to me that patients come in to my own office asking me about recent trials. The recommendations look at all of the trials and recommend those agents that have the most evidence of benefit for my patient. Is that correct?

Dr Johnson: That is true, particularly for patients with CVD.

Dr Shubrook: What other changes found in the "Standards" do you think are important?

Dr Johnson: There is a new table with drug class–specific data. For example, look at metformin on this table, and you will find some of the contraindications—for example, advanced renal impairment. The table includes hypoglycemia risk and some other things that might be pertinent to a particular medication. It is a neat little table with a lot of information.

Dr Shubrook: I noticed that there was a statement about A1c, noting that it might not be a universal measurement. Is this something that is new?

Dr Johnson: The "Standards" document is more explicit about the interpretation of A1c measurements, but that information has been elsewhere in ADA literature. Just for an example, sickle cell trait in an African American patient may lower A1c 0.3%[6] due to increased red blood cell turnover as well as glucose-phosphate dehydrogenase positivity. That can lower A1c to 0.7% to 0.8% in homozygous women and men, respectively.[7]

Dr Shubrook: That's important to remember. If you're using hemoglobin A1c, a viable hemoglobin must be part of that measurement.

Dr Johnson: I think the takeaway here is that if it seems like the A1c is markedly discrepant compared with what you are seeing with fasting blood sugar or oral glucose tolerance test data, you should be thinking about the possibility of some kind of hemoglobinopathy that might be contributing to this.

Dr Shubrook: That's an excellent point. You've talked about cardiovascular trials, an updated pharmacologic treatment protocol, and A1c universality. What other important points would you want to share with the audience today?

Dr Johnson: The clarification on combination therapy in dyslipidemia is important. There's some new language that's a little more explicit about dyslipidemia treatment beyond statin therapy, and I think it will be a little more understandable for the reader. This has to do with ezetimibe or the use of PCSK9 inhibitors for those who are on maximal doses of statins but aren't necessarily getting their LDL below 70.

Dr Shubrook: Eric, today you've shared some really important practical pointers about the "Abridged Standards" that will be useful for primary care.

Dr Johnson: This summary document really has most everything that a primary care provider would need for their everyday management of patients with diabetes. The "Abridged Standards" refer back to the larger "Standards of Diabetes Care," so if a provider needs to have more information on a particular topic, it's easy to find. Both of these are available online to anyone who wants to see them. You do not need to be an ADA member to find them.

Dr Shubrook: We appreciate the work that you and the Primary Care Advisory Group at the ADA are doing. So glad to have the opportunity to have these short, concise documents that can help us in our everyday care of diabetes patients. Thank you.

Dr Johnson: Thank you.

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