COMMENTARY

2020 ADA Standards: A 'New Concept' in Treating T2D

Anne L. Peters, MD

Disclosures

February 28, 2020

This transcript has been edited for clarity.

Today I'm going to continue my overview of the 2020 American Diabetes Association (ADA) Standards of Medical Care in Diabetes.

Pharmacologic approaches to the management of glycemia in patients with type 2 diabetes (T2D) are discussed in section 9. This section is mistitled, because diabetologists in 2020 are now looking at two things: glycemic management, to be sure, but also cardiovascular risk reduction. As everyone now knows, our diabetes drugs do two things: They lower glucose levels and they lower the risk for cardiovascular events, heart failure, and progression to chronic kidney disease (CKD). So the world of cardiology and the world of diabetes are getting closer.

The cardiologists have changed their guidelines, essentially throwing out metformin and instead using GLP-1 receptor agonists and SGLT2 inhibitors as first-line therapy in patients who have other high-risk characteristics such as existing CKD, atherosclerotic cardiovascular disease (CVD), or heart failure. The ADA still sticks with metformin as the first-line therapy for patients with T2D, but they also say that if a patient has those high-risk characteristics (established CVD, CKD, or heart failure), don't bother looking at the A1c; go ahead and also start them on a GLP-1 receptor agonist or an SGLT2 inhibitor.

So it's not a stepwise treatment approach. If a patient fits those categories, you should start them on two therapies: metformin plus a drug to help their cardiovascular risk. That's a new concept. We don't come out and say to start with dual combination therapy, but in essence that's what we mean.

What if a patient has an A1c of 6.8% and has atherosclerotic CVD? Should I put them on metformin and at the same time add a GLP-1 receptor agonist? I might not give this person metformin, even though that's my opinion, not what the ADA is saying in these guidelines. You have to take these guidelines and then use common sense. I believe that if you have a patient with atherosclerotic CVD, CKD, or heart failure, or who is high risk, your goal is to get that person on a medication that prevents further damage and that lowers further risk for atherosclerotic CVD or the others. That is important.

A1c Still Matters

Now, glycemia does matter. Many of the patients you're going to be treating will have a higher A1c at diagnosis, and you will want to start them on metformin to lower their glucose levels. But again, in patients who are in that category with cardiovascular risk, you will need to add another agent right away, whereas you would not necessarily add a second agent in patients with glycemia alone.

Some cardiologists with whom I've spoken say, "We don't really care that much about glycemia. Why does A1c matter?" A1c matters a lot to a patient because a higher A1c is associated with an increased risk for microvascular complications. And I can tell you, my patients don't want to have retinopathy, nephropathy, or painful neuropathy. Most people I know, including physicians, don't want to have an A1c of 9% if they can have an A1c below 7%. So, glycemia matters. We need to use medications to improve those outcomes, but we also want to use medications that reduce cardiovascular risk.

When patients need a GLP-1 receptor agonist or an SGLT2 inhibitor, you need to ask yourself, Is this a patient in whom atherosclerotic cardiovascular disease predominates or is this a patient in whom heart failure and/or CKD predominate?

For patients who have had a known atherosclerotic CVD event or an indicator of high atherosclerotic CVD risk—they're 55 years or older with coronary, carotid, or lower-extremity artery stenosis of greater than 50%, or left ventricular hypertrophy—they should be preferentially started on a GLP-1 receptor agonist with proven CVD benefit on the label.

For patients in that heart failure/CKD category, particularly if they have a left ventricular ejection fraction < 45% or if they have CKD (defined as an estimated glomerular filtration rate [eGFR] of 30-60 mL/min/1.73 m2 or a urine albumin-creatinine ratio > 30, and particularly those who have a urine albumin-creatinine ratio > 300), use an SGLT2 inhibitor, for which there is evidence of improvement in heart failure or CKD in the cardiovascular outcomes trials.

We know that there will be reasons why patients can't necessarily be on the drug you want them to be on. For example, patients who have a significantly reduced eGFR may not be able to use an SGLT2 inhibitor. In that case, you'd use a GLP-1 receptor agonist. You can also go through the algorithm and combine the two drugs. This is basically the framework we use to think about this, in terms of which agent to use and how to choose among them.

Cardiovascular Disease and Risk Management

Section 10 specifically discusses cardiovascular disease and risk management. For the second time in a row, this section has been endorsed by the American College of Cardiology. It is important to have all of us on the same page, particularly when we're teaching in primary care.

This section provides very detailed information on the cardiovascular outcomes trials and includes tables and summaries of the data. Hopefully this will enable everyone to understand the data used to support some of the newer recommendations.

Caring for Older Adults

Section 12 discusses diabetes treatment in older adults. It talks about the importance of assessing for cognitive decline and impairment. Sometimes it's hard to know at what level a patient can function, particularly if they're living by themselves and having to make complicated decisions about diabetes management.

The section includes a discussion about costs—the cost of insulin and the cost of these newer agents, and how we determine what's best for a patient in the context of the patient's life and finances. For the first time, this section also talks about older adults with type 1 diabetes and their special challenges.

Children and Adolescents

The section on children and adolescents discusses individualizing targets, managing cardiovascular risk in children and adolescents, and retinopathy screening, which may be less often than previously recommended. If you're taking care of pediatric patients, I suggest looking at this section

Diabetes in Pregnancy

Section 14, on managing diabetes in pregnant women, emphasizes the need for preconception care. This isn't always possible because we know that not all pregnancies are planned. But certainly, for any woman who has the potential for getting pregnant, it's important to discuss this.

The Standards talk about the use of continuous glucose monitoring during pregnancy. This is an area with good data, but we need more. I personally use continuous glucose monitoring in my pregnant patients and have found that these women do quite well. Again, that is an area where a lot more research is needed. The standards also cover postpartum care and managing diabetes in that challenging setting.

Those are the major changes in the ADA Standards of Care. I encourage everyone to read more about these changes. We've made living updates to the Standards throughout the year and intend to continue throughout the next year.

Anne L. Peters, MD, is a professor of medicine at the University of Southern California (USC) Keck School of Medicine and director of the USC clinical diabetes programs. She has published more than 200 articles, reviews, and abstracts and three books on diabetes, and has been an investigator for more than 40 research studies. She has spoken internationally at over 400 programs and serves on many committees of several professional organizations.

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