ADA 2021 Standards Address Financial Hardship in Diabetes

Miriam E. Tucker

December 14, 2020

For 2021, the American Diabetes Association (ADA) offers new guidance on assessing patients' financial and social barriers to care, especially given the COVID-19 pandemic, individualizing treatment of patients with type 2 diabetes, and use of diabetes technology.

As it does every year, the annual update incorporates new clinical information that has become available since the last Standards, with occasional revisions during the year as needed. "Standards of Medical Care in Diabetes — 2021," was published online as a supplement to Diabetes Care.

The new Standards advise that patients be assessed for food and housing insecurity, social support, and "cost-related medication nonadherence," and those found to have difficulty referred to appropriate community resources.

"Clinicians need to be sensitive to the fact that patients may have very good reasons for not taking their medication, [as in] if they can't afford it," ADA chief science & medical officer Robert A. Gabbay, MD, PhD, told Medscape Medical News in an interview.

Gabbay noted that "a heightened awareness" of social determinants of health is weaved throughout the 2021 Standards due to the pandemic, with information on the topic derived from a July 2020 joint consensus statement in Diabetes Care, endorsed by a number of other societies, as well as a November publication also in Diabetes Care.

"We made several recommendations that speak to social determinants of health, placing an emphasis on engaging in conversations around this subject and screening for related issues such as food insecurity that weren't there previously."

"Screening tools are suggested. It helped us to have an in-depth scientific review of the literature to know the prevalence of this in people with diabetes...Having the science to put it in was a key step," Gabbay noted.

Consider Kidney, Heart Disease in Type 2 Treatment Individualization

Recent data from trials such as CREDENCE and DAPA-HF, among others, have been added to inform the choice of pharmacological treatment in patients with type 2 diabetes with comorbid diabetic kidney disease and chronic heart failure.  

"ADA has been advocating individualization of treatment based on comorbidities for a while, but we've taken more steps in that direction. Beyond lifestyle for all individuals with type 2 diabetes, clinicians want to think early on about which comorbidities patients have and then think about the appropriate treatment based on that," Gabbay said.

And for the third year in a row, the section on cardiovascular disease and risk management has been endorsed by the American College of Cardiology (ACC).

"All the things in that section are very much aligned with ACC and that's been a great partnership," Gabbay said.

Now, ADA is in discussions with other professional societies representing relevant specialties to create further such unified messages.

"What we all want to avoid is having multiple different guidelines. We want to speak with one voice and find common ground as much as possible…It makes it much easier for clinicians to know what to do. That's the goal of all this," he noted.

Diabetes Technology: The Rise of CGM During Pandemic and Beyond

New information about continuous glucose monitoring (CGM) has been added to the diabetes technology section. Use of CGM is now recommended for anyone with diabetes who takes multiple daily injections or uses an insulin pump, regardless of age or diabetes type. The document provides expanded advice on use of time in range data for glycemic monitoring, particularly during the COVID-19 pandemic when remote monitoring is preferable.

Insurers are increasingly covering CGM for patients on insulin, but it's far from universal. While the ultimate goal is to ensure access to CGM for everyone with diabetes, those treated with multiple daily insulin doses are the priority for now.

"Our hope is that as there's greater evidence there will be more movement towards coverage. There are still so many people for whom it's quite clear they would benefit because they're on insulin but don't have access to it. That's an important area that ADA is advocating for, and it's reflected in the Standards of Care," Gabbay said.

In another technology-related revision, the term "blinded" CGM has been replaced with "professional CGM," because clinic-based use of the devices can be "blinded" to the patient or monitored in real-time by both the patient and clinician. Also, a new recommendation has been added to address skin reactions associated with diabetes technology use.

Information about use of CGM in hospital settings during the COVID-19 pandemic has also been added in the technology section.

The COVID-19 pandemic comes up again in the section on vaccines.

"We mention that people with diabetes should be considered high priority [for COVID-19 vaccines], and that's something that ADA is strongly advocating for because 40% of COVID-19 deaths have been in people with diabetes."

Gabbay has reported being on the advisory boards of Onduo, Health Reveal, Vida Health, Lark, and Form Health.

Diabetes Care. Published online December 9, 2020. Full text

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