COMMENTARY

Key Changes to the 2021 ADA Standards of Care

Anne L. Peters, MD

Disclosures

January 04, 2021

This transcript has been edited for clarity.

The American Diabetes Association (ADA) 2021 Standards of Care have just been released, and I'm going to discuss the key changes that I think are important. I will go through some of the sections and highlight the differences from the prior year's standards of care.

Section 1: Improving Care and Promoting Health in Populations

In Section 1, we focus on the notion of understanding the social determinants of health for an individual patient. I encourage you to look at the scientific review that was recently published discussing social determinants of health in people with diabetes.

Section 2: Classification and Diagnosis of Diabetes

The big difference in Section 2, at least in my mind, is that we now include latent autoimmune diabetes in adults (LADA). "LADA" is kind of an oddball term because it's very commonly used in the general population. A lot of patients say they have LADA, but we have not really defined it.

The key to LADA is that it's really an awareness that the patient is having an autoimmune beta-cell destructive process. This can occur in adults and appears to be different than the process in children. Adults can have a very long duration of marginal insulin secretory capacity and look to all the world like somebody with garden variety type 2 diabetes, except they eventually become fairly significantly insulin deficient, and many will require insulin.

Because the term "LADA" is common and acceptable in clinical practice, we don't want to say not to use it, but rather, think about this as a process of autoimmune beta-cell destruction. So, those patients may need insulin sooner than others and may be at risk for the development of diabetic ketoacidosis, especially if they are stressed and/or are on an sodium-glucose co-transporter 2 (SGLT2) inhibitor.

Other changes in this section include discussion of other types of diabetes — types of diabetes associated with HIV, as well as cystic fibrosis–related diabetes and how to deal with it. Finally, we discuss posttransplantation diabetes in more detail.

Section 4: Comprehensive Medical Evaluation and Assessment of Comorbidities

We strengthened Section 4 by adding more in terms of overall health status, risk for hypoglycemia, and using the cardiovascular risk calculator to understand cardiovascular risk. We also talk about low testosterone in men and how to approach it.

This section has been reorganized in a way that makes it more clinically practical when you are following it in order to understand what to do at each patient visit.

Section 6: Glycemic Targets

A subsection of Section 6 that was previously titled "A1c" is now called "Glycemic Assessment." This is to allow the use of other glycemic measures aside from A1c — such as time in range, glucose management indicator, time below range, and time above range — as glycemic goals for many nonpregnant adults. We're trying to make sure that we avoid hypoglycemia but manage patients in a way that is most effective. We also suggest an assessment of hypoglycemia that is somewhat more intense and occurs at every visit, and to use that as a key feature in guiding our therapeutic treatment targets.

Section 7: Diabetes Technology

There are a number of changes in Section 7. In the past, we subdivided recommendations between adults and children and gave different recommendations, but now we lump everybody together. So, instead of saying that adults should do this and children should do that, we say that when used properly, real-time continuous glucose monitoring (CGM) — in conjunction with multiple daily injections, continuous subcutaneous insulin infusion, and other forms of insulin therapy — is a useful tool to lower and/or maintain A1c levels and/or reduce hypoglycemia in adults and youth with diabetes. Adults and youth are combined, and diabetes is just diabetes. It's not defined as type 1 or type 2, but basically anybody who has diabetes and is on insulin can benefit from real-time CGM.

We did the same thing with intermittently scanned CGM. It can be helpful for the treatment of people with type 1 or type 2 — any kind of insulin-requiring diabetes in both adults and youth.

We then say that you should use real-time CGM devices as close to daily as possible for maximal benefit in patients on multiple daily insulins or on insulin pumps. But we subsequently say that you could use devices intermittently — say, in somebody with type 2 diabetes where you are looking more for a sense of patterns rather than real-time management. Intermittently scanned devices should be scanned at a minimum of once every 8 hours.

Instead of looking at blinded CGM and separating it out, we now call it "professional CGM." Use of professional CGM and/or intermittent real-time or intermittently scanned CGM can be helpful in identifying and correcting patterns of hypo- and hyperglycemia and improving A1c levels in people with diabetes on noninsulin as well as basal insulin regimens. You can use CGM as a tool for people who are not on intensive insulin therapy, but who are on any therapy if you use the tool in a way to help make adjustments in their regimen. This is really broadening the use of CGM to include pretty much anybody with diabetes, but always with the notion that this has to be coupled with education and adjustments of medications if necessary.

When we consider what is important in terms of how we assess glycemia, we suggest that the ambulatory glucose profile should be the standard printout for all CGM devices. We talk about time in range and its association with the risk for microvascular complications, and that a time in range of 70% or more is acceptable for patient management in those who are reaching glycemic targets, as well as to target an A1c < 7%.

We talk about skin reactions in the use of CGM, which are a real issue for some of our patients. We wanted to update you with information about the causes of skin reactions and how to help patients deal with them.

People with type 2 diabetes and other forms of diabetes, such as cystic fibrosis–related diabetes, who are on multiple daily insulin injections could be treated with an insulin pump. Insulin pumps are a reasonable therapy for anybody with diabetes of any sort who is on multiple daily insulin injections and needs a change in their regimen.

We then talk about systems that combine technology and online coaching, the notion of the virtual diabetes clinic. That is the end of the recommendations on technology.

I will move on to Section 9 in my next recording. Thank you very much for listening.

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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