COMMENTARY

"Heart" of the New ADA Guidelines: Pharmacologic Approaches to Glycemic Treatment

Anne L. Peters, MD

Disclosures

January 07, 2021

This transcript has been edited for clarity.

Welcome back. Now I will go over revisions to the final sections of the 2021 American Diabetes Association (ADA) Standards of Care.

Section 9: Pharmacologic Approaches to Glycemic Treatment

Section 9 is the most important part of these standards because it goes through how we should treat our patients with diabetes and hopefully provides some useful detail as to how to approach an individual patient. It is the heart of these guidelines, and it's long and complicated. I encourage you to read the tables and the figures to really get a sense of what this section is all about. I will explain what has changed.

In terms of insulin, we talk about the benefits of using sensor-augmented insulin pumps. We also talk about the concern for overbasalization in patients on insulin therapy — how to avoid this and how to assess for it.

The big change is in Figure 9.1, which now has a dedicated pathway for how to choose treatments for patients with chronic kidney disease (CKD) or heart failure. It starts out the way all of our figures do for the treatment of type 2 diabetes: First-line therapy is metformin and lifestyle. But then, independent of the patient's A1c target and even whether or not they are on metformin, you look at them in three buckets: whether the patient has indicators of being at high risk for cardiovascular disease or has established atherosclerotic cardiovascular disease, whether they have CKD, and whether they have heart failure.

For patients with atherosclerotic high risk or known atherosclerotic cardiovascular disease, it's going to be a glucagon-like peptide 1 (GLP-1) receptor agonist or a sodium-glucose co-transporter 2 (SGLT2) inhibitor. For the set with heart failure, we say to use an SGLT2 inhibitor preferentially. We say the same thing for patients with CKD, but we look further at renal function and make some decisions there about what to do. We really drilled down more into how to help people in these high-risk categories choose between a GLP-1 receptor agonist and an SGLT2 inhibitor, with the knowledge that both are going to have benefit to some degree in these very high-risk patients.

Section 10: Cardiovascular Disease and Risk Management

We are proud to say that this is the third consecutive year where we have had representatives from the American College of Cardiology (ACC) involved in our decision making for Section 10, so we are aligned with what the ACC is doing. This section was revised to acknowledge the new trials that have been released looking at the impact of cardiovascular risk reduction in patients with diabetes, although we do note that there is not much direct evidence in patients with type 1 diabetes. This section is good to review, although not a whole lot has changed here except for being upgraded on the basis of the more recent evidence.

Section 12: Older Adults

Finally, in Section 12, we don't define "older," but we changed the A1c target. If an older adult is otherwise healthy, with few coexisting chronic illnesses and intact cognitive function and functional status, their A1c target should be < 7.0%-7.5%. I think this is reasonable because you want to assess each patient individually; we always individualize care. It's important to look at each patient's functional status, to look at the harm of treatment, to de-intensify if somebody is on too much treatment, and to really balance this to make it right for the individual.

We talk about the complex older patient in poor health. We talk about not really relying on the A1c so much; what we want to do is avoid symptoms of hypoglycemia and/or symptomatic hyperglycemia and treat patients as seems reasonable on the basis of their own targets. More than that, a target is really about quality of life — which it is for all patients, but particularly for these older, very frail, sicker patients, we want to change what we are focused on. It's a good way of looking at treating older adults. I am seeing more and more older adults, and I want to make sure that I enhance their quality of life for as long as they live.

That is the end of my updates from the 2021 ADA Standards of Care. Read what you are interested in, but do look through it. In particular, look at Section 9 on the pharmacologic treatment of diabetes because that really gives you an overview. Then look at the other sections as you are interested. Thank you very much.

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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