'A Better Picture': First AACE Guidelines on Diabetes Technology

Miriam E. Tucker

May 31, 2021

The American Association of Clinical Endocrinology (AACE) has issued its first-ever official guidelines addressing the use of advanced technologies in the management of people with diabetes.

The guidelines cover use of continuous glucose monitoring (CGM), insulin pumps, connected pens, automated insulin delivery systems, telemedicine technologies, and smartphone apps. They also address safety considerations, special situations such as hospitalization, and implementation in clinical practice.

They were presented on May 28 during the American Association of Clinical Endocrinology (AACE) Virtual Annual Meeting 2021 and simultaneously published in Endocrine Practice.

Previous AACE guidance on the clinical use of insulin pumps and CGM over the past decade has been published in the form of consensus or position statements rather than official evidence-based guidelines, task force cochair George Grunberger, MD, of the Grunberger Diabetes Institute, Bloomfield Hills, Michigan, explained.

"There's never really been until now hard-core evidence, [with] peer-reviewed, quality trials published in the literature to go after the evidence that is required for guidelines...This is not an opinion piece or position statement."

The problem with that strict approach to "guidelines" is how quickly the diabetes technology field is evolving, he acknowledged. "It's frustrating because we know what's [coming up], but we can't put it in a guideline because it hasn't been published yet."

In an AACE podcast, Grunberger said the guidelines will likely become a "living" document, along the lines of the American Diabetes Association's (ADA) annual Standards of Care, as "any cutoff date is arbitrary. More and more papers will be published on these technologies...This is certainly not a static field."

In the meantime, task force cochair and author Jennifer Sherr, MD, PhD, a pediatric endocrinologist, said she hopes the guidelines will help to reduce insurance company barriers to use of the currently available technologies.

"I am very hopeful that these guidelines will also encourage payers to change their stance. And I think that we as a community can continue to advocate and inform them of these guidelines so they can appropriately change their coverage practices," added Sherr, of Yale University School of Medicine, New Haven, Connecticut.

Recommendations Address CGM, Pumps, and Connected Systems

In the guidelines, CGM is "strongly recommended for all persons with diabetes treated with intensive insulin therapy, defined as three or more injections of insulin per day or the use of an insulin pump." For those with diabetes who use CGM, "priority metrics" include a "time in range" of greater than 70% from 14 days of active use. Targets for mean glucose should be individualized, with glycemic variability 36% or lower.

Further specific CGM target metrics are given for people with type 1 diabetes, older/high risk individuals, and for pregnant women. The recommendations align with those issued in a 2019 joint consensus statement on CGM time-in-range endorsed by several organizations, including AACE.    

In response to an audience question about whether AACE is advising that time-in-range replace A1c for glycemia assessment, Sherr responded: "I think currently we're not in a position where we can completely replace A1c with time in range. However, I'm hopeful that in future years we'll see further data gathered...to allow for that recommendation to occur."

For now, she said, "What we really want to hone in on in the guidelines is that time-in-range and use of CGM truly allow clinicians to better understand how to optimize care for their persons with diabetes. It gives us a better picture. It's not just a number of whether we're hitting target. It tells us whether we need to attack time above range or time below range. So we really think it's critical for clinical care."

The document also provides specifics about real-time versus intermittently scanned CGM and use of diagnostic/professional CGM.

The "insulin delivery technologies" section covers use of connected pens, insulin pumps without CGM, insulin pumps with separate CGM, and the more advanced combined insulin pump-CGM systems including those with low-glucose suspend, predictive low-glucose suspend, and hybrid closed-loops (sometimes called the artificial pancreas).

In general, these automated insulin delivery systems (artificial pancreas), "are strongly recommended for all persons with [type 1 diabetes], since their use has been shown to increase time in range, especially in the overnight period, without causing an increased risk of hypoglycemia," Sherr observed.

Other Tech Topics: Apps, Telemedicine, and Safety

The new guidelines say that "clinically validated" smartphone apps should be recommended to help teach or reinforce diabetes self-management skills and provide support and encouragement for healthy behaviors around food and exercise.

Grunberger pointed out: "As we know, there are tons of apps out there, and patients are using them. The problem is that very few of them have actually been validated in clinical trials in published peer-reviewed [journals]."

He recommended a joint statement on diabetes apps from ADA and the European Association for the Study of Diabetes (EASD) that was initially discussed at the 2019 EASD meeting, as reported by Medscape Medical News, and subsequently published in January 2020 in Diabetes Care and Diabetologia.

"Telemedicine, including periodic phone calls, smartphone-web interactions...by healthcare professionals...is strongly recommended to treat persons with diabetes, provide diabetes education, remotely monitor glucose, and/or insulin data to indicate the need for therapy adjustments, and improve diabetes-related outcomes/control with better engagement," the document says.

Safety issues addressed include the issue of certain medications interfering with CGM [readings]...including acetaminophen, high-dose vitamin C, and hydroxyurea, as well as cautions about what to do in the event of device malfunction and assessing that the patient is sufficiently trained in proper device use. Criteria for insulin pump discontinuation are also given.

Implementation: Who Will Be Prescribing? "This Is Not For Amateurs"

A final section on implementation recommends that "initiation and use of diabetes technology should be implemented by healthcare professionals who are trained, committed, and experienced to prescribe and direct the use of these tools. Clinicians should have the infrastructure to support the needs of persons with diabetes using the technology."

Grunberger commented, "I think the key is going to be who should be doing this? What is the role of a clinical endocrinologist in the future? What is our responsibility, [since] we don't have the manpower and womanpower to take care of all these people as these technologies advance? It's our responsibility to provide these hopefully valued recommendations as a resource for those who want to know more about it."

However, he noted, "This is not for amateurs. If you want to actually use this in your practice, you need the infrastructure, the expertise, the training, the dedication, and the energy to be there for the patients all the time...This clinical practice guideline is a foundation."

Sherr added, "To me, it's really thinking about...changing our mindset from who is an appropriate candidate to who can benefit and how vast a group that entails...I'm hopeful that we will see more technology use through continued conversations with our patients with diabetes, and hopefully through more clinicians being excited to be part of this revolution."

Grunberger has reported being on speakers bureaus for Eli Lilly, Novo Nordisk, and Abbott. Sherr has reported being a consultant and speaker for Lilly and Medtronic Diabetes, a consultant for Insulet and Sanofi, and on advisory boards for Bigfoot Biomedical, Cecelia Health, Insulet, JDRF T1D fund, and Medtronic.

AACE Virtual Annual Meeting 2021. Presented May 28, 2021.

Endo Pract. 2021;27:505-537. Full text

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

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