2022 ADA Updated Guidelines: Individualizing Care, New Screening Recommendations and Increasing Education

Anne L. Peters, MD


December 28, 2021

This transcript has been edited for clarity.

Today I'm going to talk about the ADA 2022 Standards of Care. I've been working on these guidelines for the past 3 years as part of the Professional Practice Committee, and I can tell you how hard we work on these. We review everything that's been published in the past year, and have various committees and subcommittees that go through all of the data and come up with our recommendations.

The changes never seem to be earth-shattering, although we do publish supplements during the year as updates are needed. At the end of the year, really what we're trying to do is cull together everything that we think people should be thinking about and offer a pathway to help people better manage their patients with diabetes.

Most people tend to start with section 9 because this is where we discuss the management of hyperglycemia in patients with type 2 diabetes. Our whole world has really changed in terms of how we manage people with type 2 diabetes because we have agents such as GLP-1 receptor agonists and SGLT2 inhibitors that do more than just lower glucose.

We know now that cardiologists and nephrologists are all part of our team in terms of prescribing these medications. The guidelines from, say, the cardiologists basically don't include initiating metformin in the beginning of treating these patients.

We, after much discussion, decided that we need to keep it there because we're talking about first treating hyperglycemia along with treating other risk factors. We want people to be aware of the role of metformin in treating hyperglycemia, but we also now try to take it away from it being necessary as we treat our patients with type 2 diabetes who have other risk factors.

The first paragraph starts out saying that although first-line therapy for management of hyperglycemia generally includes metformin and comprehensive lifestyle changes, other medications may also be appropriate as initial therapy, depending on comorbidities, treatment factors, and management needs.

When looking at the figure for the treatment of hyperglycemia in people with type 2 diabetes, we divide it into two sections. The section on the left is basically for patients who have high risk for or established atherosclerotic cardiovascular disease, CKD, or heart failure. We try to make this as simple as possible, and we say independent of baseline A1c or the use of metformin, people need to be on an SGLT2 inhibitor or a GLP-1 receptor agonist.

We have three subsets. The first subset is the people who have known atherosclerotic cardiovascular disease or who are at high risk for cardiovascular disease, and those people can be put on either an SGLT2 inhibitor or a GLP-1 receptor agonist. If one of those is not enough alone, we say, combine the two. Now, we don't have cardiovascular outcomes data looking at that combination, but we believe that there is synergy and therefore it's a useful combination.

In the middle, we say if a patient has heart failure, there is one basic choice, which is to use an SGLT2 inhibitor unless there's some counterindication for its use. Finally, we say that if a patient has CKD, we look to see if they have proteinuria or not. If somebody has albuminuria, we say our first choice is an SGLT2 inhibitor, but if that's not possible, patients can be on a GLP-1 receptor agonist. If a patient does not have albuminuria but has CKD, then we say you can use either a GLP-1 receptor agonist or an SGLT2 inhibitor, and eventually the combination of the two.

If a patient doesn't fit into that overall category and does not have those risk factors, we look at other factors. We look at the need to minimize hypoglycemia. We look at the need for patients to lose weight. We look at all of the other variables that are involved in these choices, which include such things as cost and access to medication.

We talk a great deal about individualizing care and choosing what's best for the patient in their given circumstance because I think it's incumbent upon us to really work hard to get patients on the best therapies for whatever their condition is. When it comes to diabetes, we have many good ways to lower glucose levels. I think it's important to be mindful of the entire patient, their circumstance, and how it is best to treat that individual.

At the end of section 9, we state that if insulin is used, combination therapy with a GLP-1 receptor agonist is recommended for greater efficacy and durability of treatment effect.

Section 7 is about diabetes devices, and more than anything, what we've done is strengthen our recommendations for using diabetes devices because we have more data than ever supporting their use. We used to be wishy-washy, saying that continuous glucose monitoring (CGM) devices are a useful tool, but we don't say that anymore. We say real-time CGM or intermittently scanned CGM should be offered for diabetes management in adults on multiple daily insulin injections or subcutaneous insulin infusion therapy who are capable of using the devices safely. We really think that these patients should be offered CGM.

We also highlight the fact that devices are not identical and that we need to choose the right CGM for the right patient. The choice of device should be made based on patient circumstances, desires, and needs. We now give specific recommendations for using CGM in people who are on basal insulin therapy.

We also talk about using insulin pens. We've actually never really talked about this before in the ADA guidelines. We now say that the use of insulin pens is recommended as preferred to vial and syringes. We know that insulin syringes work. There are some patients who prefer using vials and syringes, and there are also situations in which cost is a factor. Obviously, in those settings, people should continue to use syringes and vials.

In terms of overall treatment for people with type 1 diabetes, we now have data that automated insulin delivery systems are the most effective treatment option for managing type 1 diabetes, and we put this first in the list of the choices for these patients. We say automated insulin delivery systems should be offered for diabetes management for use in adults with type 1 diabetes and other types of insulin-deficient diabetes, such as those after pancreatectomy, who are capable of using the device safely, either by themselves or with a caregiver.

Not everyone is suitable for use of an automated insulin delivery system and some people don't want to use them, which is fine because there are other ways to manage type 1 diabetes. We do think these systems should be offered to patients along with the education and follow-up to use them safely.

I’d like to highlight a few other points. In section 2, we discuss screening asymptomatic adults starting at age 35 years, which is younger than the recommendations used to be. We talk about repeat testing every 3 years at a minimum, but if symptoms occur or there's a change in risk — for instance, if somebody gains a bunch of weight — that would trigger a repeat screening. We also talk about screening people who are 18 years and older who are overweight or obese, and making sure that they are tested for prediabetes or diabetes if they have an additional risk factor.

Finally, in section 6, there's the answer to a question I've long had, which is when I put somebody on treatment for diabetic nephropathy who has albuminuria, should I follow urine albumin excretion? What should I do? If the albuminuria is at a level of greater than 300 mg per day, we're looking to reduce that by 30% or more. You should follow their albuminuria, give your treatment, and then adjust your treatment so you can get patients to a level that is at least 30% better than at baseline.

We also say that finerenone should be used in people with albuminuric diabetic kidney disease to reduce CKD progression and heart failure risk. I think that one of the major points here is to try to properly categorize patients with CKD by measuring albuminuria, not just GFR, and treat them accordingly.

Those are just the real topline updates from this year's 2022 Standards of Care. I hope you read it and at least skim all of the sections so you can see what's most up-to-date, and hopefully interesting, in terms of the treatment of our patients with diabetes.

This has been Dr Anne Peters for Medscape. Thank you.

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