'Making Targets Easier to Achieve' Key in Diabetes Care

Anne L. Peters, MD


December 22, 2022

This transcript has been edited for clarity.

The American Diabetes Association (ADA) 2023 Standards of Care in Diabetes have been released. Before I start, I want to acknowledge the hard work of the Professional Practice Committee and the ADA CMO, Dr Robert Gabbay. Next, I am going to discuss the section updates that I think are important, and finally, I will describe how I think these guidelines can help in clinical care.

Section 1 is titled "Improving Care and Promoting Health in Populations." I work in underresourced East Los Angeles, and this is a very important topic to me because I want to provide better healthcare to underresourced patients. In this section, they add the concept of using community health workers to support diabetes management and cardiovascular risk factors. This couldn't be stressed more because these individuals are often the people who best connect with my patients.

Section 2 discusses the classification and diagnosis of diabetes. What's new is that they now say that we can use a point-of-care A1c testing machine to both screen for and diagnose diabetes. I think this is great because many of us have been doing this for a while. I know that in my office, my point-of-care machine can sometimes seem a little bit buggy. I want to make sure that everybody calibrates and keeps their machine in good shape so we're sure that our diagnosis of diabetes is done correctly.

The next section is on prevention or delay of type 2 diabetes and associated comorbidities. Here, they discuss the use of pioglitazone for reducing the risk for stroke or myocardial infarction in people with a history of stroke and evidence of insulin resistance and prediabetes.

Section 4 is titled "Comprehensive Medical Evaluation and Assessment of Comorbidities." There are a number of significant changes in this section. First, they changed the section on immunizations extensively, in part because we now have the COVID-19 vaccines. They also talk about boosters and the use of pneumococcal pneumonia vaccinations.

There's a new detailed subsection, which discusses nonalcoholic fatty liver disease. This talks much more about the diagnosis and risk stratification in both primary care and diabetes clinics, such as using the Fibrosis-4 index to assess the risk for liver fibrosis. They also include a Fibrosis-4 index risk calculator.

This isn't something that I have been doing routinely in my clinic, so I think it's important to note that this is there, and they also give helpful guidance. They give a figure and information from the American Gastroenterological Association guidelines to look at how we classify this in our patients and what we should think about and do about this problem.

Next, they talk about facilitating positive health behaviors and well-being to improve health outcomes. In the section on diabetes self-management, education, and support (DSMES), they talk about social determinants of health in how that guides treatment and DSMES delivery. They also talk about the use of telehealth delivery of care and other digital health solutions.

Then, they talk about screening for food insecurity. I think this is particularly important because I don't really know about food insecurity unless I ask. Many times, patients are shy about telling me that they are having issues with food insecurity, but it is important when you're talking to patients about nutrition and what their barriers are to eating well and managing their diabetes.

The subsection that used to be called "Psychosocial Issues" is now called "Psychosocial Care," and it emphasizes providing appropriate psychosocial support to patients with diabetes. We've discussed this many times before, but it's really front and center now.

They also discuss sleep and the concept of discussing with our patients whether they're getting enough sleep, and restful sleep, to manage their diabetes and their lives more effectively.

In the section on glycemic targets, they talk about changing the targets for those patients with frailty or who are at high risk for hypoglycemia. In terms of looking at a target of > 50% time in range, which is obviously less than the recommendation for > 70% time in range for other individuals, and of < 1% time below target range in order to stress the need to prevent hypoglycemia in these patients.

Section 7 on diabetes technology is a section near and dear to my heart. I think they did a great job updating this section. They updated the recommendations based on all the new data that we have. Trust me, there's a large amount of new data on technology that comes out every year, and they incorporated all the new references. In particular, they discussed the use of continuous glucose monitoring (CGM) in people on basal insulin and they also incorporated all of the new data that we have on automated insulin delivery (AID) systems.

They added a new table to address interfering substances with all the CGM devices, and I find this table quite interesting and useful. They added more data and information about the do-it-yourself hybrid closed-loop systems. I love that they did this because there are many people who do use these systems and need our support.

Then, they updated the inpatient care subsection to include all the updated evidence in this area, and they talk about the use of CGM in the inpatient setting that occurred during the COVID-19 pandemic.

Section 8 looks at obesity and weight management for the prevention and treatment of type 2 diabetes. More and more, it is stressed that this is vital to preventing and treating patients with type 2 diabetes.

They also talk about reinforcing that both smaller and larger weight losses are part of our treatment goals, and that we really need to look at patients on a case-by-case basis and make small appropriate targets and recommendations so that patients can really adhere to what we're suggesting and improve their outcomes. They also discuss using the dual glucagon-like peptide 1 (GLP-1)/gastric inhibitory polypeptide (GIP) receptor agonist tirzepatide as a glucose-lowering option with the potential for the greatest weight loss.

Section 9 is titled "Pharmacologic Approaches to Glycemic Treatment." This is really the headline of the Standards of Care, because everybody looks at this to determine how they should manage glycemia in their patients with type 2 diabetes. Basically, they took the consensus report that was released a few months ago from the ADA and the European Association for the Study of Diabetes (EASD) in managing patients with type 2 diabetes.

I've done a prior video on this, but I suggest that everybody make sure they understand what these guidelines are and look at both Table 9.2 and Figure 9.3, where they go through their recommendations. I'm going to talk a more about this at the end.

Section 10 is titled "Cardiovascular Disease and Risk Management," and this is the section in which I think the most changes were made. First, they lowered the blood pressure target to < 130/80 mm Hg, and they updated the tables and figures for this lower target.

In terms of lipid management, they recommend the use of high-intensity statin therapy in higher-risk individuals with diabetes who are aged 40-75 years to reduce the low-density lipoprotein (LDL) cholesterol level by ≥ 50% of baseline or to target an LDL cholesterol of < 70 mg/dL.

They recommend adding ezetimibe or a PCSK9 inhibitor to maximal tolerated statin therapy in individuals who are not reaching their targets. They recommend that in adults with diabetes who are older than 75 years and on a statin to continue that statin, and that if people aren't yet on a statin, you may want to initiate moderate-intensity statin therapy even in these older individuals.

They also discuss treatment with high-intensity statin therapy in individuals with diabetes and established cardiovascular disease to target an LDL cholesterol reduction of ≥ 50% from baseline, but an LDL cholesterol goal of < 55 mg/dL. This is the lowest LDL cholesterol target that we've had, and frankly, it makes sense in these patients who have existing cardiovascular disease.

They added a recommendation to add finerenone in the treatment of individuals with type 2 diabetes and chronic kidney disease (CKD) who have albuminuria treated with maximal tolerated doses of an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB). In terms of CKD management, in addition to what I've just mentioned, they talk about adding in a sodium-glucose co-transporter 2 (SGLT2) inhibitor if the estimated glomerular filtration rate (eGFR) is ≥ 20 mL/min/1.73 m2 and the urinary albumin excretion is ≥ 200 mg/h. They also recommend that adding an SGLT2 inhibitor might be effective in people with CKD and a urinary albumin excretion rate that is normal to 200 mg/h.

In older adults, they discuss using CGM and other technologies to help patients manage their diabetes more effectively and, in particular, avoid hypoglycemia. They discuss deintensification of treatment goals to reduce the risk for hypoglycemia if it can be achieved within the patient's individualized target goals.

They also discuss simplification of complex treatment plans, especially regarding insulin, to reduce the risk for hypoglycemia and polypharmacy, and decrease the burden of disease if it can be achieved within the individual's A1c target.

I must say I spend a large amount of time trying to do this to make life easier for our patients — and not only in older individuals. I certainly have younger individuals where simple is better, so I think this is a concept that works for almost everybody. We want to make sure people get to their targets, but make the targets possible for them to achieve.

Those are the changes I thought were most important, but there are other changes throughout the guidelines, and I'd encourage you to read them and pick out what's most important to you.

In terms of the overview, how do these guidelines really work? There are two important things. One, I think these guidelines are great in reducing cardiorenal risk, and they look at patients with established cardiovascular disease, with CKD, and with obesity. They are helpful for expanding how we think about people with diabetes and what their risks are.

I think the guidelines let us down when it comes to looking at how to manage hyperglycemia. For instance, if you have a patient who comes in with new-onset diabetes and has preexisting heart failure or CKD, you're not supposed to look at the A1c. You're supposed to start an SGLT2 inhibitor. If their A1c is 8.5 or 9 and you put them on an SGLT2 inhibitor, you're not going to get them to target.

If you add in a GLP-1 receptor agonist, which seems like a great idea, you may be able to get them lower, but that's a very expensive combination and, frankly, not one that has good outcomes in terms of whether that really adds to the benefit.

In LA County, where I work, if you look at the data that we can get on patients, we find that probably 35% or 40% of our patients with diabetes have an A1c that's greater than 9. Every time I work in clinic, I see patients with significant nephropathy, retinopathy, and neuropathy — all complications directly related to hyperglycemia.

I can also tell you that my providers in LA County are wonderful primary care providers, but they have trouble managing hyperglycemia. They're really pretty good at managing lipids — most patients are on a statin — and they're not so bad at managing hypertension.

When it comes to managing glucose, particularly in patients where it's more complicated rather than simple, it's really difficult. We've been struggling in the county to write guidelines to teach primary care providers how to manage hyperglycemia in their patients.

It's taken us over a year to make a protocol that makes sense. Yes, we use SGLT2 inhibitors, and yes, we use GLP-1 receptor agonists in the county of Los Angeles, but we have to choose in whom, and we have to choose it based on our formulary and on what we can reasonably provide to our patients.

I really hope that the American Diabetes Association — and everybody who writes these guidelines — doesn't forget the need to think about glucose and to provide pathways for patients who don't yet have cardiovascular disease, CKD, or heart failure, to help them reach their targets so they don't develop the microvascular complications of diabetes.

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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