Every January, the American Diabetes Association (ADA) updates their Standards of Care in Diabetes to include the most recent medication approvals and cutting-edge evidence for diabetes management. The Standards of Care includes all aspects of diabetes prevention, diagnosis, and management, and is one of the most valuable guidelines for clinicians who work with people with diabetes.
Some of the updates included this year included:
New recommendations for weight loss and medications that can help facilitate weight loss
More conservative biometric goals in persons with diabetes
New medication recommendations for management of complications in diabetes
Expansion of technology, telehealth, and telemedicine
The ADA has taken a stance this year that obesity is a chronic and often progressive health condition and should be treated as such through several modalities to help with weight loss, both in people who have diabetes or who have prediabetes. Behavioral therapy is recommended to help guide patients to more nutrient-dense foods, reduce calorie intake, and effective exercise plans. Clinical benefits can be seen in as little as 3% weight loss, and more intensive weight loss can help achieve further health improvements.
With the development of incretin mimetics (such as Ozempic, Trulicity, and Mounjaro) to treat diabetes and the added benefit of helping with weight loss, patients can see much more substantial weight loss that can help achieve blood sugar goals and avoid or prevent the progression of complications; in patients with prediabetes, this weight loss can also help stop and reverse progression towards diabetes. As a result of this, the ADA is recommending as much as a 15% weight loss, which can be achieved through comprehensive weight management treatment with incretin mimetics combined with intensive behavioral therapy.
Diabetes alone is a risk factor for experiencing a heart attack or stroke, and having elevated blood pressure or cholesterol continues to increase this risk. Because of this, the ADA is taking a stronger stance on controlling blood pressure and cholesterol. In regard to high blood pressure, the ADA previously recommended a blood pressure goal of less than 130/80 mmHg but diagnosed hypertension at a blood pressure above 140/90 mmHg. With the 2023 update, they have lowered this diagnosis level to match the treatment goal, as well as align with the American Heart Association and American College of Cardiology diagnosis of hypertension at blood pressures above 130/80 mmHg.
This change encourages faster action for initiation of medication to begin lowering blood pressure to help protect the heart and reduce risk of heart attack and stroke. An additional benefit with this approach is the preservation of the blood vessels that provide oxygen to organs and reduce the risk of organ damage, such as kidney damage and vision loss. In persons who have already experienced a heart attack or stroke, the ADA is also taking additional measures to help prevent an additional recurrence through more conservative cholesterol goals.
Previously, the ADA recommended LDL (or “bad” cholesterol) to be less than 70 mg/dL; however, in light of newer evidence, they are recommending further LDL lowering to less than 55 mg/dL. To do this, they recommend first-line to utilize a family of medications called statins, as these have the most evidence showing reduction of heart attack and stroke, as an initial or subsequent event.
Managing Complications of Diabetes
Common complications that exist with diabetes include heart failure and kidney disease, which can be both costly and cause a variety of quality-of-life disruptions for people with these conditions. The ADA has provided guidance regarding new medications available for these conditions to help slow the progression and reduce symptoms. A family of medications called SGLT2 inhibitors (Farxiga, Jardiance) that has previously been approved for diabetes to lower blood sugar is also now recommended in kidney disease to help prolong kidney function, and now is also recommended in people with diabetes and heart failure. Studies have proven benefit with these medications to maintain heart function, reduce the risk of heart-related death, and overall help reduce symptoms associated with heart failure.
These medications are being recommended for anyone with any cardiovascular concerns, such as a prior heart attack, or impaired kidney function with diabetes. Along these lines, studies have shown a new medication finerenone (Kerendia) provides benefit in people with diabetes who have kidney disease with albuminuria (protein in the urine) by helping reduce the risk of progression of kidney disease, as well as improves cardiovascular outcomes. The ADA recommends the consideration for use of finerenone to be used in people with diabetes with kidney disease and any risk factors that may make them more at risk for a heart attack or stroke.
Continuous Glucose Monitors (CGMs) are a wonderful tool for people with diabetes to monitor and manage their blood sugars 24/7, rather than using traditional fingerstick blood sugar monitoring at various times of the day. With growing data on the reliability and improvement of blood sugars with this tool, the ADA now recommends the consideration for use of a CGM in all people with diabetes who use multiple daily insulin injections and has expanded this recommendation as well to those on a single dose of long-acting insulin.
The use of a CGM gives a patient real time information about the impact a meal or physical activity has on their blood sugar to promote adherence to healthier habits, as well as immediate alerts for rapidly rising or falling blood sugars to avoid dangerous blood sugar readings. Additionally, the ADA is encouraging for the expanding use of telehealth and telemedicine for diabetes care, typically complementary to in-person visits. They cite evidence that supports the use of telephonic or virtual modalities to provide patient care to help safely lower A1c and blood sugar, and can be particularly useful in rural communities, under resourced areas, and in people with transportation barriers or disabilities.
The ADA cites the ability practitioners have for more frequent encounters, whether direct communication or via text messaging or email, and the allowance of increased motivational interviewing and behavioral therapy encounters for positive health changes.
Formulary and Plan Design Implications
Tria Health recommends including incretin mimetics in your formulary. However, since these medications are expensive, Tria Health recommends including a prior authorization that requires a diabetes diagnosis to ensure these medications are not being prescribed and used off-label. In addition, Tria Health recommends including incretin memetics to treat obesity as well, but these should also include a prior authorization that requires an intensive weight management program to ensure necessary lifestyle behavior changes occur. Similarly, making CGMs available to those members who would benefit is appropriate. The key is having a skilled practitioner, like a Tria Health pharmacist, who can consult with the patient to determine the appropriate course of action to ensure that the right medication or device is getting to the right patient at the right time. This will maximize health outcomes while reducing plan waste.
The American Diabetes Association’s Standards of Care in Diabetes – 2023 in full text can be accessed through https://diabetesjournals.org/care/issue/46/Supplement_1.
ElSayed NA, Aleppo G, Aroda VR, et al., American Diabetes Association. 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: Standards of Care in Diabetes—2023. Diabetes Care 2023;46(Suppl. 1):S128–S139