Anne L. Peters, MD
The new American Diabetes Association Standards of Care-2024 is a really interesting, updated document. There aren’t any huge headlines, but there are many subtle changes. I think it’s important that people really understand what the guidelines say and how we can apply this to patients.
The guidelines are long. There are 328 pages, and I’ve read every word. I’ve summarized into two videos what I really think is important to know. This first video is going to be more of the basic overview, and the second video will discuss treatment of people with type 2 diabetes.
I am most interested in section two, entitled, “Diagnosis and Classification of Diabetes.” The reason this section resonates so much with me is because it really characterizes what I do as a diabetologist. Recommendation 2.5 says to classify people with hypoglycemia into appropriate diagnostic categories to aid in personalized management. It then goes on to say, “Diabetes is conveniently classified into several clinical categories, although these are being reconsidered based on genetic, metabolomic, and other characteristics and pathophysiology.”
The reason this resonates with me so much is because as I’ve used continuous glucose monitoring (CGM) more extensively in my patients and as we’ve had newer treatments for our patients with diabetes, I’ve learned that there must be many, many different types of diabetes because people vary greatly in how they respond and what their glucose profiles look like. I find that this validates the fact that I often can’t really tell what type of diabetes a person has, but I do know they have diabetes. What I do clinically is try to figure out the best way to treat them.
The title of section two has been changed. It used to be called “Classification and Diagnosis of Diabetes,” but now it’s called “Diagnosis and Classification of Diabetes.” Basically, what that means is, first, let’s figure out whether this patient does or does not have diabetes and then we’ll try to classify it, but it might not fit into those simple categories that we all were trained on. It may not be classic type 1, classic type 2, classic other, or gestational diabetes. What is this? We really need to think that way.
They also focus on improving the standardization of approaches to diagnostic testing for diabetes. They discuss hemoglobin A1c levels as the go-to tool that most of us use for diagnosing diabetes. They also reinforce the need for a second test to confirm the diagnosis.
The standards now talk about how we see — not uncommonly, particularly when using CGM — that there may be a discordance between the glucose values that we see for CGM or fingerstick and the A1c test results. They discuss the potential need for use of other biomarkers, such as fructosamine, and glycated albumin as an alternative method for measuring states of chronic hyperglycemia.
They also discuss pancreatic diabetes, or diabetes in the context of disease of the exocrine pancreas. They talk about the importance of screening for diabetes in people following an episode of acute pancreatitis. Those individuals should be screened 3-6 months after they’ve had an episode of acute pancreatitis, and then annually in individuals who have chronic pancreatitis, to make sure they’re not developing hyperglycemia.
One of the biggest changes in the guidelines is regarding the use of teplizumab to help people with stage 2 type 1 diabetes slow progression to stage 3 type 1 diabetes. For those of you who want to learn more about this, I would strongly encourage you to read the guidelines because they go into great detail about screening, who should be screened, what antibodies mean, and following patients over time.
Suffice it to say, not all prediabetes is actually pre-type 2 diabetes. In individuals, particularly those who have first-degree family members with type 1 diabetes, screening for islet autoantibodies can be very important in terms of understanding what type of prediabetes they might have.
When you’re following these patients over time — so you’ve diagnosed somebody with positive islet autoantibodies and you want to see if they’re developing overt type 1 diabetes stage 3 — you can follow them with an A1c level or with an oral glucose tolerance test. Less specifically, you can follow them with CGM. I have a number of patients that I follow over time to watch to see if they are in fact progressing to stage 3 type 1 diabetes. I think it’s important to learn about this concept because we’ve never had anything before that can help slow progression to overt stage 3 type 1 diabetes.
Turning to bone health, section four includes recommendations for the regular evaluation and treatment of bone health, as well as general and diabetes-specific risk factors for fracture. They did this section in conjunction with the American Society for Bone and Mineral Research. Table 4.5, I think, is really useful because they try to provide specific guidance in monitoring bone mineral density, assessing and preventing fracture risk, and helping clinicians make treatment decisions.
The diabetes-specific risk factors are a lumbar spine or hip T score ≤ -2; frequent hypoglycemic events; diabetes duration of greater than 10 years; use of insulin, thiazolidinediones, and sulfonylurea agents; an A1c > 8%; peripheral and autonomic neuropathy; and retinopathy and nephropathy. I think this really adds to who we think of when we think about bone health in our patients with diabetes.
The ADA Standards of Care in Diabetes-2024 continue to emphasize the very important focus on psychosocial health. The Standards discuss the concern over an increased rate of suicidality among patients with diabetes. In terms of risk screening, it’s important to do what is considered appropriate for the patient and follow up accordingly.
In terms of other kinds of screening, the ADA now specifies that diabetes distress screening should be done at least annually, and in some cases, we do this more often in patients who have higher levels of distress to see if we’re making a difference.
For depression, the ADA also recommends at least annual screening and more frequent screening in patients who’ve had a history of depression. I really want to highlight the toolkit that’s available to use in helping us care for our patients who have behavioral health concerns. There’s a 12-page guide for healthcare providers on how to support adults with type 1 or type 2 diabetes who have a whole host of psychosocial health issues, from anxiety, to depression, to barriers to using insulin.
They also include multiple questionnaires for us to use when we’re trying to assess patients, to look at whether they have distress or fear of hypoglycemia. The questionnaires are all in one place. I’m always looking for questionnaires, so it’s really great that it’s there. They also have a document of handouts for healthcare providers to share with patients that cover topics related to psychosocial health issues. Not only do they give us recommendations, but they also give us this toolkit, which I think is very important.
In terms of the management of patients with type 1 diabetes in pregnancy, the use of CGM is further reinforced in addition to ongoing blood glucose monitoring. However, they do state that there are still not enough data to recommend the use of CGM in gestational diabetes or in pregnancy in people with type 2 diabetes. Now, I personally use CGM in people in both of these categories, but officially, there aren’t yet enough data to support this. They also state that CGM use should be individualized based on treatment regimen, circumstances, preference, and needs.
In terms of technology, they basically have an open-ended sentence. They say that diabetes devices should be offered to people with diabetes. There’s a greater emphasis on education, and I couldn’t stress that enough. I think if you couple a device with education, you can really help people make real changes in terms of their diabetes management.
They also talk about automated insulin delivery systems and advocate for automated insulin delivery initiation in all adults with type 1 diabetes, and even discuss its use at diagnosis. Again, they really go into the use of any of these tools along with education. They also talk, as always, about individualizing the use of technology and discussing with patients what works best for them.
They also have this part in the technology section, which I find really interesting and useful to think about. They think that healthcare providers should consider establishing technology-based competencies, meaning that healthcare providers should actually have a level of training and skill at using these technologies so that they can further help patients. They recommend the use of online tutorials and training videos, as well as written material, to help providers understand the use of these devices.
That ends part 1 of the update on the Standards of Care in Diabetes-2024. Although most of the changes may seem small, they really do represent changes in how we think about our patients and how we think about delivering care, devices, and all sorts of services to our patients who need them.
Stay tuned for part 2, which will discuss management of type 2 diabetes and diabetes complications. Thank you.
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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