DIABETES MELLITUS:
HEALTHCARE STANDARDS
AIMED AT PATIENTS
WITH DIABETES
By: Dr. Ángel Comulada, MD
Endocrinology Specialist – MCS Provider Network
According to the American Diabetes Association (ADA), someone in the U.S. is diagnosed
with diabetes every 23 seconds. Given the high incidence, the ADA annually reviews the
Standards of Medical Care in Diabetes guidelines that include the clinical parameters of this
chronic disease.
These guidelines, which are consulted by healthcare providers nationwide, allow healthcare
professionals who provide services to patients with diabetes to be at the forefront.
Because diabetes is the third leading cause of death in Puerto Rico, understanding the
guidelines is essential for facilitating diagnoses and optimizing treatments for those with
diabetes. The document also includes strategies for preventing or delaying type 2 diabetes
and its comorbidities, and shares therapeutic approaches that may reduce complications,
mitigate cardiovascular and renal risks, and improve patient health.
This year, the ADA revised nearly every section under the Standards of
Medical Care:
Screening. Now, the age for preventive screening to diagnose prediabetes and Type
2 diabetes in patients without risk factors dropped from age 45 to 35.
Diagnosis, Prevention, Evaluation and Management of Comorbidities. For patients with comorbidities or at risk of complications, although metformin has
been the first treatment option for managing this disease, the new guidelines
recommend the use of GLP-1 receptor antagonists or SGLT2 inhibitors (or
nonsteroidal mineralocorticoid receptor antagonist-finerenone when the SGLT2
are not well tolerated) in conjunction with or in substitution of metformin. This
recommendation is for patients at risk of atherosclerosis, heart failure or chronic
kidney disease, in order to help them reduce cardiovascular events and disease
progression. Past guidelines recommended using the SGLT-2 inhibitor or GLP-1
receptor antagonist for heart or kidney disease. However, a combination of both is
now recommended to further reduce risks.
- This year, recommendations are included for managing patients with
conditions such as nonalcoholic fatty liver disease (NAFLD) and nonalcoholic
steatohepatitis (NASH).
- Regarding diabetic retinopathy, the guidelines indicate that intraocular
injections are the alternative to laser treatment and reduce the risk of vision
loss. Also, these injections are added as a recommendation for patients with
diabetic macular edema
- It states that low blood sugar levels are an urgent matter and that it’s
important to assess the patient’s risk of hypoglycemia and educate the
individual on making adjustments to his or her treatment.
Patient education by doctors with an individualized approach allows patients to
have quality of life and improve their physical activity, weight and diet, as well as
become familiar with new technologies.
Vaccination. Because diabetes and obesity are risk factors for COVID-19,
recommendations for vaccinations against this virus and the flu are included for
patients with diabetes and cardiovascular disease.
Weight Control The guidelines added evidence of the importance of addressing
obesity and recommend establishing a weight-loss plan that includes
recommendations on what to eat and how much to achieve a 7% initial weight loss
and increase physical activity to at least 150 minutes per week. Evidence for new
FDA-approved weight-loss drugs was also added, along with recommendations
related to the causes and treatments for hypoglycemia after bariatric surgery
Children and Adolescents. This section now includes tables with
recommendations for screening and treatments for complications and conditions
related to this population for type 1 and type 2 diabetes. Similarly, the importance of
caregivers in their role of supporting the patient is discussed, so that self-care of
their condition is not transferred prematurely at an early age. In addition, greater
importance is given to cardiovascular conditions, including more information on the
screening time and treatment. The guidelines have also added recommendations on
the use of the continuous glucose monitoring (CGM) system for those children with
type 2 diabetes receiving multiple daily injections or continuous infusions of
subcutaneous insulin.
Pregnancies. A new recommendation with telemedicine evidence in women with
gestational diabetes was included, as well as one for physical activity. For women
planning to become pregnant, a fasting sugar test is recommended, especially if the
individual has risk factors.
Technology as an ally in the health of patients with diabetes
Section 7 of these guidelines includes those technological advances that support patients
in their daily lives, especially when monitoring their glucose. Specifically, the continuous
glucose monitoring (CGM) system is one of the devices that helps patients be more aware
of their sugar levels, 24 hours a day. Last year, a CGM was recommended for those using
rapid-acting insulin (Novolog, Humalog and Fiasp, among others). Now, those using
long-acting (basal) insulin and children with type 1 and type 2 diabetes using rapid-acting
insulin have been added.
With the CGM, patients can make more informed choices in their diet and physical activity
than with a traditional glucometer, as they can see how their blood sugar levels behave
throughout the day. For patients who work and have active lives and that are prone to
neglect with prolonged periods of not eating or eating adequately, they can benefit by
having a CGM that warns them when their sugar is not under control.
These readings are recorded for the patient’s benefit and allow his or her physician to
analyze the glucose data, see trends, and evaluate ranges when the patient eats or engages
in physical activity. Evidence has shown that patients with CGMs have a more active role in
their treatment, as well as better control of their diet and drugs. This device improves their
quality of life, and helps them take timely steps to prevent their health from being affected
or going to the hospital.
While diabetes healthcare standards demonstrate the benefits of using technology as an
ally in managing this condition, they also highlight the importance of patients and their
caregivers receiving the appropriate education and training, evaluating their skills to handle
these devices, understanding their data, and using them to promote self-care, so they can
properly manage their condition.
References:
- “American Diabetes Association.” American Diabetes Association | Research, Education, Advocacy, https://diabetes.org/?ada_source=WWP211001LW001M001CC&ada_sub_source=go ogle&utm_source=google&utm_medium=search&utm_campaign=awareness-campaign &utm_term=one-time&utm_content=ad&autologin=true&s_src=AAP181101LXXXX M001CC%E2%80%9D&gclid=CjwKCAjwvsqZBhAlEiwAqAHElW6gER-oTFd0uSSEFq-J w3LHIeO1oEI3nI3tZOZ6oGS_kZA3v1AfnxoCKn8QAvD_BwE&gclsrc=aw.ds.
- “Continuous Glucose Monitoring.” National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Department of Health and Human Services, https://www.niddk.nih.gov/health-information/diabetes/overview/managing-diabetes/co ntinuous-glucose-monitoring.
- “The ADA's 2022 Standards of Medical Care in Diabetes Update.” National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Department of Health and Human Services, https://www.niddk.nih.gov/health-information/professionals/diabetes-discoveries-practi ce/ada-2022-standards-of-medical-care-in-diabetes-update.
- “Tipos De Insulina.” Diabetes Education Online, https://dtc.ucsf.edu/es/tipos-de-diabetes/diabetes-tipo-2/tratamiento-de-la-diabetes-tip o-2/medicamentos-y-terapias-2/prescripcion-de-insulina-para-diabetes-tipo-2/tipos-deinsulina/.
- “Your Guide to the 2022 Changes to the ADA Standards of Care.” DiaTribe, Nov. 2022, https://diatribe.org/your-guide-2022-changes-ada-standards-care.
- . CGM Pocket Guide - Diabetes Educator. https://www.diabeteseducator.org/docs/default-source/living-with-diabetes/guides/pock et_cgm_guide_english.pdf?sfvrsn=2.
