Q&A: New diabetes guideline helps PCPs ‘keep up with latest updates’
The American Diabetes Association 2021 Standards of Medical Care in Diabetes reflects important updates regarding overbasalization, HbA1c goals in older adults and hypoglycemia assessments, according to the association.
The recommendations — which were given a grade of A, B, C or E, depending on the level of evidence supporting its use in clinical practice — also address topics such as immunizations in patients with diabetes and preventing diabetes.
Elbert Huang, MD, MPH, a primary care physician who is also director of the Center for Chronic Disease Research and Policy at the University of Chicago and a member of the American Diabetes Association’s Professional Practice Committee, discussed these and other updates to the recommendations that PCPs need to know.
Q: A new recommendation was added to caution providers about the potential for overbasalization with insulin therapy. How common is overbasalization? How can PCPs identify patients who are at risk for it?
A: This is an important new area of glycemic management that many of us can pursue. Overbasalization is a basal insulin dosage that is above 0.5 international units per kilogram. Patients who receive more insulin than that usually do not see a benefit and are at risk for weight gain and hypoglycemia. Though the exact prevalence of overbasalization is unknown, it is not hard to find patients with the condition because it is based on the measurement above.
Q: Why was the A1C goal for older adults modified?
A: The medical history of older patients with diabetes can vary. We know that there are there are at least three distinct groups of older patients with diabetes. There are different, reasonable goals for each of those groups.
The first group, patients who are 65 years of age and older who are otherwise relatively healthy, should now pursue a glucose target or HbA1C level of less than 7% to 7.5%, instead of less than 7.5%. The second group, patients with diabetes and multiple co-existing chronic conditions, still have a target glucose target or HbA1C level of less than 8%. And for that group, we did not change the recommendation.
We modified recommendations for the third group of older patients. This group is very complex living with an end-stage chronic illness or dementia or functional dependence. Since we do not have hard evidence of a definitive HbA1C level for this group of people, we recommend a range of fasting sugars and bedtime sugars.
Q: A new subsection focuses on lifestyle behaviors for diabetes prevention. What do PCPs need to know about this? How can they help patients change their lifestyle behaviors?
A: This subsection is meant to be a very practical review of CDC’s Diabetes Prevention Program in clinical practice for PCPs like me. The best studied program is the CDC National Diabetes Prevention Program. Unfortunately, because it is very hard to become a certified Diabetes Prevention Program provider, there are some communities without a provider and uptake of this program has been low.
Therefore, this subsection discusses alternative versions of the Diabetes Prevention Program, including those run by community health workers, registered dietitians and nurses. This subsection also discusses mobile application programs and books sponsored and sold by the American Diabetes Association that may be a better way to help patients prevent diabetes.
Q: Why were significant changes to the immunization section needed?
A: We wanted to have a more comprehensive description of what vaccines patients with diabetes need. We also wanted to better align our recommendations with the CDC’s Advisory Committee on Immunization Practices. So, we gathered all the existing evidence surrounding these vaccines and created one table that doctors can refer to when vaccinating patients with diabetes.
Q: What do PCPs need to know about the changes to the hypoglycemia assessment recommendations?
A: The Standards of Medical Care in Diabetes now provides more details on the three levels of hypoglycemia — those patients with glucose levels below 70 mg/dL, below 54 mg/dL and those who need medical assistance.
In addition to screening for the occurrence of hypoglycemia, we also recommend screening for hypoglycemia unawareness, where a patient’s body is unable to respond to hypoglycemia. Given the dangers of hypoglycemia unawareness, we need to make sure this group of patients receive education on hypoglycemia avoidance and have a reevaluation of their treatment regimen.
Q: A study in JAMA Internal Medicine last year suggested that Medicare Part D list prices in 2019 for second-line drugs for glycemic control sometimes cost hundreds of dollars more than the older, “traditional” formulations. The Standards of Medical Care in Diabetes recommends the more expensive drugs. How much do the benefits outweigh the high costs? When should providers consider prescribing the older formulations?
A: This is a beautifully complicated question you have asked. The Professional Practice Committee of the American Diabetes Association has always recognized that the high costs of medications patients is an important factor when developing a treatment plan with a patient. . Every year when we revisit the Standards of Care for Diabetes, Therefore, as we approach our recommendations, we look at the state of clinical trials and evidence-based medicines for diabetes treatment and ask ourselves the best way to care for patients that will optimize their health outcomes. After we review the evidence and identify all available treatment options, we ask how the cost of medicines might alter treatment decisions.
PCPs need to individualize goals for each patient with diabetes. Ask: What is the patient like? What are his or her glycemic targets? What is their lifespan? What is the likelihood of them benefiting from tight glucose control? Does the patient need a drug to begin with? We also need to ask about their social determinants of health, since we are not doing a patient a favor if we prescribe a drug that he or she cannot afford. PCPs need to ask these questions more.
Currently, to achieve glycemic goals, we too easily prescribe medications instead of promoting lifestyle interventions first. In instances where medication is still warranted, our guidelines recommend individualizing this form of treatment based on a patient’s risk for cardiovascular disease, presence of chronic kidney disease and likelihood of side effects, which are different for each glycemia-lowering drug.
While it is true that the older drugs are cheaper, the new ones have cardiovascular benefits the older ones do not. If we decide to prescribe an expensive newer agent, we have to ensure that the drug is affordable to the patient or we risk a patient going without medicines entirely. The risk is a a patient’s diabetes is completely unmanaged when drugs are unaffordable. As you can see, there are complicated questions to answer when deciding on the best regimen for a patient.
Q: What other updates to the Standards of Medical Care in Diabetes should PCPs be aware of?
A: The average primary care doctor is struggling to keep up with all the latest updates. I personally find it very hard to keep up with all the new trial literature during this time of incredible promise for patients with diabetes. The Standards of Medical Care in Diabetes is a nice way to succinctly get updates on reviews of existing literature, recommendations around first-, second- and third-line drugs for treatment and new technologies for diabetes management. Though the Standards of Medical Care in Diabetes is updated throughout the year, many PCPs look forward to January when the new edition is published.