Diabetes
Olivia C. Welter, PharmD
The American Diabetes Association (ADA) released its latest round of updates to their standards of care in diabetes for 2024 at the end of 2023. The updated guidelines include many gold standards for practitioners to follow when managing patients who have or who are at risk of developing diabetes.
The guideline also provides important updates on weight loss medications, hypoglycemia prevention and management, delaying onset of T1D, and even some changes to the diagnosis and classification of diabetes.
Diagnosis and classification changes
In the new update, ADA added a recommendation that directs practitioners to classify patients with hyperglycemia into appropriate diagnostic categories to aid providers in personalizing management for each patient. The different categories include T1D, T2D, diabetes caused by other factors, and gestational diabetes, though the standards offer additional subcategories in the ADA position statement, “Diagnosis and Classification of Diabetes Mellitus.”
The subsection titled “Type 1 Diabetes” refines diagnostic criteria to align with the recent FDA approval of a new drug—teplizumab-mzwv (TZIELD)—that delays the incidence of T1D. A new flowchart was added to the same subsection to visually guide clinicians in investigating suspected T1D in newly diagnosed adults.
Delaying onset of T1D
FDA recently approved teplizumab-mzwv as an infusion to prevent the onset of symptomatic stage 3 T1D in patients 8 years old or older with stage 2 T1D. Recommendation 3.15 was added to the standards to reflect that this new therapy can now be used in the selected population.
Hypoglycemia monitoring and management
ADA updated several recommendations previously presented in this section to address strategies for managing hypoglycemia.
Notably, the standards recommend glycemic assessments every 3 months instead of twice a year for individuals not meeting treatment goals, those with frequent or severe hypoglycemia or hyperglycemia, patients changing health status, or for youth growing and developing. A new recommendation, 6.11d, was added to highlight the benefits of continuous glucose monitoring (CGM) for hypoglycemia prevention.
ADA said health care providers should prescribe glucagon for everyone taking insulin or those at high risk for hypoglycemia. Additionally, individuals close to the patient should be educated on how to administer it, according to the standards.
ADA also recommended prioritizing re-evaluation of a patient’s diabetes treatment plan if they experience one or more episodes of level 2 or level 3 hypoglycemia. Level 2 is defined as when a patient’s blood glucose is less than 54 mg/dL, while level 3 is the most severe classification and is characterized by altered mental and/or physical status requiring assistance for hypoglycemia treatment.
Obesity and weight management
In the standards, ADA updated a series of recommendations to add certain factors including waist circumference, waist-to-hip ratio, and waist-to-height ratio to encourage personalized body fat assessments. Previously, BMI was the primary anthropometric measurement; the updates recognize that BMI doesn’t give a full picture of how an individual’s weight affects their diabetes.
In addition, ADA added a recommendation to clarify that the preferred pharmacotherapy for obesity management in diabetes is GLP-1 receptor agonists or a combination approach with GLP-1 receptor agonists and glucose-dependent insulinotropic polypeptide (GIP).
Pharmacologic approaches to glycemic treatment
Adults. The 2024 version of the standards revisited recommendations for treating hyperglycemia in adults, resulting in several updates. Specific drug classes are included as preferred options for managing patients with comorbidities, such as atherosclerotic CVD, heart failure, and chronic kidney disease.
Additionally, dual GLP-1 receptor agonists and GIPs were included as an option for greater glycemic management, an approach that is even preferred to insulin, although insulin therapy can be considered at any stage of diabetes irrespective of other glucose-lowering medications in certain circumstances.
Children and adolescents.For children and adolescents who need glycemic management, the standards say clinicians should consider empagliflozin prior to initiating and/or intensifying insulin therapy plans.
Aging populations.Recommendations related to aging populations highlight that older adults often have more complex health conditions and therefore need more personalized glycemic goals. In the standards, ADA suggested that deintensifying therapy should be a priority in older adults, especially with medications that are known to cause hypoglycemia such as insulin, sulfonylureas, and meglitinides.
Medication costs
Recommendations to address medication costs and reimbursement rules were included throughout the guidelines. One such change modified a recommendation to align with revised Medicare reimbursement rules, which allow CGM for adults with T2D on any insulin.
The recent decrease in insulin pricing is highlighted, along with costs of specific insulins, glucagon products, and glucose monitoring devices. ■