Endocrinology

Breaking Down the 2020-2021 Diabetes Guidelines

In this Practical Updates for Primary Care 2020 Virtual Series session, the complex 2020-2021 diabetes guidelines were broken down to make it easier for health care providers to understand.

This topic of discussion was presented by Daniel Einhorn, MD, who is an endocrinologist and medical director at Scripps Whittier Diabetes Institute in San Diego, California.

He discussed the 2020 Standards of Medical Care in Diabetes by the American Diabetes Association. The latest updates to the guidelines included the official definition of prediabetes, pharmacologic interventions for prediabetes, and goals of care for a patient’s comorbidities.

Prediabetes

The American Diabetes Association now acknowledges prediabetes as a medical condition. It can be established using the following parameters:

  • Fasting plasma glucose of 100 mg/dL to 125 mg/dL ; 5.6 mmol/L to 6.9 mmol/L (impaired fasting glucose) OR
  • 2-hour plasma glucose during 75-gram oral glucose tolerance test of 140 mg/dL to 199 mg/dL ; 7.8 mmol/L to 11.0 mol/L (impaired glucose tolerance) OR
  • A1C of 5.7% to 6.4% (39-47 mmol/mol).

 

“When we started off with prediabetes, we got a lot of pushback,” Dr Einhorn said. “Again, ‘too many people, everybody would have a diagnosis. We can’t treat so many people.’ But it’s a real thing, and prediabetes fills in that gap between normal and diabetes.”

Metformin is preferred for the prevention of type 2 diabetes, especially in patients with prediabetes who have high risk for developing into type 2 diabetes and those who have a higher body mass index.

Patient-Centered Decision-Making

Dr Einhorn said to bring the patient and his or her family into the decision-making process early and establish the goals of care (see Figure 1). Give the person options, and they are more likely to adhere to medication/treatment regimen. He also recommended to set goals that are achievable and understandable to the patient.

Figure 1

Figure 1. Click the image to enlarge.

 

The then suggested using technology to help monitor patients, via continuous glucose monitoring, intermittent continuous glucose monitoring, and meaningful remote monitoring with telemedicine.

Pharmacologic Interventions

Then Dr Einhorn discussed the pharmacologic approaches to glycemic control (see Figure 2).

Figure 2

Figure 2. Click the image to enlarge.

 

“The mantra is GLP-1 and SGLT2 more or less together, as much as possible, after metformin,” he said in summary. “And it’s not just the American Diabetes Association. Every organization involved in making guidelines agrees with this. And not only agrees with it, agrees with it independent of A1C, and increasingly it may be independent of having diabetes.”

Other guidelines, such as the American Association of Clinical Endocrinologists, reflect the new approach to simplifying the treatment regimens and management strategies as much as possible.

“You decide on the patient who deserves SGLT2s and GLP1s, with the exception being pioglitazone, which is recommended for patents with prior stroke and/or fatty liver disease.”

Dr Einhorn also said that established cardiovascular disease is defined by the provider, not the US Food and Drug Administration or the package insert.

—Leigh Precopio

Reference:

Einhorn D. Diabetes guidelines 2020-2021: evolution accelerates. Talk presented at: Practical Updates in Primary Care 2020 Virtual Series; November 6-7, 2020; Virtual.