See page S101. Ann Intern Med. Join ADA's Chief Scientific and Medical Officer, Robert Gabbay, MD, PhD, for a presentation on the key updates and highlights from the 2021 Standards of Medical Care in Diabetes.. View Webcast View Webcast with CE. Thus, trial results support injectable GLP-1 RAs as the preferred option for patients requiring the potency of an injectable therapy for glucose control (Fig. Insulin has the advantage of being effective where other agents are not and should be considered as part of any combination regimen when hyperglycemia is severe, especially if catabolic features (weight loss, hypertriglyceridemia, ketosis) are present. Alternatively, in a patient on basal insulin in whom additional prandial coverage is desired, the regimen can be converted to two doses of a premixed insulin. The safety and efficacy of hybrid closed-loop systems has been supported in the literature in adolescents and adults with type 1 diabetes (15,16), and recent evidence suggests that a closed-loop system is superior to sensor-augmented pump therapy for glycemic control and reduction of hypoglycemia over 3 months of comparison in children and adults with type 1 diabetes (17). Pharmacologic approaches to glycemic treatment: Standards of medical care in diabetes – 2020. A, 9.3 Patients with type 1 diabetes should be trained to match prandial insulin doses to carbohydrate intake, premeal blood glucose, and anticipated physical activity. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Glycemic Targets Assessment of Glycemic Control A1C Testing A1C Goals Hypoglycemia Intercurrent Illness S57 7. Diabetes Care. However, there is no consensus to guide the choice of injection or pump therapy in a given patient, and research to guide this decision-making is needed (12). National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Would you like email updates of new search results? The addition of the glucagon-like peptide 1 (GLP-1) receptor agonists (RAs) liraglutide and exenatide to insulin therapy caused small (0.2%) reductions in A1C compared with insulin alone in people with type 1 diabetes and also reduced body weight by ∼3 kg (29). Pharmacologic Approaches to Glycemic Treatment Pharmacologic Approaches to Glycemic Management: Standards of Medical Care in Diabetes - 2020.Diabetes Care 2020… Recommendations: Injectable and oral glucose-lowering drugs have been studied for their efficacy as adjuncts to insulin treatment of type 1 diabetes. 1):S98–S110. The U.S. Food and Drug Administration (FDA) has also approved the first hybrid closed-loop pump system. Once a basal/bolus insulin regimen is initiated, dose titration is important, with adjustments made in both mealtime and basal insulins based on the blood glucose levels and an understanding of the pharmacodynamic profile of each formulation (pattern control). People with type 2 diabetes are generally more insulin resistant than those with type 1 diabetes, require higher daily doses (∼1 unit/kg), and have lower rates of hypoglycemia (77). Description: 9.1 Most people with type 1 diabetes should be treated with multiple daily injections of prandial and basal insulin, or continuous subcutaneous insulin infusion. As referenced above, there are now numerous evidence-based insulin delivery recommendations that have been published. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2020American Diabetes Association Add to Selected Citations Diabetes Care 2020 Jan; 43 (Supplement 1): S98-S110. Despite the introduction of advanced insulin analogs and improvements in insulin delivery devices, many patients with type 2 diabetes continue to experience suboptimal glycemic control. Titration can be based on home glucose monitoring or A1C. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. All patients require spirometry (FEV1) testing to identify potential lung disease prior to and after starting inhaled insulin therapy. In addition, the American Diabetes Association position statement “Type 1 Diabetes Management Through the Life Span” provides a thorough overview of type 1 diabetes treatment (19). Although there are numerous trials comparing dual therapy with metformin alone, there is little evidence to support one combination over another. DSMES, diabetes self-management education and support; FPG, fasting plasma glucose; FRC, fixed-ratio combination; GLP-1 RA, glucagon-like peptide 1 receptor agonist; max, maximum; PPG, postprandial glucose. Sign In to Email Alerts with your Email Address. Despite the advantages of insulin analogs in patients with type 1 diabetes, for some patients the expense and/or intensity of treatment required for their use is prohibitive. Considerations include cardiovascular comorbidities, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences (Table 9.2 and Figure 9.1). Intensifying to injectable therapies. If basal insulin has been titrated to an acceptable fasting blood glucose level (or if the dose is >0.5 units/kg/day) and A1C remains above target, consider advancing to combination injectable therapy (Fig. E, 9.9 Among patients with type 2 diabetes who have established atherosclerotic cardiovascular disease or indicators of high risk, established kidney disease, or heart failure, a sodium–glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit (Table 9.1, Table 10.3B, Table 10.3C) is recommended as part of the glucose-lowering regimen independent of A1C and in consideration of patient-specific factors (Figure 9.1). In addition to hyperglycemia, insulinopenia can contribute to other metabolic disturbances like hypertriglyceridemia and ketoacidosis as well as tissue catabolism that can be life threatening. In cardiovascular outcomes trials, empagliflozin, canagliflozin, dapagliflozin, liraglutide, semaglutide, and dulaglutide all had beneficial effects on indices of CKD. To approach this variability in people using insulin treatment, strategies have evolved to adjust prandial doses based on predicted needs. 2017 Oct 3;167(7):493-498. doi: 10.7326/M17-1259. Similarly, results have been reported for several agents currently approved only for the treatment of type 2 diabetes. Please enable it to take advantage of the complete set of features! Cardiovascular Disease and Risk Management–2020.  |  Longer-acting basal analogs (U-300 glargine or degludec) may convey a lower hypoglycemia risk compared with U-100 glargine when used in combination with oral agents (68–74). Proper insulin injection technique includes injecting into appropriate body areas, injection site rotation, appropriate care of injection sites to avoid infection or other complications, and avoidance of intramuscular (IM) insulin delivery. Additional large randomized trials of other agents in these classes are ongoing. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. In people with type 1 diabetes, treatment with analog insulins is associated with less hypoglycemia and weight gain as well as lower A1C compared with human insulins (4–6). A, 9.6 Early combination therapy can be considered in some patients at treatment initiation to extend the time to treatment failure. Results of recent large trials with cardiovascular and renal outcomes are emphasized. Insulin initiation and titration can be challenging for many primary care providers who are involved in the treatment of patients with type 2 diabetes. Created Date: The FDA has also approved a concentrated formulation of rapid-acting insulin lispro, U-200 (200 units/mL). Thank you for your interest in spreading the word about Diabetes Care. 9.2). E. The American Diabetes Association/European Association for the Study of Diabetes consensus report “Management of Hyperglycemia in Type 2 Diabetes, 2018” and the 2019 update (33,34) recommend a patient-centered approach to choosing appropriate pharmacologic treatment of blood glucose (Fig. For patients without established ASCVD, indicators of high ASCVD risk, HF, or CKD, the choice of a second agent to add to metformin is not yet guided by empiric evidence. © 2021 by the American Diabetes Association. The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. U-500 regular insulin is, by definition, five times more concentrated than U-100 regular insulin. The arrival of continuous glucose monitors to clinical practice has proven beneficial in specific circumstances. However, there is data to support initial combination therapy for more rapid attainment of glycemic goals (43,44), and a recent clinical trial has demonstrated that this approach is superior to sequential addition of medications for extending primary and secondary failure (45). 1):S98–S110 - August 01, 2020, http://www.diabetesjournals.org/content/license, http://www.fda.gov/Drugs/DrugSafety/ucm493244.htm, http://www.micromedexsolutions.com/micromedex2/4.34.0/WebHelp/RED_BOOK/Introduction_to_REDB_BOOK_Online.htm, https://data.medicaid.gov/Drug-Pricing-and-Payment/NADAC-National-Average-Drug-Acquisition-Cost-/a4y5-998d, 9. Diabetes Care, 43 (Supplement 1), S98-S110. For appropriate context, see Fig. American Diabetes Association S98 Diabetes Care Volume 43, Supplement 1, January 2020 9. Figure 9.2 outlines these options, as well as recommendations for further intensification, if needed, to achieve glycemic goals. Classification. With the advent of improved continuous glucose monitors, closed-loop pump-sensor systems, and devices that offer alternative approaches for patients with hypoglycemia unawareness, the role of pancreas transplantation alone, as well as islet transplant, will need to be reconsidered. care.diabetesjournals.org Pharmacologic Approaches to Glycemic Treatment S101 ©2019 ... Current pharmacologic treatment op-tions for youth-onset type 2 diabetes are limited to three approved drugsd ... January 2020 ©2019 American Diabetes Association. Therefore, consideration of cost is an important component of effective management. 9.2). These concentrated preparations may be more convenient and comfortable for patients to inject and may improve adherence in those with insulin resistance who require large doses of insulin. 9.2). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2020 American Diabetes Association Diabetes Care 2020 Jan; 43 … There are now multiple large randomized controlled trials reporting statistically significant reductions in cardiovascular events in patients with type 2 diabetes treated with an SGLT2 inhibitor (empagliflozin, canagliflozin, dapagliflozin) or GLP-1 RA (liraglutide, semaglutide, dulaglutide); see Section 10 “Cardiovascular Disease and Risk Management” (https://doi.org/10.2337/dc20-S010) for details. However, patients receiving these treatments require life-long immunosuppression to prevent graft rejection and/or recurrence of autoimmune islet destruction. Diabetes Care 2020;43(Suppl. To develop the 2020 Standards, the ADA Professional Practice Committee, comprising physicians, adult and pediatric endocrinologists, diabetes educators, registered dietitians, epidemiologists, pharmacists, and public health experts, continuously searched MEDLINE (English language only) from 15 October 2018 through August-September 2019 for pertinent studies, including high-quality trials that addressed pharmacologic management of type 2 diabetes. For these patients, incorporating one of the SGLT2 inhibitors or GLP-1 RAs that have been demonstrated to have cardiovascular disease benefit is recommended (Table 9.1). Inhaled insulin is contraindicated in patients with chronic lung disease, such as asthma and chronic obstructive pulmonary disease, and is not recommended in patients who smoke or who recently stopped smoking. doi: 10.2337/dc18-S008. Inhaled insulin is available for prandial use with a limited dosing range; studies in people with type 1 diabetes suggest rapid pharmacokinetics (7). In addition, new longer-acting basal analogs (U-300 glargine or degludec) may confer a lower hypoglycemia risk compared with U-100 glargine in patients with type 1 diabetes (9,10). On the other hand, two doses of premixed insulin is a simple, convenient means of spreading insulin across the day. Drug-specific and patient factors to consider when selecting antihyperglycemic treatment in adults with type 2 diabetes. Adapted from Davies et al. Section 12 “Older Adults”(https://doi.org/10.2337/dc20-S012) has a full discussion of treatment considerations in older adults, a setting where changes of glycemic goals and de-escalation of therapy is common. Ann Intern Med. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes. Methods: 9.2). Recommended starting dose is 500mg daily with the evening meal, increasing as needed to achieve goals to a total dose of 2000mg per day (ADA, 2020). Exogenous-delivered insulin should be injected into subcutaneous tissue, not intramuscularly. Pharmacologic Approaches to Glycemic Treatment. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Pharmacologic approaches to the management of glycemia in patients with type 2 diabetes (T2D) are discussed in section 9. Diabetes Care 2020;43(Suppl. 2020 Jan;43(Suppl 1):S98-S110. Epub 2017 Mar 14. Each approach has advantages and disadvantages. A recent randomized trial confirmed previous observations that metformin use is associated with vitamin B12 deficiency and worsening of symptoms of neuropathy (38). 9 [ea] Section 9. Medication costs can be a major source of stress for patients with diabetes and contribute to worse adherence with medications (56); cost-reducing strategies may improve adherence in some cases (57). ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; CV, cardiovascular; CVD, cardiovascular disease; CVOTs, cardiovascular outcomes trials; DPP-4i, dipeptidyl peptidase 4 inhibitor; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide 1 receptor agonist; HF, heart failure; SGLT2i, sodium–glucose cotransporter 2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione. Starting with a single prandial dose with the largest meal of the day is simple and effective, and it can be advanced to a regimen with multiple prandial doses if necessary (87). The addition of basal insulin, either human NPH or one of the long-acting insulin analogs, to oral agent regimens is a well-established approach that is effective for many patients. The combination of basal insulin and GLP-1 RA has potent glucose-lowering actions and less weight gain and hypoglycemia compared with intensified insulin regimens (84–86). 2018 Jan;41(Suppl 1):S73-S85. Comprehensive education regarding self-monitoring of blood glucose, diet, and the avoidance and appropriate treatment of hypoglycemia are critically important in any patient using insulin. Diabetes can be classified … As of 2018, the ADA updates and revises the online version of the Standards of Care throughout the year, making necessary additions and annotations as new evidence and regulatory changes merit immediate incorporation. Section 12 “Older Adults” (https://doi.org/10.2337/dc20-S012) and Section 13 “Children and Adolescents” (https://doi.org/10.2337/dc20-S013) have recommendations specific for older adults and for children and adolescents with type 2 diabetes, respectively; Section 10 “Cardiovascular Disease and Risk Management” (https://doi.org/10.2337/dc20-S010) and Section 11 “Microvascular Complications and Foot Care” (https://doi.org/10.2337/dc20-S011) have recommendations for the use of glucose-lowering drugs in the management of cardiovascular and renal disease, respectively. For patients with established ASCVD or indicators of high ASCVD risk (such as patients ≥55 years of age with coronary, carotid, or lower-extremity artery stenosis >50% or left ventricular hypertrophy), established kidney disease, or heart failure, an SGLT-2 inhibitor or GLP-1 RA with demonstrated CVD benefit (Table 9.1, Table 10.3B, Table 10.3C) is recommended as part of the glucose-lowering regimen independent of A1C and in consideration of patient-specific factors (Figure 9.1). Treatment ” in the complete 2020 Standards of Care for. This includes consideration of efficacy and key patient factors: 1) important comorbidities such as atherosclerotic cardiovascular disease (ASCVD) and indicators of high ASCVD risk, chronic kidney disease (CKD), and heart failure (HF) (see Section 10 “Cardiovascular Disease and Risk Management,” https://doi.org/10.2337/dc20-S010, and Section 11 “Microvascular Complications and Foot Care,” https://doi.org/10.2337/dc20-S011), 2) hypoglycemia risk, 3) effects on body weight, 4) side effects, 5) cost, and 6) patient preferences.  |  Epub 2015 Mar 13. Many individuals with type 2 diabetes require doses of insulin before meals, in addition to basal insulin, to reach glycemic targets. 1): S64-S74 Over the last 25 years, rapid-acting and long-acting insulin analogs have been developed that have distinct pharmacokinetics compared with recombinant human insulins: basal insulin analogs have longer duration of action with flatter, more constant plasma concentrations and activity profiles than NPH insulin; rapid-acting analogs (RAA) have a quicker onset and peak and shorter duration of action than regular human insulin. Pharmacologic Approaches to Glycemic Treatment of Type 2 Diabetes: Synopsis of the 2020 American Diabetes Association's Standards of Medical Care in Diabetes Clinical Guideline Ann Intern Med . Patients and/or caregivers should receive education about proper injection site rotation and to recognize and avoid areas of lipohypertrophy. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. American Diabetes Association (ADA) 2020 Standards of Medical Care in Diabetes 2020 Summary of Revisions American Diabetes Association (ADA) 2020 Summary of Revisions 2020 Pharmacologic Approaches to Glycemic Treatment American Diabetes Association (ADA) Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes 2020