Standards of Medical Care in Diabetes—2018 Abridged for Primary Care Providers
This article contains updated information as of October 5, 2018.
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.
Read more about the living Standards of Care.
Read about the methodoloy.
8. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2018
This article contains updated information as of October 5, 2018.
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.
Read more about the living Standards of Care.
Read about the methodoloy.
Insulin-treated patients with hypoglycemia unawareness or an episode of clinically significant hypoglycemia should be advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. A
This recommendation is offically updated to state the following:
Insulin-treated patients with hypoglycemia unawareness or an episode of level 2 (<54 mg/dL [3.0 mmol/L]) hypoglycemia should be advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. A
Reason for Change: Alignment of terminology/definitions will minimize confusion for practitioners. To align hypoglycemia definitions between a consensus report (reference below) and the Standards of Care, hypoglycemia has been re-categorized into 3 levels as outlined in the annotation to table 6.3.
References:
Agiostratidou G, Anhalt H, Ball D, et al. Standardizing Clinically Meaningful Outcome Measures Beyond HbA1c for Type 1 Diabetes: A Consensus Report of the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endocrine Society, JDRF International, The Leona M. and Harry B. Helmsley Charitable Trust, the Pediatric Endocrine Society, and the T1D Exchange. Diabetes Care 2017;40:1622-1630.
American Diabetes Association. 6. Glycemic targets: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S55–S64. Retrieved from https://hyp.is/wmtWGjwnEeiOWY_FhVG-zA/care.diabetesjournals.org/content/41/Supplement_1/S55.
Annotation published April 11, 2018.
Annotation approved by PPC: March 10, 2018.
Suggested Citation: American Diabetes Association. Standards of Medical Care in Diabetes—2018 Abridged for Primary Care Providers [web annotation]. Clinical Diabetes 2018;36(1):14-37. Retrieved from https://hyp.is/GRjHQj2iEei1dkdhu5hlMw/clinical.diabetesjournals.org/content/36/1/14.
Glucagon should be prescribed for all individuals at increased risk of clinically significant hypoglycemia, defined as blood glucose <54 mg/dL (3.0 mmol/L), so it is available should it be needed. Caregivers, school personnel, or family members of these individuals should know where it is and when and how to administer it. Glucagon administration is not limited to health care professionals. E
This recommendation is officially updated to state the following:
Glucagon should be prescribed for all individuals at increased risk of level 2 hypoglycemia, defined as blood glucose <54 mg/dL (3.0 mmol/L), so it is available should it be needed. Caregivers, school personnel, or family members of these individuals should know where it is and when and how to administer it. Glucagon administration is not limited to health care professionals. E
Reason for Change: Alignment of terminology/definitions will minimize confusion for practitioners. To align hypoglycemia definitions between a consensus report (reference below) and the Standards of Care, hypoglycemia has been re-categorized into 3 levels as outlined in the annotation to table 6.3.
References:
Agiostratidou G, Anhalt H, Ball D, et al. Standardizing Clinically Meaningful Outcome Measures Beyond HbA1c for Type 1 Diabetes: A Consensus Report of the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endocrine Society, JDRF International, The Leona M. and Harry B. Helmsley Charitable Trust, the Pediatric Endocrine Society, and the T1D Exchange. Diabetes Care 2017;40:1622-1630.
American Diabetes Association. 6. Glycemic targets: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S55–S64. Retrieved from https://hyp.is/wmtWGjwnEeiOWY_FhVG-zA/care.diabetesjournals.org/content/41/Supplement_1/S55.
Annotation published April 11, 2018.
Annotation approved by PPC: March 10, 2018.
Suggested Citation: American Diabetes Association. Standards of Medical Care in Diabetes—2018 Abridged for Primary Care Providers [web annotation]. Clinical Diabetes 2018;36(1):14-37. Retrieved from https://hyp.is/bRFwXD2hEeidg9OXP8lExw/clinical.diabetesjournals.org/content/36/1/14.
The hypoglycemia alert value in hospitalized patients is defined as blood glucose ≤70 mg/dL (3.9 mmol/L) and clinically significant hypoglycemia as glucose values <54 mg/dL (3.0 mmol/L).
This section is officially updated to state the following:
"Level 1 hypoglycemia in hospitalized patients is defined as a blood glucose <70 mg/dL (3.9 mmol/L) and level 2 hypoglycemia as glucose values <54 mg/dL (3.0 mmol/L)."
Reason for Change: Alignment of terminology/definitions will minimize confusion for practitioners. To align hypoglycemia definitions between a consensus report (reference below) and the Standards of Care, hypoglycemia has been re-categorized into 3 levels as outlined described in the annotation to table 6.3.
References:
Agiostratidou G, Anhalt H, Ball D, et al. Standardizing Clinically Meaningful Outcome Measures Beyond HbA1c for Type 1 Diabetes: A Consensus Report of the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endocrine Society, JDRF International, The Leona M. and Harry B. Helmsley Charitable Trust, the Pediatric Endocrine Society, and the T1D Exchange. Diabetes Care 2017;40:1622-1630.
American Diabetes Association. 6. Glycemic targets: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S55–S64. Retrieved from https://hyp.is/wmtWGjwnEeiOWY_FhVG-zA/care.diabetesjournals.org/content/41/Supplement_1/S55.
Annotation published April 11, 2018. Annotation approved by PPC: March 10, 2018.
Suggested Citation: American Diabetes Association. Standards of Medical Care in Diabetes—2018 Abridged for Primary Care Providers [web annotation]. Clinical Diabetes 2018;36(1):14-37. Retrieved from https://hyp.is/ZrydmD2iEeiE8GuxzoHaoA/clinical.diabetesjournals.org/content/36/1/14.
14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2018
This article contains updated information as of April 11, 2018.
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. The annotated Standards of Medical Care are referred to as the "living" Standards.
Read more about the living Standards.
Read about the [methodology] (https://professional.diabetes.org/content-page/living-standards) behind the living Standards.
The hypoglycemia alert value in hospitalized patients is defined as blood glucose ≤70 mg/dL (3.9 mmol/L) (17) and clinically significant hypoglycemia as glucose values <54 mg/dL (3.0 mmol/L). Severe hypoglycemia is defined as that associated with severe cognitive impairment regardless of blood glucose level (17).
For alignment with the annotation to table 6.3, this section of text is officially updated to state the following:
"Level 1 hypoglycemia in hospitalized patients is defined as a measurable glucose concentration <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L). Level 2 hypoglycemia (defined as a blood glucose concentration <54 mg/dL [3.0 mmol/L]) is the threshold at which neuroglycopenic symptoms begin to occur and requires immediate action to resolve the hypoglycemic event. Lastly, level 3 hypoglycemia is defined as a severe event characterized by altered mental and/or physical functioning that requires assistance from another person for recovery."
Annotation published April 11, 2018.
Annotation approved by PPC: March 10, 2018.
Suggested citation: American Diabetes Association. 14. Diabetes care in the hospital: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S144–S151. Retrieved from https://hyp.is/ah1vYjwrEeiRdH_dRhvglA/care.diabetesjournals.org/content/41/Supplement_1/S144.
GLP-1 receptor agonists
Semaglutide now included among GLP-1 receptor agonists
In December 2017, the U.S. FDA approved the GLP-1 receptor agonist semaglutide as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes.
Reference:
U.S. Food & Drug Administration. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&applno=209637. Accessed January 1, 2018
Rationale: Approval of new treatments (medications or devices) has the potential to impact patient care.
Annotation published April 11, 2018.
Annotation approved by PPC: March 10, 2018.
Suggested citation: American Diabetes Association. 8. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S73–S85. Retrieved from [link to annotation].
SGLT2 inhibitors
Ertugliflozin now included among SGLT2 inhibitors
In December 2017, the U.S. Food and Drug Administration approved the SGLT2 inhibitor ertugliflozin as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes.
Reference:
U.S. Food and Drug Administration. Drugs@FDA: FDA Approved Drug Products. Available from https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&applno=209803. Accessed 1 January 2018
Rationale/Reason for Change: Approval of new treatments (medications or devices) has the potential to impact patient care.
Annotation published April 11, 2018.
Annotation approved by PPC: March 10, 2018.
Suggested citation: American Diabetes Association. 8. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S73–S85. Retrieved from https://hyp.is/1LVY-jwpEeiYsffMyzm1HQ/care.diabetesjournals.org/content/41/Supplement_1/S73.
Table 8.2
Table 8.2 to include semaglutide
In December 2017, the U.S. FDA approved the GLP-1 receptor agonist semaglutide as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes.
Reference:
U.S. Food & Drug Administration. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&applno=209637. Accessed January 1, 2018
Rationale/Reason for Change: Approval of new treatments (medications or devices) has the potential to impact patient care.
Annotation published April 11, 2018.
Annotation approved by PPC: March 10, 2018.
Suggested citation: American Diabetes Association. 8. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S73–S85. Retrieved from https://hyp.is/D0tVED2WEeiK8ZvLIDyLZg/care.diabetesjournals.org/content/41/Supplement_1/S73.
Table 8.2
Table 8.2 to include ertugliflozin
In December 2017, the U.S. Food and Drug Administration approved the SGLT2 inhibitor ertugliflozin as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes.
Reference:
U.S. Food and Drug Administration. Drugs@FDA: FDA Approved Drug Products. Available from https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&applno=209803. Accessed 1 January 2018
Rationale/Reason for Change: Approval of new treatments (medications or devices) has the potential to impact patient care.
Annotation published April 11, 2018.
Annotation approved by PPC: March 10, 2018.
Suggested citation: American Diabetes Association. 8. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S73–S85. Retrieved from https://hyp.is/8Qjypj2VEei_E2-Ft0MSjQ/care.diabetesjournals.org/content/41/Supplement_1/S73.
14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2018
This article contains updated information as of April 11, 2018.
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. The annotated Standards of Medical Care are referred to as the "living" Standards.
Read more about the living Standards.
Read about the [methodology] (https://professional.diabetes.org/content-page/living-standards) behind the living Standards.
8. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2018
This article contains updated information as of April 11, 2018.
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. The annotated Standards of Medical Care are referred to as the "living" Standards.
Read more about the living Standards.
Read about the [methodology] (https://professional.diabetes.org/content-page/living-standards) behind the living Standards.
6. Glycemic Targets: Standards of Medical Care in Diabetes—2018
This article contains updated information as of April 11, 2018.
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. The annotated Standards of Medical Care are referred to as the "living" Standards.
Read more about the living Standards.
Read about the [methodology] (https://professional.diabetes.org/content-page/living-standards) behind the living Standards.
14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2018
This article contains updated information as of April 11, 2018.
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. The annotated Standards of Medical Care are referred to as the "living" Standards.
Read more about the living Standards.
Read about the [methodology] (https://professional.diabetes.org/content-page/living-standards) behind the living Standards.
6. Glycemic Targets: Standards of Medical Care in Diabetes—2018
This article contains updated information as of April 11, 2018.
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. The annotated Standards of Medical Care are referred to as the "living" Standards.
Read more about the living Standards.
Read about the [methodology] (https://professional.diabetes.org/content-page/living-standards) behind the living Standards.
Glucagon should be prescribed for all individuals at increased risk of clinically significant hypoglycemia, defined as blood glucose <54 mg/dL (3.0 mmol/L), so it is available should it be needed. Caregivers, school personnel, or family members of these individuals should know where it is and when and how to administer it. Glucagon administration is not limited to health care professionals. E
For alignment with the annotation to table 6.3, this recommendation is offically updated to state the following:
Glucagon should be prescribed for all individuals at increased risk of level 2 hypoglycemia, defined as blood glucose <54 mg/dL (3.0 mmol/L), so it is available should it be needed. Caregivers, school personnel, or family members of these individuals should know where it is and when and how to administer it. Glucagon administration is not limited to health care professionals. E
Annotation published April 11, 2018.
Annotation approved by PPC: March 10, 2018.
Suggested citation: American Diabetes Association. 6. Glycemic targets: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S55–S64. Retrieved from https://hyp.is/7fVa4jwnEeiJD0vde2XXyw/care.diabetesjournals.org/content/41/Supplement_1/S55.
Insulin-treated patients with hypoglycemia unawareness or an episode of clinically significant hypoglycemia should be advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. A
For alignment with the annotation to table 6.3, this recommendation is offically updated to state the following:
Insulin-treated patients with hypoglycemia unawareness or an episode of level 2 (<54 mg/dL [3.0 mmol/L]) hypoglycemia should be advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. A
Annotation published April 11, 2018.
Annotation approved by PPC: March 10, 2018.
Suggested citation: American Diabetes Association. 6. Glycemic targets: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S55–S64. Retrieved from https://hyp.is/DIadcjwoEeiDyj_McVdDvg/care.diabetesjournals.org/content/41/Supplement_1/S55.
Recommendations from the International Hypoglycemia Study Group regarding the classification of hypoglycemia in clinical trials are outlined in Table 6.3 (75). Of note, this classification scheme considers a blood glucose <54 mg/dL (3.0 mmol/L) detected by SMBG, CGM (for at least 20 min), or laboratory measurement of plasma glucose as sufficiently low to indicate clinically significant hypoglycemia that should be included in reports of clinical trials of glucose-lowering drugs for the treatment of diabetes (75). However, a hypoglycemia alert value of ≤70 mg/dL (3.9 mmol/L) can be important for therapeutic dose adjustment of glucose-lowering drugs in clinical care and is often related to symptomatic hypoglycemia. Severe hypoglycemia is defined as severe cognitive impairment requiring assistance from another person for recovery
For alignment with the annotation to table 6.3, this section of text is officially updated to state the following:
"Recommendations regarding the classification of hypoglycemia are outlined in Table 6.3. Level 1 hypoglycemia is defined as a measurable glucose concentration <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L). A blood glucose concentration of 70 mg/dL has been recognized as a threshold for neuroendocrine responses to falling glucose in people without diabetes. Because many people with diabetes demonstrate impaired counterregulatory responses to hypoglycemia and/or experience hypoglycemia unawareness, a measured glucose level <70 mg/dL (3.9 mmol/L) is considered clinically important, independent of the severity of acute hypoglycemic symptoms. Level 2 hypoglycemia (defined as a blood glucose concentration <54 mg/dL [3.0 mmol/L]) is the threshold at which neuroglycopenic symptoms begin to occur, and requires immediate action to resolve the hypoglycemic event. Lastly, level 3 hypoglycemia is defined as a severe event characterized by altered mental and/or physical functioning that requires assistance from another person for recovery."
Annotation published April 11, 2018.
Annotation approved by PPC: March 10, 2018.
Suggested citation: American Diabetes Association. 6. Glycemic targets: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S55–S64. Retrieved from https://hyp.is/wZBZiDwoEeihcafMFp0hhw/care.diabetesjournals.org/content/41/Supplement_1/S55.
Table 6.3
Table 6.3 is officially updated to align with a recently published Consensus Report: "Standardizing Clinically Meaningful Outcome Measures Beyond HbA1c for Type 1 Diabetes: A Consensus Report of the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endocrine Society, JDRF International, The Leona M. and Harry B. Helmsley Charitable Trust, the Pediatric Endocrine Society, and the T1D Exchange. The consensus report categorized hypoglycemia into 3 levels as outlined in the following table:
Reference:
Agiostratidou G, Anhalt H, Ball D, et al. Standardizing Clinically Meaningful Outcome Measures Beyond HbA1c for Type 1 Diabetes: A Consensus Report of the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endocrine Society, JDRF International, The Leona M. and Harry B. Helmsley Charitable Trust, the Pediatric Endocrine Society, and the T1D Exchange. Diabetes Care 2017;40:1622-1630
Rationale/reason for change:
To align hypoglycemia definitions between the consensus report and the Standards of Care. Alignment of terminology/definitions will minimize confusion for practitioners.
Annotation published April 11, 2018.
Annotation approved by PPC: March 10, 2018.
Suggested citation: American Diabetes Association. 6. Glycemic targets: Standards of Medical Care in Diabetes—2018 [web annotation]. Diabetes Care 2018;41(Suppl. 1):S55–S64. Retrieved from https://hyp.is/wmtWGjwnEeiOWY_FhVG-zA/care.diabetesjournals.org/content/41/Supplement_1/S55.