This fall/winter have been a busy season for guideline updates! From the buzz surrounding the ACC/AHA '17 hypertension guidelines to these new guidelines from the American Diabetes Association, it is clear that there are some changes on the horizon. I just finished reading through the 2018 ADA guidelines and figured I'd put together a summarized student break-down about some notable recommendations/sections that I found interesting. I'm also going to include some of my own tables that I've created to help me remember testing criteria and risk factors, feel free to download and use them as well!


Improving Care and Promoting Health in Populations

The ADA recommendations regarding diabetes and population health are focused around the importance of patient-centered care. Care should be aligned with evidence-based guidelines, and balanced with patient preference, prognoses and comorbidities. In other words, the focus of care should really be centered around the individual and not the disease.

Something I found interesting about this section was that the national mean A1c has declined from 7.6% (1999-2002) to 7.2% (2007-2010), but despite this up to 50% of patients with diabetes do not meet their targets for glycemic control, lipids or blood pressure. Only 14% meet the recommendations for all three. This has huge implications considering the risk for cardiovascular disease associated with diabetes and the recent push to prescribe anti-diabetic agents with additional cardiovascular benefit.

In order to improve upon our current diabetes care delivery standards and quality of care delivered, the ADA introduces the Chronic Care Model (CCM). It consists of six elements:

1. Delivery system design (moving from a reactive to a proactive care delivery system where planned visits are coordinated through a team-based approach)
2. Self-management support
3. Decision support (basing care on evidence-based, effective care guidelines)
4. Clinical information systems (using registries that can provide patient-specific and population-based support to the care team)
5. Community resources and policies (identifying or developing resources to support healthy lifestyles)
6. Health systems (to create a quality-oriented culture)

Type 2 Diabetes Mellitus




Comprehensive Medical Evaluation and Comorbidities

This section stresses the importance of comprehensive medical care, where all comorbidities, psychosocial issues and patient factors are evaluated and addressed initially and at future follow-up visits. Additionally, aspects like past medical and family history, social history, medications, vaccinations, physical exam, laboratory measures and technology use should be documented initially and at each visit.

This a great section to read to understand many of the comorbidities patients with diabetes are at risk for or commonly develop and how to manage them. In particular, I'd like to highlight the recommendations for immunizations. Patients with diabetes are especially at risk to developing infections like pneumococcal pneumonia and influenza, which could led to further complications like hyperglycemia due to infection, bacteremia, and even death. It is important that vaccinations are talked about and documented at every follow up visit and that precise records are kept.

Immunizations recommendations

• Annual influenza is recommended to anyone >6 months of age including those with diabetes
• 3-dose series of Hepatitis B should be administered to patients 19yo-59yo with diabetes. Vaccination can be considered to patients with diabetes >60yo
• Pneumococcal pneumonia vaccination should include the 4-dose PCV13 before age 2yo, and then an additional PPSV23 for ages 2-64yo.
• Zoster, HPV and TdAP vaccines are recommended following the same CDC guidelines for the general public without diabetes

Glycemic Targets

There is little evidence directed us on how to prescribe self-monitoring blood glucose for patients on basal insulin and oral agents compared to those on intensive insulin regimens. That being said, the decision to prescribe self-monitoring blood glucose should take into account the patient's preference, ability and glycemic control. For patients on intensive insulin regimens, the ADA lists many situations where testing may be recommended (before meals, after meals, before driving, at bedtime, the list goes ON). The burden of testing this many times a day (6-10 if you went by their recommendations) makes it even more necessary to include patient factors in the decision on how many times to test. Otherwise, the goals themselves haven't really changed:

A1c goals

• Non-pregnant adults: <7%
• More stringent goals like <6.5% can be recommended for selected individuals if it can be achieved without hypoglycemia or other adverse effects or polypharmacy
• Less stringent goals like <8% can be considered for those with a history of severe hypoglycemia, limited life expectancy, advanced micro or macrovascular complications or extensive comorbidities