Each update will be published in several ways: Annotations to the published Standards of Care Guidelines, email notifications, revised standards of care slide deck, APP, and professional education programs.

Bookmark this page to keep up: http://care.diabetesjournals.org/living-standards

We published a summary of the 2019 ADA Standards of Care in WAFP PharmAid in February 2019.

The important updates made to the ADA March 27th include:

Section 10. Cardiovascular Disease and Risk Management **Endorsed by ACC**

• The MARCH UPDATE to this section includes:
  
  • Lipids: A recommendation that icosapent ethyl be considered for patients with DM and ASCVD or other cardiac risk factors on a statin with controlled LDL-C but elevated TG (135-499) to reduce CV risk.  This is based on the outcome of the REDUCE-IT trial (Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial), which determined the addition of icosapent ethyl to statin therapy for patients with high TG levels reduced CV events.

Section 9. (Pharmacologic Approaches to Glycemic Treatment), Section 10 (CV), and Section 11 (Microvascular Complications)

• The original December publication updated these sections with a new algorithm to match ADA/EASD to include consideration of key factors related to CV and Kidney disease when choosing drug therapy. The additions included heart failure and CKD as a consideration for therapy choices, and recommendations to use GLP1Ra and/or SGLT2inhibitors in patients with ASCVD, Heart Failure, or CKD. (see chart below)

• At that time, current evidence did not support using all drugs in the GP1RA and SGLT2I classes for reduction in Major Adverse Cardiac Events.  The drugs with evidence included liraglutide and semaglutide (GLP1RA), empagliflozin and canagliflozin (SGLT2I). 

• The MARCH UPDATE:
  
  • The DECLARE-TIMI 58 Trial (Dapagliflozin Effect on CV Events-Thrombosis in MI 58) showed a reduction in hospitalization for heart failure and a reduction in progression of CKD.
    
  • Updated Prescribing information for dapagliflozin has revised the approved use in patients with CKD down to > 45 ml/min eGFR (was previously > 60 ml/min eGFR)
    
    

COMING NEXT?….. Although the ADA has not made changes based on the REWIND trial (Researching CV Events with a Weekly Incretin in Diabetes). This trial was designed to test the long-term (5-year) CV effect of dulaglutide (Trulicity®) in a lower risk group to represent a general practice.  Early reports show a significant reduction in major CV events.  Based on this trial, I am adding it to my algorithm below in anticipation of the next update.

ADA Algorithm review (with updates):

• Prioritize patient centered care and shared decision making

• Medication choices should be based on patient preference and presence of comorbid cardiovascular or renal conditions, access, cost, and insurance coverage

• All patients should have access to diabetes self-management education and support, and individualized MNT

• Drug therapy choices:
  
  • METFORMIN remains the preferred first line choice PLUS lifestyle modification
    
  • Stepwise addition to initial medication is recommended based on comorbidities and patient preference: (see table below for a reminder of brand/generic names of drugs in each class)
    
  • This is a VERY abbreviated depiction of the ADA algorithm; please see the reference for full algorithms.

REFERENCE:
LEXICOMP and Living Standards of Medical Care in Diabetes: http://care.diabetesjournals.org/living-standards?utm_source=soc-032719&utm_medium=email&utm_content=living-standards&utm_campaign=PRO&s_src=email&s_subsrc=645245 .  Accessed March 28,2019