By What Standard Should We Manage Diabetes?
It is now a tradition for Clinical Diabetes to publish an abridged version of the American Diabetes Association (ADA)’s annual Standards of Medical Care in Diabetes. The 2018 abridged Standards appear in this issue, starting on p. 15. In it, the ADA Primary Care Advisory Group has summarized the latest clinical practice recommendations to make them more relevant to and accessible for primary care providers (PCPs).
These annually updated guidelines are the gold standard for diabetes medical management, laying out expectations for optimal care and providing opportunities to ensure the most favorable outcomes for patients. Within this year’s abridged Standards, PCPs will learn that the results of several recently completed cardiovascular outcome trials of antidiabetic agents (1–4), have reframed the goal of diabetes medical care from a focus on attaining A1C targets, to the more expansive evidence-based approach to decreasing the cardiovascular consequences of the disease. Individualized therapy and shared decision-making are still fundamental precepts of high-quality diabetes care, and the burgeoning armamentarium of therapeutic agents offer us wonderful options for pharmacological intervention, particularly as we garner a greater understanding of the core physiological defects associated with the diabetic state.
Since the Standards were first published in 1989, there have been multiple updates, each recognizing the consensus of the day. We have come to understand that, in addition to failing β-cells, insulin resistance plays a crucial role. We now accept that there are multiple dysfunctional aspects of the disordered diabetic physiology, and with that understanding have come new therapies targeting these various dysfunctions.
But how should we use these medications? In which order? Can our patients tolerate the side effects? Will these agents cause hypoglycemia? What about their costs and inclusion in insurance formularies? The Standards provides a framework for evaluating all of these considerations, as well as strategies to address them. Diabetes is personal, and these recommendations are personalized.
Although many PCPs state that they abide by ADA recommendations, their knowledge of the details may in some cases be sparse. For generalists, this is perhaps understandable, given that there are literally thousands of guidelines directed to primary care that reflect the breadth of our practice. It is difficult to be an expert in all of the conditions we treat. However, given the increasing prevalence of diabetes and its complexity, it is incumbent on us to have a working knowledge of these comprehensive guidelines. The 2018 Standards represent the best of our current thinking about and understanding of diabetes. They contain a review of all available therapeutic options and guidance on when and how best to use them. The Standards are a resource for reference and a guide for all aspects of diabetes management.
As PCPs, we have reason to be optimistic. Although the pandemics of both diabetes and obesity are increasing, we have more tools available now than ever before to prevent and treat these diseases.
Duality of Interest
No potential conflicts of interest relevant to this article were reported.
- © 2018 by the American Diabetes Association.
Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0 for details.
