Standards of Medical Care in Diabetes—2022
The field of diabetes care is changing rapidly with the emerging research, treatments, and technology helping the fraternity to improve the health and well-being of people with diabetes. Like previous years, American Diabetes Association has put forward the guidelines for this year as well under the title “Standards of Medical Care in Diabetes—2022”. Given below is the highlights of updated guidelines:
Objective:
To provide updates in existing recommendations in accordance with new evidence.
Method:
The guideline was developed from the currently available evidence and scientific and medical knowledge.
Guidelines:
Updates among each session in new guidelines are as follow:
Section 1- Improving health and promoting health in the population
Information about online platforms is added in order to assist behavior change and well-being.
There is elaborated discussion about cost of medications and treatment goals under the subsection renamed as “Cost Considerations for Medication-Taking Behaviors”
The “Health Literacy and Numeracy” subsection were included for the discussion of concept and role of health numeracy in diabetes prevention and management.
The community health workers’ content was expanded.
Section 2 – Classification and Diagnosis of Diabetes
A revised recommendation for blood glucose testing and diagnosis is added.
Recommendations have been added in the “Type 1 Diabetes” subsection based on new management guidelines for adults by ADA and EASD.
Immune checkpoint inhibitors have been added under the “Classification” subsection.
Recommendations 2.9 and 2.24 have been updated with screening and testing guidelines
Section 3 – Prevention or Delay of Type 2 Diabetes and Associated Comorbidities
Modified recommendation for individualized monitoring of diabetes (Recommendation 3.1) and intensive lifestyle behavior (Recommendation 3.2) is added.
Recommendation regarding metformin therapy (Recommendation 3.6) and discussion on vitamin D supplementation in the “Pharmacologic Interventions” subsection.
There is a new subsection and recommendation on weight management and associated comorbidities.
Section 4- Comprehensive Medical Evaluation and Assessment of Comorbidities
The revised “Immunizations” subsection has additional information on the “Influenza vaccine” as well as the “Covid-19 vaccine” based on evolving evidence.
The “Nonalcoholic Fatty Liver Disease” subsection has been extensively updated based on new guidelines. Table 4.6 summarized management of patients with nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), and Table 4.7 provides a summary of published NAFLD guidelines
Section 5 – Facilitating Behavior Change and Well-being to Improve Health Outcomes
Recommendation 5.5 in the “Diabetes Self-Management Education and Support” subsection contains guidelines for effective methods of education and support.
“Carbohydrates” subsection contains guidelines on quality of carbohydrate, fiber goal, mixed meals, insulin dosing, and impact on glycemia.
A new subsection on cognitive capacity/impairment with regards to diabetes has been added.
Section 6. Glycemic Targets
Time in range thresholds was shifted from Recommendation 6.4 to Table 6.2.
“Hypoglycemia” subsection was added with information about Glucose variability and the association of hypoglycemia, hypoglycemia prevention, including Dose Adjusted for Normal Eating (DAFNE) the Blood Glucose Awareness Training, and DAFNE plus programs.
Section 7. Diabetes Technology
Various recommendations about the selection of technology are added in the newly introduced technology section unlike the previous concept was it was distributed throughout the section.
“Self-monitoring of blood glucose (SMBG)” was renamed as “blood glucose monitoring (BGM)”. This subsection consists of recommendations from U.S. Food and Drug Administration regarding when an individual might need access to BGM.
Recommendation regarding the use and frequency of CGM is added in the “Continous Glucose Monitoring Devices” subsection. The recommendation for the use of CGM in adults and youth is mentioned separately.
“Smartpens” are renamed as “connected insulin pens”. More evidence and discussion have been added to the insulin pens content.
The discussion of automated insulin delivery (AID) systems has been combined with the insulin pumps subsection.
Section 8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes
The title has been changed.
Evidence stressing the importance of addressing has been added as diabetes and obesity increase the risk of covid infection.
The “Assessment” subsection has been updated with the concept of weight distribution and weight gain pattern and trajectory, along with weight and BMI.
“Diet, Physical Activity, and Behavioral Therapy” subsection discuss the lack of clear evidence to clarify the effectiveness of dietary supplements in weight loss.
The “Medical Devices for Weight Loss” subsection include updates on a newly approved oral hydrogel.
Recommendation 8.21 has been revised and now contains guidelines for behavioral support and routine monitoring of metabolic status.
Postbariatric hypoglycemia is discussed in detail in the new recommendation (Recommendation 8.22) Medications approved by the FDA for the treatment of obesity (including semaglutide) are mentioned in table 8.2.
Section 9. Pharmacologic Approaches to Glycemic Treatment
Along with carbohydrate, fats and protein content are added in recommendation 9.3 as part of education on matching mealtime insulin dosing.
Updated figures and tables have been added about insulin management in the “Pharmacologic Therapy for Adults with Type 1 Diabetes” subsection
Recommendations have been updated for first-line therapies, use of insulin and combination therapy, use of metformin.
Section 10. Cardiovascular Disease and Risk Management
Figure 10.1 has been added to summarize the recommendation for the comprehensive approach to decrease the risk of diabetes-related complications.
Include updates for screening and diagnosis, targets, and therapy approach for hypertensive patients.
A new subsection on statins and discussion on the use of evolocumab therapy and reduction in all strokes and ischemic stroke is added.
A discussion of ADAPTABLE and TWILIGHT trials is mentioned.
Recommendation 10.42c in the “Cardiovascular Disease: Treatment” subsection now provides guidance for patients with T2DM and ASCVD.
Various drugs and their risk management strategies were updated.
Section 11. Chronic Kidney Disease and Risk Management
The content under section “Microvascular Complications and Foot Care”, is now divided into sections 11 and section 12.
Recommendations 11.3a and 11.3c has being revised for therapy options, GFR, and urinary albumin cut-offs.
“Acute Kidney Injury” subsection has been updated with a discussion regarding the use of ACE inhibitors or ARBs
Section 12. Retinopathy, Neuropathy, and Foot Care
More discussion regarding the use of GLP-1 receptor agonists and retinopathy was added to the “Diabetic Retinopathy” subsection.
Recommendation 12.11 and 12.12 was updated with indications for intravitreous injections of anti-vascular endothelial growth factor in patients with proliferative diabetic retinopathy and diabetic macular edema, respectively.
A new recommendation 12.13 was included on macular focal/grid photocoagulation and intravitreal injections of corticosteroid.
Section 13. Older Adults
“Hypoglycemia” subsection was updated with glycemic variability in older adults with physical or cognitive limitations with respect to the use of CGM.
The upper threshold of 8.5% was removed from goals of patients with cognitive impairment, multiple coexisting chronic illnesses, or functional dependence in Recommendation 13.6.
This subsection also contains discussion about the classification of older adults, benefits of exercise programs, overtreatment, and monitoring.
Section 14. Children and Adolescents
New tables were created to provide an overview of complications and treatment in pediatric type 1 patients.
This section includes updates on the timing of screening and treatment, ACE inhibitors and ARBs, use of CGM, and screening and management for hypertension.
Section 15. Management of Diabetes in Pregnancy
A new recommendation regarding telehealth visits for pregnant women with GDM, discussion about the use of insulin in treatment for T2DM women in pregnancy was included.
Section 16. Diabetes Care in the Hospital
Discussion on the use of CGM during the COVID-19 pandemic to minimize contact between health care providers and patients, especially those in the intensive care unit is been added.
Section 17. Diabetes Advocacy
No changes were conducted in this section
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