New Diabetes Guidelines Fail to Guide

At the beginning of each year, the American Diabetes Association (ADA) releases their new standards of care. In their 2018 Standards of Medical Care in Diabetes,^[1] the real headline is how they have incorporated the cardiovascular (CV) outcome trials data^[2,3,4] into the guidelines.

To summarize, these standards integrate a person's known CV disease status at step two in the treatment algorithm. The first-line therapy for type 2 diabetes is still lifestyle and metformin, but when you go to that second step of adding second-line therapy—the dual-therapy step—the standards of care divide the world into people who have atherosclerotic CV disease and those who do not.

Those who do not have CV disease have a whole world of choice in terms of a second-line agent, but for those who have CV disease, the ADA recommends adding an agent that has been shown to have CV disease benefit, or to reduce CV mortality, or both. The guidelines discuss drugs that improve CV outcomes and reduce mortality, and they include empagliflozin and liraglutide as two agents that do that. Then they describe agents that are known to reduce CV events; canagliflozin is listed as the agent that does that.

In that second step, the ADA recommends that practitioners choose an agent that has CV benefits for patients with known CV disease. This is also included in the treatment algorithm figure, which has been changed from past years. The figure itself does not actually list the medications. Rather, it refers the reader back to a table, Table 8.1, which lists all of the medications for the treatment of diabetes and a whole bunch of characteristics about them. The table has 11 columns and eight rows. That is the basic guidance for a practitioner when choosing second-line therapy.

Where's the Help?

I personally do not find this table helpful. It does not guide me, but instead it requires that I read through each one of these drug descriptions.

Table 8.1 lists basic clinical characteristics. A second table, Table 8.2, goes through all of the basic mechanisms of action of each of the agents. A third table, Table 8.3, looks at the final cost of these drugs.

Thus, you can no longer simply go through the algorithm to understand what treatment you should use in your patient and when you should use it. This is an issue that many primary care providers face all the time; they do not know what specific second- and third-line drug to use.

The intent is to encourage us to individualize therapy for our patients.

You can use an injectable as part of your second-line therapy, but when you get to the bottom of the initial algorithm figure, you jump to a page titled, "Starting Basal Insulin." There is very little discussion of glucagon-like peptide-1 (GLP-1) receptor agonist therapy plus basal insulin. Instead, they talk a lot about using prandial insulin and how to start patients on that combination. But the problem with this is that the patient may already be taking a combination injectable therapy.

I find this algorithm much less useful than previous algorithms for guiding a clinician, because most of it refers you back to this very complicated table that describes the individual agents in great detail. I know the intent; the intent is to encourage us to individualize therapy for our patients. But I wish it could be made simper and somehow more "algorithmic," or at least that it would describe different scenarios and then discuss them.

If a patient is taking one injectable, say a GLP-1 receptor agonist, how do you add basal insulin? Or how do you use combination basal insulin and GLP-1 receptor agonist therapy? When adding prandial insulin, do we need to stop the GLP-1 receptor agonist? I do not know if anybody knows the answer to that question.

If someone with CV disease is taking liraglutide, is it a good idea to stop the liraglutide, given what we know about its renal benefits as well as its CV benefits?

This whole field has become quite complicated, but I find the current updated way of looking at the choices even more difficult, because it does not allow me to envision the step.

No Fix for What's Not Broken

Some other sections in the Standards of Care were not revised in this 2018 update, and I happen to like these sections a lot. For example, the algorithm for how to approach a patient with hypertension is very clear and easy to follow, and it takes a complex field and simplifies it. The ADA did not change their hypertension standards, which may be an issue for some, but I believe that the standards are clear and detail-oriented in the way they approach this issue.

This document does talk more about diabetes technology and, in particular, continuous glucose monitoring, and they are a little less "gung-ho" than I am about it. I love continuous glucose monitoring. The guidelines repeatedly stress that people who use continuous glucose monitoring need education, and practitioners need to make sure patients understand what they are doing and how to do it.

The ADA has tried to incorporate some of these new devices, new changes, new ways of treating diabetes into the 2018 Standards of Medical Care in Diabetes, and it flows quite nicely in terms of treating type 1 diabetes.

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