2023 American Diabetic Association Standard of Care Selected Updates | June 2023 | Clinical Corner

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June 15, 2023

2023 American Diabetic Association Standard of Care Selected Updates

The American Diabetes Association (ADA) provides an update to their Standards of Care (SOC) every year to include developments in research and published literature. Selected 2023 SOC updates that may change practice delivery include:

  • Patients diagnosed with type 2 diabetes mellitus (T2DM) should be treated with a medication known to reduce cardiorenal risk (SGLT2 inhibitor, GLP-1 RA) if they have established or are at high risk of atherosclerotic cardiovascular disease, heart failure and/or chronic kidney disease.
  • While on maximum tolerated doses of an ACE or ARB, Finerenone should be added to improve cardiovascular outcomes and reduce the risk of chronic kidney disease progression in patients with T2DM and CKD with albuminuria.
  • An SGLT2 inhibitor can be initiated in patients with:
    • T2DM and established heart failure with either preserved or reduced cardiac ejection fraction.
    • T2DM and diabetic kidney disease with an estimated glomerular filtration rate of at least 20mL/min/1.73m2 and urinary albumin to creatinine ratio of at least 200 mg/g.
  • Sustained weight loss of greater than 10% could have disease-modifying effects, while smaller weight loss (3% to 7%) may confer glycemic benefits. Tirzepatide (Mounjaro), a dual glucagon-like peptide1 (GLP1)/glucose-dependent insulinotropic polypeptide receptor agonists (RAs) is a newly mentioned glucose-lowering therapy associated with weight loss effects.
  • High-intensity statin and atherosclerotic cardiovascular disease:
    • Initiate primary prevention for those aged 40 to 70 years with a known higher cardiovascular risk. The goal is to reduce LDL by at least 50% and to target an LDL less than 70 mg/dL. For ages 70 years and older, continuing statins is reasonable, while initiating a moderate-intensity statin could be considered.
    • The goal for secondary prevention is to reduce LDL by at least 50% to an LDL less than 55 mg/dL.
    • For both primary and secondary prevention, LDL goals may be reached with a maximum tolerated high-intensity statin, followed by adding either ezetimibe or a proprotein convertase subtilisin/kexin type 9 serine protease (PCSK9) inhibitor, if needed.
  • Aligning with the American College of Cardiology and American Heart Association guidelines, a hypertension diagnosis is now defined as multiple blood pressure readings with a systolic BP of at least 130 mmHg or a diastolic BP of at least 80 mmHg. The initiation of an antihypertensive should occur at a persistently elevated BP of at least 130/80 mmHg, accompanied with goal BP of less than 130/80 mmHg after starting therapy.
  • Continuous glucose monitoring (CGM) users should be educated on potential substances (e.g., acetaminophen, vitamin C, tetracycline, aspirin) and associated doses that could interfere with reading accuracy of certain CGM devices.

References:
1. CPS Pharmacy Newsletter May 2023.

2. 2023 American Diabetes Association Standards of Care.