Updated ADA guidelines question routine self-monitoring in type 2 diabetes

Every year, the American Diabetes Association (ADA) releases updated guidelines for management of diabetes. “Standards of Medical Care in Diabetes–2019,” published in Diabetes Care, includes 16 sections, with a dedicated new section on diabetes technology. Numerous revisions were made throughout the updated guidelines, with key revisions focusing on updated diagnostic criteria, changes in pharmacological management of type 2 diabetes, and the importance of the integrated care team and patient preferences.

The new diabetes technology section (Section 7) contains information on self-monitoring of blood glucose (SMBG) and a review of insulin delivery devices and blood glucose meters. The recommendation to use SMBG was changed to state that routine monitoring in patients who are not receiving insulin therapy is of limited clinical benefit.

“Pharmacists and other health professionals have traditionally been taught that SMBG is a valuable tool in the management of diabetes,” said Charles D. Ponte, BS, PharmD, BC-ADM, BCPS, CDE, CPE, FAPhA, professor of clinical pharmacy and family medicine at West Virginia University in Morgantown.

“It can assess glucose in real time and can be used to monitor the efficacy of a treatment plan, reinforce adherence or nonadherence to lifestyle modification and therapeutic interventions, and even validate suspected hypoglycemic episodes,” Ponte said.

Ponte noted that the value of SMBG is unquestioned in management of type 1 diabetes, but its place in type 2 diabetes is less clear. “Emerging evidence supports the notion that SMBG may be unnecessary and cost-ineffective in most persons with well-controlled type 2 diabetes not using insulin or taking oral hypoglycemic medication.”

In the classification and diagnosis section (Section 2), the criteria for diagnosing diabetes was changed to include two abnormal test results from the same sample or in two separate samples, such as a fasting plasma glucose and A1C from the same sample. In the comprehensive medical evaluation and assessment of comorbidities section (Section 4), a new recommendation was made to call out the importance of the diabetes care team.

ADA noted that this team should include primary care physicians, subspecialty physicians, nurse practitioners, physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals. A decision cycle for patient-centered glycemic management in type 2 diabetes was also added to this section to emphasize the importance of shared decision making.

Section 9, which covers pharmacologic approaches to glycemic treatment, was substantially changed for management of type 2 diabetes. ADA noted that treatment decisions should consider patient comorbidities, hypoglycemic risk, effects on body weight, adverse effects, costs, and patient preferences.

A glucagon-like peptide 1 receptor agonist was newly recommended as the initial choice before insulin in most patients who need an injectable medication for management of type 2 diabetes. Changes were also made to other sections, including the lifestyle management section.

For the full article, please visit www.pharmacytoday.org for the March 2019 issue of Pharmacy Today.