Comprehensive Diabetes Care - A 2024 Update

Kaitlin Bredenkamp, PharmD; Minnesota Community Care

Background: The Standards of Care in Diabetes - 2024 is the latest update to clinical practice guidelines for diabetes management as put forward by the American Diabetes Association (ADA). Each year, the ADA’s Professional Practice Committee reviews current literature to ensure that the clinical practice guidelines promote the best evidence-based clinical interventions. Updates reflected in the Standards of Care in Diabetes - 2024 include revisions to terminology, medication recommendations, positive health behavior and weight management recommendations, monitoring technology recommendations, comorbidity risk reduction and monitoring recommendations, and considerations for special populations. 

Evidence/Discussion: Several sections include general updates to language and terminology, particularly focused on inclusive and culturally sensitive language, while other sections advocate for the benefits of diabetes technology, such as continuous glucose monitors and automated insulin devices, and discuss the use of telehealth in diabetes management. 

The following table outlines specific medication-related changes: 

Section

Medication Related Updates

3: Prevention or Delay of Diabetes and Associated Comorbidities

  • Recommendations for the use of teplizumab, a humanized anti-CD3 monoclonal antibody approved for delaying the onset of stage 3 type 1 diabetes in adults and pediatric patients (aged 8 and above) with stage 2 type 1 diabetes

4: Comprehensive Medical Evaluation and Assessment of Comorbidities

  • Vaccine recommendations updated to include COVID-19 for individuals 6 months of age and above and, as well as RSV vaccinations, particularly targeting adults aged 60 and above with diabetes, who are identified as a high-risk group

5: Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes

  • Cannabis discussion added, with recommendation to avoid cannabis due to increased risk of diabetic ketoacidosis, hyperglycemic ketosis, and cannabis hyperemesis syndrome in adults with type 1

8: Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes

  • Preference for GLP-1 or GLP-1/GIP receptor agonists with high weight loss efficacy for obesity management in people with diabetes

9: Pharmacologic Approaches to Glycemic Treatment

  • Preference for insulin analogs or inhaled insulin over injectable human insulins in type 1 diabetes
  • Recommendation to prescribe glucagon for patients taking insulin or at high risk for hypoglycemia
  • Recommendation to start combination therapy early to shorten time to attaining treatment goals
  • Recommendations to consider therapies that address weight management for those who would benefit from weight loss
  • Prioritization of agents with established CV and/or renal benefit in patients with ASCVD, HF, or CKD (GLP-1 or SGLT2i)
  • Recommendation for SGLT2i use in patients with HF
  • Recommendation to consider insulin at any stage, regardless of other therapies if there is evidence for catabolism, hyperglycemic symptoms persist, A1c >10, or blood glucose >300. 

10: Cardiovascular Disease and Risk Management

  • Addition of bempedoic acid as an option for primary prevention of ASCVD in  patients  intolerant to  statin therapy
  • Recommendation for use of bempedoic acid, PCSK9 inhibitors/inclisiran as alternative/additional cholesterol-lowering agents if intolerant to statins or not meeting targets 
  • Recommendation to use either SGLT2i or SGLT1/2i in patients with HF (all types)

11: Chronic Kidney Disease and Risk Management

  • Recommendation for the use of ACEi or ARB in patients with moderately increased albuminuria. 
  • Strong recommendation for use of ACEi or ARB in patients with severely increased albuminuria and/or eGFR <60 mL/min/1.73m2 to prevent progression of CKD and reduce CV events 

13: Older Adults

  • Treatment goals in older patients should be based on the patient’s individual complex comorbid conditions
  • Recommendations to consider de-intensification of agents, specifically hypoglycemia-causing agents such as insulins, sulfonylureas, and meglitinides
  • Recommendation to include agents with cardiorenal benefits in patients with established ASCVD, HF, and/or CKD or are at high risk for these conditions  

14: Children and Adolescents

  • Insulin dosing should be based on meal composition for type 1 diabetes
  • Recommendation for empagliflozin to be considered prior to initiating and/or intensifying insulin in ages 10+ with type 2 diabetes

15: Management of Diabetes in Pregnancy

  • Glyburide and metformin should not be used first-line (alone or in combination)
  • Patients with GDM may be candidates for aspirin if single high risk factor of multiple moderate risk factors are present for pre-eclampsia

Abbreviations: ACEi, Angiotensin-Converting Enzyme Inhibitors; ARB, Angiotensin Receptor Blockers; ASCVD, Atherosclerotic Cardiovascular Disease; CKD, Chronic Kidney Disease; CV, Cardiovascular; GDM, Gestational Diabetes Mellitus; GIP, Gastric Inhibitory Peptide; GLP1, Glucagon-like Peptide-1; HF, Heart Failure; PCSK-9i, Proprotein Convertase Subtilisin-Kexin type 9 Inhibitors; SGLT2i, Sodium-Glucose Cotransporter-2 Inhibitors

Clinical Impact: The overall updates are designed to help practitioners make the best clinical decisions for patients with diabetes. The updates provide specific guidance on agent selection where decisions may have otherwise been vague and re-evaluate diabetes in special populations, particularly those with comorbidities, advanced age, and/or pregnancy as therapies continue to evolve.. Much of diabetes care remains the same as previous years, but care decisions become more and more nuanced as new agents are developed. 

Citations: 

  1. American Diabetes Association Professional Practice Committee. Summary of Revisions: Standards of Care in Diabetes-2024. Diabetes Care. 2024 Jan 1;47(Supplement_1):S5-S10.
  2. ElSayed NA, Aleppo G, Aroda VR, et al, on behalf of the American Diabetes Association. Summary of Revisions: Standards of Care in Diabetes-2023. Diabetes Care. 2023 Jan 1;46(Suppl 1):S5-S9.