Updates to the American Diabetes Association Standards of Care in Diabetes
A notable revision now includes a dual GIP and GLP-1 receptor agonist (tirzepatide) as an additional option for glycemic management, preferred over insulin.
Each year the American Diabetes Association (ADA) issues updates to its Standards of Care in Diabetes, incorporating revisions that reflect the current state of the field. Given the yearly updates, it becomes imperative to identify the relevant revisions based on new evidence, aiming to enhance the health and well-being of individuals with diabetes.
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Various updates have been implemented across different sections of the Standards of Care.1 This summary, however, will specifically focus on selective sections which may impact a pharmacist managing diabetes.
Section 4: Comprehensive Medication Evaluation and Assessment of Comorbidities
Vaccines
The Respiratory Syncytial Virus (RSV) vaccine has been added to Table 4.4, which outlines recommended vaccinations for individuals with diabetes, particularly those over 60 years of age. This aligns with the CDC recommendations, emphasizing that individuals over 60 years old with comorbidities such as diabetes are at an increased risk of severe RSV disease and may likely benefit from the RSV vaccine.2
Assessment of Fractures
The subsection formerly known as "Fractures" has been revised to "Bone Health" to mirror current best practices. Significant changes have been made to this subsection with a comprehensive assessment of bone health. A new table, 4.5, has been added, incorporating diabetes-specific risk factors for fractures.1 The update underscores the importance of maintaining glucose control, minimizing hypoglycemic episodes, and assessing fracture risk in older adults with diabetes as part of routine care. Additionally, certain glucose-lowering medications, such as thiazolidinediones, insulin, or sulfonylureas, contribute to a higher risk of fractures, necessitating individualized treatment considering fracture risk and medication effects on bone metabolism.2
The Bone Health subsection also reviews otherglucose-lowering agents which may have neutral or potentially positive effects on bone health. In clinical trials and postmarketing data, Dipeptidyl peptidase-4 inhibitors (DDP-4) and glucagon-like peptide-1 receptor agonists (GLP-1) suggest neutral impact on bone health. Additionally, a newer agent used for diabetes management, dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist tirzepatide has demonstrated a positive effect on bone health through its GIP receptor agonism, preventing bone loss associated with weight loss.2
Medications Affecting Fracture Risk
The revision has also updated its previous subsection concerning the utilization of sodium–glucose cotransporter 2 inhibitors (SGLT2i) and the associated risk of fractures. Previously, the guideline indicated the class of SGLT2i increases risk of fractures, but it now specifies canaglifozin, which can significantly increase the risk of fractures compared to a placebo. The statement emphasizes the limited data available associating the use of empagliflozin, ertugliflozin, or dapagliflozin with negative effects on bone health. It strongly advises careful consideration of therapies for frail individuals, advocating the avoidance of aggressive therapeutic approaches to prevent hypoglycemic events and falls. The revision also discusses primary and secondary prevention of fragility fractures.2
Routine Testing
The update also recommends routine testing for individuals with type 2 diabetes lacking other comorbidities. Specifically, a dual-energy x-ray absorptiometry function (DEXA) scan at least 5 years post-diagnosis, with subsequent reassessments advised every 2 to 3 years, contingent upon screening evaluations and the presence of additional risk factors.2
Supplement Recommendations for Bone Health
The subsection also reviews adequate calcium and vitamin D intake for osteoporosis and fracture prevention. The guideline abstains from specifying an optimal level of 25-hydroxyvitamin D due to controversies surrounding perceived sufficient serum levels. Instead, they recommend adhering to the US-recommended daily allowance of vitamin D supplementation for individuals51 to 70 years of age or over 70 years. It is noted, however, that the recommended dose of vitamin D supplementation may vary based on individual patient goals and needs.2
Section 9: Pharmacological Approaches to Glycemic Treatment
Pharmacologic approaches for diabetes management section had no major changes affecting clinical practice, but the guideline recommends continuing to focus on comorbidities of cardiovascular disease, kidney disease, and obesity to determine appropriate therapy for patients with diabetes. However, a notable revision to recommendation 9.23 now includes a dual GIP and GLP-1 receptor agonist (tirzepatide) as an additional option for glycemic management, preferred over insulin.1,3
The revision emphasizes counseling individuals with diabetes about the potential for ileus with subcutaneous semaglutide and advises against dual GIP and GLP-1 receptor agonist treatment (tirzepatide) for individuals with a history of gastroparesis.1,3
Section 10: Cardiovascular Disease and Risk Management
Previously, the guideline reviewed trials of newer lipid lowering agents but did not list specific recommendations for when it would be appropriate to utilize those agents. The update introduces bempedoic acid as an alternative cholesterol-lowering therapy in individuals with diabetes for primary and secondary prevention. This aligns with the FDA's new indication for bempedoic acid in the treatment of primary hyperlipidemia. Inclisiran has also been added as an alternative agent for those who are statin intolerant for secondary prevention, with the caveat that it is not recommended as monotherapy but in conjunction with PCSK9 inhibitor therapy due to limited evidence for cardiovascular outcomes.1,4
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