Recommendations updated from 2015 offer updates for more than 170 evidence-based clinical practice recommendations for treating patients with diabetes.

The American Association of Clinical Endocrinology (AACE) updated its clinical practice guidelines to reflect and include changes in evidence-based recommendations for treating and managing type 2 diabetes and pre-diabetes.¹ The previous update came in 2015, and the process for updating clinical practice guidelines included the Oversight Committee for the AACE confirming updates in the literature and the AACE Board of Directors approving the updates. There was a robust literature pool — 1,840 articles and links to 31 websites — used to inform the clinical practice guidelines update.

During the literature review process, evidence levels (EL) of 1 – 4 were assigned to each study reviewed to ensure rigor and to ensure compliance with AACE’s evidence ratings. Grades for each recommendation were also provided (e.g., A – D) to reflect the strength and confidence of aggregated evidence. This process yielded four categories with recommendations:¹

1. Screening, diagnosis, glycemic targets, and glycemic monitoring
2. Comorbidities and complications that included obesity and its management via lifestyle, nutrition, bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease
3. Management of pre-diabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy
4. Education and new topics regarding diabetes mellitus (DM) and infertility, nutritional supplements, post transplantation, secondary diabetes, social determinants of health (SDOH), and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with DM

All the information presented below was taken from the American Association of Endocrinology’s updated clinical guidelines. All recommendations are summarized in the source material in Table 2.¹

Category 1: Screening, Diagnosis, Glycemic Targets, Glycemic Monitoring

This first category was driven by three questions, which resulted in 15 recommendations, of which nine were scored with the highest rating, Grade A, EL 1. The three questions driving this section were: (Q1) How is the diagnosis of DM made and what is the current screening protocol for prediabetes and diabetes?; (Q2) What are the glycemic treatment goals for persons with DM?; and (Q3) When and how should glucose monitoring be used?

Question 1: How is the diagnosis of DM made and what is the current screening protocol for prediabetes and diabetes?

There were seven recommendations associated with question 1; two scored the highest rating of Grade A, EL 1.

R 1.4 indicates that all adults ≥35 y of age with risk factors should be screened for diabetes.

R 1.6 indicates that pregnant women should be tested for gestational diabetes (GDM) at 24 – 28 weeks and that GDM should be diagnosed with either a one-step approach or a two=step approach.

The one-step approach adopts 2-hour 75-g oral glucose tolerance (OGTT) following ≥ 8 hours of fasting. The diagnostic cutoff should be one or more FPG ≥92 mg/dL, 1-h PG ≥180 mg/dL, or 2-h PG ≥153 mg/dL.

The two-step approach adopts a non-fasting 1 hour 50-g glucose challenge with 130 or 140 mh/dL as the screening threshold. If women are screened as positive, then the 3-h 100-g OGTT should be used to diagnose when there are 2 or more PG test that in the ranges of FPG ≥95 mg/dL, 1-h ≥180 mg/dL, 2-h ≥155 mg/dL, 3-h ≥140 mg/dL.

Question 2: What are the glycemic treatment goals for persons with DM?

There were four recommendations for question 2, each of which was scored at the highest rating, Grade A, EL 1. The two recommendations for outpatient glucose targets in non-pregnant adults were related to A1C.

R 2.1.1 indicates that the current recommendation is an A1C level of ≤ 6.5 percent in non-pregnant adults if that value can be safely achieved. Fasting Plasma Glucose (FPG) may need to be <110 mg/dL, and the 2-h postprandial glucose (PPG) may need to be <140 mg/dL to achieve a ≤ 6.5 percent target level. The recommendation is for individualization in glucose target values such that a patient’s life expectancy, cardiovascular disease risk factors, and disease duration, to name a few criteria, are considered.

R 2.1.2 indicates less stringent A1C goals (e.g., 7 – 8 percent) in patients with a history of severe hypoglycemia, limited life expectancy, advanced renal disease, extensive comorbidities, or unawareness of hypoglycemia. Additionally, an A1C of 7 – 8 percent is also recommended if the patient has had longstanding diabetes in conjunction with difficulty reaching A1C goals with intense efforts. This recommendation is contingent upon the patient not experiencing hyperglycemic symptoms.

Question 3: When and how should glucose monitoring be used?

There were four recommendations associated with question 3, three of which were scored at the highest rating of Grade A, EL 1.

R 3.2 indicates that insulin users should use continuous glucose monitoring (CGM) or blood glucose monitoring (BGM) at least twice daily and before insulin injections, ideally. For those patients taking multiple daily injections, those not at their A1C target, or those with a history of hypoglycemia, more frequent BGM is needed.

R 3.3 indicates that real-time glucose monitoring (rtCGM) or intermittently scanned continuous glucose monitoring (isCGM) is recommended for all persons with type 1 diabetes to reduce the risk of hypoglycemia and to improve A1C levels.

R 3.4 indicates that patients with type 2 diabetes who are not using insulin as part of their management plan or at a high risk for hypoglycemia and DKA should use rtCGM or isCGM.

Category 2: Comorbidities and Complications

The comorbidities and complications section was driven by seven questions, resulting in 51 recommendations of which 28 were rated with the highest score, Grade A, EL 1. Examples of questions included: (1) How should hypertension be managed in persons with diabetes? (Q4); (2) How should diabetic kidney disease or chronic kidney disease be managed? (Q6); and How should obesity be managed in persons with diabetes? (Q10).

Question 4: How should hypertension be managed in persons with diabetes?

There were five recommendations associated with this question, each of which scored the highest rating, Grade A, EL 1.

R 4.1 indicates that blood pressure (BP) for most adults with diabetes or prediabetes should be <130/80 mm HG.

R 4.2 indicates that a registered dietician should be part of a patient education and lifestyle interventions for adults with hypertension. This recommendation further elaborates on the importance of a healthy diet, weight management, reduced sodium intake, and seeking as-needed support from a therapist or diabetes care specialist to support long-term behavior changes.

R 4.3 indicates that if blood pressure goals are not attained through lifestyle changes, antihypertensive pharmacotherapy should be used on an individual basis.

Question 6: How should diabetic kidney disease (DKD) or chronic kidney disease (CKD) be managed?

There were six recommendations associated with this question, with five scored as the highest rating, Grade A, EL 1.

R 6.2 indicates advising adults with diabetes and DKD about optimal glycemic control, blood pressure, lipid control, and quitting smoking as ways to mitigate the risks of CKD and cardiovascular disease and to slow disease progression.

R 6.3 indicates an angiotensin II receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor with renin-angiotensin-aldosterone system blockade for adults with albuminuria to mitigate the risks of DKD or CKD progression.

R 6.5 indicates using a GLP-1 for adults with diabetes and DKC or CKD with eGFR ≥15 mL/min/1.73 m² for glycemic control and to reduce risk of ASCVD and progression of albuminuria.

Question 10: How should obesity be managed in persons with diabetes?

There were 10 recommendations associated with this question, with only four scoring the highest rating, Grade A, EL 1.

R 10.5 indicates that adults with type 2 diabetes and adiposity-based chronic disease (ABCD) should be treated with weight loss interventions that will improve glycemic control and prevent or treat complications associated with ABCD. The weight loss target should be >5 percent to >10 percent of baseline body weight.

R 10.6 indicates that therapeutic lifestyle interventions should be adopted for adults type 2 diabetes and ABCD. The interventions should include reduced calorie meals and a healthy eating plan that is designed to achieve a ≥500 kilocalorie daily energy deficit. Daily physical activity, regular exercise (several times a week), and behavioral health practices should also be included as part of the lifestyle intervention.

R 10.8 indicates that GLP-1RAs or sodiumglucose cotransport inhibitor 2 (SGLT2s) should be used for adults with type 2 diabetes and obesity and / or ABCD when BMI is ≥27 kg/m². FDA-approved weight loss medication should be considered as an adjunct to lifestyle changes in adults with prediabetes, diabetes, and obesity and/or ABCD. These medications can reduce the risks of CVD risk factors, treat ABCD complications, and improve QoL.

Category 3: Management

The management section was driven by six questions, resulting in 69 recommendations, with two questions resulting in sub-recommendations (e.g., Q 12 R 12.1.5 and Q13 R 13.60).  Of the 64 recommendations and four sub-recommendations, 42 were scored with the highest rating of Grade A, EL 1. Examples of questions included: (1) How can glycemic targets be achieved in persons with type 2 diabetes? (Q12); and (2) How should hypoglycemia be managed? (Q14)

Question 12: How can glycemic targets be achieved in persons with type 2 diabetes?

Question 12 was broken into two sets of recommendations. This section will focus on the recommendations related to lifestyle changes. There were five recommendations, of which four scored the highest rating, Grade A, EL1.

R 12.1.1 indicates that all adults with prediabetes or diabetes should be prescribed lifestyle interventions. They should receive support and education relative to the lifestyle interventions that include a healthy eating plan, regular physical activity, and healthy behavior. Adults with diabetes should receive individualized medical nutritional therapy (MNT) at the time of diagnosis. Education follow ups should be arranged during the period of care. Counseling by a trained registered dietician, certified nutritionist, or clinician with nutrition knowledge should be arranged.

R 12.1.2 indicates that medical nutritional therapy (MNT) should consider the overall treatment plan, inclusive of medications, complications from diabetes, activity level, weight goals, hypoglycemia, and individual differences such as culture, health literacy, psychological factors, and readiness for change, to name a few.

R 12.1.4 indicates that meal plans should consider personal and cultural dietary preferences while managing diabetes in a beneficial manner. Health care professionals should emphasize the importance of consuming foods that are high in “diet quality” as assessed by the Healthy Eating Index (HEI). Patients should be encouraged to eating a high HEI diet.

Question 14: How should hypoglycemia be managed?

There were five recommendations, of which three scored the highest rating, Grade A, EL 1.

R 14.1 indicates that the oral ingestion of rapidly absorbed glucose (e.g., glucose tablets or oral intake of rapidly absorbed glucose, fruit juice) followed by a meal or a snack with protein and carbohydrates (e.g., cheese and crackers, peanut butter) should be used to treat hypoglycemia. The metric for hypoglycemia is glucose <70 mg/dL [3.9 mmol/L]. This treatment is advised only for those adults who can safely swallow.

R 14.2 indicates that glucagon delivered as intranasal, prefilled liquid stable nonaqueous formulation, prefilled aqueous liquid stable glucagon analogue or with reconstitution from powder should be used to correct hypoglycemia if individuals are unable or unwilling to ingest carbohydrates orally. After 15 minutes of no response, an additional dose (same as the first dose) may be administered. As soon as the individual is awake and able to swallow, they should receive a rapidly absorbed source of carbohydrate.

R 14.4 indicates that for adults with type 2 diabetes who develop hypoglycemia and are being treated with alpha-glucosidase inhibitors or with pancreatic diabetes, oral glucose or lactose-containing foods (dairy products) must be given because alpha-glucosidase inhibitors inhibit the breakdown and absorption of complex carbohydrates and disaccharides (e.g., table sugars or starches).

Category 4: Education and Other Topics

The education and other topics section was driven by 12 questions, with questions 19 and 20 having three and two parts, respectively. There were 33 recommendations across all questions, with 16 recommendations scored at the highest rating, Grade A, EL 1. Examples of questions included: (1) What education interventions have been shown to be most effective in management of persons with diabetes mellitus? (Q17); (2) What is the role of sleep medicine in the care of persons with diabetes? (Q21); and (3) Is telehealth/virtual care an effective care-delivery model for the management of persons with diabetes mellitus? (Q24)

Question 17: What education interventions have been shown to be most effective in management of persons with diabetes mellitus?

There was one recommendation associated with this question; it scored a rating of Grade A, EL 1.

R 17 indicates that it is appropriate for individualized diabetes self-management education and support at the time of diagnosis and when appropriate following diagnosis. Therapeutic lifestyle management must be addressed with patients diagnosed with diabetes or prediabetes at the time of diagnosis and across their lifespan. Therapeutic lifestyle management strategies include medical nutrition therapy, which must include reductions and modifications in caloric intake and fat intake in service of weight loss for adults with obesity. Tailored physical activity recommendations as well as recommendations to avoid tobacco products, and the importance of adequate sleep must also be addressed. Other topics to explore with patients include glycemia treatment options, insulin dosage, when relevant, acute complications of diabetes and the prevention, identification, and treatment of hypoglycemia.

Question 21: What is the role of sleep medicine in the care of persons with diabetes?

There were three recommendations associated with this question, of which only one was scored with a rating of Grade A, EL 1.

R 21.3 indicates that the predominant intervention to improve obstructive sleep apnea (OSA) and insulin sensitivity is weight loss. Devices that offer positive airway pressure as prescribed by a sleep specialist are effective.

Question 24: Is telehealth/virtual care an effective care-delivery model for the management of persons with diabetes mellitus?

There was only one recommendation associated with this question and it scored a rating of Grade A, EL 1.

R 24 indicates that when available and appropriate, telehealth should be offered to patients with diabetes as part of their wholistic health care plan.

New Diabetes Guidelines: Implications for Clinical Practice

While the list of updated and new evidence-based recommendations for comprehensive diabetes care was too big for the scope of this article, recommendations that seemed most salient for lifestyle interventions and pharmacotherapies were highlighted.

There are 170 updated and new evidence-based recommendations for treating and managing diabetes. Newer diabetes pharmacotherapies such as GLP-1 RA medications for managing weight loss and type 2 diabetes should be considered as part patients’ health care plan to reduce the risks associated with cardiovascular disease, chronic kidney disease, and glycemic control. Additionally, patients with obesity and/or diabetes should be supported through education on dietary and exercise lifestyle interventions.

For health care professionals who currently treat patients with obesity and diabetes, Table 2¹ offers a quick, easy to read snapshot of recommendations organized by each of the four sections: screening, comorbidities and complications, management, and education and other topics. Details for recommendations are offered within the text.¹

Key takeaways include treating each patient as an individual and developing a treatment plan tailored for their specific needs, marrying lifestyle interventions that include a healthy eating plan and physical activity, providing education and support along across patients’ lifespan once diagnosed, and applying individualized screening protocols for patients. New A1C guidelines for type 2 diabetes provide a framework for reconsidering glycemic treatment goals (i.e., R 2.1.1 and R 2.1.2). Regardless of which updated and evidence-based recommendations health care providers use, supplementing weight loss efforts for patients with obesity with scientifically formulated meal replacements is one recommendation that should be followed, particularly for patients with obesity who would benefit from the weight loss jumpstart they provide while ensuring nutritional needs are being met.

Source(s):

1 American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan—2022 Update