Diabetes Care in 2019
Peter J. Rice, PharmD, PhD, BCPS, FAPhA
Many folks make resolutions for New Years and have spent a good amount of time deciding what to do differently in 2019. But if you are a patient with diabetes (about 25% of seniors have type 2 diabetes), or a health professional caring for diabetic patients, you have it easy. Each January the American Diabetes Association publishes a revision of the Standards of Medical Care in Diabetes which contains the latest recommendations for optimal diabetes care.
The 2019 revision recognizes the importance of telemedicine in diabetes care.
My clinic phones many of our patients each week to check on their blood sugar control and to adjust medicines, including insulin, to optimize care. Even if patients cannot get out, pharmacists or clinics can keep in touch by phone.
It is easier to get a diagnosis of diabetes in 2019, as physicians are no longer required to have two independent tests confirming diabetes. Current standards allow an abnormal blood sugar along with an abnormal hemoglobin A1c – a long term indicator of blood sugar control – to confirm a diagnosis of diabetes. This is important because a large percentage of patients with diabetes – up to 1 in 4 – remain unrecognized and untreated. Testing for diabetes should begin by age 45 with retesting at least every 3 years.
Prevention of diabetes is important, and the 2019 revisions emphasize the importance of weight loss for those at high risk for developing type 2 diabetes as well as avoiding tobacco use, which contributes risk for developing diabetes.
There are new language recommendations for 2019 that encourage the vision that diabetes is a condition that is controlled through collaboration between patients and healthcare providers. You can expect to hear patient-centered language and receive individualized patient-centered care that emphasizes respect, quality-of-life, and control of symptoms. You can expect to see more diabetes care teams which include a variety of health professionals, including pharmacists, dentists, podiatrists and mental health professions.
Comprehensive medical care includes an increased emphasis on factors that can contribute to hypoglycemia (low blood sugar) and on each patient’s 10-year risk for atherosclerotic cardiovascular disease as part of overall risk assessment. Dietary recommendations were patient-specific and did not support a single ideal caloric intake or a single ideal balance of protein, fat and carbs. Meal planning should be individualized. There is a recommendation to decrease sweetened and non-nutritive sweetened drinks with water.
Pharmacotherapy of type 2 diabetes is much the same with some minor changes. Metformin remains the preferred initial therapy for type 2 diabetes and should be continued in all patients as long as it is tolerated and not contraindicated. Other medications for diabetes should be chosen based on patient diseases (such as heart failure or kidney disease) and patient-specific factors such as weight, side effects and patient preference. Good news this year is that glucagon-like peptide 1 agonists are now a first choice, ahead of insulin, for patients who require an injectable medication. GLP-1 agonists are available as once-weekly injections, compared to twice-daily for insulins, and often help patients lose weight.
There appears to be a greater emphasis on cardiovascular disease, which is increased in patients with diabetes. Aspirin and other antiplatelet therapy is recommended for some diabetes patients – ask your prescriber or pharmacist if you should be taking aspirin. Cardiovascular screening is now recommended for patients even in the absence of symptoms associated with cardiovascular disease.
Feet are still important for diabetes patients, with regular foot examinations strongly encouraged.
Some diabetes patients will lose feeling or develop foot pain; the drug gabapentin has been added to the list of medications for diabetic neuropathic pain based on its efficacy and cost savings.
While it is not exceptionally riveting reading, the annual update of diabetes treatment recommendations is freely available online. You can take a look yourself, or rely on your prescriber or pharmacist to answer your questions. Diabetes is a serious disease that places patients at risk for other complications, all of which can be avoided through effective blood sugar control. Take good care of yourself.
American Diabetes Association
Summary of Revisions: Standards of Medical Care in Diabetes—2019