Since it was first published in 1989, the American Diabetes Association (ADA) standard of care has adhered to the principle of "one change per year" and has become one of the important guidelines for medical professionals to develop a comprehensive diabetes management plan. On December 11, 2023, the 2024 ADA Diabetes Diagnosis and Treatment Standards were officially released on Diabetes Care, the official journal of the ADA.
After April, on April 15, 2024, the "2024 ADA Diabetes Diagnosis and Treatment Standards (Abridged Version)" was published in the journal Clinical Diabetes. The "Simplified Guide" focuses on the visual processing of text, and on the basis of the original guide, the core content is displayed in the form of pictures, which is more suitable for outpatient or primary diabetes diagnosis and treatment scenarios. In conjunction with the "Lite Guide", let's review the updated highlights of the 2024 version of the ADA Guide.
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Figure Screening recommendations for high-risk populations
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Table Dietary and exercise recommendations for adults at risk of type 2 diabetes
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Figure Diagnostic criteria for diabetes
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Figure Classification of diabetes
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Table Individualize glycemic control goals
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Figure Screening process for newly diagnosed adults with suspected T1DM (based on population data from white Europeans)
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Table Weight-loss efficacy of hypoglycemic drugs
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Figure Application of hypoglycemic drugs in the management of type 2 diabetes
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Figure Flowchart for hypertension management
Update point 1: All "people over 35 years old" are recommended to be screened for diabetes
The new guidelines recommend that adults with overweight/obesity with ≥1 risk factor should be screened for diabetes as soon as possible, regardless of age;
People with no risk factors and normal weight should also be screened for diabetes at age 35.
Figure 1 Screening recommendations for high-risk populations
Table 1 Dietary and exercise recommendations for adults at risk of type 2 diabetes
Update point 2: Diagnosis of diabetes mellitus - HbA1c is the first priority
In terms of diabetes diagnosis, the new guidelines recommend that HbA1c has greater convenience, better stability and less interference, and that HbA1c is less disturbed:
HbA1c, which has been certified by the National HbA1c Standardization Program (NGSP) and tested with the standardized test method of the Diabetes Control and Complications Test (DCCT), was used as the first diagnostic criterion.
Fig.2 Diagnostic criteria for diabetes
Fig.3 Classification of diabetes mellitus
Table 2 Individualized glycemic control goals
Update point 3: Classification of diabetes mellitus - Update the classification of type 1 diabetes
In terms of diabetes types, at present, there are still types of diabetes mellitus type 1 (T1DM), type 2 diabetes mellitus (T2DM), special types of diabetes and gestational diabetes mellitus (GDM). However, it was revealed that these categories are being reconsidered based on genetics, metabolomics, other characteristics, and pathophysiology.
The new guidelines update the staging and diagnostic criteria for T1DM due to the availability of immunological drugs that can delay the progression of stages 1 and 2 to stage 3. Presymptomatic screening for T1DM can be performed by testing for autoantibodies (insulin, glutamate decarboxylase, islet antigen 2, zinc transporter 8, etc.). Adults with overlapping phenotypes and T1DM should also be tested for islet autoantibodies.
Table 3 Staging and diagnostic criteria for T1DM
Update point 4: Added "Screening process for adults suspected of T1DM"
The new version of the guidelines adds a screening process for suspected T1DM in adults for patients with unclear diagnosis.
Fig.4 Screening process for newly diagnosed adults with suspected T1DM (based on population data of white Europeans)
Update point 5: Prevention and treatment of obesity and weight management in patients with T2DM
The new guidelines state that for overweight or obese diabetic patients, the drug of choice should be GLP-1RA or double glucose-dependent insulinotropic peptide (GIP)/GLP-1RA.
There is substantial evidence that metabolic surgery is associated with better glycemic management and reduced cardiovascular risk in obese patients with T2DM compared with non-surgical interventions, and the new guidelines recommend that patients with diabetes with a BMI ≥ 30 kg/m^2 (or Asian Americans with a BMI ≥27.5 kg/m^2) may consider metabolic surgery.
Table 4 Weight-loss efficacy of hypoglycemic drugs
Update point 6: drug regimen for blood glucose therapy
T1DM
The new guideline suggests that insulin analogues are superior to human insulin in reducing the risk of hypoglycemia in most adult patients with T1DM. In addition, the importance of diabetes education is emphasized. For patients at high risk of hypoglycemia, it is recommended to prescribe glucagon and learn how to manage and use it.
T2DM
It is recommended that adults with T2DM should be considered for combination therapy at the beginning of treatment to shorten the time to individualized treatment goals. The treatment process was adjusted from giving priority to atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), chronic kidney disease (CKD) and their high risk, and adjusting it to be parallel with blood glucose and weight management, so as to avoid ignoring glucose reduction and weight loss in diabetic patients with the above comorbidities, which once again highlighted the importance of combining glucose reduction and weight loss.
The new edition states that metformin remains an effective, safe, and affordable drug, and may also reduce the risk of cardiovascular events and death, and is safe to use at an eGFR > 30 ml/min/1.72 m^2.
GLP-RA or GIP/GLP-1RA dual receptor agonists are recommended over insulin in patients who require injectable therapy, but are not recommended in patients with a history of gastroparesis.
Fig.5 Application of hypoglycemic drugs in the management of type 2 diabetes mellitus
Update point 7: ≥ 130/80mmHg is hypertension, with a flow chart for hypertension management in diabetic patients
The American College of Cardiology and the American Heart Association define hypertension as systolic blood pressure ≥ 130 mmHg or diastolic blood pressure ≥ 80 mmHg. At present, the standard in mainland China is still ≥140/90mmHg.
The new guidelines state that hypertension is a major risk factor for ASCVD, heart failure, and microvascular complications, and that antihypertensive therapy can reduce ASCVD events, heart failure, and microvascular complications. For patients with diabetes mellitus and hypertension, blood pressure goals should be individualized through a shared decision-making process that takes into account cardiovascular risk, potential adverse effects of antihypertensive drugs, and patient preference. If treatment goals can be safely achieved, a blood pressure target of <130/80 mmHg is recommended.
The first-line antihypertensive drugs for patients with diabetes and coronary heart disease are angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs), and when the blood pressure of patients with complications ≥ 150/90 mmHg, the combination of two antihypertensive drugs or combination preparations should be immediately used to reduce the probability of cardiovascular events.
Serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored for 7 to 14 days after initiation of treatment and at least annually thereafter in patients treated with ACEi, ARBs, mineralocorticoid receptor antagonists (MRAs), or diuretics.
MRA therapy should be considered in hypertensive patients who do not meet their blood pressure goals on three classes of antihypertensive drugs, including diuretics.
Fig.6 Flow chart of hypertension management
*ACE inhibitors (ACEi) or angiotensin receptor blockers (ARBs) are recommended for the treatment of patients with coronary artery disease (CAD) or a urine albumin-to-creatinine ratio of 30–299 mg/g, and are highly recommended for patients with a urine albumin-to-creatinine ratio of ≥ 300 mg/g. * *Thiazide diuretics; long-acting medications such as chlorthalidone and indapamide that have been shown to reduce cardiovascular events are preferred. Dihydropyridine calcium channel blockers (CCBs). BP, blood pressure.
Update point 8: Lipid management in diabetes
The new version of the guidelines recommends that risk stratification and development of different lipid management strategies should be carried out according to the age of patients and whether they have ASCVD.
Statins remain the core, and the addition of an ezetimibe or proproteininase subtilisin-9 (PCSK9) inhibitor is recommended for patients who do not achieve LDL-C control goals despite maximally tolerated statin therapy.
For diabetic patients without cardiovascular disease, betapidicic acid is recommended if statin therapy is intolerant, and PCSK9 inhibitors and inclisiran siRNA can also be used as alternative cholesterol-lowering regimens.
Update point 9: Chronic kidney disease and its risk management
The new version of the guidelines recommends that all patients with T1DM and T2DM with a course of more than 5 years should be evaluated for urine protein (such as urine albumin-creatinine ratio) and eGFR at least once a year, and CKD staging should be carried out accordingly, and if CKD has been diagnosed, the risk degree should be divided according to the CKD stage, and the annual follow-up frequency (1~4 times) should be determined.
Optimizing blood glucose and blood pressure management is the core measure to reduce the risk of CKD and delay its progression, and SGLT-2i and GLP-1RA are the first choices for hypoglycemic drugs, and metformin is also recommended.
ACE inhibitors or ARBs are strongly recommended in nonpregnant patients with diabetes mellitus and hypertension, particularly those with proteinuria, and should not be discontinued if there is a mild to moderate increase in creatinine (≤30%) and no signs of extracellular volume reduction. In addition, for patients with CKD who are not on dialysis stage G3 or above, the target dietary intake of protein is 0.8 g/kg/day. For dialysis patients, considering the protein energy loss caused by dialysis, the dietary protein intake target is 1.0~1.2g/kg/d.
Resources
[1] American Diabetes Association Primary Care Advisory Group.Abridged Standards of Care 2024. Clinical Diabetes April 2024, Vol.42, 181. doi:https://doi.org/10.2337/cd24-aint
[2] Dong Xiaoying, Yin Jingxia, Yu Li, Pu Danlan, Liao Yong.Interpretation of the key points of the American Diabetes Association's 2024 edition of the updated diabetes diagnosis and treatment standards.Modern Medicine and Health.2024.
[3] American Diabetes Association Professional Practice Committee.9.Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2024.Diabetes Care 2024; 47(Supplement_1):S158–S178.https://doi.org/10.2337/dc24-S009
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