'Subtle Changes' to the 2024 ADA Standards of Care in Diabetes

Anne Peters, MD, provides an overview of the updates to the ADA Standards of Care in Diabetes.
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The new American Diabetes Association Standards of Care-2024 is a really interesting, updated document. There aren't any huge headlines, but there are many subtle changes. I think it's important that people really understand what the guidelines say and how we can apply this to patients.

The guidelines are long. There are 328 pages, and I've read every word. I've summarized into two videos what I really think is important to know. This first video is going to be more of the basic overview, and the second video will discuss treatment of people with type 2 diabetes.

I am most interested in section two, entitled, "Diagnosis and Classification of Diabetes." The reason this section resonates so much with me is because it really characterizes what I do as a diabetologist. Recommendation 2.5 says to classify people with hypoglycemia into appropriate diagnostic categories to aid in personalized management. It then goes on to say, "Diabetes is conveniently classified into several clinical categories, although these are being reconsidered based on genetic, metabolomic, and other characteristics and pathophysiology."

The reason this resonates with me so much is because as I've used continuous glucose monitoring (CGM) more extensively in my patients and as we've had newer treatments for our patients with diabetes, I've learned that there must be many, many different types of diabetes because people vary greatly in how they respond and what their glucose profiles look like. I find that this validates the fact that I often can't really tell what type of diabetes a person has, but I do know they have diabetes. What I do clinically is try to figure out the best way to treat them.

The title of section two has been changed. It used to be called "Classification and Diagnosis of Diabetes," but now it's called "Diagnosis and Classification of Diabetes." Basically, what that means is, first, let's figure out whether this patient does or does not have diabetes and then we'll try to classify it, but it might not fit into those simple categories that we all were trained on. It may not be classic type 1, classic type 2, classic other, or gestational diabetes. What is this? We really need to think that way.

They also focus on improving the standardization of approaches to diagnostic testing for diabetes. They discuss hemoglobin A1c levels as the go-to tool that most of us use for diagnosing diabetes. They also reinforce the need for a second test to confirm the diagnosis.

The standards now talk about how we see — not uncommonly, particularly when using CGM — that there may be a discordance between the glucose values that we see for CGM or fingerstick and the A1c test results. They discuss the potential need for use of other biomarkers, such as fructosamine, and glycated albumin as an alternative method for measuring states of chronic hyperglycemia.

They also discuss pancreatic diabetes, or diabetes in the context of disease of the exocrine pancreas. They talk about the importance of screening for diabetes in people following an episode of acute pancreatitis. Those individuals should be screened 3-6 months after they've had an episode of acute pancreatitis, and then annually in individuals who have chronic pancreatitis, to make sure they're not developing hyperglycemia.

One of the biggest changes in the guidelines is regarding the use of teplizumab to help people with stage 2 type 1 diabetes slow progression to stage 3 type 1 diabetes. For those of you who want to learn more about this, I would strongly encourage you to read the guidelines because they go into great detail about screening, who should be screened, what antibodies mean, and following patients over time.

Suffice it to say, not all prediabetes is actually pre-type 2 diabetes. In individuals, particularly those who have first-degree family members with type 1 diabetes, screening for islet autoantibodies can be very important in terms of understanding what type of prediabetes they might have.

When you're following these patients over time — so you've diagnosed somebody with positive islet autoantibodies and you want to see if they're developing overt type 1 diabetes stage 3 — you can follow them with an A1c level or with an oral glucose tolerance test. Less specifically, you can follow them with CGM. I have a number of patients that I follow over time to watch to see if they are in fact progressing to stage 3 type 1 diabetes. I think it's important to learn about this concept because we've never had anything before that can help slow progression to overt stage 3 type 1 diabetes.

Transcript in its entirety can be found by clicking here:
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