Countdown to 2021 ADA Annual Meeting! Review of the main points of the new ADA guide (Part 1)│ Reviewing the past and learning the new

The 81st American Diabetes Association (ADA) Annual Meeting will be held in the form of an online conference from June 25-29, 2021, Eastern Time in the United States
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As the meeting is approaching, we will briefly review the "2021 ADA Medical Diagnosis and Treatment Standards for Diabetes" (hereinafter referred to as the "New ADA Guidelines") to see that as new technologies, new therapies and evidence-based evidence continue to emerge, the new ADA What are the important updates to the guide
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 The new ADA guidelines continuation of the 2020 version of the chapter arrangement, is divided into 16 chapters, the main issue on the "glycemic control targets" 1 and 2 focus on interpretation of the relevant sections of "hypoglycemic drug treatment programs"
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01 The new version of the ADA Guidelines for Blood Glucose Control Goals supplements and revises this part on the basis of previous standards.
The main points of the update include emphasizing the importance of blood glucose evaluation methods, recommended frequency of blood glucose evaluation, blood glucose control goals, and hypoglycemia assessment
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Because HbA1c monitoring is limited by many interference factors and cannot provide information about blood glucose fluctuations and hypoglycemia, the guidelines first emphasize that in addition to HbA1c when assessing blood glucose control, other blood glucose assessment methods, including continuous glucose, should also be paid attention to.
Monitoring (CGM) and Self-Glucose Monitoring (SMBG)
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At the same time, considering that regular blood glucose monitoring can provide patients with a more timely treatment adjustment plan, the new version of the guide also revised the recommendations on blood glucose evaluation on the original basis: ● It is recommended that patients who meet the treatment standard (stable blood glucose control) should be evaluated at least 2 times a year Secondary blood glucose status (HbA1c or other blood glucose assessment methods); ● Patients who have changed the treatment plan or whose blood glucose control is not up to standard are evaluated once every 3 months
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Two prospective studies have shown that glucose in target range (TIR) ​​has a strong correlation with HbA1c.
The TIR control target of 70% corresponds to the HbA1c control target of 7%.
In view of this, the new version of the ADA guidelines will have no severe hypoglycemia The blood glucose control goals of non-pregnant adult diabetic patients are divided into two parts: ●Recommended HbA1c<7%; ●If the dynamic glucose profile (AGP)/glucose management index (GMI) is used to evaluate blood glucose management, the recommended control corresponding to the HbA1c target The target is TIR>70% and the time that glucose is below the target range (TBR)<4%
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Regarding the goal of glucose control for hospitalized patients, the results of a landmark clinical trial showed that in critically ill patients who need surgery in the near future, insulin is used compared with the standard treatment regimen that achieves the target blood glucose range of 10-12mmol/L.
The treatment plan to achieve the target blood glucose range of 4.
4-6.
1mmol/L can reduce the mortality rate by 40%
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Based on this, the new version of the ADA guidelines refines the blood glucose control goals for hospitalized patients, and recommends two types of goals, "relaxed" and "strict" according to the individual conditions of the patients3
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Considering that hypoglycemia is the main limiting factor affecting blood glucose control in diabetic patients, severe hypoglycemia can progress to loss of consciousness, seizures, coma and even death.
Therefore, the guidelines emphasize that hypoglycemia prevention is an important part of diabetes management, and patients are recommended to follow-up every time.
All should assess the risk of hypoglycemia and investigate according to the instructions to clarify the cause of hypoglycemia
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      02 Hypoglycemic drug treatment plan For the drug treatment of type 2 diabetes (T2DM), the new version of the ADA guidelines follow the previous standards, and once again emphasize the patient-centered guidance on the choice of drugs
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The factors that clinicians need to consider when formulating a treatment plan include: cardiovascular and renal comorbidities, efficacy, risk of hypoglycemia, impact on body weight, adverse reactions, costs, and patient preferences
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In view of the above considerations, the guidelines have updated the treatment pathways for T2DM (Figure 1), adding dedicated decision-making pathways for chronic kidney disease and heart failure
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For T2DM patients diagnosed with atherosclerotic cardiovascular disease (ASCVD) or with high risk factors for ASCVD, diagnosed kidney disease or heart failure, regardless of the baseline HbA1c level, the guidelines recommend sodium-glucose with clear cardiovascular benefits Cotransporter 2 inhibitor (SGLT2i) or glucagon-like peptide 1 receptor agonist (GLP-1 RA) as part of hypoglycemic therapy
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At the same time, the guidelines emphasize that it is recommended to choose basal insulin for the initial insulin treatment.
Considering the requirement to minimize the risk of hypoglycemia, it is recommended to choose a new generation of basal insulin analogs with a lower risk of hypoglycemia, such as insulin glargine U300 treatment
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The BRIGHT study showed that the risk of hypoglycemia during the initial dose adjustment period (the first 12 weeks) of insulin glargine U300 treatment was significantly lower than that of insulin deglubber U100 by 23% to 43%4
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Figure 1 The overall path of T2DM hypoglycemic drug treatment 5 In addition, the new version of the ADA guidelines also make relevant recommendations for combined injection therapy
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Studies have confirmed that compared with intensive insulin therapy, basal insulin combined with GLP-1RA therapy can effectively reduce blood sugar, while weight gain and hypoglycemia are less
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Therefore, the guidelines emphasize that if the dose of basal insulin has been adjusted to an acceptable fasting blood glucose level, but HbA1c is still higher than the target value, basal insulin or multi-dose insulin combined with GLP-1RA treatment can be considered, and insulin glargine can also be selected.
Senatide injection is a compound preparation for treatment
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In summary, the 2021 version of the ADA guidelines is based on the latest evidence and revised the original content.
In addition to emphasizing the importance of blood glucose assessment in blood glucose management, it also refines the blood glucose control goals for patients with different types of diabetes
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In the relevant chapters of hypoglycemic drug treatment, the new version of the guide has once again deepened the patient-centered individualized treatment thinking, supplemented and updated the treatment path of T2DM, and made relevant recommendations for combined injection therapy.

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References: 1.
American Diabetes Association.
6.
Glycemic Targets: Standards of Medical Care in Diabetes-2021.
Diabetes Care.
2021 Jan;44(Suppl 1):S73-S84.
2.
American Diabetes Association.
9.
Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2021.
Diabetes Care.
2021 Jan;44(Suppl 1):S111-S124.
3.
American Diabetes Association.
15.
Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2021 Diabetes Care.
2021 Jan;44(Suppl 1):S211-S220.
4.
Rosenstock J, et al.
Diabetes Care 2018, 41(10):2147-2154.
5.
Cai Jinghao, Zhou Jian.
Chinese Journal of Medical Frontiers (Electronic Edition) ),2021,13(02):13-23.
MAT-CN-2111263 Plan approval date: June 2021‍