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Pearls from the ADA 2022 Updates on Standards of Medical Care in Diabetes

Updated: 17 hours ago

By Da Som Kim, PharmD; Kathleen Horan, PharmD; Rebecca Khaimova, PharmD, BCACP

Diabetes is a chronic and progressive disease characterized by lack of insulin production or ineffective insulin use in the body.(1) It is one of the major causes of atherosclerotic cardiovascular disease (ASCVD) and may also cause microvascular complications, such as renal disease, blindness, and lower limb amputation.(2) This post will highlight updates from the 2022 American Diabetes Association (ADA) Standards of Medical Care in Diabetes, focusing on pharmacologic management of diabetes with emphasis on comorbidities and the expanded use of diabetes technology for improved assessment of diabetes care.(3) The recommendations are rated based on the level of evidence:

  • A: based on large well-designed clinical trials or meta-analyses

  • B: based on well-conducted cohort studies or case-control study

  • C: based on poorly controlled or uncontrolled studies

  • E: expert consensus with conflicting or no evidence from clinical trials

Pharmacologic Approaches to Glycemic Treatment Since 2008, the ADA and European Association for the Study of Diabetes consensus statement on managing hyperglycemia in type 2 diabetes recommended metformin as first-line treatment along with lifestyle modifications.(4) The 2022 ADA guideline recommends choosing first-line therapies based on glycemic and comorbidity management needs, as well as patient-specific treatment factors (e.g., cost, side effects) (Grade A). This individualized approach expands the selection of first-line agents beyond metformin to include sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1 RAs). These two classes have more robust data for use in patients with certain comorbidities including ASCVD, chronic kidney disease (CKD), and heart failure (Grade A). This approach allows for management of hyperglycemia as well as reduction in the risks of complications that contribute to morbidity and mortality in patients with diabetes. A summary of cardiovascular and renal outcome trials for SGLT2 inhibitors and GLP-1 RAs are provided in Table 1 and Table 2.

The guideline also includes a new section for managing and preventing CKD, which emphasizes the recommendation to choose agents with proven renal and cardiovascular benefits. Specifically, the guideline recommends consideration for SGLT2 inhibitor therapy when eGFR >25 ml/min/1.73m2 or urinary albumin creatinine >300 mg/g (Grade A). For patients who are unable to take SGLT2 inhibitors, the guideline recommends a nonsteroidal mineralocorticoid receptor antagonist, finerenone (Kerendia), for patients at an increased risk of CKD progression and cardiovascular events (Grade A).

Lastly, the use of injectable GLP-1 RAs was updated in comparison to or in combination with insulin therapy. Recent trials found similar, if not greater, glycemic efficacy with lower risk of hypoglycemia and weight loss benefit when using GLP-1 RA versus basal insulin. Based on these outcomes, the guideline recommends GLP-1 RA over basal insulin when injectable medication is needed (Grade A). If intensification of preexisting basal insulin therapy is required, combining basal insulin with GLP-1 RA is recommended to provide greater efficacy and durability than intensification to basal-bolus therapy (Grade A).

Diabetes Technology Update

​​Diabetes technology is constantly evolving. Updates in this area include:

  • A broad terminology change from “self-monitoring of blood glucose (SMBG)” to “blood glucose monitoring (BGM).”

  • Simplified recommendation on the professional use of CGM states that professional CGM use can be helpful for diabetes management in circumstances where continuous use of CGM is not appropriate, desired, or available (Grade C). Professional CGMs are owned and applied by a clinic and provide blinded or unblinded data for a discrete time period. Personal CGMs are owned by the user and are unblinded and intended for frequent/continuous use.

  • Discussion of automated insulin delivery (AID) systems has been combined with the insulin pump subsection and the non-FDA-approved “do-it-yourself closed loop systems” section. AID systems consist of an insulin pump, a continuous glucose sensor, and an algorithm that determines insulin delivery. It increases or decreases insulin dosage based on sensor-derived glucose levels to approximate physiologic insulin delivery. AID systems should be offered to youth and adults with T1DM (Grade A) and patients with other types of insulin-dependent diabetes (Grade E) provided they can use the device safely.

  • Patients who can safely use diabetes devices should be allowed to continue using them in an inpatient setting or during outpatient procedures when proper supervision is available (Grade E).

Table 1: Summary of cardiovascular and renal outcome trials for SGLT2 inhibitors

Table 2: Summary of cardiovascular and renal outcome trials for GLP-1 RAs

  1. World Health Organization. Diabetes. November 10, 2021. Accessed March 7, 2022.

  2. Center for Disease Control and Prevention. Prevalence of both diagnosed and undiagnosed diabetes. Updated December 29, 2021. Accessed March 7, 2022.

  3. American Diabetes Association. Standards of medical care in diabetes–2008. Diabetes Care 2008;31:S12–S54.

  4. American Diabetes Association. Standards of medical care in diabetes—2022. Diabetes Care 2022;45(Supplement_1):S1–S254.

  5. Neal B, Perkovic V, Mahaffey KW, et al. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med 2017; 377:644-657.

  6. Wiviott SD, Raz I, Bonaca, et al. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2019; 380:347-357.

  7. Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015;373:2117-2128.

  8. McMurray JJV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med 2019; 381:1995-2008.

  9. Packer M, Anker SD, Butler J, et al. Cadiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med 2020; 383:1413-1424.

  10. Anker SD, Butler J, Filippatos G, et al. Empagliflozin in heart failure with a preserved ejection fraction. N Engl J Med 2021; 385:1451-1461.

  11. Perkovic V, Jardin MJ, Neal B, et al. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med 2019; 380:2295-2306.

  12. Heerspink HJL, Stefansson BV, Correa-Rottere R, et al. Dapagliflozin in patients with chronic kidney disease. N Engl J Med 2020; 383:1436-1446.

  13. Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375(4):311-322.

  14. Gerstein HC, Colhoun HM, Dagenais GR, et al. Dulaglutide and cardiovascular outcomes in type 2 diabetes (Rewind): a double-blind, randomised placebo-controlled trial. Lancet. 2019;394(10193):121-130.

  15. Marso SP, Bain SC, Consoli A, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2016;375(19):1834-1844.



Da Som Kim, PharmD, PGY-2 Ambulatory Care Resident (1) (left)

Kathleen Horan, PharmD, PGY-2 Ambulatory Care Resident (1) (center)

Rebecca Khaimova, PharmD, BCACP (1,2) (right)

(1) One Brooklyn Health-Brookdale Hospital Medical Center

(2) Long Island University Arnold & Marie Schwartz College of Pharmacy and Health Sciences

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