COVID-19 vaccination, the use of nutritional supplements, telehealth, and both male and female infertility are some of the topics addressed by the American Association of Clinical Endocrinology (AACE) in its updated guideline for the care and management of people with or at risk for diabetes mellitus (DM). The guideline, which was last updated in 2014, features 170 evidence-based clinical practice recommendations for DM at every stage, including prevention, diagnosis, and treatment, according to Susan L. Samson, MD, PhD, FRCPC, FACE, and colleagues, authors of the guidelines.
Recommendations are separated into four sections:
› Screening and diagnosis
› Comorbidities and complications
› Management of DM
› New topics related to diabetes (Table)

‘We Aimed to Look at the Whole Patient’

“Due to the growing volume of literature that exists on DM, the updated guideline was 2 to 3 years in the making,” Dr. Samson says. “A key strength of this guideline is that we took a patient-centered approach that goes beyond glucose control. While glucose levels are certainly an important part of DM management, we aimed to look at the whole patient. Does this patient have heart disease or kidney disease? Are they at risk for stroke? This was a paradigm shift that will enable clinicians to tailor the right treatment for their patients with DM who have comorbidities.”

She adds that it is a multidisciplinary, not a one size-fits-all, approach to DM care and management, and the guideline is not directed solely toward endocrinologists, but to primary care and other physicians as well. “For example, obstructive sleep apnea (OSA) is a condition that is underdiagnosed in people with DM,” Dr. Samson says.
“Left untreated, it can lead to other comorbidities and worse QOL.”

Therefore, patients with DM presenting with sleep problems should be screened for OSA, especially if they present with obesity with other clinical features of OSA, she continues.

New Antihyperglycemic and Weight Loss Therapies

Several novel pharmacotherapies, including newer antihyperglycemic therapies and weight-loss medications, are outlined in the guideline. “Today’s treatments have enhanced safety with reduced risk for hypoglycemia, and at least two classes, SGLT2 inhibitors and GLP-1 RAs, have been found to improve outcomes for patients with chronic kidney disease, cardiovascular disease, and/or heart failure, independent of glycemic control,” she says.

New medical treatments have emerged for patients with obesity, with considerable improvements in weight loss. Insulin formulations now include more individual patient profiles and lifestyles, and insulin delivery systems and CGM technologies continue to improve.

Mental illness, particularly depression and diabetes distress, also can affect how effectively persons with diabetes can manage their disease, Dr. Samson explains. “The guideline suggests that addressing mental health challenges in people with DM can improve their ability to partner with their provider in the management of their disease.”

Exploring the Future of Virtual Medicine

The guideline also includes recommendations for patients with DM working in occupations with public safety implications, such as commercial drivers and airline pilots. “For people with DM working in these professions, continuous glucose monitoring to predict hypoglycemia in real time and pharmacotherapy that minimizes hypoglycemia are recommended as effective strategies,” Dr. Samson notes.

Through the COVID-19 pandemic, virtual telemedicine has grown in popularity, and evidence suggests that virtual care is acceptable for both patients and clinicians and provides outcomes comparable to in office consultations, according to the study team. It is anticipated that “in the near future, telemedicine will become seamlessly integrated into traditional care programs, improving access to care,” the study authors wrote, and that artificial intelligence and
machine-learning applications “will lead to unexpected clinical insights.”

Dr. Samson and colleagues concur that while they share optimism about recent developments in the diagnosis and treatment of DM, access to care and new anti-diabetes agents remains a major challenge and will require greater cooperation between both private and public sectors in the future.