It’s That Time of Year Again

In the ever-evolving world of diabetes research, the American Diabetes Association (ADA) has once again published new Standards of Medical Care in Diabetes (SOC) (1). Each year, an expert ADA committee reviews newly published studies and incorporates key findings into recommendations that should be considered when making therapeutic decisions for patients with diabetes. Since the first SOC was published in 1989, 11 new classes of medications have been developed, and we have witnessed advances in technology such as continuous glucose monitoring and hybrid closed-loop insulin delivery systems. These advancements necessitated periodic updates of the SOC since the first iteration. An updated version of the SOC is published online and in a supplement to Diabetes Care annually; more recently, ADA has started providing interim online updates as needed through its Living Standards process (2).

To make these comprehensive clinical practice guidelines more accessible to primary care clinicians, the ADA’s Primary Care Advisory Group each year develops an abridged version of the SOC, which is published in Clinical Diabetes and on its website (3,4). The 2020 abridged SOC appears in this issue (p. 10). It reflects a primary care perspective regarding appropriate approaches to diabetes management, taking into consideration the latest research and our understanding of diabetes pathophysiology.

Although ADA’s recommendations are considered the gold standard for diabetes clinical management, other regional and national organizations have published different guidelines based on their own experts’ interpretation of the data, as well as specific cultural and socioeconomic issues. In August 2018, I had the honor of representing the ADA at the Chinese Endocrinology Society annual meeting in Wuhan, China. I presented the ADA’s current SOC and contrasted it with some of the Chinese recommendations (5). The Chinese guidelines were published in 2016, and an update was planned for late 2019. Many of the recommendations were similar to those of the ADA; however, an obvious divergence concerned the use of α-glucosidase inhibitors as an alternate to metformin for first-line therapy.

I also had the opportunity to represent the Primary Care Metabolic Group (www.pcmg-us), which I direct, at a meeting of Primary Care Diabetes Europe (PCDE) (www.pcdeurope.org). This organization consists of primary care providers from 14 European countries. The goals of this meeting were to bring a primary care perspective to the modern management of diabetes and to develop relevant guidelines. Publication of this consensus document is planned for early 2020 in PCDE’s journal Primary Care Diabetes (www.primary-care-diabetes.com).

As the science of diabetes evolves from a purely glucocentric approach and objectives change to a more appropriate outcome-based focus, the need to know the right pharmacotherapeutic choice after metformin becomes crucial. Perhaps we also need to decide whether metformin is indeed even the right first step.