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ADA Embraces CV Risk Calculator, Calls for Using GLP-1s Before Insulin in Type 2 Diabetes


The 2019 Standards of Care reflect an ongoing collaboration between the American Diabetes Association and the American College of Cardiology.

The growing connection between treatment for diabetes and management of cardiovascular risk bore more fruit December 17 with the release of the American Diabetes Association (ADA) 2019 Standards of Medical Care in Diabetes, which marked the first the time the chapter on cardiovascular disease management was endorsed by the American College of Cardiology (ACC).

ADA’s new Standards of Care endorse the use of ACC’s and Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator Plus, which assesses a person’s 10-year ASCVD risk in people with diabetes.

A separate change updates ADA’s recommendation for injectable medication in patients with type 2 diabetes (T2D): in most cases, those who need additional help lowering glucose should start with glucagon-like peptide-1 (GLP-1) receptor agonists before adding basal insulin or switching to a GLP-1/insulin combination therapy.1

The update comes less than a month after ADA similarly endorsed the cardiologists’ new pathway for patients with T2D and ASCVD. The updated ADA standards feature new language on the role of sodium glucose co-transporter 2 (SGLT2) inhibitors and GLP-1 receptor agonists in T2D care, and the need to consider heart failure in overall diabetes care.2

“For prevention and management of both ASCVD and heart failure, cardiovascular risk factors should be systematically assessed at least annually in all patients with diabetes,” the recommendation states. The ADA document notes that risk scores and biomarkers have been developed for secondary prevention, which could help identify patients who could be candidates for lipid-lowering therapies.

The changes come as the FDA weighs possible changes to practice-changing cardiovascular outcomes trials, which emerged a decade ago in the wake of concerns about the safety of some classes of glucose-lowering treatments for diabetes. Not only did these trials demonstrate that SGLT2 inhibitors and GLP-1 receptor agonists did not cause heart attacks, strokes, or cardiovascular death, but the studies showed that some treatments offered cardiovascular benefits.

More trials are under way to study additional benefits to patients with heart failure or chronic kidney disease (CKD), and the ADA recommendations address the usefulness of SGLT2 inhibitors and GLP-1 receptor agonists for patients with CKD.

The 2019 Standards of Care also carry forward ADA’s previous statements about the need to make insulin more affordable and the recent joint statement with the European Association for the Study of Diabetes on treatment for hypertension in people with diabetes.

Additional updates discuss diabetes technology, medical nutrition, reducing therapeutic inertia, managing diabetes in overweight youth, and simplifying or scaling back medication for persons with diabetes who 65 years of age or older.

“The latest evidence-based research continues to provide critical information that can optimize treatment options and improve patient outcome and quality of life,” ADA Chief Scientific, Medical and Mission Officer William T. Cefalu, MD, said in a statement, noting the importance of the collaboration with ACC and the alignment of recommendations.


  1. American Diabetes Association. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019; 42(suppl 1): S90-S102. doi: 10.2337/dc19-S009.
  2. American Diabetes Association. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019; 42(suppl 1): S103-S123. doi: 10.2337/dc19-S010.
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