Insulin Pathways and Cost Estimates Included in New ADA Standards for Diabetes Care


In its 2017 Standards of Medical Care in Diabetes, the American Diabetes Association (ADA) has added a new insulin algorithm to guide glucose management for people with type 2 diabetes as well as tables that include average monthly cost estimates for glucose lowering medicines.


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The updated Standards include several changes and additions affecting recommendations for pharmacologic approaches to glycemic treatment. A new insulin algorithm is included to guide glucose management options for people with type 2 diabetes and consists of a detailed care recommendation flow chart, showing numerous pathways that may be considered for patients using insulin. The algorithm reflects new research, showing basal insulin plus glucagon-like peptide 1 receptor agonist to be noninferior to basal insulin plus rapid-acting insulin versus two daily injections of premixed insulin, and showing multiple dose premixed insulin regimens to be noninferior to basal-bolus therapy.

Several changes were made to address concerns associated with high costs of medications for diabetes. The algorithm for choosing antihyperglycemic therapy for patients with type 2 diabetes compare different treatments on criteria of efficacy, hypoglycemia risk, impact on body weight, potential side effects, and costs. In the updated Standards, the costs associated with insulin therapy are now listed as “high.” The Standards also caution that “cost-effectiveness models have suggested that some of the newer agents may be of relatively lower clinical utility based on high cost and moderate glycemic effect.”

Additionally, two new tables have been added to the new Standards, one showing the median monthly costs of maximum approved daily dose of noninsulin glucose-lowering agents in the US, and the other showing median cost of insulins in the US. These additions were made “to assist providers in addressing any concerns about medications costs that patients living with diabetes face,” the ADA said in a press release.

Finally, based on the results of two large clinical trials, a recommendation was added to consider empagliflozin or liraglutide in patients with long-standing suboptimally controlled type 2 diabetes and established atherosclerotic cardiovascular disease. These medications have been shown to reduce cardiovascular and all-cause mortality when added to standard care. Ongoing studies are investigating the cardiovascular benefits of other agents in these drug classes.

The Standards, published in Diabetes Care, were developed by a multi-disciplinary team of 12 leading experts in the field of diabetes care, and includes physicians, diabetes educators, registered dietitians and others who have experience in areas including adult and pediatric endocrinology, epidemiology, public health, lipid research, hypertension, preconception planning and pregnancy care.