We are moving toward comprehensive diabetes care. How do we maintain momentum?

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In 2023, there has been a welcome focus at the federal level on lowering the notoriously high cost of insulin. The issue has been in the spotlight, from the Inflation Reduction Act to President Joe Biden’s February State of the Union speech. In April, U.S. Senators Jeanne Shaheen (D-New Hampshire) and Susan Collins (R-Maine) introduced the bipartisan Improving Needed Safeguards for Users of Lifesaving Insulin Now (INSULIN) Act to address the cost of insulin. By ensuring people with diabetes can afford the cost of their lifesaving medications, the U.S. government can play a role in reducing the burden of diabetes and improving patient outcomes. As clinicians, we must use our voices to champion reforms that will allow Americans to access needed medications. Likewise, we must also consider cost and access to medications when making decisions related to diabetes management.

Susan L. Samson, MD, PhD

What else can we do as clinicians to make progress in the fight against diabetes and all its complications? In 2023, we are at a unique point in the history of diabetes care. In the past, our approach to diabetes care could be considered glucose-centric. Although we know that achieving a particular glucose threshold is essential to preventing many complications of diabetes, the path by which we arrive there has been evolving. With a widening array of available therapies for treating people with diabetes and gathering evidence on diabetes complications and comorbidities, we now are better equipped to propose a patient-centered and personalized approach.

The American Association of Clinical Endocrinology (AACE)recently released its 2023 Comprehensive Type 2 Diabetes Management Algorithm, which provides concise and visual guidance to assist health care professionals in decision-making for the management of Type 2 diabetes (T2D). The 2023 algorithm update incorporates a complications-centric approach to choosing a patient-centered management pathway. It first considers present health conditions, such as cardiovascular disease and kidney disease, and then provides a pathway for therapeutic decision-making. Notably, for the first time, the algorithm includes access and cost of medications as factors related to health equity that should be considered in clinical decision-making. These nuanced shifts over the past three years, since AACE last published such an algorithm, reflect how the U.S. health care community is beginning to prioritize a person-centered approach to help improve care for people with prediabetes and diabetes.

Although the previous algorithms have always emphasized the importance of lifestyle modification as a key pillar in the management of prediabetes and diabetes, the updated algorithm also highlights the importance of weight-loss medications and bariatric procedures that that the U.S. Food and Drug Administration has approved to help reverse some of the metabolic derangements that occur with increased weight. Guidance regarding the goals and tools of treatment for hypertension and dyslipidemia are also included. Additionally, the new algorithm reiterates the importance of recommended immunizations for people with prediabetes and diabetes. A broader endocrine care team, including primary care, is especially well positioned to encourage patients to meet all vaccination recommendations.

Given the prevalence of T2D in the population, it is not possible for the finite number of endocrinologists in the community to care for all of those with T2D, so there is a need to encourage the expansion of the diabetes care team to include other clinicians outside of our specialty, including primary care and internal medicine physicians, as well as advanced practice providers. It is vital that clinicians who care for people with diabetes remain up to date regarding the continuously evolving medical advancements in our field, to arrive at the best patient outcomes. Providing uninterrupted, multidisciplinary support for the prevention, screening, and management of diabetes is key to reducing the overall burden of diabetes and improving overall patient outcomes. I hope the latest algorithm is the next step toward achieving that vision.

Susan L. Samson, MD, PhD, FRCPC, FACE, is president-elect of the American Association of Clinical Endocrinology (AACE) and chair of the AACE Consensus Statement: Comprehensive Type 2 Diabetes Management Algorithm – 2023 Update. She is chair of the Division of Endocrinology, Diabetes and Metabolism, Department of Medicine at Mayo Clinic in Jacksonville, Florida. Originally from Canada she is a fellow of the Royal College of Canada in Internal Medicine and Endocrinology, and is current chair of the Longitudinal Knowledge Assessment Approval Committee for Endocrinology, Diabetes and Metabolism at the American Board of Internal Medicine.