What are the AACE guidelines for the use of advanced technology in the management of diabetes mellitus (DM)?

Updated: Oct 08, 2021
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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Answer

In May 2021, the American Association of Clinical Endocrinology (AACE) released guidelines on the use of advanced technologies in diabetes management. The following recommendations are among those published. [198, 199]

The percentage of time in range (%TIR) and below range (%TBR) should serve as a starting point for the evaluation of the quality of glycemic control and form the basis for therapy adjustment.

For all persons with diabetes who are undergoing intensive insulin therapy (ie, three or more injections of insulin per day or treatment with an insulin pump), continuous glucose monitoring (CGM) is strongly recommended. For individuals on insulin therapy for whom success with CGM has been limited (or for those who are unable or unwilling to use CGM), structured self-monitoring of blood glucose (SMBG) is recommended. CGM is recommended for all individuals with problematic hypoglycemia (frequent/severe hypoglycemia, nocturnal hypoglycemia, hypoglycemia unawareness), for children/adolescents with type 1 diabetes; for pregnant women with type 1 or type 2 diabetes treated with intensive insulin therapy, and for women with gestational diabetes mellitus (GDM) on insulin therapy. CGM may be recommended for women with GDM who are not undergoing insulin treatment and for individuals with type 2 diabetes who are undergoing less intensive insulin therapy.

For persons with diabetes who have problematic hypoglycemia (frequent/severe hypoglycemia, nocturnal hypoglycemia, hypoglycemia unawareness) and need predictive alarms/alerts, real-time CGM (rtCGM) should be recommended over intermittently scanned CGM (isCGM). Consideration should also be given, however, to a patient’s lifestyle and to other factors.

The management of persons with diabetes who meet one or more of the following criteria should entail the use of diagnostic/professional CGM:

  • Newly diagnosed with diabetes mellitus
  • Not using CGM
  • No access to personal CGM, despite having problematic hypoglycemia
  • Persons with type 2 diabetes who, although undergoing non-insulin therapy, would derive educational benefit from episodic use of CGM
  • Persons who, before committing to daily use of CGM, wish to know more about it

Importantly, continued adjunctive use of SMBG must be employed by patients who are using “masked” or “blinded” diagnostic/professional CGM, to assist in daily diabetes self-care.

Persons with diabetes in whom glycemic targets are being reached with minimal TBR, infrequent episodes of symptomatic hypoglycemia are being reported, and SMBG is being used on a regular basis (at least 4 times daily for persons with type 1 diabetes) could employ an insulin pump without CGM.

In all persons with diabetes who are undergoing intensive insulin management but who prefer to forgo the use of automated insulin suspension/dosing systems or have no access to them, use of an insulin pump with CGM or a sensor-augmented pump (SAP) is recommended.

To reduce hypoglycemia’s severity and duration in persons with type 1 diabetes, low-glucose suspend (LGS) is strongly recommended; for mitigation of hypoglycemia in these patients, predictive low-glucose suspend (PLGS) is strongly recommended.

It is strongly recommended that all persons with type 1 diabetes use automated insulin dosing (AID) systems; these have been shown to raise the TIR, especially in the overnight period, without increasing the hypoglycemia risk.

In persons with diabetes who are hospitalized but are suffering no cognitive impairment, consideration should be given to the continuation of CGM and/or continuous subcutaneous insulin injection (CSII) (insulin pump, SAP, LGS/PLGS). The presence of a family member who is knowledgeable and educated in the use of these devices or the availability of a specialized inpatient diabetes team for advice and support is ideal in such situations.

To enable persons aged 65 years or older with insulin-requiring diabetes to improve glycemic control, reduce episodes of severe hypoglycemia, and improve quality of life, use of rtCGM is recommended. Owing, however, to this population’s increased comorbidities and lowered capacity to detect and counter-regulate against severe hypoglycemia, glycemic goals should be individualized.

As a means of tracking glucose before, during, and after exercise in persons with diabetes; monitoring the glycemic response to exercise; and helping to direct insulin and carbohydrate consumption to prevent the development of hypoglycemia and hyperglycemia, clinicians should prescribe CGM.

It is strongly recommended that telemedicine be used in the treatment of diabetes, provision of diabetes education, remote monitoring of glucose and/or insulin data, and improvement of diabetes-related outcomes/control.

As a means of teaching/reinforcing diabetes self-management skills, encouraging engagement, and supporting/encouraging desired health behaviors, clinically validated smartphone applications should be recommended to persons with diabetes.

Comprehensive training in the proper use and care of insulin delivery technology should be provided to all persons with diabetes using that equipment.

It is strongly recommended that, in the absence of pump therapy, FDA-cleared and clinically validated smartphone bolus calculators be used to reduce the frequency of hypoglycemia or severe postprandial hyperglycemia.


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