COMMENTARY

ADA's Practice Guidelines for 2011

Anne L. Peters, MD, CDE

Disclosures

March 09, 2011

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Hi. I'm Dr. Anne Peters, and today I'm going to discuss the 2011 clinical recommendations for the management of diabetes from the American Diabetes Association. These clinical practice recommendations are available in a publication that comes out in January each year from the American Diabetes Association and are also available for free on their Website.[1] The good news about these 2011 practice recommendations is that they don't differ hugely from previous recommendations, so we don't have to change our practice that much. The area in which they differ the most is in terms of screening for gestational diabetes, which I'll discuss in a moment.

It's nice to know that the targets we've been striving for are actually still applicable. We've had a number of clinical trials in the past few years that have led to some confusing data about the safety of normalizing blood glucose levels, but the current target of an A1c [level] of less than 7% seems to still be a reasonable target. More normal blood glucose levels clearly reduce the risk for microvascular complications such as retinopathy, nephropathy, and neuropathy. If tight glucose control is started early in the course of the disease, it will also lead to reductions in macrovascular complications.

We also have learned that we really must individualize our care. A young healthy person in their 40s or 50s who can get to an A1c [level] of even less than 6% without excessive hypoglycemia is doing really well. That's a great target, but in older patients, someone who is on insulin, someone who is trying really hard but hypoglycemia develops and [he or she] really can't do any better than a hemoglobin A1c of 7.5% or even 8%, those are patients in whom I will accept a higher target because I don't want to cause any harm, particularly if that harm comes in terms of episodes of severe hypoglycemia.

Not only were our glucose targets validated, but so were our other targets. The blood pressure target remains less than 130/80 [mm Hg]. The LDL [low-density lipoprotein] target remains less than 100 mg/dL unless a patient has known cardiovascular disease, and then it's lowered to less than 70 mg/dL.

In terms of gestational diabetes, we're really doing away with the old 50-gram screen and then the follow-up 100-gram glucose tolerance test. It's now recommended that all pregnant women who are between 24 and 28 weeks of gestation undergo a 75-gram 2-hour glucose tolerance test. Blood should be drawn for glucose levels at baseline, at 1 hour, and at 2 hours. A woman only needs to have a single abnormal value to be diagnosed with gestational diabetes.

The cutpoints are as follows. The fasting cutpoint is greater than or equal to 92 mg/dL. The 1 hour cut point is greater than or equal to 180 mg/dL. The 2-hour cutpoint is greater than or equal to 153 mg/dL. If a woman is found to go above any of these cutpoints, she's diagnosed with gestational diabetes and treated accordingly. It's also very important to remember that women who have had gestational diabetes in the past should be screened at least every 3 years to be sure that true diabetes -- usually type 2 diabetes -- [doesn't develop] in the future.

Another area that is touched upon but not yet addressed is the notion of care for the transitioning adult. Young people between the ages of 18 and 30 years are really not yet adults or at least full adults and they're not children. For many of our patients, particularly those in whom diabetes develops in childhood, it's a real transition leaving their pediatrician behind and finding an adult care provider. In this transition, many of these youths tend to get lost and their diabetes care suffers. New guidelines for the treatment of transitioning adults will be published soon by the American Diabetes Association.

Those are the clinical practice recommendations for 2011 by the American Diabetes Association. This has been Dr. Anne Peters for Medscape. Thank you.

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