Barbara Boughton

April 28, 2011

April 28, 2011 (San Diego, California) — In an effort to address the dangerous comorbid conditions that often accompany diabetes, as well as the symptoms of the disease itself, the American Association of Clinical Endocrinology (AACE) has released new clinical practice guidelines that emphasize individualized, comprehensive healthcare for patients with diabetes. Until now, that comprehensive care has been a missing piece in the healthcare that patients with diabetes receive, said 2 experts here at the AACE 20th Annual Meeting and Clinical Congress.

"When you look at comorbid conditions that commonly affect those with diabetes, such as heart attack, congestive heart failure, and chronic kidney disease, statistics show us that diabetic patients suffer these complications at a rate 3 to 7 times greater than those without diabetes," said Yehuda Handelsman, MD, president of AACE and medical director of the Metabolic Institute of America. Unfortunately, many patients with diabetes do not have the most common complications of the disease — high lipids and high blood pressure, in addition to high blood sugar — under control, Dr. Handelsman said.

Only 7% to 13% of patients with diabetes in the United States have good cholesterol, blood sugar levels, and blood pressure that are under control and also take aspirin to reduce the risk for heart attack, according to Dr. Handelsman.

"Diabetics are not getting comprehensive care, and with the new guidelines, we hope to address that problem," he added.

"This is the first year that our guidelines have been so comprehensive," said Daniel Einhorn, MD, immediate past president of AACE and clinical professor of medicine at the University of California–San Diego. The new guidelines address not only high blood sugar and comorbid conditions such as heart and kidney disease but also underrecognized problems affecting patients with diabetes, such as depression and sleep apnea, he said. They also provide modified diagnostic criteria for diabetes and new diagnostic criteria for gestational diabetes. There is also a new emphasis on decreasing obesity through lifestyle, medications, and surgery, including with laparoscopic-assisted gastric banding or Roux-en-Y gastric bypass for patients with diabetes with a body mass index higher than 30 or 35 kg/m2.

The new guidelines for type 1 and type 2 diabetes are written in a question-and-answer format and were developed by 23 of the nation's leading diabetic experts. The guidelines were first announced in early April and discuss the importance of achieving a treatment plan that avoids hypoglycemia, which is now thought to be a continual and pressing concern for many patients with diabetes. The guidelines recommend a blood glucose target of an HbA1c level of 6.5% if it can be achieved safely — a level more stringent than that recommended by the American Diabetes Association, which recommends 6.9% or below. "The majority of diabetics can achieve 6.5% safely, and this target helps avoid possible complications," Dr. Handelsman said.

The new AACE guidelines are published in supplement 2 of the March/April issue of the association's official medical journal, Endocrine Practice.

The guidelines emphasize a personalized approach to controlling diabetes and achieving blood glucose targets with care plans that take into account patients' risk factors for complications, comorbid conditions, expected life span, and psychological, social, and economic status. Although the guidelines recommend a blood glucose target of HbA1c level of 6.5% if it can be achieved safely, a treatment plan should take into account a patient's risk for development of severe hypoglycemia. The new guidelines also provide information on appropriate use of new technologies such as insulin pumps and continuous glucose monitoring.

In the guidelines, AACE recommends comprehensive diabetes lifestyle management education at the time of diagnosis, as well as throughout the course of diabetes. The importance of medical nutrition therapy, physical activity, avoidance of tobacco products, and adequate quantity and quality of sleep should be discussed with patients who have prediabetes as well as type 1 and type 2 diabetes, according to the new guidelines.

The guidelines also address healthcare for special populations, such as children, those with gestational diabetes, patients in hospitals, and people with prediabetes.

Although providing patients with diabetes with comprehensive care can demand more of health clinicians, the guidelines also provide support for using treatment approaches for diabetes that are truly evidence-based, Dr. Handelsman noted. "The guidelines are a result of consensus and consideration of the scientific evidence by the best minds in endocrinology in the United States," Dr. Handelsman said.

Yet it may take time for the new guidelines to be disseminated throughout the health clinician community, Dr. Einhorn said.

"We hope that the guidelines are transformative for both diabetic patients and their clinicians," Dr. Handelsman added.

Dr. Handelsman and Dr. Einhorn have disclosed no relevant financial relationships.

American Association of Clinical Endocrinologists (AACE) 20th Annual Meeting and Clinical Congress. Presented April 15, 2011.

Endocr Pract. 2011;17(Suppl 2):1-53. Full text