What's New in ADA's Latest Diabetes Guidelines?

Anne L. Peters, MD, CDE


February 07, 2013

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Hi. I am Dr. Anne Peters. Today I am going to talk about a few modifications that the American Diabetes Association made in their 2013 diabetes treatment recommendations.[1]

Every year in January, the American Diabetes Association publishes new recommendations. They are available in print and online. These recommendations provide the backbone of how to treat patients with type 1 and type 2 diabetes as well as all the other situations [involving diabetes], such as gestational diabetes and inpatients with diabetes. Whatever you need, it is here.

The recommendations are formulated by the professional practice committee of the American Diabetes Association, a group of really smart people who work very hard to review all of the new literature and findings and build upon last year's recommendations to make this year's recommendations.

Generally, practice does not change that much in a year, which I think generally is good. But this year, 2 big changes in these recommendations concern blood pressure and monitoring of blood glucose levels in patients with type 1 diabetes.

First, the new recommendation for blood pressure is to aim for a systolic blood pressure target of < 140 mm Hg rather than < 130 mm Hg. I personally find this somewhat freeing because I have always struggled to get patients down to that < 130 mm Hg mark. I often could get people's blood pressures down to < 140 mm Hg, but that extra push to get it to < 130 mm Hg often was hard to accomplish. [The professional practice committee] found that treating patients' blood pressures more intensively is not beneficial, by and large, and is unnecessary.

Obviously, for some patients the lower target will be indicated -- younger patients, patients who have an easier time reaching the lower targets, and so on. But for an overall target, the systolic blood pressure has been raised to 140 mm Hg. The diastolic target continues to be < 80 mm Hg.

The other recommendation that has changed is about self-monitoring of blood glucose levels in patients who are on multiple daily insulin injections or insulin pumps. The bane of my life as a diabetologist is the necessity of filling out form after form after form to get approval for my patients to test more often than 3 times a day. I am not talking about patients taking oral medications. I am talking about patients who are testing and dosing before each meal and really need to be able to test as often as they need to test to avoid hypo- and hyperglycemia.

This year, instead of suggesting a number like 3 times a day, the American Diabetes Association included a paragraph stating that patients on multiple-dose insulin or insulin-pump therapy should do self-monitoring of blood glucose at least prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect a low blood glucose level, after they're treating a low blood glucose level to see that it comes back to normal, and before doing critical tasks such as driving.

There is no way that that amounts to using 3 testing strips a day, right? That means that it is reasonable to prescribe more strips based on how often each patient [needs to test him- or herself]. Most of my patients with type 1 diabetes who have good control are testing from 4 to 6 times a day. Many of them test more than that. I believe that patients who are on these intensive regimens should be given the tools they need in order to test as frequently as necessary.

Finally, I rather like one other small recommendation, which states that inpatients who are hyperglycemic and have not previously been found to have diabetes, but who have risk factors for diabetes, should have a hemoglobin A1c measured in the hospital. That is a good way of finding whether a patient had prehospitalization diabetes and needs to be followed up and subsequently treated for diabetes.

This has been Dr. Anne Peters for Medscape. Thank you.