COMMENTARY

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

Anne L. Peters, MD, CDE

Disclosures

February 03, 2015

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Today I am going to discuss the American Diabetes Association (ADA) 2015 Standards of Care.[1]

Each year a new Standards of Care is published and each year they change a little bit from the prior year and incorporate some of the newest and most interesting findings in the treatment of diabetes.

This year they tackled the really big issue that was brought up by the change in the American College of Cardiology/American Heart Association (ACC/AHA) lipid treatment guidelines. The ADA now is publishing its own take on this issue. But I will discuss that later. First, I am just going to go through some of the more minor changes in the recommendations.

First, the cut-off point for screening Asians in terms of their BMI is now 23 instead of 25, and this is because Asians develop diabetes or a risk for diabetes at a lower BMI than non-Asians. It is important to know that and to screen at a lower BMI.

Second, they recommend that people be more physically active during the day, particularly people who are sitting for 90 or more minutes at a time. They recommend that people get up and move around, which I personally think is a very good idea because we all sit too much at work and therefore don't get enough daily activity.

Third, they suggest that e-cigarettes have not been proven to be useful either in smoking cessation or as a safe alternative to cigarettes. So they do not suggest e-cigarettes as an alternative for smoking cessation or as an alternative to regular cigarettes.

They also raise the diastolic blood pressure target from 80 to 90. And in terms of glycemia, they finally made a change that I have been hoping for for a while. The old pre-meal target was 70 to 130, and they have raised that to 80 to 130, which I think is a good thing because that is the target I use more commonly. I have patients, particularly those on insulin, who avoid hypoglycemia below 70.

Now the lipid guidelines: Basically, they follow the ACC/AHA recommendations but they do not use a risk calculator as they do in the cardiology recommendations. So first of all, divide patients into two groups: those who are younger than 40 years of age and those who are 40 years of age or older. Basically, everybody who is above 40 years of age is going to be on a statin, and the choice is going to be whether it is a moderate-intensity statin or a higher-intensity statin. For the most part, those on a moderate-intensity statin are going to be those who really don't have much in the way of other risk factors. Those on a high-intensity statin will be those with risk factors, as well as those who have had a cardiovascular disease event.

When you look at individuals younger than 40 years of age, you want to look at whether an individual has risk factors. The risk factors that are listed are an LDL cholesterol above 100, being overweight or obese, cigarette smoking, and hypertension. Those are all individuals who, even though younger than 40 years, should also be on a moderate-intensity statin. And obviously, anyone who has had a cardiovascular disease event before the age of 40 needs to be on a statin as well.

Now, all of that sounds simple and easy to implement, but in my own experience it gets a bit more complicated. You will note that this really doesn't look much at LDL cholesterol levels except to categorize people into higher-risk or lower-risk groups. So, a lipid panel is recommended at baseline and then periodically thereafter to assess for adherence and to see what is happening to the LDL cholesterol level.

My problem tends to be that I get many patients who are either entirely statin intolerant or who can't tolerate a maximal or even half-maximal dose of a statin. Those are patients for whom I am not exactly sure where to go next—whether I should give them ezetimibe, whether I should really push on diet, what other combinations of therapies do I use? And in the recommendations they do touch on that a bit, but mostly they are very statin focused. And again, my issue as a clinician is that I have many patients for whom just giving a statin is often not possible or is something that I can only do at a lower dose than I would otherwise like to use.

The other key component of this is that they do stress (and I always stress) the role of lifestyle. People, by changing their diet, can effectively lower their cholesterol levels. I think that is very important to encourage as patients are put on medications for the treatment of their elevated lipid levels.

There are a couple other caveats. First is that we know very little about treating lipid disorders, treating these higher-risk patients who are younger than age 40. I think it is particularly important to note that, obviously, many women below the age of 40 are fertile, and it really needs to be individualized in terms of assessing risk and determining which women should be on a statin and which should not.

The other group where we lack data is individuals with type 1 diabetes. We know that people with type 1 diabetes are at increased risk for cardiovascular events and that the risk isn't quite the same as for individuals with type 2 diabetes. Nonetheless, the recommendations suggest that we follow similar guidelines for individuals with type 1 diabetes as for those with type 2. I do encourage this, particularly for patients who have had longer duration of disease. Anybody with 20 or more years of type 1 diabetes really does have a significantly higher risk for cardiovascular disease and probably should be treated with a statin. But, again, I think individualizing therapy, particularly in the younger group and for individuals with type 1 diabetes, is important as we implement these new standards of care.

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

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