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Diabetes update: Your guide to the latest ADA standards

SUMMARY

TITLE: Diabetes update: Your guide to the latest ADA standards AUTHORS: Johnson, Eric et al

SOURCE: THE JOURNAL OF FAMILY PRACTICE, Vol. 65, No. 5

DATE:  MAY 2016

The American Diabetes Association (ADA) updates its “Standards of Medical Care in Diabetes” annually to incorporate new evidence or clarifications.

Diagnosis and Screening

Have the 2016 ADA standards changed the way diabetes is diagnosed? No

Diabetes and prediabetes are still screened for and diagnosed with any of the following: Fasting plasma glucose (FPG); 2-hour 75-g oral glucose tolerance test (OGTT); Random plasma glucose >200 mg/dL , A1C .

Have screening recommendations
been revised? Yes

Any age who are overweight or obese and have one or more additional risk factors for diabetes, the 2016 standards recommend screening all adults 45 years and older, regardless of weight.

Is an A1C <7% the recommended
 treatment goal for everyone with diabetes? No.

An A1C <7% is considered reasonable for most, but not all, nonpregnant adults.

Pregnancy

The 2016 standards have a new target for pregnant women with diabetes: The ADA previously recommended an A1C <6% for this patient population, but now recommends a target A1C between 6% and 6.5%.

Prediabetes and Prevention

What is prediabetes and what can I do 
to prevent patients with prediabetes from developing diabetes?

Patients with impaired glucose tolerance, impaired fasting glucose, or an A1C between 5.7% and 6.4% are considered to have prediabetes and are at risk for developing type 2 diabetes.

Goals should include a minimum 7% weight loss and moderate-intensity physical activity, such as brisk walking, for at least 150 minutes per week. .

Should I consider initiating oral antiglycemics in patients with prediabetes? Yes

Pharmacologic agents, including metformin, acarbose, and pioglitazone, have been shown to decrease progression from prediabetes to type 2 Diabetes.

How often should I screen patients
with prediabetes?


Patients with prediabetes should be screened annually.

Obesity Management

What do the 2016 ADA standards recommend for obese patients
with diabetes?

The ADA recommends a sustained weight loss of 5%, which can improve glycemic control and reduce the need for diabetes medications, although weight loss of ≥7% is optimal. Interventions should be high-intensity. Long-term (≥1 year) comprehensive weight maintenance programs.

Glycemic treatment

What are some of the key factors
 that distinguish the different type 2 diabetes medications from one another?

Metformin The preferred initial medication for all patients who can tolerate it and have no contraindications.

Sulfonylureas/meglitinides Stimulate insulin secretion in a glucose-independent manner.

Thiazolidinediones Improve insulin sensitivity in the periphery and have a low risk of hypoglycemia.

Dipeptidyl peptidase-4 inhibitors (DPP4Is) Reduce the breakdown of endogenous incretin hormones.

Glucagon-like peptide 1 receptor agonists (GLP-1RAs) Injectable, also work via incretin hormones and stimulate insulin in a glucose-dependent manner.

Sodium glucose transporter 2 inhibitors (SGLT2Is) Help block the reabsorption of glucose, thereby lowering glucose levels, blood pressure, and weight in many patients.

Insulin Needed by most patients with type 2 diabetes who live long enough to see the disease progress.

Not included in the algorithm but are included in the 2016 standards, and may be helpful for certain patients: Alpha-glucosidase inhibitors, Bile acid sequestrants, Bromocriptine, Pramlintide

Cardiovascular risk reduction

Has the ADA revised its recommendations for cardiovascular disease risk management? Yes.

Aspirin therapy The standards now call for considering aspirin therapy (75-162 mg/d) in both women and men ≥50 years as a primary prevention strategy for those with type 1 or type 2 diabetes with a 10-year ASCVD risk of >10%.

Hypertension The ADA’s recommendations for treating hypertension in patients with diabetes have not changed; the goal remains <140/<90 mm Hg.

Lipids Patients ages 40 or older will need moderate to high intensity statin therapy to respectively lower ASCVD risk.

Microvascular complications

DIABETIC KIDNEY DISEASE


How should I diagnose nephropathy? Annual assessment of urinary albumin for patients who have had type 1 diabetes for ≥5 years and all patients who have type 2 diabetes.

What can be done to prevent or slow
 the progression of DKD? Optimal BP and glycemic control are key, along with diet and medication.

RETINOPATHY


How should I manage retinopathy
in patients with diabetes? Optimize glycemic and BP control to reduce the risk, or slow the progression, of retinopathy.

When should patients with diabetes
be screened for retinopathy? Patients with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years of the onset of diabetes. Those with type 2 diabetes should have such an exam shortly after diagnosis.

PERIPHERAL NEUROPATHY


When and how should I screen patients with diabetes for neuropathy? All patients should be screened for diabetic peripheral neuropathy (DPN) starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes, and continued at least annually thereafter. Assessment should include a detailed history and 10-g monofilament testing, as well as at least one of the following tests: pinprick, temperature, and vibration sensation. How should I manage patients
who have DPN?

Tight glycemic control, pregabalin, duloxetine, and tapentadol for the treatment of pain associated with DPN.

FOOT CARE/PERIPHERAL ARTERIAL DISEASE


What does the ADA recommend regarding foot care for patients with diabetes? ADA’s standards recommend an annual comprehensive foot examination to identify risk factors predictive of ulcers and potential amputations.

Which patients with diabetes
are at higher risk for foot complications?

The following are risk factors for foot complications: previous amputation, prior foot ulcer, peripheral neuropathy, foot deformity, peripheral vascular disease, visual impairment, peripheral neuropathy, poor glycemic control, and smoking.

When should patients be referred
to a foot specialist?

Refer patients to a foot care specialist for ongoing preventive care and lifelong surveillance if they smoke or have a history of lower-extremity complications, a loss of protective sensation, structural abnormalities, or PAD.

IMMUNIZATION


Are there special immunization recommendations for people
with diabetes? No

Children and adults with diabetes should be vaccinated according to age-related recommendations for the general population, the standards state.

 

 

 

 

 

 

 

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