Transcript
A (0:03)
Hello, I'm Dr. Neal Skolnick and I'd like to welcome you to this special edition of Diabetes Corps Update. On this special series of podcasts, we will be interviewing faculty who presented during the American Diabetes Association's Scientific Sessions Diabetes is Primary Conference on June 6, 2015. In part one of the Diabetes Primary Podcasts, we will cover Dr. Andrew Reinhart's discussion and update of the standards of care. And then we'll talk to Dr. John Buesse who discussed new medications for diabetes. In Part two of our Diabetes is Primary special series of Diabetes Core Update that will come out mid July, we will hear Dr. Charles Schaefer discussing what to do after basal insulin is no longer sufficient and then talk to Dr. Jim Chamberlain about his talk hypoglycemia. In part three of our diabetes is Primary special edition of Diabetes Core Update, which will come out mid August, we will hear Dr. Jay Shubrook discuss atypical diabetes, Dr. Henry Rodriguez discuss diabetes in adolescence, and Dr. Eric Johnson discuss a wonderful talk on continuous glucose monitoring and insulin pump therapy for primary care. For more details and in fact for the full talks of the Diabetes is Primary lecture series done at the Scientific Sessions 2015 of the American Diabetes association, please visit www.professional.diabetes.org ce to access the webcasts of these lect. Our Next speaker is Dr. Andrew Reinhardt.
B (2:03)
Who is the Chief Medical Officer for Glytech, who discussed the changes in the Standards of care. An update for our audience.
A (2:14)
Dr. Reinhart, welcome.
C (2:16)
Thank you for having me.
A (2:17)
If you can give us just the highlights of your talk for our audience.
C (2:22)
Okay, well that's what I'll have to do. I actually went over the entire standards, which is about a two hour lecture we've got in 45 minutes. But to highlight the actual changes from last year's standards, the first one is in terms of the BMI cutoff for screening for folks for type 2 diabetes. And the big change was a bmi less than 25. But for Asians a BMI cutoff of 23 as a new screening criteria for for once again screening for type 2 diabetes. So anybody that you have that is overweight, obese, meets these criteria and is at high risk for other reasons. They may have high ethnic risk factors, they may have physical activity, is low, have a history of low HDL, have a history of high triglycerides, etc. Those are the types of people people we want to be screening. But that cutoff for Asian BMI is what changed to 23 and then certainly in terms of activity A big change is get up and what we mean by that. I said I love my new Apple watch because it's telling me it reminds me to get up every hour. And the standard is saying make sure people are up and at least standing or moving every 90 minutes throughout the day. So you don't want to just be sitting there for hours upon end at your desk or with other activity or in a car. If you're a truck driver off the side of the road, get up and move a little bit. Not big fans of E cigarettes. There's no great data showing that they're very helpful. Is another change in the standard and surrounding immunizations. There was a change and basically the change was just to mirror the current CDC guidelines for prevention regarding the pneumococcal vaccine 13 and 23 in older adults. So really the only change was mirroring what the CDC is saying in terms of that vaccination. So not a big change there. There was a change regarding glycemic targets, which I think is interesting. For years we talk about the 70 to 130 target. The ADA has pushed for pre meal targets and they've changed that target from 70 to 130 to 80 to 130 to more closely match what those averages probably mean in terms of A1C. The postprandial target of less than 180. Peak 1 to 2 hour post meal has not changed and the A1C target has not changed. But I don't think it's important to stress the individualization of that ADA target of less than 7. So less than 7 is a general target. This hasn't changed, but I think I'd just like to stress it. And so we really want to individualize that target based on a patient's how long they've had diabetes, their complications, whether they have cardiovascular disease, socioeconomic issues that they may be dealing with. So some folks less than six and a half may be appropriate, some people closer to eight may be appropriate. But what actually changed in the guideline was the pre meal 80 to 130 is now the target in terms of the treatment output position statement. It didn't necessarily change except they added the SGLT2 inhibitor class as one of those five now six classes of medications we can add after metformin. And so that is another change. And I'd like to highlight too, as we do choose that second agent. The idiot does a very great job of what do we need to look at as we do that. So let's look at cost, let's look at efficacy. Let's look at hypoglycemia risk. We'll also look at side effects as and I'm just absolutely blanked on the 5th. And then we also want to, I like to add on to look at whether you're having a fasting or postprandial issue. So I think it's really important to look at those things as we add those second agents. Now the other big changes revolve around the cardiovascular disease. So the first change is blood pressure target. So we move from a 140 over 80 target to 140 over 90 or less target for blood pressure. However, if you can get to that 130 over 80 easily without undue treatment burden, you may want to try to get folks there. But the big change was making that systolic change from 80 to 90. And this is all evidence based. The other big change is around statin therapy. And really basically what the ADA has decided is, hey, we're going to kind of mirror and go more towards the cardiology, the ACC American Heart association guidelines. And that is initiating statin therapy regardless of ldl, more related to risk and using moderate and high intensity statins. Anybody 40 and over should be on a statin. Anybody younger than 40 that has cardiovascular disease needs a high intensity statin. At high risk for cardiovascular disease needs a moderate dose statin or moderate intensity statin. And the only group of people not to be on statin therapy are folks younger than 40 with no cardiovascular risk factors, which are very few folks with type 2 diabetes. Another addition to the guidelines or a change was really surrounding microvascular complications and foot care. And basically what the guideline says now is that all patients with an insensate foot or a loss of protective, loss of protective sensation have foot deformities or a history of a foot ulcer. You really want to examine their feet at every visit and not just once a year or not those it at all. So everybody we want to. If I have patients with no risk of foot problems and have never had any, a yearly exam is fine. But what they're saying now in the guideline is if you have somebody high risk or had problems, had ulcers, they've got a big bunion or have had calluses in the past, have hammer toes or insensate, you really want to check them every time they're in, just tell them, hey, go ahead and take those shoes and socks off after the nurse gets them in the room. So those are the big changes regarding adults, the only one regarding adolescents and children There used to be a slow increase or decrease over time for adolescents and children in terms of their A1C target. So real young kids less than 8 and a half and then 8 7.5. Now it's just 7.5 across the board for adolescents and children. So I think that's important to talk about as well because especially for our family practitioners and pediatricians out there that take care of younger kids. But less than seven and a half is our target for all this change.