← Diabetes Core Update
Diabetes Core Update
Standards of Medical Care in Diabetes - 2013
00:21:36
Diabetes Core Update is a monthly podcast that presents and discusses the latest clinically relevant articles from the American Diabetes Association’s four science and medical journals – Diabetes, Diabetes Care, Clinical Diabetes, and Diabet
Loading summary
Transcript34 lines
- [00:02]
A
Welcome to the American Diabetes Association Core Update. While we usually go over the most important articles from the core journals published by the American Diabetes association, today we will cover the American Diabetes Association's position statement on the standards of medical Care in Diabetes 2013, published in the January edition of Diabetes Care. Joining us today will be our usual host, Dr. Neal Skolnick, as well as committee member and incoming chair of next year's committee, Dr. Richard Grant. Dr. Skolnick.
- [00:38]
B
Each year in the January issue of Diabetes Care, the American Diabetes association publishes the Standards of Medical Care in Diabetes, which essentially establishes the ongoing standard of care for diabetes in the United States. The committee serving to put together the standards meets early in the fall and reviews new evidence that's been published over the previous year and then discusses and formulates any changes that are necessary based on the evidence. Joining us today is committee member and incoming chair of next year's committee, Dr. Richard Grant. Dr. Grant is a research scientist, Kaiser Permanente Division of Research, an adjunct associate professor in the Department of Epidemiology and Biostatistics at the University of California State University, San Francisco, and is a primary care physician in the Kaiser Permanente Oakland Medical Center. Welcome, Dr. Grant.
- [01:34]
C
Thank you. Pleasure to be here.
- [01:37]
B
Since we only have about 20 minutes to discuss the standards, we'll restrict our discussion to the highlights of the guidelines and encourage our listeners to go to the American Diabetes association website@www.diabetes.org to download and read the full standards of care. For Our first question, Dr. Grant, can you give us an overview of the process used to create the standards? It's really a mystery for most physicians, and it'd be interesting to hear what goes into developing the standards.
- [02:07]
C
Sure. The committee consists of between 15 and 20 experts from different fields. We have endocrinologists and primary care family physicians, diabetes educators, registered dietitians, and other experts like pediatricians. And we all volunteer and we meet in person twice a year. At the first meeting, we sort of assign multiple people to each section of the prior year's clinical recommendations. Then these groups go and they review the literature. We actually go back two years to make sure we didn't miss anything in the prior year and try to see if there's anything substantial that's been published or that's changed that we should consider when we revise this year's recommendations.
- [02:54]
B
That's really interesting to hear what goes into it. Let's move now onto the standards themselves. First, can you discuss which tests are recommended for making the diagnosis of diabetes and some of the differences between using fasting glucose, A1C and the two hour oral glucose tolerance test.
- [03:11]
C
Well, so you just pointed out what the three tests were. The use of A1C to diagnose diabetes is relatively new. We first recommended it in 2010. And I think there's two ways of thinking about these tests. One is the practical application of them. And the reason why A1C has been used is that it doesn't require fasting or any additional actions. And so it's much more convenient. As, you know, up to a quarter of patients with diabetes are undiagnosed. And so definitely we want to make it easier to identify these cases. The tests themselves, they sort of address different facets of the pathophysiology of hyperglycemia. And so you can definitely find some patients who will be positive with one test and within a normal range in another test. And generally the recommendation is, if you have for some reason tested them with two different tests, is to repeat the one that's abnormal.
- [04:10]
B
Interesting. And what are the recommendations on who should be screened for diabetes?
- [04:17]
C
Well, we like to cast the wide net because there's a lot of risk, as you know, associated with diabetes and changing your lifestyle. And screening for other risk factors is an important life saving thing to do. So the recommendations are essentially any adult over 45 and then for those adults under 45, if they're overweight, and of other risks associated with diabetes, such as hypertension and family history.
- [04:48]
B
Okay, and what is the recommended test to do that screening with?
- [04:54]
C
Well, any of those three tests that we alluded to. Fasting glucose, an A1C or an OGT.
- [05:02]
B
Okay, can you discuss the category of increased risk for diabetes that's often called prediabetes?
- [05:11]
C
Well, we think of diabetes, it's a black or white diagnosis, it's a yes or no, but it's really a continuum of risk. And so we set these diagnostic tests, whether it's a fasting glucose or an A1C as a specific threshold, recognizing that if you're just below that threshold, you might not have formally diagnosed diabetes, but you're certainly at increased risk for developing it compared to someone with an absolutely normal glucose level. And so this interim area where you're not formally diagnosed but you're not completely normal is what we call pre diabetes. And we know from epidemiologic studies that these folks are at much increased risk of progressing onto diabetes.
- [05:57]
B
It's an important area because roughly a third of adults fall into that category and they're clearly at increased risk of developing diabetes. Moving into the future and at increased risk of developing cardiovascular disease. Can you discuss recommendations for addressing this group with regard to preventing progression to diabetes?
- [06:20]
C
Yes. So there's sort of two parts to this. The foundation of all prediabetes and diabetes treatment is lifestyle changes. And in fact, it's pretty much the foundation for everyone's health. We all need to engage in exercise and all need to eat healthy and avoid being overweight. So those recommendations apply in particular to people with prediabetes. The other option which can be added is metformin. It's a medicine that's been tested in people with prediabetes, for example, in the Diabetes Prevention Program, which was a large rct, and it also decreases the rate of progression to diabetes. So that's another option in the appropriately chosen patient.
- [07:05]
B
Those are important points. What are the current recommendations for self monitoring of blood glucose?
- [07:13]
C
This is an area where we made some modifications from last year's guidelines and we did it just to try to convey the idea that there's a lot of variability in what's appropriate. There are patients on multiple dose insulin who really would benefit from testing themselves many times a day, before meals, after meals, in different situations. And then there are other patients, for example, those who aren't prescribed insulin, who there's no evidence to support the idea that they need to do self monitoring of blood glucose. And we wanted to get away from this idea that everyone needs to be tested at the same rate or three times a day, or once a day. And this is sort of a broader theme, but really the therapy and treatment of patients with diabetes has to be individualized as much as possible. So the recommendation here in the guidelines is that the testing might need to be more frequent in some patients, less frequent in others. And underlying it all, if patients are going to be self monitoring, it has to be in a context where the results are used. So you can't just prescribe the monitor, but you have to teach them how to use it and what to do with the results.
- [08:30]
B
That's important. People need to be actively involved in their participants in their own healthcare. Continuing on with the theme that you just brought up, which is individualization of treatment, if you can say a few words about setting A1C goals, there's a common misconception out there that all patients with diabetes should have an A1C goal of less than 7%. And in fact, many of our practices are graded by insurance companies using A1C goals of less than 7% as one of the quality measures. What does the standards of care, though recommend with regard to setting A1C goals.
- [09:10]
C
For patients, we recommend flexibility. This is an interesting difference between evidence and caring for the patient in front of you. When we set these recommendations, we use results, ideally from large, rigorous, randomized control trials, but these trials report the average results for a population of patients. And of course, we don't take care of populations, we take care of individuals. And so the recommendations are that it's reasonable from the evidence that most patients with diabetes should have an A1C goal of less than 7. We know from large recent trials of trying to achieve tighter control in type 2 diabetes that there's not necessarily a benefit and there could even be some harm in certain patients. So what we recommend is in some patients, for example, those who have early diagnosis or are younger of age, a goal of 6.5 might be reasonable if it can be achieved without undue burden. And conversely, there are much sicker, older patients, perhaps with decreased lifespans, who the effort and burden of getting their A1C down to 7 might not be worth the costs and the consequences. And so it's reasonable for sicker patients or those with a history of severe hypoglycemia and other examples to have a less stringent A1C goal, such as less than 8%.
- [10:40]
B
Those are really critical points. As we move from, essentially, as you said, population medicine to individualize both treatment goals as well as treatments, we won't take the time on today's podcast to discuss pharmacologic therapy for hypoglycemia, other than to say the standards are in agreement with the position statement of the American Diabetes association and the EASD on the management of hyperglycemia and type 2 diabetes that came out in Diabetes Care in June. That statement stresses exactly what we've been talking about, an individualized, patient centered approach that takes into account patient preferences, cost, side effects, effect on body weight and hypoglycemic risk. Our audience is referred to both the statement itself, which is available from diabetesjournals.org as well as the podcast from about six months ago that we did with Dr. Inzuchi. But back to the current standards. Dr. Grant, can you discuss the importance that the standards now place on the recognition and management of hypoglycemia?
- [11:49]
C
Yes, this is another slight modification from the prior year standards, but there's recent data pointing to the connection between hypoglycemia and future cognitive decline, and also the converse, which is patients who are in cognitive decline have increased risk of hypoglycemia. And so this year's Standards highlight the importance of asking patients about hypoglycemic episodes and being increased focus on hypoglycemia, unawareness, and ongoing assessment of cognitive function.
- [12:30]
B
Those are important points. And when we see hypoglycemia, it's important to, I guess, scale back therapy, at least for a while, to address that. Can you update us, I guess, on the recommendations regarding immunizations for patients with diabetes?
- [12:50]
C
Yeah, the one change, this is based on analysis conducted by the CDC that we should be administering Hep B vaccines among unvaccinated adults with diabetes. And they did a cost analysis, which was published since the prior year's guidelines, and it's really most effective for patients under 60. So we definitely recommend Hep B vaccination for all unvaccinated adults between 19 and under 60, and it could be considered in patients over 60 as well.
- [13:26]
B
Thanks. So now Hep B is on the map. In addition to influenza and pneumococcal vaccine. Cardiovascular disease is clearly a critical outcome and consequence of having diabetes, and therefore, control of cardiovascular risk factors has always been an important, important component in the treatment of diabetes. For years, the recommended blood pressure goals for patients with diabetes has been less than 130 over 80. This year's standards includes important changes to the recommendations about blood pressure goals. Can you tell us about these new goals as well as explain the rationale for the change?
- [14:08]
C
Absolutely, and I think it's probably worth spending a couple of minutes on this change to make sure that no one misunderstands the thinking behind it. The goals of treatment for blood pressure initially were based on randomized trials and were also augmented by evidence from epidemiologic cohort analyses. And from trials, we know that aiming for a blood pressure less than 140 is beneficial. And from epidemiology, we know that patients with lower blood pressure seem to have better results. And so those two combinations that led to the idea that lower is better. And so the traditional guideline of 130, 80. What's clear, though, is in observational analysis, if a patient has a lower blood pressure, they probably also have other reasons of being at lower risk for future cardiovascular problems. And in fact, since the prior year's guidelines, there was a meta analysis published that took all of the studies that used a specific threshold of blood pressure and found that the benefit going below 140 was very small, and it was mostly related to a slight decrease in the risk of stroke. But when you treat patients that aggressively to a lower blood pressure, there's always adverse consequences and Particularly in older patients, you have risks of hypotension, falls and hospitalization. And so what the new recommendations are is that all patients with diabetes, if possible, should have their blood pressure treated to below 140. In certain patients, for example, younger patients who have a long road ahead of them, and patients who tolerate treatment, it's certainly reasonable to try to go lower than 140. But conversely, the fact that we change the threshold from 130 to 140 does not in any way diminish the importance of blood pressure control. We'd rather have 100% of people below 140 than 50% of people below 130. So we also added.
- [16:26]
B
I'm sorry, yeah, that's a great point.
- [16:31]
C
And to emphasize that we added the importance, when you recognize someone who has elevated blood pressure over 140, over 80, we need to promptly initiate entitrate therapy. There's this history of delays in recognizing, treating and achieving goal. And some patients, they see their doctor a couple times a year. You make an adjustment every time a year goes by before it's under control. So what the standards now emphasize is that we need to be timely in diagnosing and treating hypertension and we should try for everyone, unless contraindicated, to get a blood pressure below 140. Going much below that has risks and consequences and that needs to be weighed on an individual basis. But the idea of getting a frail little 89 year old to a very low blood pressure on four medicines, it's not really supported by the evidence.
- [17:34]
B
That's probably the most important change that our listeners need to be aware of because it really has a large impact on the number of medicines that often need to be used for patients. Our patients with diabetes are already on a lot of medicines between treating their hyperglycemia, their hypertension and their hyperlipidemia. Which brings us to our last major topic area, which are the recommendations for lipid management. Dr. Grant, your thoughts there?
- [18:07]
C
Yeah. So the change there is the publication of a couple of important studies, the ACCORD study and also the AIM High study looking at combination therapy. So the question is, does adding a fibrate help in addition to statins? And the results are actually disappointing. And so our recommendation is that combination therapy, meaning a statin with a non statin for lipid control is generally not recommended. So really it's statins and LDL lowering.
- [18:44]
B
Great point. And in terms of what goal, just to clarify for our listeners, is recommended, which hasn't changed for an LDL goal for patients with diabetes.
- [18:58]
C
Right. So the goal is less than 100, but for patients with overt cardiovascular disease, it's reasonable to try to go even lower, like less than 70.
- [19:08]
B
Thanks. So, due to time constraints, we had to be selective in going over the highlights and changes to the standards of care for our listeners. The full standards contain recommendations on many other topics, including screening and management of neuropathy, nephropathy, retinopathy, management of diabetes during illness, as well as inpatient admissions, medical, nutrition therapy and exercise, and as well as many other aspects of diabetes care. For more details, I want to refer our audience to www.diabetesjournals.org to download and read the full standards. Dr. Grant, I really want to thank you for your participation and contributions to our podcast.
- [19:54]
C
Thank you.
- [19:55]
B
We've covered a lot of material today to recap for our listeners. We talked about screening for diabetes. We talked about identification and management prediabetes. We discussed individualization of both setting A1C goals as well as treatment the increased importance attached to identifying and addressing hypoglycemia. We talked about important changes with regard to goal setting and the management of elevated blood pressure, specifically a change in the generally recommended systolic target from what used to be a target of 130 to the current target of 140. And we talked about cholesterol management for the American diabetes association. I'm Dr. Neal Skolnick and thanks for listening.