Review of diabetes care guidelines 2017

The annual update of the American Diabetes Assn Standards of Medical Care in Diabetes had a few changes over last year's (​see dm diabetes care fulltext2017in dropbox, or Diabetes Care, Janurary 2017; 40, suppl 1). I will highlight those changes (see the text for the overall recommendations).

promoting health and reducing disparities in populations (a major update): 

--they acknowledge (finally) that psychosocial care is important in the overall care of diabetics, including self-management, mental health, communication, and life-stage considerations. 

--specific recommendations to look at the patients' social context (including assessing food insecurity, housing stability and financial barriers) and make use of local community resources and support for self-management​

classification and diagnosis of diabetes: 

--having a baby ≥ 9 pounds was bumped from the list as an independent risk factor for development of prediabetes or Type II diabetes. and for women with gestational diabetes, they extended the earlier time to check postpartum from 6-12 weeks to 4-12 weeks with oral glucose challenge test

comprehensive medical evaluation and assessment of comorbidities (a new section):,

--recommends a patient-centered communication style using active listening; eliciting patients preferences and beliefs; and assessing literacy, numeracy, and potential barriers to care (but not mentioning motivational interviewing.  perhaps next year???). 

--they also recommend "considering" screening for anxiety in patients who exhibit anxiety or worries, “consider” annual screening for depression as well as at the diagnosis of diabetic complications, consider screening for eating disorders (esp if hyperglycemia and weight loss are unexplained), annual diabetes screening for patients on atypical antipsychotics

lifestyle management:This section was renamed to focus on the importance of lifestyle management. There are few changes this year:

-- nutrition therapy was updated to those on flexible insulin therapy to include counting fat (in particular increasing mono-unsaturated fats which may improve glucose metabolism and lower heart disease risk) and protein (protein seems to increase insulin response without increasing plasma glucose concentrations), as well as counting carbohydrates, to reflect the effect of these dietary factors on insulin dosing and blood glucose levels. They also suggest eating foods rich in long-chain omega-3 fatty acids, though the beneficial role of dietary supplements is not supported by the evidence.

-- they recommend that prolong sitting be interrupted every 30 minutes with short bouts of physical activity, such as briefly standing, walking, or performing other light physical activities..

-- they also added a recommendation stressing the importance of balance and flexibility training in older people

-- they highlight the importance of the psychosocial issues: they should be integrated with a collaborative, patient-centered approach and provided to all people with diabetes, with the goal of optimizing health outcomes and health-related quality of life.

-- Consider screening for cognitive impairment and depression in those >65 yo

Prevention or delay of type II diabetes

-- more emphasis on screening for prediabetes using an assessment tool or informal assessment of risk factors. Patient should receive intensive behavioral lifestyle interventions

-- metformin should be considered as preventive therapy in those with prediabetes especially if the BMI is >35,if they are <60 years old, or in women with prior gestational diabetes and/or those with rising A1c despite lifestyle intervention.

-- There is also a recommendation that vitamin B12 levels be measured periodically, given the newer data linking metformin use to vitamin B12 deficiency

Glycemic targets

-- they redefined clinically significant hypoglycemia as a glucose <54 mg/dl (3.0 mmol/L)

-- no significant changes in the overall A1c goals, noting that a reasonable goal for many nonpregnant adults is <7%. Consider <6.5% for selected individuals (e.g. those with short duration diabetes, diabetes that is treated with lifestyle or metformin only, long life expectancy, no significant cardiovascular disease) who can achieve it without significant hypoglycemia or other adverse effects. And less stringent goals such as <8% may be appropriate for those with a history of severe hypoglycemia, limited life expectancy, advanced microvascular microvascular complications, extensive comorbid conditions

obesity management

-- for overweight and obese patients with type 2 diabetes who are ready to lose weight, there should be a combination of diet, physical activity, and behavioral therapy to achieve >5% weight loss. Such an intervention should be high intensity (≥16 sessions in 6 months), focusing on a 500-750 kcal/d energy deficit. It's okay to use very low-calorie diets (<800 kcal per day) in carefully selected patients, monitored closely, for a three-month intervention only

-- weight loss medications may be effective as an adjunct in those with a BMI >27

-- metabolic surgery (a.k.a. bariatric surgery) “should be recommended” in patients with a BMI >40 (BMI >37.5 in Asian Americans), and in adults with BMI 35-40 (32.5-37.4 in Asian Americans) when hyperglycemia is inadequately controlled. There needs to be long-term lifestyle support and routine monitoring of micronutrient and nutritional status after surgery.

Pharmacologic approaches

-- consider empagliflozin or liraglutide in patients with established cardiovascular disease to reduce mortality risk

-- they comment on the noninferiority of basal insulin plus glucagon-like peptide 1 (GLP-1)  receptor agonist as compared to basal insulin plus rapid acting insulin

-- they modified their therapy pyramid to include the costs, especially since the cost of insulin has gone up so dramatically (mean AWP of > $300 per vial). However, they continue suggesting that after metformin monotherapy, one could choose any of the following agents without specific preference: sulfonylurea, thiazolidinedione, DPP-4 inhibitor, SGLT2 inhibitor, GLP-1 receptor agonist, or basal insulin.

Cardiovascular disease and risk management

-- for patients without albuminurea, can use any of 4 classes of antihypertensives: ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics, or dihydropyridine calcium channel blockers. The general target blood pressure is <140/90 mmHg (as with JNC8), though lower target such as 130/80 may be appropriate for those at high cardiovascular risk and this can be achieved without undue treatment burden

-- lipid management: they do focus on lifestyle modification. For patients <40 years old with additional atherosclerotic risk factors, consider using moderate or high intensity statin along with lifestyle changes. In those 40-75 years old without additional atherosclerotic risk factors, consider using moderate or high intensity statin, high intensity statin if they have additional atherosclerotic risk factors. And consider using a moderate intensity statin in those >75 years old, and high intensity statin if additional risk factors. Also should consider adding ezetimibe to moderate intensity statin in those with acute coronary syndrome and LDL >50 and those who cannot tolerate a statin.

-- Consider aspirin therapy for primary prevention in those with diabetes, including most women and men > 50 years old with at least one additional cardiovascular risk factor but who are not at increased risk of bleeding.

-- they changed the target for pregnant women with diabetes and chronic hypertension, suggesting a blood pressure goal of 120-160/80-105 mmHg. They also highlight the increased risk of retinopathy in women with pre-existing diabetes who are planning pregnancy or are pregnant

Microvascular complications

-- not much change overall. They do state that if there is no evidence of retinopathy and the glycemia is well-controlled, ophthalmologic exams can be done every 2 years. They do reinforce that retinal photography is an acceptable screening tool but is not a substitute for comprehensive eye exam. For neuropathy, see recent blog specifically on those recommendations.

Commentary:

--personally, i have always felt that diabetes management is probably the most difficult of "medical" diseases, in part because of the complex array of psychosocial issues at all stages of diabetes (and beginning in pre-diabetes), and in part because of the necessity yet complexity of working with patients to make major, consistent changes in lifestyle (diet, weight control, exercise, etc), more difficult in a society which does not prioritize or even clearly articulate these generally healthful patterns in a meaningful way: witness how difficult it was to deal with trans fats, where the data against them have been compelling for decades; the push-back, specifically from the perspective from industry have been shown to be minimal/insignficant; and many in public health have gone against the tide/status quo over years to remove trans fats formally from the diet, still with incomplete success.

--it is pretty remarkable to me that the psychosocial issues have taken so long to bubble up to the being recognized and emphasized, along with suggestions for action. the suggestions are still pretty reserved: i personally feel that we should always have been looking at patient education as a 2-way street (and the backbone of treatment), incorporating patients values and understanding, and providing motivation for lifestyle changes mainly by involving the patient in the discussion as the main driver (vs lecturing them on diet and exercise). and given the diverse perceptions on what diabetes is and the potentially devastating effects of its complications, i personally would do more than just "consider" screening for depression and anxiety...

-- as per many of my blogs, I remain quite impressed with the GLP-1 receptor agonists, which can be given as a simple once a week injection, and I regularly prescribe them now as my 2^nd medication after metformin. They do not cause hypoglycemia, usually are very well-tolerated, help with weight loss, and I have seen quite dramatic effects. Last week I saw 2 patients on long-standing metformin and insulin, and when a GLP-1 agonist was added, their A1c in both cases went from about 9.5 to 6.5, in one case with the patient stopping their insulin. And they have the benefit of likely decreasing cardiovascular events (eg, see http://gmodestmedblogs.blogspot.com/2017/08/liraglutide-new-indication-for.html  ). A recent report on empagliflozin found benefit for those with established cardiovascular disease, though I have concerns about the quality and conclusions of that study (see http://gmodestmedblogs.blogspot.com/2015/12/empagliflozin-good-and-bad.html  )

-- these recommendations still do not deal with my concerns about using A1c as the target of therapy, which the FDA has allowed since the mid-1990s. Some medications that lower A1c pretty well have significant serious adverse reactions (the most obvious example being rosiglitazone and its attendant increase in cardiovascular disease), whereas others lower cardiovascular risk (such as the GLP-1 agonists), and others seem to be pretty neutral (although a lot of these are newer agents and we don't really know their long-term adverse consequences).So, I do disagree with the approach of ADA that all of the second-tier drugs, after metformin, are equal options.

see http://blogs.bmj.com/ebm/category/diabetes/ for many blogs on diabetes

see http://gmodestmedblogs.blogspot.com/search/label/diabetes   for recent blog on B12 deficiency in diabetes

see for blog on ADA recommendations for neuropathy sent out a few days ago but not yet posted