new diabetes guidelines: 2020

Brief review of the 2020 diabetes guidelines recently published by the Am Diabetes Assn (see https://care.diabetesjournals.org/content/43/Supplement_1). I’m focusing on type II diabetes and the specific changes or different nuances in these guidelines over prior ones. Last year's review was a bit more comprehensive (see http://gmodestmedblogs.blogspot.com/2019/01/2019-diabetes-guidelines.html ). there was also a mid-year ADA update pushing SGLT2s as well as GLP1s for those with CKD (see http://gmodestmedblogs.blogspot.com/2019/06/diabetes-guideline-update-pushing-sglt.html ). my comments are imbedded in the text.

-- Tailoring treatment for social context

    -- assess patient for potential food insecurity, housing stability, financial barriers; use this information for treatment decisions

    -- refer patients to local community resources

    -- provide self management support: health coaches, navigators, community health workers

-- A1c issues

    -- when there is unexpected discordance between A1c and glycemia: consider sickle-cell or other hemolytic anemias, pregnancy (2^nd and 3^rd trimesters and postpartum), G6PD deficiency, HIV, hemodialysis, recent blood loss/transfusion, erythropoietin therapy. Do not rely on A1c for diagnosis of diabetes but use instead the blood sugar measurements

    -- they do comment again this year that the goal of diabetes management should not simply be the A1c level but also decreasing the risk of CAD

--diagnosing diabetes

    -- prediabetes: test asymptomatic people of any age who are overweight/obese, and have one of or more risk factors, including first-degree relatives with diabetes, high risk ethnicities (African-American, Latinx, history CVD or hypertension or HDL<35, women with PCO, physical inactivity)

    -- those with prediabetes should have yearly A1c measurements

    -- women with gestational diabetes should have lifetime testing at least every 3 years. 

    -- all persons should be tested at age 45 or older

--diabetes prevention/delay

    -- intensive behavioral lifestyle intervention: 7% loss of initial body weight if overweight/obese and increase moderate-intensity physical exercise (diabetes prevention programs should be covered by third-party payers). 

    -- nutrition: variety of eating patterns are appropriate including Mediterranean, low-calorie low-fat; mixed results from low glycemic index diets [the usual issue with diets is the ability of people to maintain them longterm.  there are impressive reasons to push the low glycemic index diet, including the fact that the low-fat diet actually decreases basal metabolic rate, as compared to the low GI one. see http://gmodestmedblogs.blogspot.com/2018/09/high-glycemic-index-diet-causes-obesity.html ]

--comprehensive assessment

    -- include psychosocial health both in the initial exam and follow-ups

    -- perform 10-year cardiovascular risk assessment using race and sex-specific equations

    -- routine vaccinations

    -- osteoporosis: 

        -- check BMD or FRAX score, since diabetics are prone to osteoporosis and fractures

        -- vitamin D supplementation as needed

        -- TZD’s and SGLT-2s should be used with caution, since both may increase fracture risk

    -- consider screening for hypogonadism in men if symptomatic (decreased libido, erectile dysfunction)

    -- those with type I diabetes should be screened for autoimmune thyroid disease and celiac disease. 

--glycemic targets

    --A1c: check at least 2 times a year, quarterly in those whose therapy has changed or are not at goal

    -- A1c goal of <7% is appropriate for many nonpregnant adults. <6.5% may be acceptable if it can be achieved safely without significant hypoglycemia or other adverse effects

    -- A1c goal of <8% may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education

    -- reassess the diabetes goal over time

--cardiovascular disease

    --the relation between diabetes control and cardiovascular risk is mixed. No great long-term studies, only some observational ones.

    -- recommendation is to use either GLP1s or SGLT2s in those with established CVD or indicators of high risk. in patients who are already on dual diabetic therapy, consider switching to GLP1 or SGLT2 if not already on one of those agents

--glucagon should be prescribed to all individuals at risk of moderately severe hypoglycemia (defined as blood glucose <54 mg/dL). educate family members on how to administer.

    -- consider programs for hypoglycemia avoidance in those with hypoglycemia unawareness or one or more episodes of severe hypoglycemia.

--Self-monitoring of blood glucose (SMBG) 

    -- SMBG should be done regularly in those on intensive insulin regimens (eg, multiple daily doses) to help guide treatment decisions

    -- those on non-insulin therapies have not been shown to have a significant reduction of A1c with SMBG, though SMBG may be helpful when altering diet,  physical activity, and/or medications [I have found that SMBG gives direct feedback to the patients about the effect of their diet or exercise on their blood sugar. In several patients, awareness of the effects of rice on blood sugar, for example, have led them to moderate their rice intake]

    -- high-dose vitamin C can interfere with glucose meter accuracy

    -- Continuous glucose monitoring, which can be done intermittently, in conjunction with insulin therapy is a  useful tool for lowering A1c and/or hypoglycemia

--obesity management

    -- for those overweight/obese: diet, physical activity, and behavioral therapy designed to achieve and maintain >5% weight loss is recommended.

        -- these intervention should be high intensity (>15 sessions in 6 months)

      -- recommend metabolic surgery in those with BMI >40 (>37.5 in Asian Americans), as well as those with BMI 35-40 (32.5-37.4 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hypoglycemia) with nonsurgical methods.

    -- consider metabolic surgery as an option for those with type II diabetes and BMI 30-35 (27.5- 32.5 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities with tested efficacious nonsurgical methods

--pharmacologic therapy: 

    -- Metformin continues to be the preferred initial med and continued as long as it is tolerated, in addition to other meds as needed (see http://gmodestmedblogs.blogspot.com/2019/03/metformin-in-ckd-dec-cv-eventsmortality.html for studies on metformin and dose reductions in those with CKD)

    -- Early introduction of insulin should be considered if there is ongoing evidence of catabolism (weight loss), symptoms of hypoglycemia are present, or when the A1c >10. 

    -- Those with established atherosclerotic disease or indicators of high risk (including age> 55 with any arterial stenosis >50% or left ventricular hypertrophy), established  kidney disease, or heart failure: an SGLT2 inhibitor or GLP-1 agonist is recommended. If needing more than oral agents, a GLP-1 agonist is preferred over insulin. 

        --They do note the dramatic increase in insulin costs, and these can be a major source of stress for patients with diabetes and contribute to worse adherence with medications (see http://gmodestmedblogs.blogspot.com/2019/01/more-on-high-insulin-costs-and.html, and http://gmodestmedblogs.blogspot.com/2020/01/medication-nonadherence-due-to-cost.html). 

            --There really is not a clear advantage of long-acting basal insulins over NPH insulin (which is older and cheaper)

            -- GLP-1 agonists can be added to insulin when basal insulin >0.5 units/kg/d and the A1c as above target [and, not mentioned, there have been recent studies finding improved glycemic control when usign GLP1 with SGLTs, which my experience confirms]

--cardiovascular disease management: 

    -- hypertension is diagnosed with a blood pressure greater than 140/90, though a blood pressure less than 130/80 may be appropriate in those at higher cardiovascular risk (though this is different from the AHA guidelines: see http://gmodestmedblogs.blogspot.com/2019/03/new-aha-blood-pressure-measurement.html ). 

        --140/90 target is okay in those with diabetes and hypertension but at lower cardiovascular risk. 

        -- if BP >120/80, lifestyle interventions are preferred, including weight loss, DASH diet, reducing sodium, increasing potassium, moderation of alcohol intake, and increased physical activity

        -- if confirmed office-based blood pressure >140/90, initiation of prompt meds has been demonstrated to reduce cardiovascular events: ACE inhibitors, ARBs, thiazide-like diuretics, DHP calcium channel blockers.

            -- in those with macroalbuminuria (urinary albumin to creatinine ratio >300) as a grade A recommendation, and in those with microalbuminuria of 30-300 as a grade B recommendation,  

ACE inhibitors/ARBs should be prescribed at maximum tolerated dose indicated for blood pressure treatment, as first-line treatment of hypertension

        --monitor creatinine and serum potassium at least annually

        -- they are in favor of bedtime dosing for antihypertensives (see http://gmodestmedblogs.blogspot.com/2015/09/take-blood-pressure-meds-at-night-to.html)

        -- consider a mineralocorticoid receptor antagonist in those who are not meeting blood pressure targets on 3 classes of BP meds

    -- lipids

        -- lifestyle modification is primary, including reduction in saturated fats, increases in n-3 fatty acids, viscous fiber, and plant sterols/stanols

        -- patients aged 40 to 75 without atherosclerotic disease:  use moderate-intensity statin in addition to lifestyle

        -- patients aged 20 to 39 with additional ASCVD risk factors: it may be reasonable to initiate statins [note: statins are contraindicated in pregnancy]

        -- patients with diabetes and at higher risk or age 50-70:  it is reasonable to use high-intensity statins

        -- patients with a 10 year ASCVD risk >20%: it may be reasonable to add ezetimibe to maximally tolerated statins in order to reduce LDL by 50% or more

        -- patients with fasting triglycerides >500 mg/dL, evaluate for secondary causes and consider medical therapy to reduce the risk of pancreatitis

        -- pateints with triglycerides 175 to 499 mg/dL, treat lifestyle factors and secondary factors associated with hypertriglyceridemia

        -- patients with ASCVD or other cardiovascular risk factors on a statin with controlled LDL but elevated triglycerides, consider the addition of icosapent ethyl to reduce cardiovascular risk (see http://gmodestmedblogs.blogspot.com/2019/04/diabetes-assn-update-dapagliflozin-and.html).

        -- aspirin therapy okay as secondary prevention, and may be considered as a primary prevention strategy for those at increased cardiovascular risk

--microvascular complications

    -- nephropathy:

        -- consider use of an SGLT2 if eGFR is >30 and urinary albumin >30 (especially if >300) to reduce both CKD and cardiovascular risk

        -- consider use of a GLP1 agonist to reduce progression of albuminuria, cardiovascular events, or both

    -- retinopathy:

        -- eye screening every 1 to 2 years if there is no evidence of retinopathy

    -- neuropathy: 

        --assess for distal symmetric polyneuropathy for both small fiber function (temperature or pinprick) and large fiber function (128 Hz tuning fork)

        -- pregabalin, duloxetine, or gabapentin are recommended as initial pharmacologic treatments for neuropathy (BUT, see http://gmodestmedblogs.blogspot.com/2017/04/diabetic-peripheral-neuropathy-and-more.html , a systematic review that trashed gabapentin and pregabalin)

        -- assess for signs and symptoms of autonomic neuropathy

--older adults

    -- screen for polypharmacy, cognitive impairment, depression, urinary incontinence, falls, and persistent pain

    -- screen for early detection of mild cognitive impairment or dementia, which should be performed for adults 65 years or older at the initial visit and annually as appropriate

    -- consider lower glycemic goals such as A1c <7.5 in those who are otherwise healthy and A1c <8-8.5 in those with multiple existing chronic illnesses, cognitive, or functional dependence

    -- make sure there is adequate protein intake, to prevent the increased risk of sarcopenia and frailty

The next blog will review the differences between GLP1 receptor agonists and SGLT2 inhibitors.

geoff​

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