New ACC/AHA Guidelines: Current Lipid Management in Diabetes

Controversies and the Future

“One weak point of the guidelines for diabetes is type 1 diabetes. Type 1 is poorly represented in clinical trials. We had to lump type 1 in with type 2 diabetes. So this is an area where clinical judgment is especially important,” Dr. Eckel said.

Dr. Ganda shares Dr. Eckel’s concern.

“Type 1 and type 2 diabetes are not the same disease,” Dr. Ganda said. “There may be some cases where people with type 1 diabetes are overtreated using these guidelines. There may also be some undertreatment. What about a person with diabetes under age 40 who has significant risk factors? Should we wait until their cholesterol builds up?”

Another area of controversy for diabetes management is the focus on LDL and total cholesterol at the expense of triglycerides and apolipoprotein B (Apo-B). “Non-HDL cholesterol and Apo-B goals can enhance risk assessment. Just using LDL may underestimate risk for some people,” said Dr. Ganda.

As of now, the American Diabetes Association (ADA) guidelines still use LDL numbers for treatment goals. They have 100 mg/dL as the LDL goal for people who have diabetes but not heart disease, and 70 mg/dL for people who have diabetes and heart disease. ⁴

“Lots of people still use numbers as a goal. The new guidelines don’t say you can’t use numbers as a target. It’s a matter of clinical judgment. The ADA will be updating their guidelines in 2015, so we will have to wait and see what they do,” Dr. Eckel said. “The bottom line is that these guidelines are evidence-based from randomized, controlled trials. That’s the gold standard.”

“Some controversy is inevitable. The National Institute for Health and Care Excellence just came out. Those are the European guidelines. They are not the same as ours, so now we have a global difference of opinion. After 20 to 30 multimillion dollar projects, even the experts of the experts disagree. That just means we still have a lot to learn,” said Ganda.

References

1. AHA/ACC Cholesterol Treatment Guidelines (November, 2013): Relevance to Patients with Diabetes. Joslin Diabetes Center. http://www.joslin.org/info/summary-new-cholesterol-recommendations-11-15-13.html. Published November 15, 2013. Accessed August 2014.
2. Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. J Am Coll Cardiol. 2014;63(25):2889-2934.
3. Rubenfire M. Journal Scan Summary. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. American College of Cardiology Website. Published November 12, 2013. Accessed August 2014.
4. Diabetes Management Guidelines. National Diabetes Education Initiative Website. http://www.ndei.org/Glossary/American_Diabetes_Association_Guidelines. Published January 2014. Updated March 13, 2014. Accessed August 2014.