Revised ADA Standards Allow Personalized Approach to Diabetes Treatment

Managing Cardiovascular Disease Risk

Some of the more major updates to the Standards of Medical Care include the management of cardiovascular disease (CVD) risk in patients with diabetes.

The new guidelines, for instance, suggest less stringent BP goals, with the new diastolic BP target for patients with diabetes inching up to 90 mm Hg from 80 mm Hg.

Further, the 2015 Standards call for changes in the management of lipid disorders. The Standards are now more closely aligned with the 2013 joint guidelines on lipid management from the American College of Cardiology (ACC) and the American Heart Association (AHA).

In terms of monitoring lipid levels, the Standards recommend a screening lipid profile at diabetes diagnosis, at an initial medical evaluation and/or at 40 years of age, and periodically thereafter.

Richard W. Grant, MD, MPH, research scientist at Kaiser Permanente Division of Research and Chair of the Professional Practice Committee, said the revised standards recommend a moderate- or high-intensity statin in patients aged younger than 40 years with additional CVD risk factors. In patients aged 40 to 75 years with no additional CVD risk factors, a moderate-intensity statin is appropriate. High-intensity statins are recommended for all adults with CVD as well as those aged 40 to 75 years with additional CVD risk factors, according to the guidelines.

The big change is the recommendation of starting either moderate- or high-intensity statins based on the patient’s risk profile rather than LDL levels, according to Dr. Grant.

“Instead of just basing the decision on LDL levels, we are recommending assessing the cardiovascular risk and making decisions based on that,” said Dr. Grant in an interview with Endocrinology Advisor

Other Important Changes

Other changes to the Standards include a new recommendation that all individuals not only exercise regularly, but that they break up periods of inactivity throughout the day so that no more than 90 minutes at a time are spent being sedentary. Additionally, the ADA suggests that people with diabetes perform resistance training at least twice a week unless instructed otherwise by their physician.

The revised Standards also lower the BMI cut point from 25 to 23 for screening overweight or obese Asian Americans for prediabetes and type 2 diabetes.

The new guidelines also include a new section for the management of diabetes in pregnancy, which suggests a one-step test for screening for gestational diabetes

Individualized Therapy

Dr. Grant said the new changes are not terribly controversial, but rather reflect the recent high-quality evidence that has been published.  

“The spirit of the guidelines is to tailor treatment to the patient and individualize them for patients,” said Dr. Grant. “The message is that the majority of patients are being treated for multiple conditions, so endocrinologists need to look at the comorbidities of the patient and socioeconomic issues. Socioeconomic issues are important because so much of diabetes care involves lifestyle changes, exercise and eating healthy foods.”

Mohammed Ali, MBChB, MSc, MBA, assistant professor in the Department of Global Health at Emory University in Atlanta, said the new guidelines are aligned with current best-available evidence, noting that the move towards individualized targets is appropriate and in line with current trends.