ADA Includes Significant Updates in 2016 Standards of Medical Care in Diabetes

Updated Recommendations on Heart Disease in Diabetes

The new guidelines also tackle heart disease, with the ADA updating its atherosclerotic cardiovascular disease (ASCVD) recommendations. They call for clinicians to consider prescribing aspirin therapy to women aged 50 and older who have at least 1 additional major risk factor, such as family history of premature ASCVD, hypertension, smoking, dyslipidemia, or albuminuria. 

“Atherosclerotic cardiovascular disease replaced cardiovascular disease since ASCVD is a more specific term,” said William Herman, MD, MPH, professor of medicine and epidemiology at the University of Michigan and chair of the ADA’s Professional Practice Committee.

“We added a pharmacologic section for treating people older than 75 years. We changed the age for the aspirin recommendation for women; we decreased the age at which aspirin should be considered for women from age older than 60 years to age older than 50 years since recent evidence showed that aspirin would benefit younger women,” he added.

Another significant change involved the agent ezetimibe (Zetia, Merck). The medication was not previously recommended, but now the guidelines state it may provide additional cardiovascular benefits for select individuals with diabetes. 

“We added information about the use of ezetimibe due to the IMPROVE-IT trial results. We stated that adding ezetimibe to a moderate-intensity statin may provide additional cardiovascular benefits for certain individuals with diabetes,” Dr Herman said in an interview with Endocrinology Advisor.

“In the 2015 Standards, we did not recommend considering the use of ezetimibe. We also included a new table that provides efficacy and dosing details for high- and moderate-intensity statin use.”

Role of Novel Technology

The ADA recognizes the important role of new technology in managing diabetes, guideline authors noted. For instance, one new recommendation states that people who use continuous glucose monitoring (CGM) and insulin pumps should have continuous access after age 65. People at risk for developing type 2 diabetes should also consider the use of new technologies, such as Internet-based social networks, distance learning, and mobile applications, to effectively modify behaviors for prevention of diabetes. 

“Technology has been beneficial for those requiring intensive insulin therapy, particularly those with difficulty perceiving or treating hypoglycemia,” said Robert Ratner, MD, chief scientific and medical officer of the ADA.

“The use of continuous subcutaneous insulin infusion systems (insulin pumps), CGM, and the recently approved linked systems, including low glucose suspend features, provide added safety. We recognize their value and the aging of the diabetes population to recommend continued access for those people with diabetes aging into the Medicare system at age 65,” he noted.

Addressing Social Issues

Diabetes management requires individualized, patient-centered, and culturally appropriate strategies, according to Dr Chiang. She noted that the 2016 Standards’ new obesity management and vulnerable population sections are 2 examples where individualized care is essential.

“We realize that people with diabetes also struggle with social issues. So, we have included recommendations for those with food insecurity (inability to get nutritious food), cognitive dysfunction and/or mental illness, and HIV,” Dr Chiang told Endocrinology Advisor. “We also highlight the disparities related to ethnicity, culture, sex, and socioeconomic differences. For optimal success, we emphasize that diabetes care must integrate all aspects of the individual’s life.”