I look forward to the holidays every year. I know that this next statement may sound silly, but I look forward to the last week of December in particular. As the year is winding down, I know that the American Diabetes Association (ADA) will publish its annual “Standards of Medical Care in Diabetes.” This publication always provides an updated set of evidence-based recommendations from the organization; these recommendations may be the next grand rounds topic at your institution or discussion at the next office meeting.
In addition to the Standards, however, this year also held a surprise when the ADA, in conjunction with the European Association for the Study of Diabetes (EASD), published an updated position statement on the management of hyperglycemia.1 The last two position statements were published in 2009 and 2012. These organizations have provided an update due to new data from clinical trials.
Compared with the 2012 position statement, there have been three updates. First, sodium glucose co-transporter-2 (SGLT2) inhibitors have been incorporated as a second-line option, if a patient does not achieve desired glycemic control after 3 months of maximum dose metformin with lifestyle modifications. Lifestyle modifications remain an integral component of the therapeutic plan with any monotherapy or combination therapy.
However, 2015 ADA/EASD position statement does not provide a hierarchy for second- or third-line treatment in the management of diabetes. While these guidelines incorporated the SGLT-2 inhibitors, practitioners should also refer to the American Association of Clinical Endocrinologists (AACE) guidelines, published in April 2013. This particular set of guidelines provides a hierarchy on monotherapy, dual and triple combination therapy for the management of type 2 diabetes.
Overall, there are several factors to consider before initiating or adding another agent to a patient’s regimen. Each regimen is individualized based on the degree of hyperglycemia, risk for hypoglycemia, possible need for weight loss, patient’s preference in the therapy and cost of the drug.
In the 2015 ADA/EASD position statement, another update includes recommendations on metformin therapy. Due to clinical data, they relaxed prescribing of metformin in patients with renal impairment. Metformin can be continued in patients with a glomerular filtration rate (GFR) of 45 mL/min/1.73m2 to 60 mL/min/1.73m2, but should be discontinued when GFR drops below 30 mL/min/1.73m2.
The last update was in regards to insulin therapy among patients with type 2 diabetes. The position statement provided an expanded flow chart for basal, bolus and premixed insulin. Details are provided for initiation and titration for more flexible, less complex and less flexible, more complex insulin regimens.
Several things did not change with the 2015 position statement, such as the illustration on individualized glycemic control. This illustration was created in the last update to show what factors should be considered to determine a more or less stringent glycemic goal. This type of illustration was based on evidence from several trials such as the ACCORD, ADVANCE and VA-DT trials. The statement continues to include a chart of the medications, which can be useful for practitioners. The chart includes the therapeutic class, mechanism of action, advantages, disadvantages and cost of all approved agents.
While I have focused mainly on the 2015 ADA/EASD position statement, I would also like to comment on changes in “Standards for Medical Care in Diabetes.”2
In my clinical practice, we do not have any Asian American patients. In the 2015 Standards, the BMI has been lowered from 25 to 23 as a risk factor for prediabetes and diabetes in this specific patient population.
Additionally, the recommended blood pressure (BP) goal is 140/90 mm Hg among patients with diabetes and hypertension, which is similar to the JNC-VIII guidelines.
The ADA also agrees with the new cholesterol guidelines from American College of Cardiology (ACC) and American Heart Association (AHA), which recommend moderate- or high-intensity statin therapy for patients aged older than 40 years.
Another revision is the change in pre-prandial glycemic goals, which have been modified to be 80 mg/dL to 130 mg/dL.
While this is a short blog, I could elaborate on the evidence behind these modifications and recommendations in the publications. However, I’d like to hear your thoughts, so please share them. What do you think about the position statement? What do you think about the new recommendations? How quickly will you be implementing these recommendations into clinical practice?
Hopefully, everybody will have a chance to read these recent publications and share with your team at the beginning of the year. They are free and accessible through Diabetes Care.
Happy New Year to everyone!