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American Diabetes Association Recommends New Standards of Care
The American Diabetes Association (ADA) is recommending that clinicians adhere to a less-stringent diastolic blood pressure (DBP) target for people with diabetes and that all people with diabetes take either moderate or high doses of statins, in keeping with recent changes to guidelines for cardiovascular risk management enacted by the American College of Cardiology (ACC) and the American Heart Association (AHA). These recommendations are reflected in the most recent changes to the ADA’s annual revised Standards of Medical Care, published online in a special supplement to the January 2015 issue of Diabetes Care.
Last year, the ACC and AHA jointly issued new recommendations for cardiovascular risk management that set up a decision tree to determine when to prescribe cholesterol-lowering statins that would have placed most people with diabetes receiving this therapy. Until now, the ADA had not issued a response to these guidelines and to their appropriateness for people with diabetes, who are two to four times as likely as people without diabetes to have a heart attack or stroke. Cardiovascular disease is the number one killer of people with diabetes.
Because people with diabetes are already at high risk for heart disease, the revised Standards of Medical Care call for all people with diabetes to take statins, said Richard W. Grant, MD, MPH, Chair of the ADA’s Professional Practice Committee. The standards recommend that people with diabetes who are under 40 years of age, or who are between 40 and 75 years of age with no additional cardiovascular disease (CVD) risk factors, should take a moderate-intensity statin, whereas those of all ages who have CVD, or those aged 40 to 75 years who have additional CVD risk factors, should take a high-intensity statin.
“The big change here is to recommend starting either moderate- or high-intensity statins based on the patient’s risk profile,” said Grant, “rather than on the LDL [low-density lipoprotein] level. Since all patients with diabetes are at increased risk, it is just a matter of deciding whom to start on moderate- versus high-intensity statin doses.”
The revised recommendations also call for a less-stringent DBP goal of 90 mm Hg, up from 80 mm Hg, for people with diabetes.
“While observational studies find that lower blood pressure generally seems to be better, the higher-quality randomized trial evidence most strongly supports the treatment target of 90 mm Hg,” Grant said.
Other changes to the standards include a new recommendation that all individuals, including those with diabetes, should not only exercise regularly, but also break up periods of inactivity throughout the day so that no more than 90 minutes at a time are spent being sedentary. They also call for people with diabetes to perform resistance training at least twice a week, unless otherwise instructed by their doctors for medical reasons.
The new standards have also:
- Lowered the body mass index (BMI) cut point for screening overweight or obese Asian Americans to 23 kg/m2 (from 25 kg/m2).
- Added a new section for the management of diabetes in pregnancy, which includes the recommendation that a one-step test be used for screening for gestational diabetes.
- Included the new hemoglobin A1C target of less than 7.5% for children and adolescents with diabetes, which was announced in a position statement earlier this year.
- Made clear that e-cigarettes are not supported by the ADA as an alternative to smoking or as a means of facilitating smoking cessation.
- Revised immunization guidelines for older adults to reflect new recommendations by the Centers for Disease Control and Prevention that people aged 65 years or older who have not received a pneumonia vaccine should receive two separate shots: PCV13 (Prevnar, Wyeth/Pfizer), followed 12 months later by PPSV23 (Pneumovax, Merck).