In 2012, 29.1 million Americans, or 9.3% of the population, had diabetes. Of this number, 21 million were diagnosed, and 8.1 million were undiagnosed. Each year almost 1.5 million Americans receive a new diagnosis of diabetes. The management of diabetes relies upon excellent primary care. Each year the American Diabetes Association reviews new evidence and publishes an updated Standards of Care in the January issue of Diabetes Care. Here we give a short overview of the guidelines with emphasis on fundamentals and changes in the standards over the past year.
Self-management education and support, nutrition therapy, and physical activity
All patients should participate in ongoing diabetes self-management education (DSME) to facilitate the knowledge, skills, and abilities necessary to obtain optimal self-care and incorporate the needs, goals, and life experiences of the person with diabetes as they face new challenges throughout a lifetime of diabetes.
In addition, each patient should receive individualized medical nutrition therapy (MNT) provided by a registered dietitian with knowledge regarding diabetes-specific MNT. Most patients should increase aerobic physical activity to 150 min/week. Providers should encourage patients to reduce the amount of time spent sedentary by briefly standing, walking, or performing other light physical activities every 30 minutes.
Glycemic targets
A reasonable hemoglobin A1c goal for many diabetic nonpregnant adults is less than 7%. A less stringent goal under 8% may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular and macrovascular complications, and extensive comorbid conditions. HbA1c measurements should be done at diagnosis and routinely to monitor glycemic control. To aid in achieving glycemic targets, self-monitoring blood glucose (SMBG) allows patients to evaluate their individual response to therapy. Integrating SMBG data into diabetes management can help guide MNT, adjust medications, determine physical activity requirements, and prevent hypoglycemia. Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter and counseled regarding treatment of hypoglycemic events.
Obesity management
There is strong and consistent evidence that obesity management may be beneficial in the treatment of type 2 diabetes. For overweight and obese patients with type 2 diabetes, interventions should be high intensity (more than 16 sessions in 6 months) and focus on diet, physical activity, and behavioral therapy designed to achieve a greater than 5% weight loss (energy deficit of 500-750 kcal/day).
For select patients, weight loss medications may be effective as adjuncts to lifestyle changes. When choosing additional pharmacologic interventions to improve glycemic control in overweight or obese patients, providers should use medications that promote weight loss or are weight neutral including metformin, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 (GLP-1) agonists, and dipeptidyl peptidase-4 inhibitors (DPP-4) versus those that cause weight gain such as insulin secretagogues, thiazolidinediones, and insulin.
Metabolic surgery should be recommended to patients with type 2 diabetes and body mass index above 40 kg/m2 (BMI above 37.5 kg/m2 in Asian Americans), regardless of adequate glycemic control and for patients with BMI above 35 kg/m2 (more than 32.5 kg/m2 in Asian Americans) without adequate glycemic control despite lifestyle modifications and optimal medical therapy. Metabolic surgery should be considered for appropriate candidates with BMIs as low as 30 if hyperglycemia is inadequately controlled despite optical medical control by either oral or injectable medications.
CV disease and risk management: BP, lipids, antiplatelet therapy, and glycemic medication management
Atherosclerotic cardiovascular disease is the leading cause of morbidity and mortality for individuals with diabetes. Screening for atherosclerotic cardiovascular disease is not recommended; rather, the emphasis is on careful risk factor management.
If systolic blood pressure (SBP) is confirmed to be above 140 mm Hg and/or the diastolic blood pressure (DBP) is confirmed to be above 90 mm Hg, pharmacologic therapy should be initiated. A meta-analysis of randomized trials of adults with type 2 diabetes comparing intensive blood pressure targets (upper limit of 130 mm Hg SBP and 80 mm Hg DBP) with standard targets (upper limit of 140-160 mm Hg SBP and 85-100 mm Hg DBP) found no significant reduction in mortality or nonfatal MI. There was a statistically significant, 35% relative risk (RR) reduction in stroke with intensive targets, but intensive targets were associated with an increased risk for adverse events such as hypotension and syncope. Recommendations suggest that antihypertension treatment in adults with diabetes without albuminuria should include any of the classes of medication demonstrated to reduce cardiovascular events in patients with diabetes, such as ACE inhibitors, angiotensin receptor blockers (ARBs), thiazide-like diuretics, or dihydropyridine calcium-channel blockers. ACE inhibitors and ARBs continue to be recommended as first-line medications for the treatment of hypertension in patients with diabetes and elevated urine albumin/creatinine ratios (above 30 mg/g creatinine). The standards also suggest consideration of administering one or more antihypertensive medications at bedtime, which may improve cardiovascular outcomes.
For patients aged 40-75 years who have diabetes without additional atherosclerotic CV disease risk factors, a moderate-intensity statin should be considered. If there are additional cardiovascular risk factors, then a high-intensity statin should be considered. For patients who are younger than 40 years of age and have diabetes with additional atherosclerotic CV disease risk factors, a less strong recommendation is to consider using moderate-intensity or high-intensity statins. For patients older than 75 years with diabetes without additional atherosclerotic CV disease risk factors, consider using moderate-intensity statin therapy; high-intensity statin therapy may be considered in older adults with risk factors for atherosclerotic cardiovascular disease.
Both women and men who are at least 50 years old and have diabetes with at least one additional cardiovascular risk factor should consider taking daily aspirin therapy (75-162 mg/day) if they do not have any risk for excessive bleeding.
In patients with long-standing suboptimally controlled type 2 diabetes and established atherosclerotic CV disease, empagliflozin or liraglutide should be considered as they have been shown to reduce cardiovascular and all-cause mortality when added to standard care.
Microvascular disease and foot care
Large prospective studies have demonstrated that optimized glucose control can reduce the onset and progression of diabetic microvascular complications. Diabetic kidney disease occurs in about 20%-40% of persons with diabetes. Annual screening includes estimated glomerular filtration rate and spot urine albumin-to-creatinine ratio. Treatment includes ACE inhibitors or ARBs in addition to a target blood pressure of under 140/90 mm Hg.
Diabetic retinopathy screening includes a dilated eye exam by an eye care professional. Treatment includes laser photocoagulation therapy for high risk nonproliferative retinopathy or proliferative retinopathy, or intravitreal injections of antivascular endothelial growth factor agents for central-involved diabetic macular edema.
Diabetic peripheral neuropathy screening includes annual 10-g monofilament and 128-HZ tuning fork vibration sensation. Medications for painful diabetic neuropathy may include gabapentin, pregabalin, duloxetine, and other agents.
Neuropathy and vascular disease are contributors to diabetic foot ulcers and amputation. A comprehensive foot examination along with appropriate risk factor oriented history to include neuropathic and vascular components (pulses, claudication) should be performed annually, while all patients with diabetes should have their feet checked at every visit.
Older adults
Prioritizing treatment goals in older adults is important in this heterogeneous population. Cardiovascular risk factor treatment is likely to be beneficial.
In setting HbA1c goals, functional status, and comorbid conditions should be considered. Metformin can still be a first-line agent for many older adults with type 2 diabetes, with consideration to renal status (creatinine clearance above 30 mL/min per 1.73 m2) and heart failure. DPP-4s have few side effects and low risk of hypoglycemia. GLP-1 receptor agonists have a low risk of hypoglycemia but may be associated with GI side effects and weight loss. SGLT-2 inhibitors have a low risk of hypoglycemia, and attention should be paid to renal thresholds for use. Thiazolidinediones should be used cautiously in those with heart failure or at elevated fracture risk. Sulfonylureas should be used cautiously because of their elevated risk of hypoglycemia. When used, a short-acting sulfonylurea – such as glipizide – is preferred, as long-acting sulfonylureas are contraindicated because of even greater hypoglycemic risk. Single-injection basal insulin may be appropriate for many with ease of use and efficacy.
The bottom line
Diabetes is a rapidly changing field and each year the American Diabetes Association updates the Standards of Medical Care document to be consistent with the latest evidence. Highlights of the standards include emphasis on diabetes self-management education, individualized glycemic goal setting, obesity management, setting blood pressure targets to less than 140/90 mm Hg, as well as statins and daily aspirin for most people with diabetes. In addition, ADA now recommends the use of specific antihyperglycemic medications to reduce cardiovascular and all-cause mortality in patients with diabetes and established cardiovascular disease.
Reference
American Diabetes Association Standards of Medical Care in Diabetes – 2017. Diabetes Care 2017; 40 (sup 1):S1-S138
Dr. Skolnik is professor of family and community medicine, Temple University School of Medicine, Philadelphia, and associate director, Family Medicine Residency Program, Abington-Jefferson Health, Abington, Pa. Dr. Johnson is associate professor at the University of North Dakota School of Medicine and Health Sciences, and practices at the Altru Diabetes Center, Grand Forks. Ms. Neuman practices at St. Mark’s Hospital, Salt Lake City.
