{"id":524,"date":"2015-01-07T20:45:56","date_gmt":"2015-01-07T20:45:56","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=524"},"modified":"2017-08-21T12:05:03","modified_gmt":"2017-08-21T12:05:03","slug":"primary-care-corner-with-geoffrey-modest-md-diabetes-recommendations-2015","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/01\/07\/primary-care-corner-with-geoffrey-modest-md-diabetes-recommendations-2015\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Diabetes Recommendations 2015"},"content":{"rendered":"

By: Dr. Geoffrey Modest<\/strong><\/p>\n

The American Diabetes Association just updated their clinical care recommendations, as they do annually.<\/p>\n

\"diabetes<\/a>I\u00a0will highlight the significant changes over last year, though I did repeat a few items of importance which did not change.<\/p>\n

–They lowered the BMI cutpoint for overweight in Asian Americans from 25 to 23 kg\/m2<\/sup>, reflecting the observation that there is an increased incidence of diabetes at lower BMIs in Asians. They continue to\u00a0recommend checking for diabetes\u00a0in\u00a0all overweight\/obese patients (with the above change for Asian Americans) who have\u00a0one additional risk factor at any age, and\u00a0to\u00a0begin at age 45 otherwise\u00a0[my comment: there are many, many studies over the years showing\u00a0that central or visceral obesity is a much stronger cardiovascular risk factor than BMI. \u00a0BMI\u00a0assesses overall weight, which\u00a0includes\u00a0the not-so-clinically-significant non-visceral adipose tissue, muscle weight, and maybe even heavier bones…\u00a0I am really at a loss that the focus of overweight is with the less consequential BMI —\u00a0\u00a0visceral fat is much more metabolically active,\u00a0is associated with increased inflammatory markers as well as insulin resistance\/metabolic syndrome\/diabetes, and is an independent cardiovascular risk factor — much more so\u00a0than BMI (which in many studies is not even\u00a0an independent risk factor). And,\u00a0it turns out that there is a relatively accurate and simple measure of visceral obesity — waist circumference. The US criteria for metabolic syndrome include a waist circumference (not BMI…)\u00a0for men of\u00a0>40 inches\u00a0and women of >35 inches. \u00a0The International Diabetes Federation had a consensus statement in 4\/4\/2005\u00a0using\u00a0ethnicity-specific waist circumference (again, not BMI)\u00a0in their definition of metabolic syndrome (ie, acknowledging 10 years ago\u00a0that there are important ethnic differences), with the following variations:<\/p>\n

–European (which they call “europoids”): men 94\u00a0cm or\u00a037 inches, women 80 cm or 31.5 inches<\/p>\n

–South Asian, Japanese, and\u00a0Chinese: men 90 cm or 35.4 inches, women 80 cm or 31.5 inches<\/p>\n

I should add that there is an increasingly strong correlation between BMI and visceral fat as the BMI gets increasingly elevated, but i have certainly seen some people with dramatic\u00a0obesity by BMI but normal waist circumference… \u00a0so, why not use waist circumference as an easy measurement and which is a better marker from both biological and epidemiological perspectives??<\/p>\n

\u200b-They note that African-Americans may have higher A1c\u00a0levels than non-Hispanic whites despite similar fasting and post-glucose-load glucose levels, citing a recent study finding that African Americans, both\u00a0with and without diabetes,\u00a0had higher A1c’s when matching for fasting glucose levels (and also higher fructosamine and glycated albumen, suggesting an actual higher glycemic burden… ???significance of this, especially given my recent blogs showing that even A1c in the high 5’s seems to be associated with\u00a0increased cardiac risk)<\/p>\n

–For goal A1c: (no change from prior recs) — try to get to A1c to 7 or less to reduce microvascular complications. Consider lower goal (6.5) if can be achieved easily and without adverse effects. Less stringent goals (eg <8%) may be appropriate if limited life expectancy\/advanced diabetic complications, or difficult to attain lower A1c\u00a0because of\u00a0history of hypoglycemia or just too difficult to attain (brings up past blog on flogging the patient with more and more meds, as in the ACCORD trial, leading to worse clinical outcomes)<\/p>\n

–They comment that electronic cigarettes (e-cigarettes) are “not supported as an alternative to smoking or to facilitate smoking cessation”. [my comment, as per prior blogs, I continue to\u00a0have very real concerns about e-cigarettes as in some ways normalizing smoking after so many years of successfully\u00a0popularizing the bad health effects, being a potential gate-way to real smoking especially for teens, and in fact including\u00a0potentially dangerous additives. That being said, I have had several patients completely stop smoking by briefly using e-cigarettes as a tool.]<\/p>\n

–They have changed the blood glucose targets to a premeal of 80-130 mg\/dL (it was 70-130), better reflecting new data correlating actual average glucose levels with A1c levels.<\/p>\n

–They have included more guidance on continuous glucose monitoring (CGM), including patient readiness and providing ongoing support. Note, CGM is only suggested for patients with type 1 diabetes (they are not totally explicit on this, but all of their references are from type 1 diabetes patients).<\/p>\n

–They have added the new drugs to their therapeutic options (eg SGLT2 inhibitors). they confirm that metformin should be given first if possible, but if\u00a0the A1c target is not reached within 3 months, then they give equal weight to sulfonylurea, thiazolidinedione, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 receptor agonists and basal insulin,\u00a0depending on patient preferences, disease and drug characteristics. [Note: remember that all of the newer agents do well at lowering A1c levels but do not have data showing decreases in diabetic clinical outcomes]<\/p>\n

–Blood pressure:\u00a0they have incorporated the new JNC-8 recommendations for blood pressure goal (systolic <140, diastolic <90), though comment that lower systolic (<130) and diastolic (<80) may be appropriate for certain people, eg younger patients, if achieved without “undue treatment burden”.<\/p>\n

Lipids:\u00a0they also totally support the 2013 ACC\/AHA lipid treatment guidelines, focusing on when to initiate statins and the dose, looking at risk status and not LDL levels (as per prior blogs, I personally disagree with these recommendations…).\u00a0However, they note that since diabetes is a risk factor, these recommendations translate to:<\/p>\n

— Age < 40 and no other risk factors (LDL>100, high blood pressure, smoking, overweight) — no med<\/p>\n

and other CAD risk factor — moderate or high dose statin<\/p>\n

and overt\u00a0CAD \u00a0— high dose statin<\/p>\n

–Age 40-75 and no other risk factor — moderate dose statin<\/p>\n

and other CAD risk factor or overt CAD — high dose statin<\/p>\n

–Age >75 and no other risk factor — moderate dose statin<\/p>\n

and other CAD risk factor — moderate or high dose<\/p>\n

and overt CAD — high dose<\/p>\n

–Aspirin: for primary prevention,\u00a0“consider” low dose aspirin in men >50\u00a0yo\u00a0and women >60 yo with at least one additional major risk factor [note: this recommendation had been more forceful until a few years ago, but then some negative studies came out with aspirin in diabetics, as the POPADAD study — see BMJ 2008; 337:a1840<\/strong>)]. They support the\u00a0use of\u00a0aspirin for secondary prevention (diabetes and history of CAD), or clopidogrel if aspirin intolerant [no change from prior recs, I\u00a0just wanted to reiterate it].\u00a0\u200b<\/p>\n

–Coronary artery disease (CAD): do\u00a0not do routine screening for CAD in asymptomatic patients (no improvement in outcomes by this. just treat the risk factors). \u00a0[this is also not a new recommendation; I just wanted to reiterate it as well]<\/p>\n

–Immunizations:\u00a0they have also incorporated the new immunization guidelines for PCV13 in those over 65 years old [though these recommendations apply\u00a0whether diabetic or not]<\/p>\n

–They stress that all diabetics with decreased sensation in their feet, foot deformities, or a history of foot ulcers have their feet examined at every visit<\/p>\n

–They have raised the target A1c for children and adolescents to <7.5%, also noting that individualization of the target is still encouraged<\/p>\n

–A new section on diabetes in pregnancy, including preconception counseling (stressing importance of trying to achieve A1c<7%), though during pregnancy there are increases in red cell turnover which lowers the normal A1c\u00a0level, so the\u00a0\u00a0A1c\u00a0target is <6% if no significant hypoglycemia;\u00a0medications (esp insulin, metformin, glyburide are the best studied, though the oral agents do cross the placenta); recommendations for\u00a0blood glucose targets; and monitoring.<\/p>\n

–There are sections on the hospital care of diabetics (including discharge planning) as well as a list of some of the ADA’s advocacy positions (care of young children with diabetes, diabetes and driving, diabetes\u00a0and employment, diabetes care in school\/daycare, diabetes in correctional institutions)<\/p>\n

 <\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

By: Dr. Geoffrey Modest The American Diabetes Association just updated their clinical care recommendations, as they do annually. I\u00a0will highlight the significant changes over last year, though I did repeat a few items of importance which did not change. –They lowered the BMI cutpoint for overweight in Asian Americans from 25 to 23 kg\/m2, reflecting […]<\/p>\n

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