ADA Releases Standards of Medical Care for Diabetes in 2013

According to the ADA, it is “recommending changes in blood pressure goals for people with diabetes as well as clarifying how frequently people with type 1 diabetes should test their blood glucose levels.”

Richard Grant, MD, MPH, incoming chair of the Professional Practice Committee and research scientist with the Kaiser Permanente Division of Research, said that raising the recommended blood pressure target goal “is not meant to downplay the importance of treating high blood pressure in people with diabetes.” It also does not imply that lower target rates are inappropriate. Grant said that lower rates “may be appropriate for some patients, particularly those who are younger and have a longer life expectancy, or for those who have a higher risk of stroke, if the lower goal can be achieved without excessive amounts of treatment and without a heavy burden of side effects from medication.”

The revised recommendations and changes include:

• Raising the treatment goal for high blood pressure from < 130 mm Hg to < 140 mm Hg. According to the ADA, “Clinical trials have demonstrated health benefits to achieving a goal of <140 mm Hg, such as reducing cardiovascular events, stroke or nephropathy (kidney disease), but limited benefit to more intensive blood pressure treatment, with no significant reduction in mortality or non-fatal heart attacks. There is a small but statistically significant benefit in terms of reducing risk of stroke, but at the expense of a need for more medications and higher rates of side effects.”
• Clarification on the number of times per day that patients who are taking multiple daily doses of insulin or using insulin pumps should test blood glucose levels. The new standards “do not specify the number of times that testing should occur but instead focus on the conditions under which testing should occur.” It is now recommended that these patients “test prior to meals and snacks, occasionally after eating, at bedtime, before exercise, when they suspect low blood glucose, after treating low blood glucose levels until they return to normal” and “prior to critical tasks such as driving.”
• Patients in non-insulin therapy who self-monitor blood glucose levels should be taught “how to use the information about glucose levels appropriately,” and receive instruction on “how frequently they need to test and under what conditions.”

The updated ADA standards of care “are intended to provide clinicians, patients, researchers, payers, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care.”

The revised standards include sections that address children with diabetes, pregnant women, and people with prediabetes, and include recommendations on “screening, diagnostic, and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes.”

Additional highlights from the revised recommendations include:

• Testing for type 2 diabetes and prediabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 kg/m²) and who have one or more additional risk factors for diabetes (including physical inactivity, first-degree relative with diabetes, high-risk race/ethnicity, hypertension, A1C ≥5.7%, and others). In patients without these risk factors, testing should begin at age 45.
• Testing for type 2 diabetes and prediabetes should be considered in children and adolescents who are overweight and who have two or more additional risk factors for diabetes.
• Clinicians should consider referring relatives of those with type 1 diabetes for antibody testing for risk assessment in the setting of a clinical research study.
• Women with a history of gestational diabetes found to have prediabetes should receive lifestyle interventions or metformin to prevent diabetes.
• Patients with impaired glucose tolerance, impaired fasting glucose, or an A1C of 5.7—6.4% should be referred to an effective ongoing support program targeting weight loss of 7% of body weight and increasing physical activity to at least 150 min/week of moderate activity such as walking.
• Metformin therapy for prevention of type 2 diabetes may be considered in those with impaired glucose tolerance, impaired fasting glucose, or an A1C of 5.7—6.4%, especially for those with BMI >35 kg/m², aged <60 years, and women with prior gestational diabetes.

The full-text version of the recommendations is available here.