December 22, 2015
New management recommendations for the treatment of type 2 diabetes were published as a part of the American Diabetes Association’s 2016 Standards of Medical Care in Diabetes in Diabetes Care.
The annually updated guidelines provide health care providers with all components of diabetes care, general treatment goals, and tools to evaluate quality care.
Below I have tried to give some salient features of the guidelines.
A. CATEGORIES OF INCREASED RISK FOR DIABETES (PREDIABETES)
Recommendations for diagnosis of DM:
1. Testing to assess risk for future diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 kg/m2 or ≥23kg/m2) in Asian Americans and who have one or more additional risk factors for diabetes.
2.First-Degree Relative With Diabetes
3.High-Risk Race/Ethnicity (E.G., African American, Latino, Native American, Asian American, Pacific Islander)
4.Women Who Delivered A Baby Weighing.9 lb or were Diagnosed With GDM.
5. Hypertension (>140/90 Mm hg Or On Therapy for Hypertension)
6.HDL Cholesterol level,35 mg/dl (0.90 Mmol/L) and/or Triglyceride Level >250 Mg/dl (2.82 Mmol/L)
7.Women with Polycystic Ovary Syndrome
8. A1c ≥ 5.7% (39 mmol/mol), IGT, Or IFG On Previous Testing
9. Other Clinical Conditions Associated With Insulin Resistance (E.G., Severe Obesity, Acanthosis Nigricans)
10.History of CVD
2.For all patients, testing should begin at age 45 years, regardless of weight.
3.If tests are normal, repeat testing carried out at a minimum of 3 year intervals is reasonable.
4. To test for prediabetes, fasting plasma glucose, 2-h plasma glucose
after 75-goal glucose tolerance test,and A1C are equally appropriate.
5.In patients with prediabetes, identify and, if appropriate, treat other
cardiovascular disease risk factors.
6.Testing to detect prediabetes should be considered in children and adolescents who are overweight or obese and who have two or more additional risk factors for diabetes.
B. TYPE 1 DIABETES
- Blood glucose rather than A1C should be used to diagnose acute onset of type 1 diabetes in individuals with symptoms of hyperglycemia.
- Inform the relatives of patients with type 1 diabetes of the opportunity to be tested for type1 diabetes risk, but only in the setting of a clinical research study.
C. PHARMACOLOGICAL THERAPY FOR TYPE 2 DIABETES
1. Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacological agent for type 2 diabetes.
2.Consider initiating insulin therapy (with or without additional agents)
in patients with newly diagnosed type 2 diabetes and markedly symp-tomatic and/or elevated blood glu-cose levels or A1C.
3. If non insulin monotherapy at maximum tolerated dose does not achieve or maintain the A1C target over 3 months, then add a second oral agent, a glucagon-like peptide 1 receptor agonist, or basal insulin.
4. For patients with type 2 diabetes who are not achieving glycemic goals, insulin therapy should not be delayed.
5. Patient-centered approach should be followed with considering efficacy, safety, cost, side effects.
D. PHYSICAL ACTIVITY
Recommendations for physical activity:
- Children with diabetes or prediabetes should be encouraged to engage in at least 60 min of physical activity each day.
- Adults with diabetes should be advised to perform at least 150 min/ week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise.
- All individuals, including those with diabetes, should be encouraged to reduce sedentary time, particularly by breaking up extended amounts of time (90 min) spent sitting.
- In the absence of contraindications, adults with type2 diabetes should be encouraged to perform resistance training at least twice per week.
Few changes in Standard Care 2016:
1) CVS disease risk management :
- A new recommendation for pharmacological treatment of older adults was added.
- To reflect new evidence on ASCVD risk among women, the recommenda-tion to consider aspirin therapy in women aged 60 years has been changed to include women aged >50 years.
- A recommendation was also added to address antiplatelet use in pa-tients aged,50 years with multiple risk factors.
- A recommendation was made to reflect new evidence that adding ezetimibe to moderate-intensity statin provides additional cardiovascular benefits for select individuals with diabetes and should be considered.
2. The recommendation to obtain a fasting lipid profile in children starting at age 2 years has been changed to age 10 years.
3. A1C recommendations for pregnant women with diabetes were changed, from a recommendation of ,6% (42mmol/mol) to a target of 6–6.5% (42–48 mmol/mol), although depending on hypoglycemia risk the target may be tightened or relaxed.
4. A recommendation was added encouraging the use of new technology such as apps and text messaging to affect lifestyle modification to prevent diabetes.