The American Diabetes Association is recommending a less stringent diastolic blood pressure 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 American Heart Association (AHA). These recommendations are reflected in the most recent changes to the Association's annual revised Standards of Medical Care, being published in a special supplement to the January issue of Diabetes Care.
The new Standards of Medical Care are updated annually to provide the best possible guidance to health care professionals for diagnosing and treating adults and children with all forms of diabetes. The Standards are based upon the most current scientific evidence, which is rigorously reviewed by the Association's multi-disciplinary Professional Practice Committee.
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 the use of cholesterol-lowering drugs, called statins, that would have placed the vast majority of people with diabetes under this therapy. Until now, the Association has not issued a response to these guidelines and 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, Research Scientist, Kaiser Permanente Division of Research and Chair of the Association's Professional Practice Committee. They recommend people with diabetes who are under 40 years of age, or who are between the ages of 40 and 75 with no additional cardiovascular disease risk factors, take a moderate-intensity statin, while those of all ages who have cardiovascular disease, or those ages 40-75 who have additional cardiovascular risk factors, 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 LDL 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 diastolic blood pressure goal for people with diabetes of 90 mmHg, up from 80 mmHg.
"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 mmHg," Grant said.
Other changes to the Standards of Medical Care include a new recommendation that all individuals, including those with diabetes, not only exercise regularly, but that they 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 been reorganized and renamed. Previously, the Association issued "Clinical Practice Recommendations" with a section on the "Standards of Medical Care." The Association now issues a single document, the "Standards of Medical Care," divided into 14 sections to highlight important topic areas and make it easier to navigate.
"We've revised our recommendations, as we do every year, to reflect the best and most current research affecting the treatment and care of people with diabetes," said Jane Chiang, the Association's Senior Vice President for Medical Affairs and Community Information. " Health care providers know that the Association Standards contain the most up-to-date information. However, we also wanted to help readers navigate through the information overload, and felt that a new format would enable easier access. Ultimately, our goal is to improve the lives of those who are living with this disease."
The new Standards have also:
- Lowered the BMI cut point for screening overweight or obese Asian Americans to 23 kg/m2 (from 25 kg/m2). The Association has issued a separate release with details outlining the reasons for making this change.
- 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 A1C target of less than 7.5 percent 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 Association 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 age 65 or older who have not received a pneumonia vaccine receive two separate shots, PCV13 (Prevnar), followed 12 months later by PPSV23 (Pneumovax).