Standards and Guidelines 2015 American Diabetes ...
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Standards and Guidelines 2015 American Diabetes Association (ADA) American Association of Clinical Endocrinologists (AACE) For Treatment of Diabetes Joanne Rinker MS, RD, CDE, LDN Director of Training and Technical Assistance Center for Healthy North Carolina
Transcript of Standards and Guidelines 2015 American Diabetes ...
Standards and Guidelines 2015
American Diabetes Association (ADA)
American Association of Clinical Endocrinologists
(AACE)
For Treatment of Diabetes
Joanne Rinker MS, RD, CDE, LDN
Director of Training and Technical Assistance
Center for Healthy North Carolina
Revisions to Standards of Medical Care in Diabetes
2015
Overview:
Review all revisions to Standards of Medical Care in Diabetes 2015. ◦ http://care.diabetesjournals.org/content/38/Supplement_1/S4.full.pdf+html
Algorithm
Diagnosis
Treatment
Section 2: Classification and Diagnosis of Diabetes
The BMI cut point for screening overweight or obese
Asian Americans for prediabetes and type 2 diabetes
was changed to 23 kg/m2 (vs. 25 kg/m2) to reflect the
evidence that this population is at an increased risk for
diabetes at lower BMI levels relative to the general
population.
Section 4: Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care, and Immunization
The physical activity section was revised to reflect evidence that all individuals, including those with diabetes, should be encouraged to limit the amount of time they spend being sedentary by breaking up extended amounts of time (>90 min) spent sitting
The committee also recommends people with diabetes do resistance training at least twice a week, unless they can't for other medical reasons
Section 4: Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care, and Immunization
Due to the increasing use of e-cigarettes, the Standards were updated to make clear that e-cigarettes are not supported as an alternative to smoking or to facilitate smoking cessation.
Section 4: Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care, and Immunization
Immunization recommendations were revised to reflect recent Centers for Disease Control and Prevention guidelines regarding PCV13 and PPSV23 vaccinations in older adults.
Section 6. Glycemic Targets
The ADA now recommends a premeal blood glucose target of 80–130 mg/dL, rather than 70–130 mg/dL, to better reflect new data comparing actual average glucose levels with A1C targets.
Section 7. Approaches to Glycemic Treatment
The type 2 diabetes management algorithm was updated to reflect all of the currently available therapies for diabetes management.
Visuals to come!
Treatment Standards of Care:
ADA: A1c target is 7% or less—with notes!
American Association of Clinical Endocrinologists (AACE): A1c target is 6.5% or less—with notes!
ADA: New standard for children and adolescents A1c 7.5% or less.
Guidelines for Screening
ADA: Screen for diabetes at age 45 and every 3 years
AACE: Screen all at risk individuals. Pre-diabetes, annual measure of FPG or OGTT.
2013: Consider referring relatives of those with Type 1 diabetes for antibody testing for risk assessment in the setting of a clinical research study.
In 2014: Inform type 1 pts of the opportunity to have relatives screened for type 1.
Guidelines for Screening Continued…
2014: Testing to detect Type 2 diabetes and pre-diabetes should be considered in children and adolescents who are overweight and who have two or more additional risk factors for diabetes.
Additional Risk Factors
Physical Inactivity
First degree relative with diabetes
Members of a high risk ethnic population
Delivered a baby greater than 9lbs.
BP greater than 140/90
HDL less than 35 and/or Triglycerides greater than 250.
Women with PCOS
A1c of greater than 5.7% or IGT or IFG on previous testing
Severely obese patients or those with acanthosis nigricans
Hx of vascular disease
Achieving Glycemic Targets: Decision Making
Inzucchi SE, et al. Diabetologia. 2012;55:1577-96;
Adapted from Ismail-Beigi F, et al. Ann Intern Med. 2011;54:554-9.
Patient attitude and expected
treatment efforts
Risks potentially associated
with hypoglycemia, other
adverse events
Disease duration
Life expectancy
Important comorbidities
Established vascular
complications
Resources, support system
More
stringent
Less
stringent
Highly motivated,
adherent, excellent
self-care capacity
Less motivated, nonadherent,
poor self-care capacity
High
Long standing
Short
Severe
Severe
Limited Readily available
Absent
Absent
Long
Newly diagnosed
Low
Approach to the management
of hyperglycemia:
AACE / ACE Glycemic Control Algorithm
Available at www.aace.com/pub. © AACE December 2009 Update
Lifestyle Modification
HbA1C 6.5%-7.5%**
Monotherapy
MET† TZD2 DPP41 AGI3
2-3 Mos.***
Dual Therapy
MET +
GLP-1 or DPP41
TZD2
Glinide or SU5
TZD + GLP-1 or DPP41
MET + Colesevelam
AGI3
2-3 Mos.***
Triple Therapy
MET +
GLP-1 or
DPP41
+
TZD2
Glinide or SU4,7
2-3 Mos.***
INSULIN
± Other
Agent(s)6
HbA1C 7.6%-9.0%
Dual Therapy8
MET +
GLP-1 or DPP41 or
TZD2
SU or Glinide4,5
2-3 Mos.***
Triple Therapy9
MET +
GLP-1 or
DPP41 + TZD2
GLP-1 or
DPP41 + SU7
TZD2
2-3 Mos.***
INSULIN
± Other
Agent(s)6
HbA1C > 9.0% Drug Naïve
No Symptoms Symptoms
INSULIN
± Other
Agent(s)6
INSULIN
± Other
Agent(s)6
MET +
GLP-1 or
DPP41 + SU7
TZD2
GLP-1 or
DPP41 + TZD2
* May not be appropriate for all patients
** For patients with diabetes and HbA1C < 6.5%, pharmacologic
Rx may be considered
*** If HbA1C goal not achieved safely
† Preferred initial agent 1 DPP4 if PPG and FPG or GLP-1 if PPG 2 TZD if metabolic syndrome and/or nonalcoholic fatty liver disease
(NAFLD) 3 AGI if PPG 4 Glinide if PPG or SU if FPG 5 Low-dose secretagogue recommended 6 a) Discontinue insulin secretagogue with multidose insulin
b) Can use pramlintide with prandial insulin 7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4 8 If HbA1C < 8.5%, combination Rx with agents that cause
hypoglycemia should be used with caution 9 If HbA1C > 8.5%, in patients on dual therapy, insulin should be
considered
Under Treatment
HbA1C Goal
≤ 6.5%*
Slides: "Reprinted with permission
from American Association of
Clinical Endocrinologists. Garber
AJ, Abrahamson, MJ, Barzilay JI,
et al. AACE Comprehensive
Diabetes Management Algorithm.
Endocr Pract. 2013;19:327-336.”
ADA Guidelines for Medication
QUESTIONS??
Section 6. Glycemic Targets
To provide additional guidance on the successful implementation of continuous glucose monitoring (CGM), the Standards include new recommendations on assessing a patient’s readiness for CGM and on providing ongoing CGM support.
Section 8. Cardiovascular Disease and Risk Management
The recommended goal for diastolic blood pressure was changed from 80 mmHg to 90 mmHg for most people with diabetes and hypertension to better reflect evidence from randomized clinical trials. Lower diastolic targets may still be appropriate for certain individuals.
Section 8. Cardiovascular Disease and Risk Management
Recommendations for statin treatment and lipid monitoring were revised after consideration of 2013 American College of Cardiology/American Heart Association guidelines on the treatment of blood cholesterol. Treatment initiation (and initial statin dose) is now driven primarily by risk status rather than LDL cholesterol level.
Section 8. Cardiovascular Disease and Risk Management
With consideration for the new statin treatment recommendations, the Standards now provide the following lipid monitoring guidance: a screening lipid profile is reasonable at diabetes diagnosis, at an initial medical evaluation and/or at age 40 years, and periodically thereafter.
Section 9. Microvascular Complications and Foot Care
To better target those at high risk for foot complications, the Standards emphasize that all patients with insensate feet, foot deformities, or a history of foot ulcers have their feet examined at every visit.
Section 11. Children and Adolescents
To reflect new evidence regarding the risks and benefits of tight glycemic control in children and adolescents with diabetes, the Standards now recommend a target A1C of <7.5% for all pediatric age-groups; however, individualization is still encouraged.
Section 12. Management of Diabetes in Pregnancy
This new section was added to the Standards to provide recommendations related to pregnancy and diabetes, including recommendations regarding preconception counseling, medications, blood glucose targets, and monitoring.
American Diabetes Association (ADA) Criteria for Diagnosis of Diabetes
1. A1c: Greater than or equal to 6.5% 2. FPG: Greater than or equal to 126mg/dl 3. 2 hour PG: Greater than or equal to 200
mg/dl during OGTT 4. Classic symptoms and random PG:
greater than or equal to 200 mg/dl 5. 2014: Noted that A1c is one of three
methods to dx diabetes.
Detection and Diagnosis of Gestational Diabetes
2014 NIH: “two step”
50g OGTT (non fasting) with glucose measurement at 1 hr. If >=140 then proceed to 100g OGTT (fasting) with glucose measurement at 3 hr. If >=140=GDM
Discussion Points
Diabetes is Progressive
Temporary decrease in insulin release can occur
ADA recommendation includes Type 1 patients should be on MDI of 3-4 injections basal and prandial or continuous subcutaneous insulin infusion (CSII).
Medications
◦ Individuals AND providers
◦ Are they taking meds?
◦ 2014: If single medications aren’t working within 3 months (prior to 2014 it was 3-6 months) introduce multiple orals, then in 3 more months (not 3-6), insulin.
◦ Early Insulinization!
◦ Introduce in office when BS are elevated.
In 2014 AADE printed a new edition (3rd) of The Art and Science of Diabetes Self-Management Education Desk Reference.
Last update was 2011
Prioritizing Clinical Problems
◦ Variability needs to be reduced first
◦ Hypoglycemia
Overnight
Bedtime and fasting
Pre-prandial
Post prandial
◦ Hyperglycemia
Fasting
Pre prandial glucose values
Post prandial glucose values
ADA Recognition Program Changes ◦ 2012 Standards: http://professional.diabetes.org/admin/UserFiles/2012%20ERP/2012-revised-standard-final.pdf
◦ ERP Recognition News Winter Edition 2013 highlighted the 9th edition changes: http://professional.diabetes.org/Recognition.aspx?typ=15&cid=93575
Changes to the Standards for ADA Programs
Standard 2: The advisory group membership requirement is not as specific now. Standard 5: All instructors only need 15 hours of CEUs Standard 6: Curriculum must be reviewed annually Standard 9: Programs must report a behavioral outcome but must also now report a participant outcome.
