New diabetes guidelines put patient front and center




The 2016 updates of the American Diabetes Association’s Standards of Medical Care in Diabetes bring an enhanced focus on patient-centered care, evidence-based updates for atherosclerotic cardiovascular disease, and a dedicated section on obesity (Diabetes Care 2016;39[Suppl. 1]:S4-S5. doi: 10.2337/dc16-S003).

According to Dr. Robert E. Ratner, chief scientific and medical officer for the American Diabetes Association in Alexandria, Va., the focus of care for individuals with diabetes is to achieve a holistic approach coordinating patient-centered disease management to maximize the benefits of an integrated team approach. The 2016 guideline puts that mission front and center.

Dr. Robert E. Ratner

Dr. Robert E. Ratner

When formulating its yearly updates, the ADA looks for new information “that makes a significant change in the practice of medicine” and that will affect patient care, Dr. Ratner said in an interview. “We are trying to make the recommendations both thorough and evidence based.”

The guidelines were formulated by a professional practice committee chaired by Dr. William H. Herman, professor of epidemiology and internal medicine at the University of Michigan, Ann Arbor. According to the guidelines, the appointed committee “adheres to the Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines,” and the draft guidelines were made publicly available for comment before publication.

What’s different for 2016? Foremost is a change in approach, to more patient-centered care. Guidelines always address best practices at the population health level, Dr. Ratner said. However, “for each individual patient, interventions must be tailored, and the intervention must be adjusted to meet individual needs.”

Dr. William H. Herman

Dr. William H. Herman

One example is a relaxation in hemoglobin A1c (HbA1c) targets for the infirm and the elderly, based on data from large Veterans Affairs studies and from the National Health and Nutrition Examination Survey that show the harms of inappropriately low HbA1c levels for fragile populations. The updated guidelines encourage those caring for these patients to “back off and be more patient centered,” said Dr. Ratner.

The practice guidelines also acknowledge new information regarding the risk of euglycemic diabetic ketoacidosis with the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors.

These changes strive to take into account new research, while acknowledging that in some areas there’s still a paucity of data, said Dr. Ratner. For example, recommendations regarding use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors for certain individuals with dyslipidemia and diabetes are included, though study of this new class of medications is ongoing; the guideline includes an evidence rating system to allow practitioners to rate the strength of recommendations when making individualized treatment decisions.

The guideline also gives the option of adding ezetimibe to a moderate statin dose for some individuals with diabetes and dyslipidemia, acknowledging the findings of the IMPROVE-IT trial. Other atherosclerotic cardiovascular disease updates include considering aspirin therapy for women 50 years and older who have diabetes with at least one additional major risk factor.

A new section devoted to obesity management acknowledges its critical importance in type 2 diabetes mellitus (T2DM). While continuing to emphasize the importance of lifestyle changes, such as healthful eating and physical activity, the guideline acknowledges that there’s a role for pharmacotherapy and surgical treatment. In addition to providing information on approved anti-obesity medication, the guideline addresses the benefit of bariatric surgery for a select group of patients. “We can’t ignore the data” that point toward a role for these interventions for some patients, said Dr. Ratner. The guideline weighs the advantages and disadvantages of each approach.

Other updates include a recommendation for testing all adults for diabetes beginning at age 45 years, without regard to weight; clarifying testing guidelines to emphasize that no one testing strategy is preferred over another; slightly relaxing HbA1c targets for pregnant women to 6%-6.5%; and enhancing guidelines for hospitalized patients with diabetes.

The complete practice guideline, which runs to 119 pages, is accompanied by an abridged version that provides a basic framework for diabetes management. Dr. Ratner said that the complete standards of care are appropriate for endocrinologists and others who focus on diabetes management, while the abridged version is a resource for primary care providers who may see some patients with diabetes in the mix of their caseload. Both documents are available to view or download free of charge. A summary of key updates precedes the full text of the guidelines, so that those using last year’s guidelines can familiarize themselves quickly with changes in the new version.

Dr. Herman reported chairing data and safety monitoring boards for Merck Sharp & Dohme, and Lexicon Pharmaceuticals. He has served as the editor for the Americas of Diabetic Medicine, and as ad hoc editor in chief of Diabetes Care.

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