Clinical Guidelines: ADA 2017 Standards of Medical Care in Diabetes
Microvascular disease and foot care
Large prospective studies have demonstrated that optimized glucose control can reduce the onset and progression of diabetic microvascular complications. Diabetic kidney disease occurs in about 20%-40% of persons with diabetes. Annual screening includes estimated glomerular filtration rate and spot urine albumin-to-creatinine ratio. Treatment includes ACE inhibitors or ARBs in addition to a target blood pressure of under 140/90 mm Hg.
Diabetic retinopathy screening includes a dilated eye exam by an eye care professional. Treatment includes laser photocoagulation therapy for high risk nonproliferative retinopathy or proliferative retinopathy, or intravitreal injections of antivascular endothelial growth factor agents for central-involved diabetic macular edema.
Diabetic peripheral neuropathy screening includes annual 10-g monofilament and 128-HZ tuning fork vibration sensation. Medications for painful diabetic neuropathy may include gabapentin, pregabalin, duloxetine, and other agents.
,Neuropathy and vascular disease are contributors to diabetic foot ulcers and amputation. A comprehensive foot examination along with appropriate risk factor oriented history to include neuropathic and vascular components (pulses, claudication) should be performed annually, while all patients with diabetes should have their feet checked at every visit.
Older adults
Prioritizing treatment goals in older adults is important in this heterogeneous population. Cardiovascular risk factor treatment is likely to be beneficial.
In setting HbA1c goals, functional status, and comorbid conditions should be considered. Metformin can still be a first-line agent for many older adults with type 2 diabetes, with consideration to renal status (creatinine clearance above 30 mL/min per 1.73 m2) and heart failure. DPP-4s have few side effects and low risk of hypoglycemia. GLP-1 receptor agonists have a low risk of hypoglycemia but may be associated with GI side effects and weight loss. SGLT-2 inhibitors have a low risk of hypoglycemia, and attention should be paid to renal thresholds for use. Thiazolidinediones should be used cautiously in those with heart failure or at elevated fracture risk. Sulfonylureas should be used cautiously because of their elevated risk of hypoglycemia. When used, a short-acting sulfonylurea – such as glipizide – is preferred, as long-acting sulfonylureas are contraindicated because of even greater hypoglycemic risk. Single-injection basal insulin may be appropriate for many with ease of use and efficacy.
The bottom line
Diabetes is a rapidly changing field and each year the American Diabetes Association updates the Standards of Medical Care document to be consistent with the latest evidence. Highlights of the standards include emphasis on diabetes self-management education, individualized glycemic goal setting, obesity management, setting blood pressure targets to less than 140/90 mm Hg, as well as statins and daily aspirin for most people with diabetes. In addition, ADA now recommends the use of specific antihyperglycemic medications to reduce cardiovascular and all-cause mortality in patients with diabetes and established cardiovascular disease.
Reference
American Diabetes Association Standards of Medical Care in Diabetes – 2017. Diabetes Care 2017; 40 (sup 1):S1-S138
Dr. Skolnik is professor of family and community medicine, Temple University School of Medicine, Philadelphia, and associate director, Family Medicine Residency Program, Abington-Jefferson Health, Abington, Pa. Dr. Johnson is associate professor at the University of North Dakota School of Medicine and Health Sciences, and practices at the Altru Diabetes Center, Grand Forks. Ms. Neuman practices at St. Mark’s Hospital, Salt Lake City.
