New American Diabetes Association (ADA) recommendations call for a less stringent diastolic blood pressure target and the use of moderate or high doses of statins for persons with diabetes mellitus (DM).
The recommendations, reflected in the most recent changes to the ADA’s Standards of Medical Care, are in keeping with recent changes to guidelines for cardiovascular (CV) risk management enacted by the American College of Cardiology (ACC) and American Heart Association (AHA).
The ADA’s standards are updated annually to provide guidance to health care professionals for evaluating and treating patients with DM. They are based on the most current scientific evidence, which undergoes rigorous review by the ADA’s multidisciplinary Professional Practice Committee.
Last year, the ACC and AHA jointly issued new recommendations for CV risk management that set up a decision tree to determine when to prescribe statins that would have placed most persons with DM under this therapy. The ADA had not issued a response to the guidelines and their appropriateness for persons with DM until now.
The reorganized and revised Standards of Medical Care (formerly called the Clinical Practice Recommendations) call for all persons with DM to take statins because they are already at high risk for heart disease, said Richard W. Grant, MD, MPH, Research Scientist, Kaiser Permanente Division of Research, and Chair of the Professional Practice Committee.
Specific recommendations include the following:
• Persons with DM who are younger than 40 years or between the ages of 40 and 75 years and have no additional CV disease risk factors take a moderate-intensity statin.
• Persons of all ages who have CV disease and those aged 40 to 75 years who have additional CV risk factors take a high-intensity statin.
• A revision of the diastolic blood pressure goal for persons with DM to 90 mmHg, up from 80 mmHg.
• All persons, including those with DM, exercise regularly and break up periods of inactivity throughout the day so that no more than 90 minutes at a time are spent being sedentary.
• Persons with DM perform resistance training at least twice a week, unless otherwise instructed by their doctors for medical reasons.
“The big change here is to recommend starting either moderate- or high-intensity statins based on the patient’s risk profile rather than on LDL level,” said Dr Grant. “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.”
Regarding the revised diastolic blood pressure goal, Dr Grant added, “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.”
The new standards include the following additional changes:
• The body mass index cut point for screening overweight or obese Asian Americans lowered to 23 kg/m2 (down from 25 kg/m2).
• A section added for the management of DM in pregnancy that recommends using a 1-step test for screening for gestational DM.
• A new A1C target of less than 7.5% for children and adolescents with DM.
• A clarification that the ADA does not support the use of e-cigarettes as an alternative to smoking or as a means of facilitating smoking cessation.
• Revised immunization guidelines for older adults to reflect new CDC recommendations that persons age 65 years or older who have not received a pneumonia vaccine receive 2 separate shots, PCV13 (Prevnar), followed 12 months later by PPSV23 (Pneumovax).
The ADA recommendations are being published in a special supplement to the January issue of Diabetes Care.