Task force updates multispecialty guidance for diabetes, cardiorenal and metabolic diseases
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Key takeaways:
- A multispecialty guide to help non-expert clinicians manage diabetes, cardiorenal and metabolic diseases has been updated.
- The guidance covers diagnosis, lifestyle management and medical management.
PHILADELPHIA — A task force has issued an updated multispeciality guide to help clinicians manage diabetes, cardiorenal and metabolic diseases.
The uppdated guidance was unveiled at the Heart in Diabetes CME Conference and simultaneously published in Metabolism. The Diabetes, Cardiorenal and Metabolism (DCRM) Diseases Multispecialty Practice Recommendations 2.0 is an update to the original, which was published in 2022.
“These clinical recommendations were designed to target both specialists and primary care physicians with a focus on the non-experts, making the recommendations simple to follow,” Yehuda Handelsman, MD, FACP, FNLA, FASCP, MACE, co-chair of Heart in Diabetes and medical director and principal investigator of the Metabolic Institute of America in Tarzana, California, said during a presentation at the Heart in Diabetes CME Conference.
‘A comprehensive practice recommendation’
“This is an update, but we also call it a global transformation,” Handelsman said. “To the 30 people who did the original DCRM, we added about 20 people from Canada and Europe. The objective was to create a comprehensive practice recommendation to assess the scope and condition of diseases and to address [integrated] management. These cardiorenal metabolic diseases often occur in the same patient, and therefore they need multidisciplinary management plans.”
The DCRM Task Force provides guidance for clinicians who manage the spectrum of cardiorenal and metabolic diseases, which includes obesity, type 2 diabetes, chronic kidney disease, atherosclerotic cardiovascular disease, heart failure, dyslipidemia, hypertension and other comorbidities.
Highlights of the update
Handelsman highlighted several areas that were updated.
The technology and digital care section recommends validated apps/wearables, fitness trackers, arrhythmia monitors and ambulatory blood pressure monitors for the appropriate populations, continuous glucose monitors for certain patients with diabetes and automated insulin delivery systems or smart pens for patients with insulin-dependent diabetes.
The clinical tests segment outlines which tests should be performed in which populations, for what purpose and how frequently.
The obesity section includes recommendations for how to make a clinical assessment in patients with obesity, how to develop treatment goals and how to determine treatment. It also provides expected weight loss results at 1 year, noting the highest for GLP-1 receptor agonists, endoscopic procedures and bariatric procedures.
The prediabetes part outlines the definition of prediabetes and the treatment goals for the population, as well as CVD-related, weight-related and antihyperglycemic-related therapy options.
The lipid disorders section defines LDL target goals according to risk status — similar to the European Society of Cardiology cholesterol guideline — and lists expected reductions from specific LDL-lowering therapies. It also offers pointers for managing hypertriglyceridemia and lists expected reductions from specific triglyceride-lowering therapies.
The hypertension segment recommends a treatment BP goal of less than 130 mm Hg systolic/80 mm Hg diastolic, offers tips on the best ways to assess BP and lists preferred BP-lowering agents, with ACE inhibitors/angiotensin receptor blockers listed as the first option.
The inflammation section advises when and how to assess for inflammatory conditions, how to incorporate inflammatory metrics into overall risk assessments and how to manage patients with inflammatory risk in terms of lifestyle, weight reduction and medical therapy.
The section on antihyperglycemic therapy in patients with type 2 diabetes advises which medications to prescribe for prevention of cardiorenal events independent of glycemic status — SGLT2 inhibitors and GLP-1 receptor agonists are recommended for many types of patients — and how to manage glycemia to individualized goals, recommending GLP-1 receptor agonists as the top option for treatment of hyperglycemia in most patients.
The pulmonary disease segment states that some pulmonary conditions share mechanisms with cardiorenal and metabolic diseases, and these patients should also be managed from a cardiorenal-metabolic perspective. These conditions include obstructive sleep apnea, pulmonary hypertension, pulmonary fibrosis, asthma and chronic obstructive pulmonary disease.
The section on metabolism dysfunction–associated steatotic liver disease (formerly known as nonalcoholic fatty liver disease) and metabolism dysfunction–associated steatohepatitis (formerly known as nonalcoholic steatohepatitis) advises how to screen for the conditions, how to risk-stratify the patients who have them and what lifestyle measures and medications to consider, noting that patients with fibrosis stages F2, F3 or F4 should be referred to a hepatologist.
The section on atherosclerotic CVD prevention and management outlines which medications are preferred for primary and secondary prevention of myocardial infarction and coronary artery disease, stroke/transient ischemic attack and peripheral artery disease in patients with or without diabetes.
The section on heart failure recommends various prevention and treatment strategies and includes a treatment algorithm based on ejection fraction (reduced: 40%; midrange: 41% to 49%; preserved: 50%). SGLT2 inhibitors are a first-line therapy for all three groups based on ejection fraction and are recommended for HF prevention in patients with type 2 diabetes with ASCVD or at high risk for it and/or chronic kidney disease.
For chronic kidney disease, the task force offers tips on risk assessment, lifestyle therapy, goal-directed pharmacotherapy and how to screen for and diagnose the condition.
Another section includes guidance on how to manage patients who have both HF and CKD.
The document also shows the effect different medication classes have on ASCVD, heart failure, the kidney, the gastrointestinal tract, the liver, the genitourinary system, bones, the eye, weight, BP, glucose, hypoglycemia, diabetic ketoacidosis, LDL cholesterol, triglycerides and other systems.
The guide also includes sections on lifestyle therapy, cognitive function, patient education, vaccinations, hypoglycemia and antiplatelet/anticoagulation therapy.
“The recommendations look at both prevention of the next event and long-term control of individual risk factors,” Handelsman said during the presentation.
Reference:
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Handelsman Y, et al. DCRM 2.0 – Multi-specialty practice recommendations for DM, cardiorenal & metabolic diseases. Presented at: Heart in Diabetes CME Conference; June 7-9, 2024; Philadelphia.
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