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Clinicians discuss concern, new information in latest ADA guidelines
Two doctors told Healio Family Medicine that there are significant changes in the American Diabetes Association’s recently updated Standards of Medical Care in Diabetes that will affect how primary care physicians and family practitioners manage patients, but one noted that some of the new information may do more harm than good.
Arch G. Mainous, III, PhD, chair, department of the health services research, management and policy, University of Florida, Gainesville, noted that the guidelines include a new pre-diabetes and undiagnosed type 2 diabetes screening tool.
“Rather than going off of a general [age] like the U.S. Preventative Services Task Force and what they’ve done in the past … what the [American Diabetes Association (ADA)] has done to screen for pre-diabetes and risk for future diabetes is an informal assessment of risk factors,” he said.
The screening tool asks a person’s age, weight, sex, activity level, family diabetic history and personal BP and diabetic history. Mainous pointed out its limitations, referring to a recent article in JAMA Internal Medicine that he said indicated about 80% of people aged over 60 that used this screening tool would be likely considered pre-diabetic.
He said there’s a potential drawback to a broad, all-encompassing conclusion.
“The problem we have is that not everyone is being detected right now. Is this a better way to get people to be detected? I think that’s unlikely simply because you already have some pushback that you’re going to overmedicalize what some people are going to say is a non-condition,” Mainous said. “I don’t think that’s really true, I don’t think that pre-diabetes is a non-condition. I think it’s a very important thing that we need to identify if we’re going to have any sort of diabetes prevention.”
Mainous noted diabetes occurs in about 14% of the U.S. population, while pre-diabetes occurs in 35-38%.
John Russell, MD, program director, family medicine residency program, Abington-Jefferson Health in Abington, Pennsylvania, said the guidelines offer the option of adding a GLP-1 receptor agonist instead of a short-acting insulin in patients who have very high sugar and have already received basal long-acting insulin. He noted the guidelines also provide information on the impact on cardiovascular risks associated with some of the newer diabetes medications, including the recommendation that the SGLT-2 inhibitor empagliflozin and the GLP-1 receptor agonist liraglutide be considered in high-risk patients.
“That is pretty novel … to single out these two particular medicines and if we are going to use medicines in their classes clinicians should at least consider those two particular medications,” Russell told Healio Family Medicine.
He discussed other areas that will impact primary care, including preventive steps.
“There’s a lot about lifestyle management. For example, they recommend that if someone has a seated job that they get up every 30 minutes and walk around the office is something I saw to be new. Nutrition therapy was also a big part of so many sections,” he said. “There was also a big section on hypoglycemia, and they now define clinically significant hypoglycemia as a blood sugar under 54 and how an alert glucose is one under 70.”
Russell He also noted the expanded importance the guidelines placed on surgical options for patients who could not be managed medically.
“There’s also a lot more written about obesity, really the role of bariatric surgery, which is now being referred to as metabolic surgery for people who have diabetes that can’t be controlled. Now, a BMI above 30 kg/m2 is the threshold for surgery candidacy, whereas previous BMI thresholds were up in that 35 to 40 30 kg/m2 range.”
Russell also said the tables in the ADA’s annual publication have information on medications, including cost, that doctors will find helpful.
“The guidelines really get into much more detail and look at all the medicines we’re looking at for diabetes, including insulin, what the average wholesale price would be for all of these,” he said. “We’re still going to start with metformin as our first-line medication. But one of the things that’s new in these guidelines is that we’ve seen some associations between B-12 deficiency and long-term metformin use.”
Other new features in the guidelines include screening adults and youths with diabetes for diabetes distress, depression, anxiety, and eating disorders; and a list of situations that warrant referral to a mental health specialist. – by Janel Miller
Disclosure: Mainous reported no relevant financial disclosures, Russell reports doing a weekly podcast for ADA.
Further reading: http://care.diabetesjournals.org/content/40/Supplement_1/S4