The American Diabetes Association (ADA)'s 2018 update to its Standards of Medical Care in Diabetes makes several notable new recommendations, including a target blood pressure below 140/90 mm Hg for most patients with hypertension, integration of continuous glucose monitoring into care, and routine screening for type 2 diabetes in high-risk youth.
The standards of care were published online Dec. 8 and are available as a supplement to the January 2018 Diabetes Care.
Important changes and updates for patients with diabetes and cardiovascular disease include the following:
- A new recommendation for adults with type 2 diabetes and heart disease that after lifestyle management and metformin, a medication proven to improve heart health should be added.
- Most adults with diabetes and hypertension should have a target blood pressure below 140/90 mm Hg, and risk-based individualization to lower targets, such as 130/80 mm Hg, may be appropriate for some patients, as summarized and outlined in a new table of four major, randomized controlled trials.
- A new algorithm illustrates the recommended antihypertensive treatment approach for adults with diabetes and confirmed hypertension, defined as blood pressure of 140/90 mm Hg or greater. The algorithm suggests selecting specific classes in certain clinical situations.
- All hypertensive patients with diabetes should monitor their blood pressure at home to help identify potential discrepancies between office and home blood pressure and to improve their medication-taking behavior.
Other recommendations include testing for prediabetes and type 2 diabetes in patients younger than 18 years of age who are overweight or obese (BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height) and have one or more additional risk factors for diabetes, such as family history. The ADA also adjusted its recommendation for continuous glucose monitoring to indicate that it helps improve glycemic control for adults with type 1 diabetes starting at age 18 years rather than ages 25 years and older, as in previous recommendations.
The ADA added language and recommendations to help ensure appropriate use of the HbA1c test, which can give skewed results in people with conditions that alter the lifespan of red blood cells or in people with genetic traits that alter the molecules in their red blood cells. HbA1c results can also be affected by age, ethnicity, and pregnancy. Clinicians must be aware of these limitations, use the correct type of HbA1c test, and consider using fasting plasma glucose levels or an oral glucose tolerance test if HbA1c and blood glucose levels disagree, the ADA emphasized.
The standards also include new recommendations highlighting the importance of individualizing pharmacologic therapy for older adults with diabetes and a guideline recommending consideration of daily low-dose aspirin starting at the end of the first trimester in all pregnant women with preexisting type 1 or type 2 diabetes to reduce the risk of pre-eclampsia. Also included is a table summarizing drug-specific and patient factors that may impact diabetes treatment, among other resources.