ADA standards call for further tailoring of diabetes care to each patient

Doctors should further individualize care in the treatment of diabetes, the American Diabetes Association (ADA) stated in its 2014 Standards of Medical Care.

Specifically, doctors should explore a variety of options when prescribing medication to treat neuropathy, consider 2 types of screening for gestational diabetes, and encourage people with diabetes to work with a nutritionist or dietitian on a diet that best fits their needs. An executive summary and the full set of standards (which are revised annually) were released online Dec. 19, 2013, and appeared in a supplement to the January 2014 Diabetes Care.

The new standards encourage doctors to try a variety of medications when treating people with diabetes for neuropathy and to carefully monitor how the patient responds to the drugs to ensure maximum relief, because no drug affects all patients the same way. The ADA committee noted that there is limited clinical evidence about the most effective treatments given the wide range of available medications: 2 drugs approved for relief of distal symmetric polyneuropathy in the U.S.—pregabalin and duloxetine—and other drugs such as venlafaxine, amitriptyline, gabapentin, valproate and opioids. “Head-to-head treatment comparisons and studies that include quality-of-life outcomes are rare, so treatment decisions must often follow a trial-and-error approach,” the authors concluded.

For treating gestational diabetes, an expert panel convened by the National Institutes of Health recommended a 2-step process, in which a nonfasting test is given first, followed by a glucose tolerance test only for a subset of women whose glucose levels reach a certain threshold. Previously, the standards recommended a 1-step screening method endorsed by the International Association of the Diabetes and Pregnancy Study Groups (IADPGS). Both panels reviewed the same data but reached different conclusions.

Regarding choice of an appropriate medical nutrition therapy, no particular diet—low-carb, high-carb or low-fat—was recommended over another, although evidence supported greater use of dietitians and nutritionists in helping patients lower their hemoglobin A1c (HbA1c) levels.

The new standards also:

• maintain support of the previous recommendation that people with diabetes limit their intake of sodium to 2,300 mg/d, the same amount recommended for people without diabetes. People who have both diabetes and high blood pressure should try to lower their intake further on an individualized basis,
• clarify that the HbA1c test is one of 3 appropriate methods for diagnosing diabetes, and
• discourage the sole use of sliding-scale insulin in the inpatient hospital setting.