Physicians should regularly measure blood pressure, waist circumference, fasting lipid profile, and blood glucose level in patients ages 40 to 75 years to identify those at metabolic risk for atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes, according to a new clinical practice guideline from the Endocrine Society.
Patients who are found to be at increased metabolic risk should have 10-year global risk assessment for ASCVD or coronary heart disease to determine therapy targets for reducing apolipoprotein B-containing lipoproteins, the guideline stated. Other recommendations include the following:
- Testing at least annually for overt type 2 diabetes is suggested for patients previously diagnosed with prediabetes.
- Lifestyle modification is recommended as first-line therapy in patients at metabolic risk.
- Global assessment of 10-year risk for coronary heart disease or ASCVD is recommended in patients at metabolic risk to help guide use of medical or pharmacological therapy.
- In patients whose blood pressure is above 130/80 mm Hg and who have a 10-year cardiovascular risk of 10% or lower, lifestyle management is suggested to lower blood pressure to below 130/80 mm Hg and to reduce ASCVD risk.
- In patients with metabolic risk but without a history of ASCVD whose 10-year cardiovascular risk is above 10% and whose blood pressure is above 130/80 mm Hg, blood pressure-lowering medication is suggested in addition to lifestyle modification for primary prevention of ASCVD only when lifestyle modification alone has failed.
- Lifestyle modification is recommended before drug therapy to reduce plasma glucose levels in patients with prediabetes. In such patients who have physical activity limitations or are not responding to lifestyle modification, metformin is recommended as a first pharmacologic approach.
The guideline updates 2008 guidance on this topic and was cosponsored by the American Diabetes Association and the European Society of Endocrinology. It was published July 31 by the Journal of Clinical Endocrinology and Metabolism.
The American Diabetes Association also recently updated its Standards of Medical Care in Diabetes, a “living” document in which updates are incorporated on an ongoing basis due to new medication approvals or publications.
The changes made on July 31 include the following:
- Section 6 on glycemic targets and Section 7 on diabetes technology have been revised based on publication of the recent consensus report “Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range.” A new table has been added showing standardized continuous glucose monitoring metrics for clinical care, and a new figure has been added with an example ambulatory glucose profile.
- Section 9 on pharmacologic approaches to glycemic treatment and Section 10 on cardiovascular disease risk management have been updated to include dulaglutide as a glucagon-like peptide-1 receptor agonist that has shown macrovascular benefits in type 2 diabetes, based on results from the REWIND trial.
- Section 13 on children and adolescents was updated to include information on liraglutide.