Diabetes Pro Quarterly - Winter 2018 - 2

Standards of Medical Care continued from page 1
include a medication validated to improve heart health. A new table outlines
the data from recent CVOTs, and a new
figure details recommendations based
on these CVOTs (section 8, p. S76;
section 9, p. S97, Table 9.4; and section
8, p. S76, Fig. 8.1; respectively).
* Four major randomized controlled
trials that compared intensive versus standard hypertension treatment
strategies are summarized and outlined
in a new table, providing support for
the ADA's recommendations that most
adults with diabetes and hypertension
should have a target blood pressure of
<140/90 mmHg and that risk-based
individualization to lower targets, such
as 130/80 mmHg, may be appropriate
for some patients. The studies highlighted include the Action to Control
Cardiovascular Risk in Diabetes
blood pressure (ACCORD BP) trial;
the Action in Diabetes and Vascular
Disease: Preterax and Diamicron MR
Controlled Evaluation-Blood Pressure
(ADVANCE BP) trial; the Hypertension
Optimal Treatment (HOT) trial; and
the Systolic Blood Pressure Intervention
Trial (SPRINT) (section 9, p. S88,
Table 9.1).
* A new algorithm illustrating the recommended antihypertensive treatment
approach for adults with diabetes and
confirmed hypertension (blood pressure ≥40/90 mmHg) has been added
(Section 9, p. S90, Fig. 9.1).
* Also new this year is a recommendation that all hypertensive patients with
diabetes monitor their blood pressure at
home to help identify potential discrepancies between office and home blood
pressure and to improve medicationtaking behavior (section 9, p. S87).

Screening Youth for Type 2 Diabetes
* Updated recommendations emphasize
that testing for prediabetes and type
2 diabetes should be considered in
children and adolescents <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 1) maternal history of

diabetes or gestational diabetes mellitus
during the child's gestation; 2) family
history of type 2 diabetes in first- or
second-degree relative; 3) high-risk
race/ethnicity (Native American,
African American, Latino, Asian
American, Pacific Islander); and/or 4)
signs of insulin resistance or conditions
associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or
small-for-gestational-age birth weight)
(section 2, p. S19, Table 2.5).

Health Technology and Diabetes
Management
* The ADA recommends including
technology-based methods, along
with individual and group visits, for
the delivery of effective diabetes selfmanagement education and support
(section 4, p. S38).
* As continuous glucose monitoring
(CGM) technology continues to evolve,
the ADA adjusted its recommendations
to align with recent data showing that
CGM helps improve glycemic control
for adults with type 1 diabetes starting
at age 18 years; previous recommendations were for those 25 years of age and
older (section 6, p. S55).
* Federal regulatory changes prompted
the ADA to include language describing CGM devices that do not require
confirmation from finger sticks to make
treatment decisions and a new type of
"flash" CGM that does not have any
alarms and only provides "on demand"
glucose readings (section 6, p. S56).

A1C Test Considerations
* Additional language and recommendations have been added to help ensure
appropriate use of the A1C test to
diagnose diabetes and for monitoring glycemic control in people with
diabetes. The ability of the A1C test to
provide a measure of average blood glucose over time is based on the lifespan
of red blood cells in the body. The test
can give skewed results in people with
certain conditions that alter the lifespan
of red blood cells, as well as in people
with certain genetic traits that alter the
molecules in their red blood cells. Age,

ethnicity, and pregnancy can also
affect A1C results. The ADA emphasizes that health care providers need
to be aware of these limitations, to use
the correct type of A1C test, and to consider alternate diagnostic tests (fasting
plasma glucose test or oral glucose
tolerance test) if there is disagreement
between A1C and blood glucose levels
(section 2, p. S14).

Diabetes Management in Specific
Groups
* Three new recommendations were added to highlight the importance of individualizing pharmacologic therapy for
older adults with diabetes to reduce the
risk of hypoglycemia, avoid overtreatment, and simplify complex regimens
while maintaining personalized blood
glucose targets (section 11, p. S122).
* A new guideline recommends that
all pregnant women with preexisting
type 1 or type 2 diabetes consider daily
low-dose aspirin starting at the end of
the first trimester to reduce the risk of
preeclampsia (section 13, p. S140).

Patient-Centered Care and
Acknowledging Cost-of-Care
Impact
* A new table summarizes drugspecific and patient factors that may
affect diabetes treatment. The chart
includes the most relevant considerations, such as risk of hypoglycemia,
weight effects, kidney effects, and costs
for all preferred diabetes medications,
in one location to guide the choice of
antihyperglycemic agents as part of
patient-provider shared decisionmaking (section 8, p. S77, Table 8.1).
* The guidelines recommend increased
awareness of and screening for social
determinants of health, such as financial
ability to afford medication, access to
healthy foods and food insecurity, and
community support (section 1, p. S9).

Additional Important Updates
* The immunization needs for people with diabetes were clarified and
updated to more closely align with
recommendations from the Centers
for Disease Control and Prevention
(section 3, p. S29-S31).
continued on page 4

Table of Contents for the Digital Edition of Diabetes Pro Quarterly - Winter 2018