Guidelines

2018 Cholesterol Guidelines: Key Points

2018 Cholesterol Guidelines: Key Points

Cardiovascular disease is the leading cause of death in the United States. Cholesterol anomaly, or dyslipidemia, is a major contributor to atherosclerosis morbidity and mortality. Multi-society new cholesterol guidelines were recently published. They were contributed and endorsed by ACC, AHA, ADA, and NLA, among other national associations. You can find below the key recommendations published in the journal of Circulation, November 2018.

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Review of 2018 ADA guidelines: dyslipidemia in the context of diabetes

Review of 2018 ADA guidelines: dyslipidemia in the context of diabetes

ADA recommendations are released each January. Below is a succinct ACP review of guidelines in screening, treatment goals, lifestyle intervention, and drug approach to dyslipidemia in the setting of diabetes mellitus. LDL-cholesterol is still a main target. Charts depict indications and doses of statins, the mainstay therapy to diabetic lipid disorders.

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Review of 2018 ADA Guidelines: hypertension in the context of diabetes

Review of 2018 ADA Guidelines: hypertension in the context of diabetes

ADA standards are released each January. Here is a succinct ACP review of guidelines in screening, diagnosis, treatment goals, lifestyle intervention, and drug approach to hypertension in the setting of diabetes mellitus. The chart depicts nicely the flow process of how to initiate and intensify the pharmacological therapy.

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Mineral bone disorder in the setting of kidney disease.

Mineral bone disorder in the setting of kidney disease.

This is a nice summary of the latest guidelines on diagnosis and management of mineral bone disease induced by chronic kidney disease. Kidney anomaly can be classified functionally via estimated GFR or structurally via proteinuria.

Guidelines emphasize the need for bone density scan, bone biopsy, parathyroid hormone, calcium and phosphorus measures in the right context. Vitamin D analogs and phosphate binders are also discussed. See below for detailed recommendations.

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Outlook on new blood pressure guidelines

Outlook on new blood pressure guidelines

Unlike previous guidelines, the 2017 guideline emphasizes individualized cardiovascular risk assessment and aggressive management of blood pressure at levels of 140/90 mm Hg or higher in patients with a 10-year risk of cardiovascular events of >10%.

Absolute risk is an important determinant of the need for treatment. It’s reasonable to consider more aggressive treatment goals in the highest-risk patients, as SPRINT showed. But while a blood-pressure treatment target of <130/80 mmHg makes sense for high-risk patients, for everyone else it seems more reasonable to continue defining hypertension as a blood pressure of 140/90 mm Hg or higher.

NEJM

An overview of new hypertension guidelines

An overview of new hypertension guidelines

New definitions:

  • Normal BP: <120/80 mmHg
  • Elevated BP “Pre HTN”: 120-130/<80
  • Stage 1 HTN: 130-140/80-90
  • Stage 2 HTN: >140/90

 

New targets for treatment:

  • If ASCVD 10-year-risk is <10%, then target BP <140/90
  • If ASCVD 10-year-risk is ≥10%, then target BP <130/80
    • Established CVD
    • DIABETES
    • CKD
    • AGE>65  and “healthy”

 

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Joint statement on metabolic surgery for diabetes

Joint statement on metabolic surgery for diabetes

Below are listed recommendations on when to consider metabolic surgery for type 2 diabetes. Decisions making would depend on BMI severity and glycemic control.

The joint statement advises surgery for patients with class III obesity, and in those with class II but have high A1c. Consideration should be given to adults with controlled class II or uncontrolled class I obesity. 

Standards are listed below with a slightly modified wording for easier and succinct reading:

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2017 ADA guidelines: dyslipidemia and diabetes

2017 ADA guidelines: dyslipidemia and diabetes

Below you can find ADA recommendations on screening, cardiovascular risks, and treatment of dyslipidemia in the context of diabetes. As always improve lifestyle choices first. If ASCVD likelihood is still high then add medications. Statins are first-line, either of moderate or high intensity. Statin selection would depend on age, CVD status, and contributing factors.

Statin plus PCSK9 inhibitor or statin plus zetia could be used in adults with residual ASCVD risk. Statin plus fenofibrate is no longer advised unless special circumstances are present; severe hypertriglyceridemia or in men with profound metabolic syndrome. Statin plus niacin is also not recommended due to stroke concerns.

For more details, ADA standards are listed below with a slightly modified wording for easier and succinct reading:

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2017 NLA guidelines: PCSK9 inhibition and cholesterol

2017 NLA guidelines: PCSK9 inhibition and cholesterol

PCSK9 inhibitors are a relatively new class of medications. They lower atherogenic cholesterol and cardiovascular disease significantly. Although effective, cost limits their use to persons at high risk for CVD in spite of being optimally manged with statins (mainly crestor or lipitor).

National Lipid Association recently published the updated guidelines on the use of PCSK9 inhibitors in patients with residual CVD risk, very high LDL-cholesterol and those with intolerance to statin therapy. Recommendations are listed below with slightly modified wording for easier and succinct reading:

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2017 ADA guidelines: diabetes during pregnancy

2017 ADA guidelines: diabetes during pregnancy

Below you can find ADA standards on proper A1c targets, blood pressure range, retinopathy monitoring and medications used in preexisting and gestational diabetes. The preferred medications during pregnancy are insulin, metformin and glyburide.

Recommendations are listed below with slightly modified wording for easier and succinct reading:

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2017 ADA guidelines: metabolic surgery for type 2 diabetes

2017 ADA guidelines: metabolic surgery for type 2 diabetes

Obesity is a pro-inflammatory state contributing to insulin resistance and type 2 diabetes. Starting with jejuno-ileal bypass in 1954 by Kremer and intestinal bypass in 1967 by Mason, various techniques of the malabsorption surgery have been developed, researched and applied over the decades. They have shown good results in reducing hyperglycemia, the number of diabetic medications and excessive body weight.

Guidance on the importance and indications of metabolic surgery for type 2 diabetes were published in Diabetes Care, January 2017. Recommendations are listed below with a slightly modified wording for easier and succinct reading:

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2017 ADA position statement: hypertension in diabetes

2017 ADA position statement: hypertension in diabetes

High blood pressure is common in patients with diabetes. Both hypertension and diabetes are independent risk factors for poor cardiovascular outcomes. Obviously the concomitant presence of both HTN and DM in an individual magnifies the chance for CVD events. It is important to screen, diagnose and treat high blood pressure appropriately in someone with diabetes, particularly type 2. 

ADA published a position statement on the subject in Diabetes Care, September 2017. The article is comprehensive in regard to proper diagnosis, clinic vs. home BP measurements, target blood pressure values, life style modifications, pharmacological agent initiation and titration, and barriers to therapy.  Recommendations are listed below with slightly modified wording for easier and succinct reading:

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2017 AHA guidelines on syncope and orthostatic hypotension

2017 AHA guidelines on syncope and orthostatic hypotension

AHA recently announced guidelines on the topic of syncope. Orthostatic hypotension is a cause in about 9% of afflicted individuals. A good portion of these patients have autonomic peripheral neuropathy from advanced diabetes mellitus. You can find below more details on syncope guidelines. Statements were published in Circulation March 2017

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2017 ADA Guidelines: Glucose Targets

2017 ADA Guidelines: Glucose Targets

Last ADA standards were published in January 2017. You could find below the recommended glucose aims for patients with type 1 and type 2 diabetes. Guidelines offer flexibility on A1c targets from <6.5-8.0% depending on person's age, life expectancy, polypharmacy, disease duration, hypoglycemia frequency and comorbidities.

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2016 guidelines: Lipodystrophy

2016 guidelines: Lipodystrophy

Lipodystrophy syndromes (LDS) are defined by severe deficiency in body fat in the absence of food restriction or starvation. They are very rare and could be classified as complete vs. partial or inherited vs. acquired.

Uncontrolled LDS could affect multiple organs including heart, liver, kidney and pancreas. Diabetes, hypertriglyceridemia, and fatty liver disease are common. Diet and exercise are the cornerstone therapies. In special cases Metreleptin could also be used.

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Endocrine Society Guidelines: Functional Hypothalamic Amenorrhea

Endocrine Society Guidelines: Functional Hypothalamic Amenorrhea

Functional hypothalamic amenorrhea stems from decreased action and release of GnRH, LH and FSH; in turn leading to lower estrogen production and inability to ovulate.

Long term consequences are low bone mass and infertility. Functional hypothalamic amenorrhea is a diagnosis of exclusion, and thus no specific cause can be found. Main culprits are excessive exercise, weight loss and stress.

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ADA update: Drugs for Diabetes Type 2

ADA update: Drugs for Diabetes Type 2

Updated ADA guidelines were recently published in Annals of Internal Medicine April 2017. First line therapy is still metformin, while the second and third line agent would depend on an open discussion between the patient and physician; regarding side effects, cost, convenience, hypoglycemia risk, route of delivery, as well as secondary benefits like weight loss, and improved CVD and blood pressure profile. This clinical modality is often called a "shared decision making" and "patient-centered" approach.

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Osteoporosis Guidelines, an ACP Update 2017

Osteoporosis Guidelines, an ACP Update 2017

The recent ACP update on osteoporosis guidelines is shown below. Interestingly, American College of Physicians recommends against the use of DEXA/bone scans for treatment surveillance; although evidence quality is low for such an advice. Recommendations are listed with slight modified wording for easier and succinct reading.

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