Guidelines

2019 Endocrine Society Guidelines: diabetes approach in older adults

2019 Endocrine Society Guidelines: diabetes approach in older adults


The Endocrine Society has just released its guidelines on how to manage the elderly with diabetes. Guidelines are overall similar to those of ADA and AACE but with greater emphasis in avoidance of adverse events such; as hypoglycemia, malnutrition, excessive weight loss, frailty, falls, and drug side effects. See below for more details.

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2019 AACE Guidelines: Diabetes Type 2 principles

2019 AACE Guidelines: Diabetes Type 2 principles

AACE standards were published in January 2019. They are a continual update of the original 2013 guidelines. Unlike ADA which recommends a general A1c target ≤7.0%, AACE promotes a tighter A1c goal of ≤6.5% for most patients with type 2 diabetes.

Recommendations also address lifestyle interventions, obesity, prediabetes, hypoglycemia, hypertension and dyslipidemia. Oral and injectable medications including insulin are discussed. A key priority is the avoidance of hypoglycemia — do no harm!

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2018 Cholesterol Guidelines: Diabetes Mellitus

2018 Cholesterol Guidelines: Diabetes Mellitus

For diabetes patients, practical recommendations would be:

  • Start moderate-intensity statin therapy if:

    • Young, age 20-39, with microvascular complications or long-standing DM.

    • Older, age 40-75, without major risk factors.

  • Start high-intensity statin ± ezetimibe if the following factors are present with the goal of reducing LDLc ≥50%:

    • Multiple risk factors

    • ASCVD 10YR ≥20%

  • For adults >75, clinician-patient discussion is needed if statin were to be started or continued.

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2018 Cholesterol Guidelines: Severe Hypercholesterolemia

2018 Cholesterol Guidelines: Severe Hypercholesterolemia

An approximate solidifying recommendation:

  • For patients with severe hypercholesterolemia defined by baseline LDLc ≥190 mg/dL; target LDLc is <100 mg/dL. To achieve this target, patients could receive the following medications in the following order: max statin ± ezetimibe ± BAS ± PCSK9 inhibitor.

    • If baseline TGs >300 mg/dL, do not use BAS

    • If baseline LDLc is very high, >220 mg/dL, then target LDLc could be <130 mg/dL

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2018 Cholesterol Guidelines: Secondary ASCVD Prevention

2018 Cholesterol Guidelines: Secondary ASCVD Prevention

Although current guidelines are an honest attempt in reflecting complex medical evidence from clinical trials, they may not be very practical or user-friendly to general practitioners.

A simplified but reasonable approach to lipid management for secondary ASCVD prevention would be:

  • Patients with established clinical ASCVD should achieve LDL-cholesterol <70 mg/dL by using statins ± ezetimibe ± PCSK9 inhibitors.

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2018 Testosterone Therapy Guidelines

2018 Testosterone Therapy Guidelines

This is an update of previous guidelines published in 2010.

We recommend T therapy for men with symptomatic T deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy and involving the patient in decision making. 

We suggest that when clinicians institute T therapy, they aim at achieving T concentrations in the mid-normal range during treatment with any of the approved formulations.

Clinicians should monitor men receiving T therapy using a standardized plan that includes: evaluating symptoms, adverse effects, and compliance; measuring serum T and hematocrit concentrations; and evaluating prostate cancer risk during the first year after initiating T therapy.

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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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