By Brenda Mooney, Special to AHC Media
BOSTON – As complex as they seem, the new evidence-based clinical practice recommendations from the American Diabetes Association (ADA) essentially boil down to one underlying recommendation: treat patients as individuals.
Or, so say two experts from the Joslin Diabetes Center, Beth Israel Deaconess Medical Center, and Harvard Medical School, who reviewed the yearly recommendations.
In a commentary published recently in Annals of Internal Medicine, Giulio R. Romeo, MD, and Martin J. Abrahamson, MD, emphasize three important new topic areas that affect how primary care physicians treat patients:
· A change in body mass index (BMI) cut points for prediabetes and type 2 diabetes screening for Asian patients, who tend to have more visceral fat, even at lower BMIs;
· A new way to look at blood glucose targets, basing them on the individual patients’ age, comorbid conditions, life expectancy, as well as their motivation and preferences;
· An emphasis on treating diabetes patients’ cardiovascular risk with statins, rather than just focusing on number goals, such as systolic and diastolic blood pressure.
The commentary notes that metformin remains the gold standard for initial treatment of diabetes.
“With the exception of sodium-glucose cotransportor 2 inhibitors, which are a welcome addition to the increasing pharmacologic armamentarium, not much has changed in the combination therapy algorithm,” Romeo and Abrahamson point out. “Metformin continues to stand out as the preferred initial treatment choice.”
The decisions become a bit more complex when metformin alone it not sufficient to help patients reach their hemoglobin A1c goals. While a major study is looking at the efficacy of four different classes of medication – a sulfonylurea, a dipeptidyl peptidase 4 inhibitor, a glucagon-like peptide-1 receptor agonist and insulin glargine – the results of the GRADE study will not be available until 2020.
“In the absence of robust comparative effectiveness data,” the commentators write, “the Standards advocate tailoring combination drug choices based on such factors as risk for hypoglycemia, effects on weight, side effects and cost.”