New, more aggressive targets for blood pressure and lipids are among the changes to the annual American Diabetes Association (ADA) Standards of Care in Diabetes — 2023, a document long considered the gold standard for care of the more than 100m Americans living with diabetes and prediabetes.
The standards now advise a blood pressure target for people with diabetes of less than 130/80 mmHg, and low-density lipoprotein (LDL) cholesterol targets of below 70 mg/dL or no greater than 55 mg/dL, depending on the person’s cardiovascular risk.
“In the 2023 version, you’ll see information that really speaks to how we can more aggressively treat diabetes and reduce complications in various ways,” ADA Chief Scientific and Medical Officer Dr Robert Gabbay told Medscape Medical News.
Other changes include a new emphasis on weight loss as a goal of therapy for type 2 diabetes; guidance for screening and assessing peripheral arterial disease in an effort to prevent amputations; use of finerenone in people with diabetes and chronic kidney disease; use of approved point-of-care A1c tests; and guidance on screening for food insecurity, along with an elevated role for community health workers.
“Managing type 2 diabetes is not just about glucose,” Gabbay said, noting that the ADA Standards have increasingly focused on cardiorenal risk as well as weight management. “We need to think about all those things, not just one.”
As it has for the past six years, the section on cardiovascular disease and risk management is also endorsed by the American College of Cardiology.
The new definition of hypertension in people with diabetes is ≥ 130 mmHg systolic or ≥ 80 mmHg diastolic blood pressure, repeated on two measurements at different times. Among individuals with established cardiovascular disease, hypertension can be diagnosed with one measurement of ≥ 180/110 mmHg.
The goal of treatment is now less than 130/80 mmHg if it can be reached safely.
In 2012, easing of the systolic target to 140 mmHg by the ADA caused some controversy.
But Gabbay said: “The evidence wasn’t there a decade ago. We stuck to the evidence at that time, although there was a belief that lower was better. Over the past 10 years, studies have made it quite clear that there is benefit to a lower target.”
New lipid targets have also been set. For people with diabetes aged 40-75 at increased cardiovascular risk, including those with one or more atherosclerotic risk factors, high-intensity statin therapy is recommended to reduce LDL cholesterol by 50% or more from baseline and to a target of less than 70 mg/dL, in contrast to the previous target of 100 mg/dL.
To achieve that goal, the document advises to consider adding ezetimibe or a PCSK9 inhibitor to maximally tolerated statin therapy.
For people with diabetes aged 40-75 with established cardiovascular disease, treatment with high-intensity statin therapy is recommended with the target of a 50% or greater reduction from baseline and an LDL cholesterol level of 55 mg/dL or lower, in contrast to the previous 70 mg/dL.
Here, a stronger recommendation is made for ezetimibe or a PCSK9 inhibitor added to maximal statins.
And for people with diabetes over 75, those already on statins should continue taking them. For those who aren’t, it may be reasonable to initiate moderate-intensity statin therapy after discussion of the benefits and risks.
Other changes for 2023 include fresh emphasis on supporting weight loss of up to 15% with the new twincretin tirzepatide (Mounjaro) – approved in the US last May for type 2 diabetes – added as a glucose-lowering drug with weight loss potential.
A novel section was added with guidance for peripheral arterial disease screening. And a new recommendation advises point-of-care A1c testing for diabetes screening and diagnosis, using only tests approved by the US Food and Drug Administration.
Also introduced for 2023 is guidance to use community health workers to support the management of diabetes and cardiovascular risk factors, particularly in underserved areas and health systems.
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