The American Association of Clinical Endocrinology (AACE) on April 14 released new clinical practice guidelines for developing comprehensive care plans for patients with type 1 and type 2 diabetes mellitus, developed by a panel of 23 of the leading diabetes experts in the U.S.
Debunking one-size-fits-all care plans, the guidelines emphasize the importance of achieving a treatment plan that avoids hypoglycemia, now considered to be a continual and pressing concern for many patients with diabetes.
The implications of the new guidelines for practicing physicians, as well as new data on low blood sugar in patients with diabetes, are being discussed at the AACE 20th Annual Meeting and Clinical Congress, now in session in San Diego.
The new AACE guidelines are also published in supplement 2 of the March/April issue of the association’s official medical journal, Endocrine Practice.
“This guidance is for individual clinicians, for insurers, for government policy and for patients so these guidelines reverberate among the 150 million people who are involved in the world of diabetes,” Daniel Einhorn, MD, 2010-2011 president of AACE, said during a press conference.
“The team of writers understood the need to be truly comprehensive in every aspect. Every single thing about the person with diabetes matters to the outcomes,” Einhorn said. “This is the first year that the guidelines are so comprehensive, and they will continue to grow and be expanded from here.”
The guidelines emphasize a personalized approach to controlling diabetes and achieving blood glucose targets with care plans that take into account patients’ risk factors for complications, comorbid conditions, and psychological, social, and economic status. Although the guidelines recommend a blood glucose target of an HbA1c level of 6.5%, if it can be achieved safely, a treatment plan should take into account a patient’s risk for the development of severe hypoglycemia.
“This comprehensive approach is based on the evidence that although glycemic control parameters (HbA1c, postprandial glucose excursions, fasting plasma glucose, glycemic variability) have an impact on cardiovascular disease risk, mortality, and quality of life, other factors also affect clinical outcomes in persons with diabetes,” the committee wrote.
One updated recommendation addresses the diagnostic criteria for gestational diabetes. Previously, pregnant women were administered a 50-g, 1-hr oral glucose tolerance test. Now, the guidelines recommend physicians use a 75-g, 2-hour OGTT to diagnose gestational diabetes.
The guidelines also now endorse a target HbA1c level lower than 6.5%, as most nonpregnant healthy adults can safely reach this goal. Physicians should, however, consider each patient’s unique situation. Aggressive treatment, for instance, would be more appropriate in a young, healthy patient than in an elderly patient or a patient with a terminal illness, Handelsman noted.
The new guidelines also provide information on the appropriate use of new technologies such as insulin pumps and continuous glucose monitoring, as well as managing conditions that may not be immediately obvious to treating physicians, such as sleep and breathing disturbances and depression.
In a statement, Yehuda Handelsman, MD, AACE president-elect and co-chair of the AACE Diabetes Guidelines Writing Committee, said that it was crucial for physicians to address not just hyperglycemia in patients with diabetes but also associated cardiovascular risk factors. “These state-of-the-art guidelines provide the most up-to-date evidence-based answers to real-life (clinical) questions,” Dr. Handelsman said.
In the guidelines, AACE recommends comprehensive diabetes lifestyle management education at the time of diagnosis, as well as throughout the course of diabetes. The importance of medical nutrition therapy, physical activity, avoidance of tobacco products, and adequate quantity and quality of sleep should be discussed with patients who have prediabetes, as well as type 1 and type 2 diabetes, according to the new guidelines.
Carefully monitoring patients with prediabetes by regularly assessing their fasting plasma glucose levels or administering OGTTs is recommended, according to Handelsman. In addition, treating obesity is essential.
“We believe that addressing, treating and managing obesity is key to preventing and controlling diabetes and comorbidities,” Handelsman said. Therefore, the guidelines discuss lifestyle modifications, nutritional management, physical activity as well as the potential benefits of surgical options, such as gastric bypass, in appropriate patient populations.
Handelsman stressed the importance of not simply aiming to control diabetes. Lipid profiles, blood pressure and cardiovascular disease risk should be taken into account, and physicians should consider all of these aspects when generating a comprehensive diabetes care plan.
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