Kathryn M. Harmes, MD Christine T. Cigolle, MD, MPH University of Michigan Medical School, Ann Arbor (Drs. Harmes and Cigolle) VA Ann Arbor Healthcare System Geriatric Research, Education and Clinical Center (Dr. Cigolle) jordankm@med.umich.edu
The authors reported no potential conflict of interest relevant to this article.
As new evidence emerges and guidelines are frequently revised, optimizing diabetes treatment with an eye toward HbA1c, blood pressure, and lipid goals becomes increasingly complex. Here’s help.
References
PRACTICE RECOMMENDATIONS
› Aim for a glycated hemoglobin of <7% for most nonpregnant patients with type 2 diabetes, with a less stringent target for those with severe hypoglycemia, limited life expectancy, advanced micro- or macrovascular complications, and/or extensive comorbidities. B › Attempt to treat patients with diabetes and hypertension to a target blood pressure<140/90mm Hg. B › Prescribe statin therapy regardless of baseline lipid levels for all patients who have diabetes and are between the ages of 40 and 75years. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE › Dennis D, age 63, was recently diagnosed with diabetes. his glycated hemoglobin (HbA1c) is 7.8%, his blood pressure (BP) is mildly elevated (145/95 mm Hg), and his body mass index (BMI) is 28.5, but his low-density lipoprotein (LDL) cholesterol is 100 mg/dl, his high-density lipoprotein (HDL) cholesterol is 52 mg/dL, and he has no history of cardiovascular disease (CVD). After an unsuccessful attempt to treat him with lifestyle modification, it is time to initiate diabetes therapy.
Other than an alpha-blocker for benign prostatic hyperplasia and a prostaglandin for glaucoma, Mr. D takes no other medications. You prescribe metformin 500 mg twice daily and consider what else to add to keep his diabetes well controlled. Should you prescribe an antihypertensive? And, despite the patient’s normal lipid levels, should he begin taking a statin?
The challenge faced by primary care physicians? Using the latest recommendations in a way that addresses the entire clinical picture, including the patient's age and overall health status, priorities, and preferences.Type 2 diabetes has been extensively studied in rigorous randomized controlled trials (RCTs). While studies have provided ample evidence in support of optimal treatment, differing interpretations of the findings are reflected in consensus guidelines developed by expert panels that don’t always see eye to eye on what diabetes treatment targets should be and how best to prevent micro- and macrovascular complications.
What’s more, recommendations continue to be updated as new data emerge. In February 2014, the Joint Committee on Prevention, Evaluation, and Treatment of High Blood Pressure (JCN 8) revised its target for patients with diabetes to <140/90 mm Hg (from <130/80 mm Hg).1 This is likely to lead to revisions in other leading consensus guidelines, as well.
Thus, primary care physicians managing the care of patients with diabetes face the challenge of using the latest recommendations in a manner that addresses the entire clinical picture, considering each patient’s age and overall health status, priorities, and preferences. We developed this evidence-based review and guide- line summary with that in mind.
