Important takeaways from 2018 ADA guidelines for PCPs

With primary care clinicians playing an ever-increasing role in the management of diabetes, staying on top of new developments in the American Diabetes Association’s Standards of Medical Care in Diabetes for 2018 is critical. Among the changes in this year’s guidelines are medication management, screening children, and diabetes distress.

Healio Family Medicine recently asked Arch G. Mainous III, PhD, department chair of health services research, management and policy at the University of Florida, Kim Pfotenhauer, DO, assistant professor of primary care at Touro University, California, and John J. Russell, MD, director of the family medicine residency program at Abington - Jefferson Health in Abington, Pennsylvania, to pick the most important takeaways for PCPs from the ADA’s most recent guidelines update.

Prediabetes screening may not be a priority

Arch Mainous
Arch G. Mainous

Mainous was co-author of a 2016 study in the Journal of the American Board of Family Medicine that found 18% of 1,248 clinicians surveyed do not follow national prediabetes screening guidelines and another 29% were not sure if they were.

Little has changed since then, he said.

“Everyone agrees we need to find these people with prediabetes — the U.S. Preventive Services Task Force, the ADA, Diabetes Canada — and so on,” Mainous told Healio Family Medicine. “The primary goal [of the guidelines] is not to manage diabetes but prevent diabetes. We can get people to look at those with higher risk, like Asians. It is true that there is some evidence that glucose and HbA1c aren’t consistently accurate in those with sickle cell disease. But we need to find these people first, and that’s why it’s so important that we screen for prediabetes. We need to look for elevated glucose in prediabetes to guide prevention.

Recommendations for screening children

“Children who are younger than 18 years, have a BMI greater than the 85th percentile, who have additional risk factors for diabetes such as their mother having diabetes while she was pregnant with the child, and children where there’s a family history of diabetes in a first or second relative, or the child is a member of a minority group that puts them at higher risk for diabetes, or the child has some physical signs of insulin resistance, should now be screened for diabetes,” Russell said.

Mainous pointed out this recommendation is based on expert opinion, which may limit its strength and value in practice.

“Expert opinion does not equate to very strong evidence,” he said. “Points graded A are very good, points graded B are pretty good, but those graded E are not always embraced by practicing physicians. I’m not saying we shouldn’t screen children, but we need to move cautiously because the amount of evidence is not as strong as people might like.”

HbA1c vs. plasma glucose in diagnosing diabetes

According to the guidelines, diabetes may be diagnosed based on A1c criteria or by using plasma glucose criteria, such as the 2-h plasma glucose value during a 75-g oral glucose tolerance test or fasting plasma glucose. The guidelines state though these tests do not necessarily detect diabetes in the same individuals, they are “generally .... equally appropriate for diagnostic testing.”

Mainous used patients with sickle cell disease to illustrate his concerns with this point.

“There are some indications that suggest HbA1c and plasma glucose don’t give the same numbers in these patients. This needs to be sorted out, so that it’s not just used for initial diagnosis, but ongoing management because you could be telling patients that they’re doing well based on these numbers when they’re really not.”

Medication management

Kimberly Pfotenhauer
Kim Pfotenhauer

“The biggest change in the guidelines is a clarification of medication management based on the patient’s risk for CVD. Previously, A1c was not tied to cardiovascular risk,” Pfotenhauer said. “We now have medications (empagliflozin [Jardiance, Boehringer Ingelheim], liraglutide [Victoza, Novo Nordisk]and canagliflozin [Invokana, Janssen]) that both decrease HbA1c and significantly reduce major cardiovascular events and the guidelines reflect this benefit.

“This clarification provides an improved roadmap for physicians who want to make treatment choices that are best for our patients when adding a second agent to a treatment regimen. It also gives physicians the added tool of assessing atherosclerotic cardiovascular disease risk when choosing that second medication after metformin,” she said.

John Russell
John J. Russell

While these clarifications are valuable clinically, Russell noted a significant concern that may affect clinician’s decision-making.

“When we’re managing diabetes for our patients, we’re also at the whim of insurance companies. The guidelines might say this is the right medicine, but the insurance company may not have identified it as a preferential medicine. They might have identified something in the same class as preferential medicine, and some of the newer medicines cost $300 a month. That’s a lot of money for most people,” Russell said.

Not all organizations follow each other’s guidelines

The American Heart Association and 10 other societies now define hypertension as BP 130 mm Hg systolic/80 mm Hg diastolic. That does not mean all other medical groups will follow suit, Russell told Healio Family Medicine.

“The ADA said patients should still have target BP of 140/90 mm Hg or greater,” he said.

“The hypertension guidelines will be the most challenging for primary care physicians,” Pfotenhauer said. “With multiple hypertension guidelines available, it is often hard to choose which to follow. It is important to realize that the ADA is using randomized controlled trials that included those with diabetes as a basis for their recommendations. Treatment should be individualized to each patient.”

  acial differences exist in some situations

“The ADA suggests that screening for elevated glucose should have a different, lower clinical cut point for Asians. They refer to a Lancet article, saying the WHO suggests that Asians with lower BMI are at increased risk for diabetes,” Mainous said. “That language from the Lancet article is true, but WHO does not advocate a different clinical cut point for Asians. In fact, they reaffirm the same cut points of 25 and 30 for everyone. It gets confusing because they say that everyone has the same clinical cut point but that Asians have lower public health triggers. That said, the Lancet article and the current WHO website reaffirm the same clinical cut points for everyone.”

Diabetes distress

“When patients experience a negative psychological reaction to the emotional burden and worries of diabetes, they have diabetes distress. This further characterization is included in the new guidelines” Pfotenhauer said. “Patients should be routinely monitored for diabetes distress, particularly at the onset of diabetes complications or when treatment goals are not met. If present, patients should be referred to specific diabetes education to address their source of worry and to improve self-care behaviors.”

She added that the ADA has a mental health provider feature on its website to help physicians and patients find a specialist who has had training specifically in diabetes distress.

Individualization of care

“Woven throughout the guidelines is individualization of care,” Russell said. “If someone is relatively healthy, we should push for a more robust HbA1c target, maybe something like 7% or 6.5% in someone who is healthier. But if you have an older person, someone who has a lot of medical conditions, you might settle for an A1c of 8% — a lot of this is based on risk for hypoglycemia.”

Ultimate impact

“There’s a lot of data in this year’s guidelines, but I’m not convinced it’s going to help everyone in practice. I know I’m not in practice, and some will say that puts me at a disadvantage of knowing how things are. But I know enough about screening behavior, detection and what happens in the office to know that some people are going to look at some of these guidelines and not follow them,” Mainous said. – by Janel Miller

For more information :

ADA. 2018 Standards of Medical Care in Diabetes. https://professional.diabetes.org/content-page/standards-medical-care-diabetes. Accessed Jan. 31, 2018.

Disclosures: Neither Mainous nor Pfotenhauer report any relevant financial disclosures. Healio Family Medicine was unable to determine Russell’s relevant financial disclosures prior to publication.

With primary care clinicians playing an ever-increasing role in the management of diabetes, staying on top of new developments in the American Diabetes Association’s Standards of Medical Care in Diabetes for 2018 is critical. Among the changes in this year’s guidelines are medication management, screening children, and diabetes distress.

Healio Family Medicine recently asked Arch G. Mainous III, PhD, department chair of health services research, management and policy at the University of Florida, Kim Pfotenhauer, DO, assistant professor of primary care at Touro University, California, and John J. Russell, MD, director of the family medicine residency program at Abington - Jefferson Health in Abington, Pennsylvania, to pick the most important takeaways for PCPs from the ADA’s most recent guidelines update.

Prediabetes screening may not be a priority

Arch Mainous
Arch G. Mainous

Mainous was co-author of a 2016 study in the Journal of the American Board of Family Medicine that found 18% of 1,248 clinicians surveyed do not follow national prediabetes screening guidelines and another 29% were not sure if they were.

Little has changed since then, he said.

“Everyone agrees we need to find these people with prediabetes — the U.S. Preventive Services Task Force, the ADA, Diabetes Canada — and so on,” Mainous told Healio Family Medicine. “The primary goal [of the guidelines] is not to manage diabetes but prevent diabetes. We can get people to look at those with higher risk, like Asians. It is true that there is some evidence that glucose and HbA1c aren’t consistently accurate in those with sickle cell disease. But we need to find these people first, and that’s why it’s so important that we screen for prediabetes. We need to look for elevated glucose in prediabetes to guide prevention.

Recommendations for screening children

“Children who are younger than 18 years, have a BMI greater than the 85th percentile, who have additional risk factors for diabetes such as their mother having diabetes while she was pregnant with the child, and children where there’s a family history of diabetes in a first or second relative, or the child is a member of a minority group that puts them at higher risk for diabetes, or the child has some physical signs of insulin resistance, should now be screened for diabetes,” Russell said.

Mainous pointed out this recommendation is based on expert opinion, which may limit its strength and value in practice.

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“Expert opinion does not equate to very strong evidence,” he said. “Points graded A are very good, points graded B are pretty good, but those graded E are not always embraced by practicing physicians. I’m not saying we shouldn’t screen children, but we need to move cautiously because the amount of evidence is not as strong as people might like.”

HbA1c vs. plasma glucose in diagnosing diabetes

According to the guidelines, diabetes may be diagnosed based on A1c criteria or by using plasma glucose criteria, such as the 2-h plasma glucose value during a 75-g oral glucose tolerance test or fasting plasma glucose. The guidelines state though these tests do not necessarily detect diabetes in the same individuals, they are “generally .... equally appropriate for diagnostic testing.”

Mainous used patients with sickle cell disease to illustrate his concerns with this point.

“There are some indications that suggest HbA1c and plasma glucose don’t give the same numbers in these patients. This needs to be sorted out, so that it’s not just used for initial diagnosis, but ongoing management because you could be telling patients that they’re doing well based on these numbers when they’re really not.”

Medication management

Kimberly Pfotenhauer
Kim Pfotenhauer

“The biggest change in the guidelines is a clarification of medication management based on the patient’s risk for CVD. Previously, A1c was not tied to cardiovascular risk,” Pfotenhauer said. “We now have medications (empagliflozin [Jardiance, Boehringer Ingelheim], liraglutide [Victoza, Novo Nordisk]and canagliflozin [Invokana, Janssen]) that both decrease HbA1c and significantly reduce major cardiovascular events and the guidelines reflect this benefit.

“This clarification provides an improved roadmap for physicians who want to make treatment choices that are best for our patients when adding a second agent to a treatment regimen. It also gives physicians the added tool of assessing atherosclerotic cardiovascular disease risk when choosing that second medication after metformin,” she said.

John Russell
John J. Russell

While these clarifications are valuable clinically, Russell noted a significant concern that may affect clinician’s decision-making.

“When we’re managing diabetes for our patients, we’re also at the whim of insurance companies. The guidelines might say this is the right medicine, but the insurance company may not have identified it as a preferential medicine. They might have identified something in the same class as preferential medicine, and some of the newer medicines cost $300 a month. That’s a lot of money for most people,” Russell said.

PAGE BREAK

Not all organizations follow each other’s guidelines

The American Heart Association and 10 other societies now define hypertension as BP 130 mm Hg systolic/80 mm Hg diastolic. That does not mean all other medical groups will follow suit, Russell told Healio Family Medicine.

“The ADA said patients should still have target BP of 140/90 mm Hg or greater,” he said.

“The hypertension guidelines will be the most challenging for primary care physicians,” Pfotenhauer said. “With multiple hypertension guidelines available, it is often hard to choose which to follow. It is important to realize that the ADA is using randomized controlled trials that included those with diabetes as a basis for their recommendations. Treatment should be individualized to each patient.”

  acial differences exist in some situations

“The ADA suggests that screening for elevated glucose should have a different, lower clinical cut point for Asians. They refer to a Lancet article, saying the WHO suggests that Asians with lower BMI are at increased risk for diabetes,” Mainous said. “That language from the Lancet article is true, but WHO does not advocate a different clinical cut point for Asians. In fact, they reaffirm the same cut points of 25 and 30 for everyone. It gets confusing because they say that everyone has the same clinical cut point but that Asians have lower public health triggers. That said, the Lancet article and the current WHO website reaffirm the same clinical cut points for everyone.”

Diabetes distress

“When patients experience a negative psychological reaction to the emotional burden and worries of diabetes, they have diabetes distress. This further characterization is included in the new guidelines” Pfotenhauer said. “Patients should be routinely monitored for diabetes distress, particularly at the onset of diabetes complications or when treatment goals are not met. If present, patients should be referred to specific diabetes education to address their source of worry and to improve self-care behaviors.”

She added that the ADA has a mental health provider feature on its website to help physicians and patients find a specialist who has had training specifically in diabetes distress.

Individualization of care

“Woven throughout the guidelines is individualization of care,” Russell said. “If someone is relatively healthy, we should push for a more robust HbA1c target, maybe something like 7% or 6.5% in someone who is healthier. But if you have an older person, someone who has a lot of medical conditions, you might settle for an A1c of 8% — a lot of this is based on risk for hypoglycemia.”

PAGE BREAK

Ultimate impact

“There’s a lot of data in this year’s guidelines, but I’m not convinced it’s going to help everyone in practice. I know I’m not in practice, and some will say that puts me at a disadvantage of knowing how things are. But I know enough about screening behavior, detection and what happens in the office to know that some people are going to look at some of these guidelines and not follow them,” Mainous said. – by Janel Miller

For more information :

ADA. 2018 Standards of Medical Care in Diabetes. https://professional.diabetes.org/content-page/standards-medical-care-diabetes. Accessed Jan. 31, 2018.

Disclosures: Neither Mainous nor Pfotenhauer report any relevant financial disclosures. Healio Family Medicine was unable to determine Russell’s relevant financial disclosures prior to publication.