February 21, 2020
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BLOG: New diabetes guidelines

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As an optometrist interested in the evolution of my profession to include more primary health care, I have my Healio email subscriptions and alerts set to receive the Primary Care News Wire. Although I often just skim these articles, I sometimes find an item of interest that has implications for optometry. Such was the case last month when I read, “New diabetes guideline reflects change in glucose therapy considerations.” Published online on Jan. 22, 2020, this article will affect my doctoring of patients with diabetes as well as those at risk for developing the disease.

The new guidelines recommend that providers look beyond patient’s glucose control, as measured by HbA1c, and add medicines that improve cardiovascular and renal outcomes for patients at risk for these complications. The particular medicines that received an “A” grade, indicating the highest level of evidence behind the recommendation, were SGLT2 inhibitors or GLP-1 receptor agonist.

Patients with diabetes who are at risk for cardiovascular or chronic kidney disease have some level of microvascular complication. Diabetic retinopathy is among the most common of these complications. Microvascular disease is also a strong predictor of macrovascular disease that often leads to heart attack or stroke.

The new diabetic guidelines also recommend the chronic care model for the care and management of patients with diabetes. This “grade A” recommendation states that this model “emphasizes person-centered team care, integrated long-term treatment approaches to diabetes and comorbidities, and ongoing collaborative communication and goal setting between all team members.”

Optometrists are clearly an important member of a care team that manages patients with diabetes. We are often the first provider to identify the microvascular changes of retinopathy. With our new OCT angiography, we can note retinal ischemia that may be an early precursor to retinopathy. Although more research is required with this technology, this earliest sign of microvascular disease may give our diabetes team members a head start in aggressively managing these patients.

These guidelines should change the way we report our findings to the team member that is leading the medicine treatment. Rather than providing a passive answer to “Retinopathy? Yes/No,” we need to step up with something like, “Your patient has background diabetic retinopathy, a microvascular complication of their disease. According to the current guidelines of the American Diabetes Association, he/she will be seeing you shortly to consider the addition of an SGLT2 inhibitor or GLP-1 receptor agonist to lower the risk of a macrovascular event, independent of their glucose management.”

Diabetes is an aggressive blinding disease. According to the CDC, it is the leading cause of blindness among U.S. working-aged adults age 20 years to 74 years and affects an estimated 4.1 million Americans. Optometrists need to be equally aggressive in our important role as essential member of the diabetes care team.

References:

Avogaro A, Fadini G. Diabetes Mellitus. 2019;doi.org/10.14341/DM10372.

Rosenson RS, et al. Atherosclerosis. 2011;doi:10.1016/j.atherosclerosis.2011.06.029.