James J. Chamberlain, MD; Eric L. Johnson, MD; Sandra Leal, PharmD, MPH, CDE; Andrew S. Rhinehart, MD, CDE; Jay H. Shubrook, DO; Lacie Peterson, MS, RD, CDE
Acknowledgment: The authors thank Sarah Bradley; Matt Petersen; and Erika Gebel Berg, PhD, for their invaluable assistance in the reviewing and editing of this manuscript. The full Standards of Medical Care in Diabetes—2018 was developed by the ADA's Professional Practice Committee: Rita R. Kalyani, MD, MHS (Chair); Christopher Cannon, MD; Andrea L. Cherrington, MD, MPH; Donald R. Coustan, MD; Ian de Boer, MD, MS; Hope Feldman, CRNP, FNP-BC; Judith Fradkin, MD; David Maahs, MD, PhD; Melinda Maryniuk, Med, RD, CDE; Medha N. Munshi, MD; Joshua J. Neumiller, PharmD, CDE; and Guillermo E. Umpierrez. ADA staff support includes Erika Gebel Berg, PhD; Tamara Darsow, PhD; Matt Petersen; Sacha Uelmen, RDN, CDE; and William T. Cefalu, MD.
Disclosures: Dr. Chamberlain reports other support from Novo Nordisk, Sanofi Aventis, Janssen, and Merck outside the submitted work. Dr. Johnson reports personal fees from Novo Nordisk, Medtronic, and Sanofi outside the submitted work. Dr. Rhinehart reports employment with and stock ownership in Glytec. Dr. Shubrook reports personal fees from Novo Nordisk, Lilly Diabetes, and Intarcia outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-0222.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Requests for Single Reprints: James J. Chamberlain, MD, St. Mark's Hospital and St. Mark's Diabetes Center, Internal Medicine at St. Mark's, 1160 East 3900 South, Suite 1200, Salt Lake City, UT 84124; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Chamberlain: Medical Director for Diabetes Services, St. Mark's Hospital and St. Mark's Diabetes Center, Internal Medicine at St. Mark's, 1160 East 3900 South, Suite 1200, Salt Lake City, UT 84124.
Dr. Johnson: Assistant Medical Director, Altru Diabetes Center, Associate Professor, Family and Community Medicine, UND School of Medicine and Health Sciences, 1301 North Columbia Road, Grand Forks, ND 58201.
Dr. Leal: Vice President for Innovation, SinfoníaRx, 1 East Toole, Tucson, AZ 85701.
Dr. Rhinehart: Chief Medical Officer, Glytec, LLC, 231 Seahorse Court, Marco Island, FL 34145.
Dr. Shubrook: Professor, Director of Diabetes Services, Touro University College of Osteopathic Medicine, 1310 Club Drive, Admin and Faculty 1, Room 117, Vallejo, CA 94592.
Ms. Peterson: Clinical Assistant Professor, Utah State University, 920 West Levoy Drive, Taylorsville, UT 84123.
Author Contributions: Conception and design: J.J. Chamberlain, S. Leal, A.S. Rhinehart, J.H. Shubrook.
Analysis and interpretation of the data: J.J. Chamberlain, S. Leal, A.S. Rhinehart.
Drafting of the article: J.J. Chamberlain, E.L. Johnson, S. Leal, A.S. Rhinehart, J.H. Shubrook, L. Peterson.
Critical revision of the article for important intellectual content: J.J. Chamberlain, E.L. Johnson, S. Leal, A.S. Rhinehart.
Final approval of the article: J.J. Chamberlain, E.L. Johnson, S. Leal, A.S. Rhinehart, J.H. Shubrook, L. Peterson.
Administrative, technical, or logistic support: J.J. Chamberlain.
Collection and assembly of data: J.J. Chamberlain, E.L. Johnson, S. Leal, J.H. Shubrook, L. Peterson.
The American Diabetes Association (ADA) annually updates its Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes.
For the 2018 standards, the ADA Professional Practice Committee searched MEDLINE through November 2017 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C depending on the quality of evidence or E for expert consensus or clinical experience. The standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions.
This synopsis focuses on guidance relating to cardiovascular disease and risk management in nonpregnant adults with diabetes. Recommendations address diagnosis and treatment of cardiovascular risk factors (hypertension and dyslipidemia), aspirin use, screening for and treatment of coronary heart disease, and lifestyle interventions.
Recommendations for the treatment of confirmed hypertension in people with diabetes.
©2018 by the American Diabetes Association. Diabetes Care. 2018;41(Suppl 1):S86-S104. Reprinted with permission of the American Diabetes Association.
This figure can also be found in the American Diabetes Association position statement “Diabetes and Hypertension.” ACEi = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BP = blood pressure; CCB = calcium-channel blocker; UACR = urinary albumin–creatinine ratio.
* An ACEi or ARB is suggested to treat hypertension for patients with UACR 30–299 mg/g creatinine and strongly recommended for patients with UACR ≥300 mg/g creatinine.
† Dihydropyridine calcium-channel blocker.
‡ Thiazide-like diuretic; long-acting agents shown to reduce cardiovascular events, such as chlorthalidone and indapamide, are preferred.
Drug-specific and patient factors to consider when selecting antihyperglycemic treatment in adults with type 2 diabetes.
ASCVD = atherosclerotic cardiovascular disease; CHF = congestive heart failure; CV = cardiovascular; CVD = cardiovascular disease; DKA = diabetic ketoacidosis; DKD = diabetic kidney disease; DPP-4 = dipeptidyl peptidase-4; eGFR = estimated glomerular filtration rate; FDA = U.S. Food and Drug Administration; GLP-1 = glucagon-like peptide-1; LDL = low-density lipoprotein; NASH = nonalcoholic steatohepatitis; NPH = neutral protamine Hagedorn; RA = receptor agonist; SGLT-2 = sodium–glucose cotransporter-2; SQ = subcutaneous; T2DM = type 2 diabetes mellitus. ©2018 by the American Diabetes Association. Diabetes Care. 2018;41(Suppl 1):S73-S85. Reprinted with permission from the American Diabetes Association.
* For description of efficacy, see Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2015;38:140-9. [PMID: 25538310] doi:10.2337/dc14-2441.
† FDA-approved for CVD benefit.
Table. CVOTs Completed After Issuance of the FDA 2008 Guidance*
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Bangladesh Institute of Family Medicine and Research
April 4, 2018
Once started, statin should be continued lifelong
This is an excellent review of 2018 ADA guideline. It is the recommendation of latest ACC/AHA (ATP-IV) guideline and ADA as well that all patients with diabetes aged 40-70yrs should come under statin in LDL-C ≥70mg/dl if not contraindicated. I like to add here that once statin is started, it should be continued lifelong.Statin discontinuation may lead to higher cardiovascular event risks .My practice shows that after 3 months of discontinuation of statin for any reason, in maximum cases, LDL-C jumps much higher compared to baseline e.g. before initiation of statin.Other non-statins; cholesterol absorption inhibitor or PCSK9 inhibitors may be used if statin is not tolerated but in the real world statin intolerant population is not so more that is traditionally though. So once statin is adjusted, according to patient’s condition, lipid profile, ASCVD risks, concomitant medications and co-morbid conditions, statin members and/or doses may be changed but statin should not be stopped.References:1. Gomez Sandoval YH Braganza MV Daskalopoulou SSStatin discontinuation in high-risk patients: a systematic review of the evidence. Curr Pharm Des 2011;17:3669-89
CHU de Charleroi
April 16, 2018
Did you say primary ?
The 2018 recommendations of the American Diabetes Association for cardiovascular disease and risk management proposes the use of aspirin in a situation described as the primary prevention of cardiovascular disease (level of recommendation C). This is a confusion between primary and secondary prevention as defined by the World Health Organization (WHO)  : this is a frequent misclassification of prevention types observed in medical literature. According to the WHO definitions, the use of chemoprohylactic agents in the presence of risk factors is virtually in fact a secondary prevention-type intervention, and the use of a clinically apparent cardiovascular disease a tertiary prevention.These recommendations are based on relatively ancient studies, and the cited meta-analysis concludes that the net benefit of this prevention is still doubtful. More recent publications have either not detected any benefit or the authors have declared themselves unable to conclude, due to the possibility of selective reporting bia s[2,3]. Biochemical models also have suggested that these patients might have reduced sensitivity to the effect of cyclooxygenase-1 inhibitor, due to persistent thromboxane-induced activation. Introducing a limitation to indications to diabetic patients over 50 years with at least one additional cardiovascular risk factor is unlikely to modify the result, since a large majority of type 2 diabetic patients respond to this definition. Furthermore, if the considered risk factor is a reversible one such as smoking, the use of a prescription drug as an alternative to smoking cessation is likely to be counterproductive. In conclusion, we propose to limit the use of aspirin to diabetic patients in tertiary prevention, ie with clinically apparent cardiovascular complications. 1. Gordon RS Jr. Gordon R et al. An operational classification of disease prevention. Public Health Rep. 1983 mar-apr;98(2):107-109. 2. LA, Wilhelm SM, Garwood CL et al. Aspirin for primary prevention of cardiovascular disease in patients with diabetes: A meta-analysis. Diabetes Res Clin Pract. 2016;20:31-39.3. S. K. Kunutsor S. Seidu K. Khuntiet al. Aspirin for primary prevention of cardiovascular and all‐cause mortality events in diabetes: updated meta‐analysis of randomized controlled trials. Diabet. Med. 2017 ;34:316–327 4. Santilli F, Pignatelli P, Violi Fet al. Aspirin for primary prevention in diabetes mellitus: from the calculation of cardiovascular risk and risk/benefit profile to personalised treatment. Thromb Haemost. 2015;114:876-882.5. Colosia AD, Palencia R, Khan S et al.. Prevalence of hypertension and obesity in patients with type 2 diabetes mellitus in observational studies: a systematic literature review. Diabetes Metab Syndr Obes. 2013 ;6:327-238
Long Island College Hospital
May 25, 2018
TO THE EDITOR
TO THE EDITOR: Chamberlain and colleagues (May 1 issue) in their Review of the American Diabetes Association Standards of Medical Care in Diabetes, maintained that the increased risk of diabetes (mellitus) associated with statins (HMG-CoA reductase inhibitors) use is small; therefore, the cardiovascular event rate reduction with statin use offsets the risk of diabetes, even in patients at high risk of developing diabetes with the use of statins.1 In general, I agree with the Chamberlain and colleagues opinion that statin therapy is usually well tolerated and currently statins are the primary medications for preventing and treating cardiovascular disease related to hyperlipidemia and even in some adults with average cholesterol level.2 But evidence from several population-based statin trials has suggested that statin therapy could increases the risk of diabetes by 9%-12%.3 This is a much higher risk of drug induced diabetes secondary to statin use than what was the course of 5 years).1 And is especially significant because it seems that based on this low risk of statins drug induced diabetes they recommended use of statins in pre-diabetic paints, which is in conflict with the recent studies.The data from morbidity and mortality outcomes relating to diabetes mellitus complications shows benefits of diabetic treatments can be offset by increasing numbers of people diagnosed with diabetes, because although hyperglycemia can be controlled, other diabetes complications frequently cannot be treated which results in an increase in mortality and morbidity and disease burden on individual patients and a financial burden on patients and health care industry alike.4,5,6 Thus diabetes mellitus complications are a major reason to prevent diabetes and this possible adverse effect of statin use cannot be overlooked. Fortunately, statin-induced diabetes may not be permanent. In some cases it can be reversed if use of the causative medication is discontinued, the does is decreased, or the patient is switch to a different statin, such pravastatin which is the least diabetogenic statin and if intolerance is associated with all statins, even at the lowest dose, non-statin drugs and certain healthy diet plans, exercise or alternative therapies may be advisable.3,4,7References1-Chamberlain JJ, Johnson EL, Leal S, Rhinehart AS, Shubrook JH, Peterson L. Cardiovascular Disease and Risk Management: Review of the American Diabetes Association Standards of Medical Care in Diabetes 2018. Ann Intern Med. 2018;168:640–650. 2-Chou R, Dana T, Blazina I, Daeges M, Bougatsos C, Grusing S, Jeanne TL. Statin Use for the Prevention of Cardiovascular Disease in Adults: A Systematic Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Available from http://www.ncbi.nlm.nih.gov/books/NBK396415/3-Laakso M, Kuusisto J. Diabetes Secondary to Treatment with Statins. Curr Diab. Rep. 2017 ;17:10. 4- Jain V, Patel RK, Kapadia Z, Galiveeti S, Banerji M, Hope L. Drugs and hyperglycemia: A practical guide. Maturitas. 2017 ;104:80-83. 5-Toth PP, Patti AM, Giglio RV, Nikolic D, Castellino G, Rizzo M, Banach M. Management of Statin Intolerance in 2018: Still More Questions Than Answers. Am J Cardiovasc Drugs. 2018 ;18:157-1736-Twigg SM, Wong J.The imperative to prevent diabetes complications: a broadening spectrum and an increasing burden despite improved outcomes. Med J Aust. 2015 ;202 :300-4.7-Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F. Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med. 2013 ;368(14):1279-.
University of South Alabama Medical center, Mobile, AL
June 1, 2018
A few clinically relevant inputs.
I peruse with interest the guidelines. However, despite the tenacity, clarity, and thoroughness of the authors, I offer a few comments to understand the guidelines in perspective and better implementation.1. As per the recent AHA/ACC 2017 guidelines, the BP must be targeted <130/80 mmHg, if tolerated by the patient(not 140/90 as mentioned in the fist sentence on BP control). Though not emphasized adequately, masked hypertension is not uncommon in diabetics, and particularly after 50-year of age, it must be ruled out preferably with 24-hour ambulatory BP monitoring (rather than home BP measurements, as they are proven to be less reliable than ambulatory BP monitoring). The isolated nocturnal hypertension and lack of nocturnal dip are another valuable features worth exploring, as Hypertension is much bigger killer than glycemia.2. The use of new agents to control glycemia with added cardiovascular benefits: empagliflozin is mentioned first by name, while other drugs like empagliflozin is equally good. Now its proven to be a class effect.3. A completely ignored issue: Subclinical magnesium deficiency is very common in diabetics, particularly with concomitant hypertension (as the soil is largely depleted of magnesium), serum magnesium is a poor marker of magnesium deficiency, the use of magnesium in patients with concomitant hypertension must be encouraged. A meta-analysis showed magnesium supplementation in poorly controlled hypertensives despite drugs, reduces BP markedly, particularly with magnesium >370 mg/day.(1)Reference:1. Rosanoff A, Plesset MR. Oral magnesium decrease high blood pressure (SBP>155 mmHg) in hypertensive subjects on antihypertensive medications: a targeted meta-analysis. Magnes Res 2013;26:93-9
Chamberlain JJ, Johnson EL, Leal S, Rhinehart AS, Shubrook JH, Peterson L. Cardiovascular Disease and Risk Management: Review of the American Diabetes Association Standards of Medical Care in Diabetes 2018. Ann Intern Med. ;168:640–650. doi: 10.7326/M18-0222
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Published: Ann Intern Med. 2018;168(9):640-650.
Published at www.annals.org on 3 April 2018
Cardiology, Coronary Risk Factors, Diabetes, Dyslipidemia, Endocrine and Metabolism.
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