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Important Updates to Diabetes Treatment Recommendations

Diane Fennell

January 4, 2013

Every year, the American Diabetes Association (ADA) reviews the current scientific literature and releases an updated version of its Clinical Practice Recommendations. This year, there have been several important revisions to the guidelines, including the adoption of more individualized recommendations for the frequency of blood glucose monitoring and the switch to a less stringent target for systolic blood pressure (the top number) .

Blood glucose monitoring
The previous recommendation for people with Type 1 or Type 2 taking multiple doses of insulin or using insulin pump therapy had been to check blood glucose levels “three or more times daily.” Some insurance companies had interpreted this to mean that allotting three blood glucose test strips per day was sufficient for everyone with diabetes.

The new guidelines for glucose monitoring have been revised to highlight the need for people taking multiple doses of insulin or using an insulin pump to check their blood glucose frequently. In these people, monitoring is now recommended at least before meals and snacks, occasionally after eating, before exercising, at bedtime, when low blood glucose is suspected, and before critical tasks such as driving.

“We’re trying to say it’s very situation-dependent…both by the patient and the patient’s context,” Richard Grant, MD, MPH, incoming chair of the ADA Professional Practice Committee, noted in an interview with Medscape Medical News.

For people with Type 2 diabetes who are taking basal insulin only or noninsulin treatments, monitoring blood glucose is still recommended as a potentially helpful tool when coupled with education about how to use the results. Monitoring “is really not any use if it’s not being acted on…. If no one looks at the results, there’s no sense testing,” noted Dr. Grant.

Blood pressure control
Goals for systolic blood pressure have been updated to reflect new evidence suggesting that there may be little benefit — but an increase in risk — in controlling blood pressure tighter than 130/80 mmHg. For most people with diabetes and high blood pressure, the new target is now below 140/80 mmHg. The looser target may allow people to take fewer blood pressure medicines, saving money and reducing the potential for side effects, according to Dr. Robert Ratner, chief scientific and medical officer for the ADA.

Representatives of the ADA note that controlling blood pressure is still vitally important for reducing the risk of cardiovascular and kidney disease, and state that the loosening of the systolic target should not be taken to mean that blood pressure control is unimportant. “We really tried to communicate that it’s crucially important that everyone with type 2 diabetes have a [systolic] blood pressure down to 140. It’s a very important threshold. Changing the recommendation is not meant to imply that excellent blood pressure control is not as much of a priority as it was,” according to Dr. Grant.

The revised recommendations note that lower systolic targets may be appropriate for certain people (such as younger individuals) if they can be achieved without “undue treatment burden.”

For more information on these and other changes to the Clinical Practice Recommendations — 2013, read the article “New Diabetes Guidelines Ease Systolic Blood Pressure Target” or see the updated guidelines in the journal Diabetes Care. (A summary of all the revision can be found here.)



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