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The American Diabetes Association has adopted the 2013 ACC/AHA cholesterol guidelines in its 2015 Standards of Care -- but not entirely.
The American Diabetes Association (ADA) recently released its 2015 update of the Standards of Medical Care in Diabetes.1 As noted in a statement by the chair of the ADA's Professional Practice Committee Richard W. Grant, MD, MPH, "The big change here is to recommend starting either moderate- or high-intensity statins based on the patient's risk profile, rather than on low-density lipoprotein level. We changed pretty substantially our recommendations from the prior year. We basically more or less adopted what ACC/AHA [American College of Cardiology, and American Heart Association, respectively] said, with caveats.” Dr Grant refers here to the 2013 ACC/AHA cholesterol guidelines2that did away with specific targets for low- and high-density lipoprotein levels, citing a lack of evidence from randomized, controlled clinical trials to support treatment to a specific target.
The new ADA guidelines place patients into 3 age groups:
* >40 years old:
- No statins for those with no CVD risk factors other than diabetes
- Moderate- or high-intensity statins for those with additional CVD risk factors (high blood pressure, obesity or overweight, smoking, baseline LDL cholesterol 100 or higher)
- High-intensity statins for those with CVD - including ACS or prior CV events
* 40-75 years:
- Moderate-intensity statins for those with no additional risk factors
- HIgh-intensity statins for those with either CVD risk factors or CVD
* > 75 years:
- Moderate-intensity statins for patients without additional risk factors
- Moderate or high-intensity statins for those with CVD risk factors
- High-intensity statins for those with CVD
Another revised recommendation: Screen overweight or obese Asian-Americans for prediabetes and type 2 diabetes at a BMI of 23 kg/m2, lowered from 25 kg/m2, as Asian-Americans are at increased risk of developing diabetes at lower BMI levels compared with other population groups.
This recommendation formalizes what many physicians have already been doing - lowering the threshold for screening these individuals, as some Asians tend to have more visceral fat. Such fat accumulates around organs such as the liver. This may explain why the prevalence of diabetes in individuals of Asian descent has not had the same link with overweight or obesity as it has with Caucasians.
The ACC/AHA guidelines themselves are still the subject of debate and controversy. Patients with type 2 diabetes have a 2-4-fold greater risk of cardiovascular disease, so most should benefit from a statin. The ADA differed from the ACC and AHA in recommending monitoring LDL as warranted to assess adherence. I think that a good number of both patients and physicians alike would prefer having a goal to aim for.
Note that ADA did not endorse the ACC/AHA risk calculator in the ADA’s updated guidelines. I don’t think that using this calculator for patients with diabetes would be as useful, given that for one, the risk of CVD in those with diabetes is already markedly elevated.
Do you still treat-to-target in your patients with type 2 diabetes? Please leave us a coment, below.
Dr Chao is associate clinical professor of Medicine at VA San Diego and UCSD School of Medicine.
1. Silvio E. Inzucchi SE, Bergenstal RM, Buse JB, 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 38:1 140-149; doi:10.2337/dc14-2441 http://care.diabetesjournals.org/content/38/1/140.full
2. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63(25_PA):2889-2934. doi: 10.1016/j.jacc.2013.11.002