482 - DM Standards of Care 2023 (Part 2) – Meds, Best Investment 2023

From the Guidelines and the American Diabetes Association (ADA)

1) Diabetes Standards of Care 2023 (Part 2) – Medications

The Standards are developed by the ADA’s multidisciplinary Professional Practice Committee, which comprises physicians, diabetes educators, and other expert diabetes healthcare professionals. The Standards include the most current evidence-based recommendations for diagnosing and treating adults and children with all forms of diabetes.  The ADA’s grading system uses A, B, C, or E to show the evidence level that supports each recommendation.  This is the 2^nd part of a two-part summary.

Pharmacotherapy Recommendations – Prediabetes:

·         Metformin for prevention of T2D should be considered in those with prediabetes, especially for those with BMI ≥35, those aged <60 years, women with prior gestational DM, and/or those with rising A1C despite lifestyle intervention. A

·         Periodic measurement of vitamin B12 levels should be considered in metformin- treated patients, especially in those with anemia or peripheral neuropathy. B

Pharmacotherapy Recommendations- Type 2 Diabetes (T2D):

·         Pharmacologic therapy should be guided by person-centered treatment factors, including comorbidities and treatment goals. A

·         In adults withT2D and established/high risk of ASCVD, heart failure, and/or CKD, the treatment regimen should include agents that reduce cardiorenal risk. A

·         The glucose-lowering treatment regimen should consider approaches that support weight management goals.  A

·         Metformin should be continued upon initiation of insulin therapy (unless contraindicated or not tolerated) for ongoing glycemic and metabolic benefits. A

·         Early combination therapy can be considered in some individuals at treatment initiation to extend the time to treatment failure. A

·         The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10%) or blood glucose levels (≥300 mg/dL) are very high. E

·         Among individuals with T2D who have established ASCVD or indicators of high CV risk, established kidney disease, or heart failure, a sodium–glucose cotransporter 2 inhibitor (SGLT2) and/or glucagon-like peptide 1 receptor agonist (GLP1) with demonstrated cardiovascular disease benefit is recommended as part of the glucose-lowering regimen and comprehensive cardiovascular risk reduction, independent of A1C. A

·         In adults with T2D, a GLP1 is preferred to insulin when possible. A

·         If insulin is used, combination therapy with a GLP1 is recommended for greater efficacy, durability of treatment effect, and weight and hypoglycemia benefit. A

·         Recommendation for treatment intensification for individuals not meeting treatment goals should not be delayed. A

·         Clinicians should be aware of the potential for overbasalization with insulin therapy. Clinical signals that may prompt evaluation of overbasalization include basal dose more than ∼0.5 units/kg/day, high bedtime–morning or postpreprandial glucose differential, hypoglycemia (aware or unaware), and high glycemic variability. Indication of overbasalization should prompt reevaluation to further individualize therapy. E

Hypertension/Blood Pressure Control in T2D – Recommendations:

·         People with diabetes and hypertension qualify for antihypertensive drug therapy when the blood pressure is persistently elevated ≥130/80 mmHg. The on-treatment target blood pressure goal is <130/80 mmHg, if it can be safely attained. B

·         Individuals with confirmed office-based blood pressure ≥160/100 should have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce CV events in people with diabetes. A

·         Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in people with diabetes. A ACE inhibitors or angiotensin receptor blockers are recommended first-line therapy for hypertension in people with diabetes and coronary artery disease. A

·         Those with HTN who are not meeting BP targets on three classes of antihypertensive medications (including a diuretic) should be considered for mineralocorticoid receptor antagonist (MRA) therapy. A

Statin Treatment in T2D – Recommendations:

Primary Prevention:

·         For those aged 40–75 years without ASCVD, use moderate-intensity statin therapy in addition to lifestyle therapy. A

·         For those aged 20–39 years with additional ASCVD risk factors, it may be reasonable to initiate statin therapy in addition to lifestyle therapy. C

·         For those aged 40–75 at higher CV risk, including those with one or more ASCVD risk factors, use high-intensity statin therapy to reduce LDL cholesterol by ≥50% of baseline and to target an LDL cholesterol goal of <70 mg/dL. B

·         For those aged 40–75 years at higher CV risk, especially those with multiple ASCVD risk factors and an LDL cholesterol ≥70 mg/dL, it may be reasonable to add ezetimibe or a PCSK9 inhibitor to maximum tolerated statin therapy. C

·         For those aged >75 years already on statin therapy, it is reasonable to continue statin treatment. B

·         For those aged >75 years, it may be reasonable to initiate moderate-intensity statin therapy after discussion of potential benefits and risks. C

Secondary Prevention

·         For those with ASCVD, treatment with high-intensity statin therapy is recommended to target an LDL cholesterol reduction of ≥50% from baseline and an LDL cholesterol goal of <55 mg/dL. Addition of ezetimibe or a PCSK9 inhibitor with proven benefit in this population is recommended if this goal is not achieved on maximum tolerated statin therapy. B

·         For those who do not tolerate the intended intensity, the maximum tolerated statin dose should be used. E

Other lipoprotein targets:

·         With fasting triglyceride levels ≥500, evaluate for secondary causes and consider medical therapy to reduce the risk of pancreatitis. C

·         With ASCVD or other CV risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL), consider addition of icosapent ethyl.  A

Other Combination Therapy:

·         Statin plus fibrate combination therapy has not been shown to improve ASCVD outcomes and is generally not recommended. A

·         Statin plus niacin therapy has not been shown to provide additional CV benefit above statin therapy alone and may increase stroke risk, so is not recommended. A

Antiplatelet Agents and T2D – Recommendations:

·         Use aspirin (75–162 mg/day) for secondary prevention in those with diabetes and a history of ASCVD. A  If aspirin allergy, use clopidogrel (75 mg/day).  B

·         Aspirin therapy (75–162 mg/day) may be considered for primary prevention in those with diabetes who are at increased CV risk, after a comprehensive discussion with the patient on the benefits versus the comparable increased risk of bleeding. A

With T2D and established ASCVD and/or Heart Failure:

·         With established ASCVD, multiple ASCVD risk factors, or CKD, a SGLT2 and/or GLP1 with demonstrated CVD  benefit is recommended.  A

·         With established heart failure with reduced ejection fraction (HFrEF), a SGLT2 with proven benefit recommended to reduce risk of worsening HF and CV death. A

·         With stable heart failure, metformin may be continued for glucose lowering if e-GFR remains >30 but should be avoided in unstable or hospitalized patients with HF. B

Patients with T2D and CKD/DKD (diabetic kidney disease) –  Recommendations:

·         Use a SGLT2 inhibitor with an e-GFR ≥25 and/or urinary albumin ≥300 to reduce CKD progression and CV events. A

·         With CKD and albuminuria treated with maximum tolerated doses of ACE-I or ARB, addition of finerenone is recommended to improve CV outcomes and reduce the risk of CKD progression. A

·         An ACE-I or ARB is not recommended for the primary prevention of CKD if normal BP, normal urinary albumin-to-creatinine ratio (<30 mg/g creatinine), and normal e-GFR rate. A

Mark’s Comments:

It is apparent we will need to become experts on the use of SGLT2 and GLP1 medications.  See the references below for some very helpful algorithms/summaries for prescribing/intensifying non-insulin medications, prescribing/intensifying insulin, and comparing all the medications with their indications, strengths, and limitations.  These would be worth saving and/or printing for future reference.    

References:

·         ElSayed N, et al.  American Diabetes Association Standards of Care in Diabetes – 2023.  Diabetes Care January 2023;46(Supl 1).  Link

·         American Diabetes Association Standards of Care in Diabetes—2023 Abridged for Primary Care Providers.  Clin Diabetes 2023;41(1):4–31.  Link

·         Use of Glucose Lowering Medications for the Management of T2D Figure 9.2: Link

·         Medications for Lowering Glucose – Summary of Characteristics Table 9.3: Link

·         Use of Injectable Therapy Figure 9.4:  Link

From PeerRxMed ( www.PeerRxMed.org )

2)  How to Invest Wisely in 2023

“If you were to make one investment in your well-being … the best one you could make long-term is to take care of your relationships.”  Robert Waldinger, MD

What makes for a meaningful, satisfying, fulfilling life – a “good life”?  Perhaps a more relevant question is, what would be the ingredients of such a life for you?  While the details of our answers would vary, there are likely some qualities that would be consistently important for all. 

It's not surprising that this is a question that has been asked through the ages, and a new book co-authored by Psychiatrist Robert Waldinger entitled “The Good Life:  Lessons from the World’s Longest Scientific Study of Happiness” provides contemporary insights into one very essential ingredient.  The book highlights the ongoing findings from the Harvard Study of Adult Development, a study that has been ongoing now for more than 80 years following two cohorts of men (and now their children) intended to identify the psychosocial predictors of healthy aging. 

Though the study has some design limitations, the findings are likely both inclusive and universal.  They conclude that strong relationships are not only central for our happiness but also for our health, and it is never too late in life to form such life-giving, health-promoting relationships.  Indeed, in the study these powerful connections were an independent variable influencing physical health, longevity, and happiness.

Seems simple, right?  Well, there’s bad news and good news.  In looking at the data from the past 4 years of the Medscape physician burnout report, a very disturbing trend emerges.  Consistently, when faced with burnout, depression, anxiety, and even suicidal thoughts, almost as many of our colleagues report that they isolate themselves to cope as those who report they reach out to family and/or close friends for support – both in the mid 40% range.  Which means statistically that a substantial number of physicians are choosing isolation as a coping strategy when dealing with the hardships of life.  As Dr. Waldinger would point out, this is no recipe for living a good life, but rather a recipe for ill health and regrets.

Here’s the good news.  Remember, Dr. Waldinger and colleagues also found it’s never too late for us to change our ways.  So this week, consider spending some time reflecting on your present relationships both within and beyond work.  How would you approach them differently if you recognized they are a lifeline to your health, longevity and happiness?  With more evidence that it’s unhealthy to care alone, connecting becomes not just a preference, but an essential practice, perhaps best summarized as “do the things you love with the people you love.”  Sounds like a good investment for 2023, and beyond!

PS:  If you’d like to learn more about Dr. Waldinger and the study, here is a TED Talk he gave in 2015.

Third Pointer - make first two lines H3

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org