Preventing complications
There are fewer recommendations for BP control and lipid management than before, reflecting an attempt to emphasize those treatments found to be most effective, Dr. Kirkman says.
In the case of hypertension, the Recommendations now specify that drug treatment begin with an ACE inhibitor or angiotensin receptor blocker (ARB), with a diuretic added if necessary to achieve target pressures.
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For dyslipidemia, the addition of statin therapy to lifestyle modification is recommended for patients with cardiovascular disease (CVD) or for those who are older than 40 or who have one or more CVD risk factors. Statins should be considered for others whose LDL remains >100 mg/dL.
Target LDL levels are set at <100 for those without overt CVD, with a lower goal (<70) an option for those with CVD, using high-dose statins if necessary. An alternative goal, added this year, is LDL reduction of 40% from baseline.
The recommendations for nephropathy have also been shortened, to focus on the use of ACE inhibitors and ARBs for micro- and macroalbuminuria.
Older adults
The 2008 Recommendations put new emphasis on older adults and are the first to include specific guidelines for them. “They stress the need to individualize treatment,” says Dr. Kirkman.
Distinctions are based on functionality and life expectancy. For those patients who are functionally and cognitively intact and who have “significant” life expectancy, the Recommendations set the same goals as for younger adults. The glycemic goals can be relaxed for other patients as long as symptomatic or acute hyperglycemia is avoided.
In screening for complications, those likely to lead to functional impairment, such as visual and lower-extremity involvement, deserve particular attention, the authors say.
The ADA’s Clinical Practice Recommendations 2008 were published in Diabetes Care (2008;31 [suppl 1]).
