Varsha Babu MD Clinical Assistant Professor

Department of Endocrinology,UCSF Fresno Medical Center

Upon completion of this activity, participants will:◦ Be able to identify important recent changes in

recommendations in care for diabetic patients

◦ Know ADA classification of diabetes and criteria for diagnosis of diabetes

◦ Know risk management of cardiovascular diseases in diabetic patients

◦ Use of aspirin controversy in primary prevention of ASCVD.

http://care.diabetesjournals.org/content/42/Supplement_1

FPG greater than or equal to 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.

OR 2-h PG greater than equal to 200 mg/dL (11.1 mmol/L) during OGTT. The test should be performed as described by the WHO, using a glucose load

containing the equivalent of 75-g anhydrous glucose dissolved in water.OR

A1C >6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.

OR In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a

random plasma glucose >200 mg/dL (11.1 mmol/L).

In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples. ADA 2019

In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA 2018

Sickle cell disease

Pregnancy

Post partum period

Glucose-6-phosphate dehydrogenase deficiency

HIV

Hemodialysis

Blood loss or transfusion

Erythropoietin therapy

Newer additions in 2019 in Bold letters

Low carbohydrate diet can be done[individualized] but not recommended in pregnant women, lactating women, children, chronic kidney disease and when patients are on SGLT2 inhibitors -ADA 2019.

In 2018 guideline there was no specific recommendation when to avoid low carbohydrate diet.

Carbohydrates higher in fiber and lower in glycemic load preferred and low carbohydrate diet generally not recommended as per 2018 and 2019 ADA guidelines.

Sodium restriction is <2300 mg/day in patients with Diabetes and Hypertension prior it was more stricter at 1500 mg per day when there was HTN associated.

Decreased use of sweetners recommended.

The recommendation to use SMBG in people who are not using insulin was changed to acknowledge that routine glucose monitoring is of limited additional clinical benefit in this population.

Heart failure included as important type of cardiovascular disease in people with diabetes.

Blood pressure recommendation were modified to emphasize the importance of individualization of targets.

More emphasize on ASCVD 10 year risk calculator as part of overall risk assessment in determining optimal treatment approaches including statins.

New updates on aspirin use in primary prevention.

Use of medications with cardiovascular benefit in people with ASCVD with and without heart failure added.

ADA 2018

ADA 2019

ADA 2018 ADA 2019

ADA 2019

ADA 2018

ADA 2019ADA 2018

ASCEND [A Study of Cardiovascular Events in Diabetes] trial randomized 15,480 patients with Diabetes and no ASCVD to aspirin 100 mg daily versus placebo.

Primary efficacy endpoint was vascular death, MI or stroke or TIA.

Primary safety outcome was bleeding [ICH,GI bleeding , sight threatening bleeding in the eye]

Mean follow up was 7.4 years 12% reduction in primary efficacy end point but major bleeding

was significantly increased. Two other large randomized trials of aspirin for primary

prevention, in patients without diabetes (ARRIVE [Aspirin to Reduce Risk of Initial Vascular Events]) and in the elderly (ASPREE [Aspirin in Reducing Events in the Elderly]) including 11% with diabetes, found no benefit of aspirin on the primary efficacy end point and an increased risk of bleeding.

Among patients with type 2 diabetes who have established atherosclerotic cardiovascular disease, sodium–glucose cotransporter 2 inhibitors or glucagon-like peptide 1 receptor agonists with demonstrated cardiovascular disease benefit are recommended as part of the antihyperglycemic regimen. ADA 2018

Among patients with atherosclerotic cardiovascular disease at high risk of heart failure or in whom heart failure coexists, sodium–glucose cotransporter 2 inhibitors are preferred. ADA 2019 in addition to one from above.

-For patients with type 2 diabetes and chronic kidney disease, consider use of SGLT2 inhibitors and GLP-1 analogues recommended.

Telemedicine programs that use validated retinal photography with remote reading by an ophthalmologist or optometrist and timely referral for a comprehensive eye examination when indicated can be an appropriate screening strategy for diabetic retinopathy. Newer to 2019 .

The presence of retinopathy is not a contraindication to aspirin therapy as no there is no sufficient data to prove aspirin increases retinal hemorrhage.

No need to do feet exams each visit as per ADA 2019 guidelines in low risk patients.

All low risk patients should have annual feet exams.

High risk patients for ulceration –Feet exam each visit.

Pregabalin, duloxetine, or gabapentin are recommended as initial pharmacologic treatments for neuropathic pain in diabetes.

Gabapentin was added in 2019 and was not there is 2018 guidelines.

Sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged.

When caring for hospitalized patients with diabetes, consider consulting with a specialized diabetes or glucose management team where possible. Newer recommendation in 2019..oops more consult for us!!

Recommended in adults with type 1 diabetes who are not meeting glycemic targets.

Real-time continuous glucose monitoring may be a useful tool in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes.

Real-time continuous glucose monitoring should be used as close to daily as possible for maximal benefit.

Real-time continuous glucose monitoring may be used effectively to improve A1C levels and neonatal outcomes in pregnant women with type 1 diabetes.

Sensor-augmented pump therapy with automatic low-glucose suspend may be considered for adults with type 1 diabetes at high risk of hypoglycemia to prevent episodes of hypoglycemia and reduce their severity.

Freestyle Libre

ADA-Standards of medical care in Diabetes-Published in January 2019 in Diabetes Care.

Thank you, Dr.Naing for this opportunity, all administrative staff who was part of this symposium and audience who could bear me patiently on this extensive update!!!!