Diabetes Management Guidelines: What Pharmacists Should Know

The American Diabetes Association (ADA) updated the Standards of Medical Care in Diabetes in January 2017.¹ With this update, the ADA addressed aspects of care including lifestyle management, self-management, comorbidities, and complications with diabetes.

The newest lifestyle management recommendation states that if a patient will be sitting for long periods of time, such as working at a desk or watching television, short periods of physical activity, such as briefly standing or walking around, should occur every 30 minutes.

These guidelines also provided a new definition of clinically significant hypoglycemia at a blood glucose <54 mg/dL. However, the glucose level of concern associated with hypoglycemia continues to be defined as < 70 mg/dL.

The guidelines provide a few updates to the pharmacologic management of the disease. When using metformin long- term, it is recommended to periodically monitor B12 levels due to an association of vitamin B12 deficiency with metformin which is known to occur with long-term use and higher daily doses of metformin.

The guidelines also recommend that empagliflozin or liraglutide be considered in patients with cardiovascular disease to reduce the risk of mortality. Studies showed a reduction of myocardial infarction, stroke, and cardiovascular death by 14% when empagliflozin was used and by 13% when liraglutide was used.

Patients that are at high risk for foot problems, such as patients with severe neuropathy, foot deformities, or history of amputation, may benefit from specialized therapeutic footwear. Wearing proper footwear can delay or prevent adverse outcomes. Pregnant patients with diabetes and chronic hypertension should be managed to achieve a goal blood pressure of 120—160/80–105 mmHg to optimize maternal health while not causing fetal harm.

Lower targets (SBP 110—119 mmHg and DBP 65-79 mmHg) may benefit maternal health even more, but they may be associated with fetal harm and growth. Insulin is emphasized as the recommended treatment for pregnant patients with diabetes.

Oral agents such as metformin and glyburide have been studied and show short-term safety; however, both agents cross the placenta and there is not long-term safety data available for any oral agent. Also, when testing women with gestational diabetes for persistent diabetes, the recommended testing range was changed from 6—12 weeks postpartum to 4–12 weeks postpartum.

Reference

Cefalu, WT Bakris G, Blonde L, et al. Standards of Medical Care in Diabetes-2017. Diabetes Care. 2017 January;40(1):S1—S135.