Action Points
- Note that these guidelines from the Canadian Diabetes Association include more aggressive recommendations for empiric pharmacotherapy in patients over a certain age, compared with prior versions.
- Be aware that many of these recommendations are based upon consensus, not solid evidence.
All patients with diabetes should start taking statins when they turn 40 and blood pressure drugs when they turn 55, even if they have no other risk factors at the time, according to new Canadian guidelines.
The guidelines also recommend that those over 30 who have had diabetes for at least 15 years also should start on statins, according to Alice Cheng, MD, of St. Michael’s Hospital in Toronto, who is chair of the guideline committee.
”In Canada, only 13% of patients with type 2 diabetes achieve all three targets in glucose, blood pressure, and LDL cholesterol control,” Cheng told MedPage Today. ”Clearly, there’s still a care gap, and we needed to find ways to address it. That’s where these guidelines come in.”
Though the recommendations from the Canadian Diabetes Association (CDA) are slightly more aggressive, they are not so far from those of the American Diabetes Association (ADA), according to Sue Kirkman, MD, of the University of North Carolina at Chapel Hill and former chair of medical affairs for ADA.
ADA recommends statins for diabetics ages 40 and up who have at least one other risk factor: ”Given that most people with diabetes have hypertension at that age, it isn’t that different from the CDA guidelines,” Kirkman told MedPage Today.
It’s a similar situation for the ACE inhibitor and angiotensin receptor blocker (ARB) recommendation in those ages 55 and up. ADA calls for blood pressure drugs in diabetes patients with hypertension, microalbuminuria, or cardiovascular disease: ”That would likely cover most people ages 55 and up,” Kirkman said.
But she cautioned that several trials have shown that these drugs don’t prevent the onset of albuminuria, and questioned the basis of the blood pressure drug recommendation in the CDA guidelines.
Cheng acknowledged that the ACE/ARB recommendation based on age alone is grade D, consensus-level evidence, as is the recommendation for statins in 30-year-olds who’ve had long-standing disease.
Starting statins at 40 is also grade D, consensus-level evidence for those with type 1 diabetes — but it is grade A, level-1 evidence for those with type 2 disease.
Cheng cautioned that since the statin recommendation in 30-year-olds likely involves women of child-bearing age, they should only be recommended after discussions with patients about pregnancy plans or ”in the presence of reliable contraception,” and should definitely be contraindicated during pregnancy.
”Statins are category X in pregnancy, and we know that about half of pregnancies among women with diabetes are unplanned, so there’s that concern,” Kirkman said.
Among the guideline committee of 120 experts, Cheng said there was a range of opinion on the new recommendations.
”There will always be those who choose to err on the side of undertreating and avoiding overtreatment, but at the other end of the spectrum you have those who prefer to overtreat some [patients] and not miss any,” Cheng said. ”[The recommendation] is somewhere in the middle, and makes the most practical sense.”
She added that the society has also updated the way it is rolling out the guidelines, using an online version that will include digital tools for both the clinician and patient. For instance, she said, patients will be able to use an online calculator to calculate their vascular risk and their need for preventive medications.
Mycket bra hemsida kring diabetes, även med video och bilder att ladda ner – en bra allmän diabetes-inspiration
From www.medpagetoday.com
Nyhetsinfo
www red DiabetologNytt
Cheng reported no conflicts of interest.
