Memorandum

ADA releases new Standards of Medical Care – December 24, 2014

Executive Highlights

  • Yesterday, the American Diabetes Association (ADA) released its updated Standards of Medical Care, which recommend statin therapy for all people with diabetes as well as a less stringent diastolic blood pressure target.
  • In addition, the new guidance establishes a lower BMI cutoff of 23 kg/m2 for type 2 diabetes screening in Asian Americans, based on evidence that this ethnic group often develops diabetes at lower BMI levels compared to the general population.

Yesterday, the American Diabetes Association (ADA) released its updated Standards of Medical Care, its annual set of evidence-based guidelines for healthcare providers on the diagnosis and treatment of patients with diabetes. The most notable revisions to the document include the call for all people with diabetes to be treated with statins, the recommendation of a less stringent diastolic blood pressure target, and the establishment of a lower BMI  cutoff for type 2 diabetes screening in Asian Americans.

  • The ADA now recommends treatment with moderate- or high-dose statins for all people with diabetes, as well as a less stringent diastolic blood pressure target. The updated guidelines for statin use now align with the latest recommendations from the American College of Cardiology (ACC) and American Heart Association (AHA). Notably, these guidelines are now based on overall cardiovascular risk rather than LDL cholesterol level alone; since diabetes is a  significant risk factor for cardiovascular disease, all patients are considered to be at high risk and therefore eligible for statin therapy. In addition, the updated standards call for a less stringent diastolic blood pressure goal of 90 mmHg rather than 80 mmHg for people with diabetes; according to the ADA, although observational studies favor lower blood pressure, evidence from randomized trials points to 90 mmHg as the most effective target.
    • The ADA’s statin use guidelines are based on age and cardiovascular risk factors. People with diabetes who are under 40 years of age, or who are between the ages of 40 and 75 with no additional cardiovascular risk factors, are advised to take a moderate-intensity statin. For those between the ages of 40 and 75 with additional cardiovascular risk factors, a high-intensity statin is recommended.
  • In addition, the new Standards of Medical Care have established a lower BMI cutoff of 23 kg/m2 for type 2 diabetes screening in Asian Americans. Previous ADA recommendations have called for the general population to be screened beginning at a BMI of 25 kg/m2. These new guidelines (which are also detailed in a position statement by the Association) recommend a lower cutoff for Asian Americans based on evidence that this ethnic group often develops diabetes at lower BMI levels compared to the general population, largely due to differences in body composition. While this recommendation does not redefine overweight or obesity for Asian Americans, we agree that it represents a significant step forward for more effective detection and prevention of diabetes in this population. We also hope that the final USPSTF recommendation for expanded type 2 diabetes screening criteria will incorporate this new standard, as such recommendations essentially determine which preventive services must be covered by insurance under the Affordable Care Act.   
  • Several other notable recommendations in the most recent guidelines include:
    • A new section on the management of diabetes in pregnancy, which includes a recommendation for the use of a one-step screening test for gestational diabetes.
    • The new A1c target of <7.5% for children and adolescents with type 1 diabetes, which was announced by the ADA earlier this year. As a reminder, this change was somewhat controversial due to concerns about hypoglycemia and the fact that many pediatric patients had difficulty meeting the previous A1c target of <8.5% - that said, the authors made it clear that just as many children at 8.5% had hypos as at 7.5%.
    • The statement that e-cigarettes are not supported by the ADA as an alternative to smoking or as a method of facilitating smoking cessation.
    • Revised immunization guidelines for older adults. These reflect the CDC’s new recommendations that those of at least 65 years of age who have not received a pneumonia vaccine should receive two separate shots (PCV13 [Prevnar] followed 12 months later by PPSV23 [Pneumovax]).  
  • The new guidelines have also been reorganized and renamed this year to make the document easier to navigate. Prior to these revisions, “Standards of Medical Care” was a section within a larger document titled “Clinical Practice Recommendations.” The Standards of Medical Care is now a single document divided into 14 sections to help reduce information overload for healthcare providers.

-- by Melissa An, Emily Regier, and Kelly Close