New diabetes mellitus practice guidelines from the American Association of Clinical Endocrinologists introduce recommendations on evaluating cancer risk, vaccinations, and special populations such as long-distance truck drivers who represent a high-risk occupational group in need of special attention in the diabetes population.
The guidelines, published in the April issue of Endocrine Practice (2015;21:1-87), expand on previous AACE recommendations on sleep disorders, breathing disorders, and depression in type 2 diabetes, and introduce more flexible and individualized targets not just for glucose and lipids but blood pressure and coagulation.
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The 2015 guidelines replace those issued by AACE in 2011, and come with an updated diabetes management algorithm largely unchanged from the 2013 version. The new algorithm, like its predecessor, is not intended to substitute for a guideline but rather serves as a quick reference for management – “a sort of cookbook” – for clinicians, said Dr. Yehuda Handelsman, director of the Metabolic Institute of America in Tarzana, Calif., and a cochair of the guidelines writing committee of the AACE task force.
The main changes to the algorithm were intended to reflect current Food and Drug Administration advice and a change in the warnings for the medications rosiglitazone and pioglitazone, and the two sodium-dependent glucose cotransporter 2 (SGLT2) inhibitors.
The guideline, meanwhile, was significantly expanded. Among AACE’s new recommendations is that all patients with type 2 diabetes be vaccinated with influenza pneumococcal, and hepatitis B virus vaccine, tetanus-diphtheria boosters every 10 years, and other vaccines as recommended by their physicians.
The guidelines also recommend that people with diabetes be screened more rigorously for common cancers and cancers associated with obesity and metabolic disorders. Moreover, the guidelines recommend that while no specific antihyperglycemic agent has been definitively linked to cancer, “when a patient with DM has a history of a particular cancer, the physician may consider avoiding a medication that was initially considered disadvantageous to that cancer.”
Commercial drivers are identified as a group at high risk for developing obesity and diabetes. Moreover, “persons with DM engaged in various occupations including commercial drivers and pilots, anesthesiologists, and commercial or recreational divers have special management requirements, namely avoiding hypoglycemia. Treatment efforts for such patients should be focused on agents with reduced likelihood of hypoglycemia,” according to the guideline.
Dr. Handelsman said the recommendations on truck drivers came about “as we started to recognize that there are about 15 million commercial drivers in the United States, about 6 million of them transcontinental drivers. They are at huge risk for gaining weight and developing diabetes and cardiovascular disease. And a lot of states will not allow them to drive if they get insulin because they are considered at risk for hypoglycemia.” The guidelines recommend long-distance commercial drivers “would particularly benefit from improved healthcare access with a focus on measures to reduce obesity.”
The guidelines also promote individualizing hemoglobin A1ctargets to below 6.5% for most and above 6.5% for less-healthy individuals. Dr. Handelsman explained that “for people who are very sick with a lot of complications, very high hypoglycemia risk, and maybe short longevity, we might relax control on this group – maybe not even follow hemoglobin A1c but make sure the glucose is within a reasonable limit,” he said.
The guidelines apply the same principle to cardiovascular and weight targets, and aspirin. Lipid targets are also adjustable: “People in a very-high-risk group ought to have an appropriate goal. Those at lesser risk for complications can have a more intensive target, and if they have a lot of complications you may want to be more lax,” Dr. Handelsman said. For example, blood pressure, though ideally at less than 130/80 mm Hg for people with diabetes and kidney disease, should also be individualized on the basis of age, comorbidities, and duration of disease, the guidelines say.
“Recently, there were so many new guidelines and different targets were proposed for blood pressure and glucose yet many if not most had no relevance: The one-size-fits all approach is dead,” Dr. Handelsman said. “The concept of individualized care not only for the glucose but for the CV parameters is new this year and this is perhaps the only guideline on the market that to focus on comprehensive personalized management for people with diabetes and related cardiometabolic conditions.”
Dr. Handelsman reported fees, honoraria, or other forms of support from Boehringer Ingelheim, GlaxoSmithKline, Novo Nordisk, Amgen, Gilead, Merck, Sanofi-Aventis, Intarcia, Lexicon, Takeda, Halozyme, Amarin, Amylin, Janssen, and Vivus. Of the guideline’s 34 authors, all but 5 disclosed industry relationships.