New Guidelines Aim to Help Doctors Achieve Better Diabetes Care
You've probably heard the dos and don'ts in your doctor's office: Do strive for an A1C below 7 percent. Don't let your blood pressure exceed 130 over 80. But where do the docs get these numbers?
The American Diabetes Association lays out the guidelines for diabetes care in its annual "Standards of Medical Care in Diabetes," which is followed by health care providers, medical organizations, and insurers across the nation. The standards are reviewed and revised each year by ADA's Professional Practice Committee, a panel of about 15 top clinicians and researchers, coordinated by the scientific and medical division of ADA. The guidelines are also approved by the Executive Committee of ADA's board of directors before being published every January in the Clinical Practice Recommendations supplement of Diabetes Care, an ADA journal for health care professionals.
For 2010, ADA has adopted changes in several key areas of diabetes care, including diagnosis, aspirin use, and blood glucose control for certain hospital patients with diabetes. Here is a look at this year's major changes.
The most fundamental change is ADA's endorsing use of the A1C test for diagnosing diabetes. The test—which reports the percentage of glucose-carrying hemoglobin molecules in the blood and the corresponding estimated average glucose (eAG)—shows a person's average blood glucose level over the past two to three months. Under the new standard, a person with an A1C of 6.5 percent (eAG of 140) or higher is diagnosed with diabetes; an A1C of 5.7 percent to 6.4 percent is considered pre-diabetes.
By approving A1C tests for diagnosis, ADA aims to minimize the number of people living with undiagnosed, untreated diabetes. This is a key goal, since an estimated 25 percent of Americans with diabetes don't know they have the disease. A major reason is that people in poorer areas who are at high risk for type 2 diabetes often have difficulty getting to the doctor, says Sue Kirkman, MD, vice president of clinical affairs at ADA. Until now, going to the doctor and finding that you need to be screened for diabetes was just the first step: Unless you hadn't eaten in the past 12 hours, you wouldn't have been able to take the fasting plasma glucose (FPG) test used to diagnose diabetes during that same doctor visit. Using the A1C test as a diagnostic tool should change that. "The idea [with A1C test diagnosis] is that you can catch someone when they do show up at the doctor," Kirkman says. "There already has been a lot of use of A1C for screening for diabetes in the medical community, but nobody really knew a cut point. I think people are glad that ADA is saying this is fine, and [an A1C of 6.5 percent] is the cut point."
What Are You Doing To Stop Diabetes?
ADA's new call to action, Stop Diabetes, is up and running. Join the thousands of people who are already sharing information about staying healthy, acting to wipe out diabetes, learning about the disease, and giving to the cause.
Here's what you can do this month: Learn about ADA's Research Foundation by visiting www.diabetes.org/researchfoundation to see how the foundation and its supporters fund groundbreaking scientific studies.
The A1C test can be administered the day of an appointment without a patient having to fast. And because the test measures average blood glucose over time, even a person who has an acute illness on the day of the doctor's visit can be screened for diabetes. The flu, for instance, might stress the body enough to cause an elevated blood glucose reading on an FPG test, but the flu wouldn't have as large an impact on an A1C result, which reflects an average over a longer period of time. Now that labs have standardized their testing methods, the A1C test is just as accurate as fasting plasma glucose testing, and perhaps more so. While the A1C test is slightly more expensive, it is almost always covered by insurance.
When to Use Aspirin
People with diabetes are at a higher risk for heart attack and stroke than people without diabetes, and aspirin is known to reduce blood clots that can contribute to these events. For many years, ADA has recommended that people with diabetes over the age of 40, or who have other risk factors for heart disease such as high blood pressure, take low-dose aspirin. New research shows that, in fact, aspirin provides no heart-health benefits to people with diabetes who have no history of heart attack or stroke, and that risking aspirin's negative side effects, such as internal bleeding, is not worthwhile for those who don't have this history. In light of these findings, ADA now recommends that low-dose aspirin be prescribed primarily for men over 50 and women over 60 who have diabetes and another risk factor—such as high blood pressure—and for people with diabetes at any age who have had a stroke or heart attack.
Blood Glucose Control in the Hospital
Standards for the treatment of critically ill people with diabetes in the hospital have also changed as a result of research. A recent study showed that intensive-care patients whose blood glucose was tightly controlled at between 80 and 110 mg/dl were more likely to die than those whose glucose was controlled to between 140 and 180 mg/dl. Scientists are unsure of what caused the higher death rate, although bouts of low blood glucose are suspected. ADA now recommends glucose targets of 140 to 180 for critical- and intensive-care patients.
However, while the new standard recognizes the risks of tight control for some patients, it is still important to avoid high blood glucose (hyperglycemia) in hospital patients, Kirkman cautions. "Hyperglycemia left untreated is a risk for dying, for being in the hospital longer, and for infection," she says.
A1Cs in Americans with diabetes have dropped significantly in the past decade, suggesting that changes in diabetes care resulting from research have been effective. "There's evidence that complication rates like amputation rates, blindness from retinopathy, and kidney failure have improved," says Kirkman. "Our emphasis on glucose control, blood pressure control, and screening for complications is really making a difference and [helping] people live longer lives."