When completed, the Look AHEAD trial should provide insight into the effects of long-term weight loss on important clinical outcomes. Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists.
The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goal. Further, individualization of the macronutrient composition will depend on the metabolic status of the patient e.
A variety of dietary meal patterns are likely effective in managing diabetes including Mediterranean-style, plant-based vegan or vegetarian , low-fat and lower-carbohydrate eating patterns , — Although brain fuel needs can be met on lower-carbohydrate diets, long-term metabolic effects of very-low-carbohydrate diets are unclear, and such diets eliminate many foods that are important sources of energy, fiber, vitamins, and minerals and that are important in dietary palatability Saturated and trans fatty acids are the principal dietary determinants of plasma LDL cholesterol.
There is a lack of evidence on the effects of specific fatty acids on people with diabetes; the recommended goals are therefore consistent with those for individuals with CVD , MNT, when delivered by a registered dietitian according to nutrition practice guidelines, is reimbursed as part of the Medicare program as overseen by the Centers for Medicare and Medicaid Services CMS www.
People with diabetes should receive DSME according to national standards and diabetes self-management support when their diabetes is diagnosed and as needed thereafter. Effective self-management and quality of life are the key outcomes of DSME and should be measured and monitored as part of care.
DSME should address psychosocial issues, since emotional well-being is associated with positive diabetes outcomes. Education helps people with diabetes initiate effective self-management and cope with diabetes when they are first diagnosed.
Ongoing DSME and diabetes self-management support DSMS also help people with diabetes maintain effective self-management throughout a lifetime of diabetes as they face new challenges and as treatment advances become available.
DSME helps patients optimize metabolic control, prevent and manage complications, and maximize quality of life in a cost-effective manner This process incorporates the needs, goals, and life experiences of the person with diabetes. The overall objectives of DSME and DSMS are to support informed decision-making, self-care behaviors, problem-solving, and active collaboration with the health care team to improve clinical outcomes, health status, and quality of life in a cost-effective manner Current best practice for DSME is a skills-based approach that focuses on helping those with diabetes make informed self-management choices.
DSME has changed from a didactic approach focusing on providing information to more theoretically based empowerment models that focus on helping those with diabetes make informed self-management decisions. Care of diabetes has shifted to an approach that is more patient centered and places the person with diabetes and his or her family at the center of the care model working in collaboration with health care professionals. Patient-centered care is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient's values guide all decision making Multiple studies have found that DSME is associated with improved diabetes knowledge and self-care behavior , improved clinical outcomes such as lower A1C , , , , , , lower self-reported weight , improved quality of life , , , healthy coping , and lower costs Better outcomes were reported for DSME interventions that were longer and included follow-up support DSMS , — , that were culturally , and age appropriate , , that were tailored to individual needs and preferences, and that addressed psychosocial issues and incorporated behavioral strategies , , — Both individual and group approaches have been found effective — There is growing evidence for the role of community health workers and peer , and lay leaders in delivering DSME and support in addition to the core team Diabetes education is associated with increased use of primary and preventive services and lower use of acute, inpatient hospital services Patients who participate in diabetes education are more likely to follow best practice treatment recommendations, particularly among the Medicare population, and have lower Medicare and commercial claim costs , The national standards for DSME are designed to define quality DSME and to assist diabetes educators in a variety of settings to provide evidence-based education The standards, currently being updated, are reviewed and updated every 5 years by a task force representing key organizations involved in the field of diabetes education and care.
DSME is also covered by most health insurance plans. In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training at least twice per week.
Exercise is an important part of the diabetes management plan. Regular exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being.
Furthermore, regular exercise may prevent type 2 diabetes in high-risk individuals 20 — Structured exercise interventions of at least 8-week duration have been shown to lower A1C by an average of 0. Higher levels of exercise intensity are associated with greater improvements in A1C and in fitness A joint position statement by ADA and the American College of Sports Medicine summarizes the evidence for benefits of exercise in people with type 2 diabetes The U.
In addition, the guidelines suggest that adults also perform muscle-strengthening activities that involve all major muscle groups 2 or more days per week. The guidelines suggest that adults over age 65 years, or those with disabilities, follow the adult guidelines if possible or if this is not possible be as physically active as they are able.
Studies included in a meta-analysis of the effects of exercise interventions on glycemic control had a mean number of sessions per week of 3. The DPP lifestyle intervention, which included min per week of moderate-intensity exercise, had a beneficial effect on glycemia in those with prediabetes.
Therefore, it seems reasonable to recommend that people with diabetes try to follow the physical activity guidelines for the general population. Progressive resistance exercise improves insulin sensitivity in older men with type 2 diabetes to the same or even a greater extent as aerobic exercise Clinical trials have provided strong evidence for the A1C lowering value of resistance training in older adults with type 2 diabetes , , and for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes , In the absence of contraindications, patients with type 2 diabetes should be encouraged to do at least two weekly sessions of resistance exercise exercise with free weights or weight machines , with each session consisting of at least one set of five or more different resistance exercises involving the large muscle groups Prior guidelines suggested that before recommending a program of physical activity, the provider should assess patients with multiple cardiovascular risk factors for coronary artery disease CAD.
As discussed more fully in section VI. CHD Screening and Treatment, the area of screening asymptomatic diabetic patients for CAD remains unclear, and a recent ADA consensus statement on this issue concluded that routine screening is not recommended Providers should use clinical judgment in this area. Certainly, high-risk patients should be encouraged to start with short periods of low-intensity exercise and increase the intensity and duration slowly. Providers should assess patients for conditions that might contraindicate certain types of exercise or predispose to injury, such as uncontrolled hypertension, severe autonomic neuropathy, severe peripheral neuropathy or history of foot lesions, and unstable proliferative retinopathy.
The patient's age and previous physical activity level should be considered. When people with type 1 diabetes are deprived of insulin for 12—48 h and are ketotic, exercise can worsen hyperglycemia and ketosis ; therefore, vigorous activity should be avoided in the presence of ketosis. Hypoglycemia is rare in diabetic individuals who are not treated with insulin or insulin secretagogues, and no preventive measures for hypoglycemia are usually advised in these cases.
In the presence of proliferative diabetic retinopathy PDR or severe nonproliferative diabetic retinopathy NPDR , vigorous aerobic or resistance exercise may be contraindicated because of the risk of triggering vitreous hemorrhage or retinal detachment Decreased pain sensation in the extremities results in increased risk of skin breakdown and infection and of Charcot joint destruction. Prior recommendations have advised non—weight-bearing exercise for patients with severe peripheral neuropathy.
However, studies have shown that moderate-intensity walking may not lead to increased risk of foot ulcers or reulceration in those with peripheral neuropathy All individuals with peripheral neuropathy should wear proper footwear and examine their feet daily to detect lesions early.
Anyone with a foot injury or open sore should be restricted to non—weight-bearing activities. Autonomic neuropathy can increase the risk of exercise-induced injury or adverse event through decreased cardiac responsiveness to exercise, postural hypotension, impaired thermoregulation, impaired night vision due to impaired papillary reaction, and unpredictable carbohydrate delivery from gastroparesis predisposing to hypoglycemia Autonomic neuropathy is also strongly associated with CVD in people with diabetes , People with diabetic autonomic neuropathy should undergo cardiac investigation before beginning physical activity that is more intense than that to which they are accustomed.
Physical activity can acutely increase urinary protein excretion. However, there is no evidence that vigorous exercise increases the rate of progression of diabetic kidney disease, and there is likely no need for any specific exercise restrictions for people with diabetic kidney disease It is reasonable to include assessment of the patient's psychological and social situation as an ongoing part of the medical management of diabetes. Consider screening for psychosocial problems such as depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment when self-management is poor.
Psychological and social problems can impair the individual's — or family's ability to carry out diabetes care tasks and therefore compromise health status. There are opportunities for the clinician to assess psychosocial status in a timely and efficient manner so that referral for appropriate services can be accomplished. However, a limited association between the effects on A1C and mental health, and no intervention characteristics predicted benefit on both outcomes, was shown Key opportunities for screening of psychosocial status occur at diagnosis, during regularly scheduled management visits, during hospitalizations, at discovery of complications, or when problems with glucose control, quality of life, or adherence are identified.
Patients are likely to exhibit psychological vulnerability at diagnosis and when their medical status changes, e. Screening tools are available for a number of these areas Indications for referral to a mental health specialist familiar with diabetes management may include gross noncompliance with medical regimen by self or others , depression with the possibility of self-harm, debilitating anxiety alone or with depression , indications of an eating disorder , or cognitive functioning that significantly impairs judgment.
It is preferable to incorporate psychological assessment and treatment into routine care rather than waiting for identification of a specific problem or deterioration in psychological status Although the clinician may not feel qualified to treat psychological problems, utilizing the patient-provider relationship as a foundation for further treatment can increase the likelihood that the patient will accept referral for other services. It is important to establish that emotional well-being is part of diabetes management.
For a variety of reasons, some people with diabetes and their health care providers do not achieve the desired goals of treatment Table 9. Rethinking the treatment regimen may require assessment of barriers including income, health literacy, diabetes distress, depression, and competing demands, including those related to family responsibilities and dynamics. Other strategies may include culturally appropriate and enhanced DSME, co-management with a diabetes team, referral to a medical social worker for assistance with insurance coverage, or change in pharmacological therapy.
Initiation of or increase in SMBG, utilization of continuous glucose monitoring, frequent contact with the patient, or referral to a mental health professional or physician with special expertise in diabetes may be useful. Providing patients with an algorithm for self-titration of insulin doses based on SMBG results may be helpful for type 2 patients who take insulin Any condition leading to deterioration in glycemic control necessitates more frequent monitoring of blood glucose and in ketosis-prone patients urine or blood ketones.
Marked hyperglycemia requires temporary adjustment of the treatment program and, if accompanied by ketosis, vomiting, or alteration in level of consciousness, immediate interaction with the diabetes care team.
The patient treated with noninsulin therapies or MNT alone may temporarily require insulin. Adequate fluid and caloric intake must be assured. Infection or dehydration are more likely to necessitate hospitalization of the person with diabetes than the person without diabetes. The hospitalized patient should be treated by a physician with expertise in the management of diabetes. For further information on management of patients with hyperglycemia in the hospital, see section IX.
Diabetes Care in the Hospital. For further information on management of DKA or nonketotic hyperosmolar state, refer to the ADA consensus statement on hyperglycemic crises Glucose 15—20 g is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. If SMBG 15 min after treatment shows continued hypoglycemia, the treatment should be repeated. Once SMBG glucose returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia.
Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemia, and caregivers or family members of these individuals instructed in its administration.
Glucagon administration is not limited to health care professionals. Individuals with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks, to partially reverse hypoglycemia unawareness and reduce risk of future episodes.
Hypoglycemia is the leading limiting factor in the glycemic management of type 1 and insulin-treated type 2 diabetes Mild hypoglycemia may be inconvenient or frightening to patients with diabetes, and more severe hypoglycemia can cause acute harm to the person with diabetes or others, if it causes falls, motor vehicle accidents, or other injury.
A large cohort study suggested that among older adults with type 2 diabetes, a history of severe hypoglycemia was associated with greater risk of dementia The acute glycemic response correlates better with the glucose content than with the carbohydrate content of the food. Although pure glucose is the preferred treatment, any form of carbohydrate that contains glucose will raise blood glucose. Added fat may retard and then prolong the acute glycemic response.
Ongoing activity of insulin or insulin secretagogues may lead to recurrence of hypoglycemia unless further food is ingested after recovery. Severe hypoglycemia where the individual requires the assistance of another person and cannot be treated with oral carbohydrate due to confusion or unconsciousness should be treated using emergency glucagon kits, which require a prescription.
Those in close contact with, or having custodial care of, people with hypoglycemia-prone diabetes family members, roommates, school personnel, child care providers, correctional institution staff, or coworkers , should be instructed in use of such kits. An individual does not need to be a health care professional to safely administer glucagon. Care should be taken to ensure that unexpired glucagon kits are available.
Prevention of hypoglycemia is a critical component of diabetes management. Patients should understand situations that increase their risk of hypoglycemia, such as when fasting for tests or procedures, during or after intense exercise, and during sleep; and that increase the risk of harm to self or others from hypoglycemia, such as with driving. Teaching people with diabetes to balance insulin use, carbohydrate intake, and exercise is a necessary but not always sufficient strategy for prevention.
In type 1 diabetes and severely insulin-deficient type 2 diabetes, the syndrome of hypoglycemia unawareness, or hypoglycemia-associated autonomic failure, can severely compromise stringent diabetes control and quality of life. The deficient counter-regulatory hormone release and autonomic responses in this syndrome are both risk factors for, and caused by, hypoglycemia. Hence, patients with one or more episodes of severe hypoglycemia may benefit from at least short-term relaxation of glycemic targets.
Patients with type 2 diabetes who have undergone bariatric surgery need life-long lifestyle support and medical monitoring. The long-term benefits, cost-effectiveness, and risks of bariatric surgery in individuals with type 2 diabetes should be studied in well-designed controlled trials with optimal medical and lifestyle therapy as the comparator.
Remission rates tend to be lower with procedures that only constrict the stomach and higher with those that bypass portions of the small intestine. Additionally, there is a suggestion that intestinal bypass procedures may have glycemic effects that are independent of their effects on weight, perhaps involving the incretin axis. The latter group lost only 1.
Bariatric surgery is costly in the short term and has some risks. Rates of morbidity and mortality directly related to the surgery have been reduced considerably in recent years, with day mortality rates now 0. Longer-term concerns include vitamin and mineral deficiencies, osteoporosis, and rare but often severe hypoglycemia from insulin hypersecretion.
Cohort studies attempting to match subjects suggest that the procedure may reduce longer-term mortality rates Recent retrospective analyses and modeling studies suggest that these procedures may be cost-effective, when one considers reduction in subsequent health care costs — Some caution about the benefits of bariatric surgery might come from recent studies.
A propensity score—adjusted analyses of older severely obese patients with high baseline mortality in Veterans Affairs Medical Centers found that the use of bariatric surgery was not associated with decreased mortality compared with usual care during a mean 6. Nearly one of three patients experienced band erosion, and almost half had required removal of their bands. Studies of the mechanisms of glycemic improvement and long-term benefits and risks of bariatric surgery in individuals with type 2 diabetes, especially those who are not severely obese, will require well-designed clinical trials, with optimal medical and lifestyle therapy of diabetes and cardiovascular risk factors as the comparator.
Other indications for repeat vaccination include nephrotic syndrome, chronic renal disease, and other immunocompromised states, such as after transplantation. Influenza and pneumonia are common, preventable infectious diseases associated with high mortality and morbidity in the elderly and in people with chronic diseases. Though there are limited studies reporting the morbidity and mortality of influenza and pneumococcal pneumonia specifically in people with diabetes, observational studies of patients with a variety of chronic illnesses, including diabetes, show that these conditions are associated with an increase in hospitalizations for influenza and its complications.
Safe and effective vaccines are available that can greatly reduce the risk of serious complications from these diseases , There is sufficient evidence to support that people with diabetes have appropriate serologic and clinical responses to these vaccinations. At the time these standards went to press, the CDC was considering recommendations to immunize all or some adults with diabetes for hepatitis B.
ADA awaits the final recommendations and will support them when they are released in CVD is the major cause of morbidity and mortality for individuals with diabetes and the largest contributor to the direct and indirect costs of diabetes. The common conditions coexisting with type 2 diabetes e. Numerous studies have shown the efficacy of controlling individual cardiovascular risk factors in preventing or slowing CVD in people with diabetes.
Large benefits are seen when multiple risk factors are addressed globally , There is evidence that measures of year coronary heart disease CHD risk among U. Blood pressure should be measured at every routine diabetes visit. Based on patient characteristics and response to therapy, higher or lower SBP targets may be appropriate. Patients with a SBP of — mmHg or a DBP of 80—89 mmHg may be given lifestyle therapy alone for a maximum of 3 months and then, if targets are not achieved, be treated with addition of pharmacological agents.
Lifestyle therapy for hypertension consists of weight loss, if overweight; Dietary Approaches to Stop Hypertension DASH -style dietary pattern, including reducing sodium and increasing potassium intake; moderation of alcohol intake; and increased physical activity.
Pharmacologic therapy for patients with diabetes and hypertension should be with a regimen that includes either an ACE inhibitor or an ARB. If one class is not tolerated, the other should be substituted. Multiple drug therapy two or more agents at maximal doses is generally required to achieve blood pressure targets.
Hypertension is a common comorbidity of diabetes, affecting the majority of patients, with prevalence depending on type of diabetes, age, obesity, and ethnicity. Hypertension is a major risk factor for both CVD and microvascular complications. In type 1 diabetes, hypertension is often the result of underlying nephropathy, while in type 2 diabetes it usually coexists with other cardiometabolic risk factors.
Measurement of blood pressure in the office should be done by a trained individual and follow the guidelines established for nondiabetic individuals: measurement in the seated position, with feet on the floor and arm supported at heart level, after 5 min of rest. Cuff size should be appropriate for the upper arm circumference. Elevated values should be confirmed on a separate day.
However, the preponderance of the clear evidence of benefits of treatment of hypertension in people with diabetes is based on office measurements. The primary outcome was a composite of nonfatal MI, nonfatal stroke, and CVD death; the hazard ratio for the primary end point in the intensive group was 0. Of the prespecified secondary end points, only stroke and nonfatal stroke were statistically significantly reduced by intensive blood pressure treatment, with hazard ratios of 0.
If this finding is real, the number needed to treat to prevent one stroke over the course of 5 years with intensive blood pressure management is In those randomized to standard glycemic control, the event rate for the primary end point was 1. Other recent randomized trial data include those of the ADVANCE trial in which treatment with an ACE inhibitor and a thiazide-type diuretic reduced the rate of death but not the composite macrovascular outcome.
However, this has not been formally assessed. The absence of significant harms, the trends toward benefit in stroke, and the potential heterogeneity with respect to intensive glycemia management suggests that previously recommended targets are reasonable pending further analyses and results. Although there are no well-controlled studies of diet and exercise in the treatment of hypertension in individuals with diabetes, the Dietary Approaches to Stop Hypertension DASH study in nondiabetic individuals has shown antihypertensive effects similar to pharmacologic monotherapy.
These nonpharmacological strategies may also positively affect glycemia and lipid control. Their effects on cardiovascular events have not been established. Several studies suggested that ACE inhibitors may be superior to dihydropyridine calcium channel blockers in reducing cardiovascular events — However, a variety of other studies have shown no specific advantage to ACE inhibitors as initial treatment of hypertension in the general hypertensive population, but rather an advantage on cardiovascular outcomes of initial therapy with low-dose thiazide diuretics , , In people with diabetes, inhibitors of the renin-angiotensin system RAS may have unique advantages for initial or early therapy of hypertension.
In a nonhypertension trial of high-risk individuals, including a large subset with diabetes, an ACE inhibitor reduced CVD outcomes In patients with congestive heart failure CHF , including diabetic subgroups, ARBs have been shown to reduce major CVD outcomes — , and in type 2 patients with significant nephropathy, ARBs were superior to calcium channel blockers for reducing heart failure Though evidence for distinct advantages of RAS inhibitors on CVD outcomes in diabetes remains conflicting , , the high CVD risks associated with diabetes, and the high prevalence of undiagnosed CVD, may still favor recommendations for their use as first-line hypertension therapy in people with diabetes Recently, the blood pressure arm of the ADVANCE trial demonstrated that routine administration of a fixed combination of the ACE inhibitor perindopril and the diuretic indapamide significantly reduced combined microvascular and macrovascular outcomes, as well as CVD and total mortality.
The improved outcomes could also have been due to lower achieved blood pressure in the perindopril-indapamide arm The compelling benefits of RAS inhibitors in diabetic patients with albuminuria or renal insufficiency provide additional rationale for use of these agents see section VI. Nephropathy Screening and Treatment. If needed to achieve blood pressure targets, amlodipine, HCTZ, or chlorthalidone can be added.
Evidence is emerging that health information technology can be used safely and effectively as a tool to enable attainment of blood pressure goals. Using a telemonitoring intervention to direct titrations of antihypertensive medications between medical office visits has been demonstrated to have a profound impact on SBP control An important caveat is that most patients with hypertension require multidrug therapy to reach treatment goals, especially diabetic patients whose targets are lower If blood pressure is refractory to optimal doses of at least 3 antihypertensive agents of different classifications, one of which should be a diuretic, clinicians should consider an evaluation for secondary forms of hypertension.
Growing evidence suggests that there is an association between increase in sleep-time blood pressure and incidence of CVD events. A recent RCT of participants with type 2 diabetes and hypertension demonstrated reduced cardiovascular events and mortality with median follow-up of 5.
During pregnancy in diabetic women with chronic hypertension, target blood pressure goals of SBP — mmHg and DBP 65—79 mmHg are reasonable, as they contribute to long-term maternal health. Lower blood pressure levels may be associated with impaired fetal growth. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin.
Chronic diuretic use during pregnancy has been associated with restricted maternal plasma volume, which might reduce uteroplacental perfusion In most adult patients, measure fasting lipid profile at least annually. Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients:.
For patients at lower risk than those above e. However, LDL cholesterol—targeted statin therapy remains the preferred strategy. If targets are not reached on maximally tolerated doses of statins, combination therapy using statins and other lipid-lowering agents may be considered to achieve lipid targets but has not been evaluated in outcome studies for either CVD outcomes or safety.
Patients with type 2 diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of CVD. For the past decade or more, multiple clinical trials demonstrated significant effects of pharmacologic primarily statin therapy on CVD outcomes in subjects with CHD and for primary CVD prevention Low levels of HDL cholesterol, often associated with elevated triglyceride levels, are the most prevalent pattern of dyslipidemia in persons with type 2 diabetes.
However, the evidence base for drugs that target these lipid fractions is significantly less robust than that for statin therapy Nicotinic acid has been shown to reduce CVD outcomes , although the study was done in a nondiabetic cohort.
Gemfibrozil has been shown to decrease rates of CVD events in subjects without diabetes , and in the diabetic subgroup of one of the larger trials However, in a large trial specific to diabetic patients, fenofibrate failed to reduce overall cardiovascular outcomes Lifestyle intervention, including MNT, increased physical activity, weight loss, and smoking cessation, may allow some patients to reach lipid goals.
Glycemic control can also beneficially modify plasma lipid levels, particularly in patients with very high triglycerides and poor glycemic control. In those with clinical CVD or who are over 40 years of age with other CVD risk factors, pharmacological treatment should be added to lifestyle therapy regardless of baseline lipid levels. Statins are the drugs of choice for lowering LDL cholesterol.
In patients other than those described above, statin treatment should be considered if there is an inadequate LDL cholesterol response to lifestyle modifications and improved glucose control, or if the patient has increased cardiovascular risk e. Very little clinical trial evidence exists for type 2 patients under the age of 40 years or for type 1 patients of any age. Although the data are not definitive, consideration should be given to lipid-lowering goals in type 1 diabetic patients similar to those in type 2 diabetic patients, particularly if they have other cardiovascular risk factors.
Virtually all trials of statins and CVD outcomes tested specific doses of statins against placebo, other doses of statin, or other statins, rather than aiming for specific LDL cholesterol goals In individual patients, LDL cholesterol lowering with statins is highly variable and this variable response is poorly understood Niacin, fenofibrate, ezetimibe, and bile acid sequestrants all offer additional LDL cholesterol lowering. The evidence that combination therapy for LDL cholesterol lowering provides a significant increment in CVD risk reduction over statin therapy alone is still elusive.
Some experts recommend a greater focus on non—HDL cholesterol and apolipoprotein B apoB in patients who are likely to have small LDL particles, such as people with diabetes Severe hypertriglyceridemia may warrant immediate therapy of this abnormality with lifestyle and usually pharmacologic therapy fibric acid derivative, niacin, or fish oil to reduce the risk of acute pancreatitis.
In the absence of severe hypertriglyceridemia, therapy targeting HDL cholesterol or triglycerides has intuitive appeal but lacks the evidence base of statin therapy. Niacin is the most effective drug for raising HDL cholesterol. Combination therapy, with a statin and a fibrate or statin and niacin, may be efficacious for treatment for all three lipid fractions, but this combination is associated with an increased risk for abnormal transaminase levels, myositis, or rhabdomyolysis.
The risk of rhabdomyolysis is higher with higher doses of statins and with renal insufficiency and seems to be lower when statins are combined with fenofibrate than gemfibrozil In the recent ACCORD study, the combination of fenofibrate and simvastatin did not reduce the rate of fatal cardiovascular events, nonfatal MI, or nonfatal stroke, as compared with simvastatin alone, in patients with type 2 diabetes who were at high risk for CVD.
The AIM-HIGH trial randomized over 3, patients about one-third with diabetes to statin therapy plus or minus addition of extended release niacin. Clearly, a reliable risk assessment tool for the United States is needed.
Since risk increases with age, there will be a progressive increase in the number of people of advancing age eligible for statins. Eventually everyone becomes statin eligible by this algorithm — most men in their 60s and more women in their 70s. Certainly not all men and women will benefit from statins.
Unless a better means of risk assessment is developed, unnecessary treatment will be common in older persons who have very little coronary or carotid atherosclerosis. One solution is measurement of coronary artery calcium CAC.
CAC scoring will allow for more targeted therapy for those persons who actually have coronary atherosclerosis. A recent publication demonstrates the utility of CAC in differentiating between those who will and who will not suffer CHD. For any year risk estimate, middle-aged persons will have a higher lifetime risk than older people. The risk algorithm is also more likely to identify those with subclinical atherosclerosis because age will be less of a confounding risk factor.
But again, CAC scoring if available would be useful detecting finding persons who are developing significant atherosclerosis. Other risk factors likewise should be sought in young adults. Risk factors clearly associate with development of atherosclerosis in the age range of years. Those with hypercholesterolemia i. Ten-year risk estimates are of little value in this age range; but the Framingham study 16 documented a high lifetime risk is present when cholesterol levels are relatively high.
ATP III offered recommendations on treatment of several of atherogenic dyslipidemias, including hypertriglyceridemias. The metabolic syndrome nonetheless remains a major cardiovascular risk factor that needs clinical attention.
They give lip service to lifestyle intervention but are embarrassed by a lack of RCTs to underpin lifestyle recommendations. They further can be questioned because they make risk assessment based on older data that may not be suitable for the current US population. Therefore, if using these guidelines, the physician must rely on a heavy dose of clinical judgment. IV Dec 18, Scott M. Older Persons Since risk increases with age, there will be a progressive increase in the number of people of advancing age eligible for statins.
J Am Coll Cardiol Circulation ; J Am Coll Cardiol. However, the issues outlined in this review demonstrate that only a few environments may be appropriate for this test, such as electronics manufacturing and pharmaceuticals where any organic contamination is considered problematic. These are highly controlled areas that may be best served by the test. More dynamic facilities, such as those in healthcare, education, and the food continuum may not be appropriate for this type of test.
In essence, the overall value of the ATP test can be best summarized in the level of chemical complexity. In those that are simple, the test is appropriate. But in areas where the chemical complexity is high, it may be best to look at another option. The authors are grateful to Mr.
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