The American Diabetes Association is recommending changes in blood pressure goals for people with diabetes as well as clarifying how frequently people with type 1 diabetes should test their blood glucose levels.
The new guidelines were published in a special supplement to the January issue of Diabetes Care (not affiliated with DiabetesCare.net) as part of the Association's revised Standards of Medical Care, which are updated annually to provide the best possible guidance to health care professionals for diagnosing and treating adults and children with all types of diabetes. The Standards are based upon the most current scientific evidence, which is rigorously reviewed by the Association's multi-disciplinary Professional Practice Committee.
The revised recommendations include raising the treatment goal for high blood pressure from < 130 mm Hg to < 140 mm Hg, based on several new meta-analyses showing there is little additional benefit to achieving the lower targets. Clinical trials have demonstrated health benefits to achieving a goal of < 140 mm Hg, such as reducing cardiovascular events, stroke or nephropathy (kidney disease), but limited benefit to more intensive blood pressure treatment, with no significant reduction in mortality or non-fatal heart attacks. There is a small but statistically significant benefit in terms of reducing risk of stroke, but at the expense of a need for more medications and higher rates of side effects.
"Raising the recommended blood pressure target goal, however, is not meant to downplay the importance of treating high blood pressure in people with diabetes," said Richard Grant, MD, MPH, incoming chair of the Professional Practice Committee and research scientist with the Kaiser Permanente Division of Research. "Untreated hypertension can be very dangerous. Nor should this be taken to mean that lower target rates are inappropriate. They may be appropriate for some patients, particularly those who are younger and have a longer life expectancy, or for those who have a higher risk of stroke, if the lower goal can be achieved without excessive amounts of treatment and without a heavy burden of side effects from medication."
The new Standards also clarify when people who are taking multiple daily doses of insulin (MDI) or using insulin pumps, typically those who have type 1 diabetes, should test their blood glucose levels. Previously, the Standards called for those taking insulin to test "three or more" times throughout the day, a recommendation that was sometimes misinterpreted to mean that three times per day was sufficient. Recognizing that the frequency of testing will differ by individual and by situation, the new standards do not specify the number of times that testing should occur but instead focus on the conditions under which testing should occur. For example, the Standards now specify that patients on MDI or insulin pumps should test prior to meals and snacks, occasionally after eating, at bedtime, before exercise, when they suspect low blood glucose, after treating low blood glucose levels until they return to normal and "prior to critical tasks such as driving."
"What we are now saying is that how often and when to test blood glucose levels should be dictated by the needs and treatment goals of the patient," said Carol Wysham, MD, outgoing chair of the Professional Practice Committee and section head for the Rockwood Center for Diabetes and Endocrinology. "Many patients will need to test 6-8 times per day, but some will need to test more, depending upon their activity level, how often they eat and what other types of activities their day may include. It is not reasonable or practical to set a specific number for all people with diabetes who are on intensive insulin regimens, as no two people's lives are the same. Even for the same individual, no two days are exactly alike. A person may need to test six times one day and 10 the next. Our new Standards of Care reflect that necessary flexibility."
Additionally, the Standards highlight that for patients on less intensive regimens or non-insulin therapies, self-monitoring of blood glucose needs to be linked to educating the patient about how to use the information about glucose levels appropriately. These patients must also be educated about how frequently they need to test and under what conditions.
"The evidence base for self-monitoring of blood glucose (SMBG) in non-insulin users is murky," said Grant. "When it is felt to be indicated, patients should be taught how to use SMBG data to adjust food intake, exercise, or pharmacological therapy to achieve specific goals, and the ongoing need for and frequency of SMBG should be re-evaluated at each routine visit."