Highlights: ADA Diabetes Treatment Standard Update (Cardiovascular, Microvascular Complications, and Foot Care)

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Recently, Diabetes Care published the latest 2020 edition of the American Diabetes Association (ADA) Diabetes Diagnosis and Treatment Standard.This diagnosis and treatment standard is equivalent to the clinical practice guideline, and has a great academic influence internationally.In this article, the chapters “Cardiovascular Diseases and Risk Management for Diabetics” and “Microvascular Complications and Foot Care” are organized for your reference.Blood pressure management for diabetic patients 1. Screening and diagnosis 10.1 Patients’ blood pressure should be measured at each visit. If the patient’s blood pressure is increased (≥140 / 90mmHg), repeated measurements should be performed, including allowing the patient to take measurements on another day.Diagnosis of hypertension.B 10.2 All diabetic patients with hypertension should keep their blood pressure checked in their daily lives.B 2. Antihypertensive goals 10.3 For diabetic patients with hypertension, comprehensive considerations (cardiovascular risk, potential side effects of antihypertensive drugs, and patient preferences) should be taken into account to develop personalized blood pressure goals.C 10.4 For patients with hypertension and hypertension, if the cardiovascular risk is high (currently with ASCVD or 10-year ASCVD risk ≥ 15%), the recommended blood pressure control target is <130/80 mmHg.C 10.5 For patients with hypertension and hypertension, if the risk of cardiovascular disease is low (10-year ASCVD risk <15%), the recommended blood pressure control target is <140 / 90mmHg.A 10.6 For pregnant women with a history of diabetes and hypertension, it is recommended to control blood pressure to ≤135 / 85mmHg to reduce the risk of hypertension during pregnancy (A) and minimize the impact on fetal development (E).3. Treatment strategy 10.7 If the patient's blood pressure is> 120 / 80mmHg accompanied by overweight or obesity, it is recommended to focus on weight loss through lifestyle intervention. DASH diet can be adopted in the diet: reduce sodium intake, increase potassium intake, and moderate alcohol consumption, Increase exercise.4. Drug intervention 10.8 If a diabetic patient is diagnosed with hypertension (≥140 / 90mmHg), lifestyle intervention should be given and medication should be given immediately.A 10.9 For diabetic patients with blood pressure levels ≥160 / 100mmHg, lifestyle interventions should be taken and immediately combined with two antihypertensive drugs (or compound preparations) to reduce the risk of cardiovascular events.A 10.10 Antihypertensive drugs for patients with hypertension and diabetes, you can choose drugs that can reduce cardiovascular events, such as angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), thiazinesDiuretics or dihydropyridine calcium channel blockers.A 10.11 Achieving blood pressure goals often requires a combination of multiple medications, but ACEi and ARB should not be used simultaneously, nor should ACEi / ABR and direct renin inhibitors be used simultaneously.A 10.12 ACEi or ARB is a first-line antihypertensive medication for patients with diabetes and hypertension (recommended grade A for patients with urinary albumin / creatinine ≥300mg / g and recommended grade B for patients with 30-299mg / g), such as intolerance, You can choose another one.10.13 For patients treated with ACEi, ARB, or diuretics, serum creatinine / eGFR and serum potassium levels should be monitored annually.B 5. Refractory hypertension 10.14 The use of 3 types of antihypertensive drugs (including diuretics) still fails to achieve the antihypertensive goal, and treatment with mineralocorticoid receptor antagonists (MRA) should be considered.B. Lipid management in diabetic patients 10.15 Overweight / obese patients should adjust their lifestyles to lose weight; Mediterranean or DASH diet can be used to help lower blood pressure; saturated fat and trans fat intake should be reduced; n-3 fatty acids should be increasedIntake of viscous fibers and phytosterols; increasing physical activity is recommended to improve blood lipids and reduce the risk of atherosclerotic cardiovascular disease in diabetic patients.A 10.16 For diabetic patients with elevated triglyceride levels (1.7 mmol / L) and / or decreased HDL-C (males <1.0 mmol / L, females <1.3 mmol / L), lifestyle interventions and blood glucose control should be strengthened.C 10.17 For adult patients who are not taking statins (or other lipid-lowering drugs), blood lipid testing should be performed when diagnosing diabetes.If the patient is <40 years of age, blood lipid testing should be performed every 5 years. If there are signs of abnormal blood lipids, increase the frequency of testing.E 10.18 Serum lipids should be monitored 4-12 weeks after starting statins (or other lipid-lowering drugs) or changing doses.Blood lipid testing should be performed every year thereafter, which may help to understand the effect of treatment and patient compliance.E 1. Use of statins (primary prevention) 10.19 For patients with diabetes aged 40-75 years without ASCVD, moderate-intensity statins can be selected on the basis of comprehensive lifestyle management.A 10.20 For 20 to 39-year-old diabetic patients with ASCVD risk factors, it may be reasonable to enable statins on the basis of integrated lifestyle management.C 10.21 The use of high-intensity statins may be reasonable for diabetic patients with high risk, especially with multiple ASCVD risk factors or ages 50-70.B 10.22 It may be reasonable to increase ezetimibe in the maximum tolerated dose of statins to reduce LDL-C levels (≥50%) in diabetic patients with a 10-year ASCVD risk ≥20%.C 2. Use of statins (secondary prevention) 10.23 For diabetic patients (all ages) with ASCVD, high-intensity statins should be applied based on integrated lifestyle management.A 10.24 For diabetic patients with ASCVD, if the maximum tolerated dose of statin is still ≥70mg / dL for LDL-C, consider increasing ezetimibe or PCSK9 inhibitors.A 10.25 For patients who cannot tolerate the expected strength of statins, the maximum tolerated dose of statins should be used.E 10.26 Statins should be continued in patients> 75 years of age who have been treated with statins.B 10.27 For diabetic patients> 75 years of age, after discussing the potential benefits and risks, it may be reasonable to start statin therapy.C 10.28 Statins are contraindicated in pregnant patients.B 3. Other aspects of lipid management 10.29 For patients with fasting triglyceride levels ≥500 mg / dL, secondary causes of hypertriglyceridemia should be assessed and drug treatment should be considered to reduce the risk of pancreatitis.C 10.30 For adults with moderate hypertriglyceridemia (175-499mg / dL), clinicians should manage and treat lifestyle factors that may lead to elevated levels.Also look at other secondary factors (diabetes, chronic liver or kidney disease, hypothyroidism), and whether patients are taking drugs that may raise triglyceride levels.C 10.31 For diabetic patients with ASCVD or other cardiovascular risk factors, if the use of statins can effectively control LDL-C levels but triglyceride levels are still elevated (135-499mg / dL), consider combining icosapent ethyl toReduce cardiovascular risk.A 4. Unrecommended combination protocol 10.32 The combination of statins and fibrates does not improve the prognosis of ASCVD, so it is not recommended to use them in combination.A 10.33 The combination of statins with nicotinic acid does not show better cardiovascular benefits than statins alone, and may also increase the risk of stroke and other side effects, and is not recommended for combination use.A 5. Antiplatelet therapy 10.34 Diabetics with a history of ASCVD can use aspirin (75-162mg / d) as a secondary prevention program for the disease.A 10.35 Clopidogrel (75mg / d) can be used in diabetic patients with ASCVD who are allergic to aspirin.B 10.36 The use of dual antiplatelet therapy (low-dose aspirin combined with a P2Y12 inhibitor) within one year after the onset of acute coronary syndrome in patients is reasonable (A), and there may be benefits beyond this time (B).10.37 Aspirin (75-162mg / d) may be a reasonable primary prevention strategy in diabetic patients with increased cardiovascular risk, and doctors should inform patients of the benefits and possible bleeding risks before medication.A. Diabetic cardiovascular disease 1. Screening 10.38 For asymptomatic patients, routine screening for coronary artery disease is not recommended, as the final outcome cannot be improved even with ASCVD risk factors.A 10.39 Patients should be examined for coronary artery disease when any of the following conditions occur: atypical cardiac symptoms (such as apnea due to dyspnea, chest discomfort); signs or symptoms of related vascular disease, including carotid murmur, transientIschemic attack, stroke, claudication, or peripheral arterial disease; abnormal electrocardiograms (such as Q waves).E 2. Treatment 10.40 For patients with diabetes known to have ASCVD cardiovascular disease, consider using ACEi or ARB to reduce the risk of cardiovascular events.B 10.41 For patients with a history of myocardial infarction, beta-blockers should be used at least 2 years after the event.B 10.42 For patients with T2DM and stable heart failure, if eGFR> 30 mL / min, metformin can be continued to control blood glucose.However, metformin should be avoided in patients with heart failure associated with unstable or current hospitalization.B 10.43 For patients with T2DM diagnosed with ASCVD or kidney disease, SGLT-2i or GLP-1RA is recommended as part of the hypoglycemic regimen.A 10.43a For T2DM patients with ASCVD, multiple atherosclerotic cardiovascular disease, or diabetic nephropathy, the use of SGLT-2i with proven cardiovascular benefits is recommended to reduce the risk of major adverse cardiovascular events and hospitalization for heart failure.A 10.43b For patients diagnosed with ASCVD or T2DM with multiple risk factors for ASCVD, the use of GLP-1RA with proven cardiovascular benefits is recommended to reduce the risk of major adverse cardiovascular events.A 10.43c For T2DM patients with heart failure, the use of SGLT-2i may reduce the risk of hospitalization for heart failure.C. Diabetic chronic kidney disease 1. Screening 11.1 For patients with T1DM and all T2DM who have a course of ≥ 5 years, urine albumin levels and glomerular filtration should be tested at least once a year (recommended level B); for urine albumin / creatinine ratioPatients> 30mg / g and / or eGFR <60mL / min / 1.73m ^ 2 should be monitored twice a year to guide treatment (recommended level C).2. Treatment 11.2 Optimize blood glucose control, reduce the risk of chronic kidney disease (CKD) or delay its progress.A 11.3 For T2DM patients with diabetic nephropathy, such as eGFR ≥30mL / min / 1.73m ^ 2 and urinary albumin / creatinine ratio> 30mg / g (especially> 300mg / g), consider using SGLT-2i to reduce CKDProgression, cardiovascular events (recommended grade A).In T2DM patients with CKD and increased risk of cardiovascular events, consider using GLP-1RA to reduce urinary protein progression and risk of cardiovascular events (recommended grade C).11.4 Optimize blood pressure control to reduce the risk of CKD or delay its progress.A 11.5 Do not discontinue use of renin-angiotensin system blockers due to a slight increase in serum creatinine (<30%) without hypovolemia.B 11.6 For patients with non-dialysis-dependent chronic kidney disease, the dietary protein intake should be approximately 0.8 g / kg body weight (recommended daily intake).For dialysis patients, higher levels of dietary protein intake should be considered, as malnutrition is a major problem for some dialysis patients.B 11.7 For non-pregnant diabetic patients with hypertension, such as moderate increase in urinary albumin / creatinine ratio (30-299mg / g), ACEi or ARB can be selected for treatment (recommended level B);/ Creatinine ratio ≥300mg / g and / or eGFR <60mL / min / 1.73 m ^ 2 is highly recommended for these patients (recommended grade A).11.8 When patients use ACEi, ARB, or diuretics, monitor serum creatinine and potassium levels regularly to understand changes in creatinine levels.B 11.9 For diabetic patients with normal blood pressure, normal urine albumin / creatinine ratio (<30mg / g), and normal eGFR, ACEi or ARB is not recommended as a primary prevention of chronic kidney disease.A 11.10 If the patient's eGFR is less than 30mL / min / 1.73m ^ 2, they should be referred to a nephrologist for evaluation.A 11.11 Consult a doctor with experience in kidney disease care in a timely manner.A Diabetic retinopathy 11.12 Optimize glycemic control to reduce the risk or slow progression of diabetic retinopathy.A 11.13 Optimize blood pressure and lipid control to reduce the risk or slow the progression of diabetic retinopathy.A 1. Screening 11.14 Adult patients with T1DM should undergo a comprehensive eye examination within 5 years after the onset of the disease.B 11.15 T2DM patients should undergo a comprehensive eye examination at the time of diagnosis.B 11.16 If no evidence of retinopathy is found in one or more annual eye examinations and blood glucose is well controlled, screening should be considered every 1-2 years; if there is any degree of diabetic retinopathy, it should be at least annuallyCheck 1 time.If retinopathy progresses or vision is impaired, more frequent examinations are required.B 11.17 For screening for diabetic retinopathy, retinal photography may be a suitable strategy.B 11.18 Women with type 1/2 diabetes who are pregnant or planning to conceive should be informed of the risk and / or progression of diabetic retinopathy.B 11.19 For female patients with type 1 or type 2 diabetes, an eye examination should be performed before pregnancy or the first 3 months of pregnancy, and then the patient should be monitored every 3 months and 1 year postpartum based on the degree of retinopathy.B 2. Treatment 11.20 Patients with any degree of macular edema, severe non-proliferative diabetic retinopathy (a precursor to proliferative diabetic retinopathy), or any proliferative diabetic retinopathy should be referred immediately for treatment in diabetic retinopathyAn ophthalmologist with extensive treatment experience.A 11.21 The traditional standard treatment regimen, panretinal laser coagulation, is believed to reduce the risk of vision loss in patients with high-risk proliferative diabetic retinopathy, and in some cases, it can also reduce the risk of severe non-proliferative diabetic 11.22 Intravitreal injection of anti-vascular endothelial growth factor ranibizumab is not worse than traditional panretinal laser photocoagulation, and it can also reduce the risk of vision loss in patients with proliferative diabetic retinopathy.A 11.23 Intravitreal injection of anti-vascular endothelial growth factor can cause diabetic macular edema in the center, which may affect vision.A 11.24 Retinopathy is not a contraindication to aspirin for cardioprotection because aspirin does not increase the risk of retinal bleeding.A. Diabetic neuropathy 1. Screening 11.25 All patients should be evaluated for diabetic peripheral neuropathy at the time of T2DM diagnosis or 5 years after T1DM diagnosis, and at least once a year thereafter.B 11.26 Evaluation of distal symmetrical polyneuropathy should include: asking the patient for a detailed medical history, assessing the patient's temperature or acupuncture (small fiber function), and using a 128Hz tuning fork to evaluate the patient's vibration (large fiber function).All patients should undergo a 10-gram nylon silk test each year to assess the risk of foot ulcers and amputations.B 11.27 Symptoms and signs of autonomic neuropathy should be assessed in patients with microvascular complications.E 2. Treatment 11.28 Optimize blood glucose control to prevent or delay the development of neuropathy in patients with type 1 diabetes (recommended level A); delay the progression of neuropathy in patients with type 2 diabetes (recommended level B).11.29 Evaluate and treat patients to reduce pain and improve quality of life associated with diabetic peripheral neuropathy and autonomic neuropathy.E 11.30 Pregabalin, duloxetine, or gabapentin are recommended as initial medications for diabetic neuropathic pain.A Diabetic Foot Care 11.31 Perform a comprehensive foot assessment at least annually to determine risk factors for foot ulcers and amputations.B 11.32 Patients with sensory loss or signs of foot ulcers or amputations should have their feet checked at each visit.B 11.33 The doctor should carefully ask the patient's relevant medical history, such as ulcers, amputations, Charcot's feet, angioplasty or vascular surgery, smoking, retinopathy and kidney disease, assess neuropathy (pain, burning, numbness) and blood vesselsCurrent symptoms of the disease (leg fatigue, lameness).B 11.34 Examinations should include skin examination, foot deformity assessment, neurological assessment (10-g nylon rope test, accompanied by at least one other assessment: acupuncture, temperature, vibration), vascular assessment (leg, foot pulse).B 11.35 For patients with claudication symptoms or reduced / disappeared foot pulsation, the ankle brachial index should be compared with further evaluation of vascular conditions as appropriate.C 11.36 For patients with foot ulcers and high-risk foot risks (such as dialysis patients, Charcot's feet, history of ulcers, or amputations), multidisciplinary treatment and management are recommended.B 11.37 It is recommended that patients who smoke or have a history of lower extremity complications, loss of protective sensation, structural abnormality, or history of peripheral arterial disease be referred to a foot care specialist for ongoing preventive care and life-long monitoring.C. 11.38 Provide foot self-care education for all people with diabetes.B 11.39 For patients with high-risk diabetes (including severe neuropathy, foot deformities, ulcers, corpus callosum, poor peripheral circulation, or a history of amputation), it is recommended to use special therapeutic shoes.The above content is only authorized for exclusive use by, please do not reprint without the authorization of the copyright party.


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