10/21/2017 Cardiovascular Disease (CVD) & Diabetes Guidelines ADA | NDEI

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DIABETES MANAGEMENT GUIDELINES
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Source: American Diabetes Association. Standards of medical care in diabetes—2016.
Press Room Diabetes Care. 2016;39(suppl 1):S1-S106. Available here.
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Refer to source document for full recommendations, including class of recommendation and level of
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Screening & Diagnosis Diabetes Complications

Glycemic Targets Pregnancy/Gestational Diabetes
Type 2 Diabetes Prevention In-Patient Glycemia
Type 2 Diabetes Pharmacologic Therapy Older Adults
Type 1 Diabetes Pharmacologic Therapy Children & Adolescents
Insulin & Glucose Monitoring Psychosocial Care
Lifestyle Changes Immunizations
Obesity & Bariatric Surgery HIV
Cardiovascular Disease Cystic Fibrosis

Cardiovascular Disease (CVD) & Diabetes

Blood Pressure (Hypertension) Management & Treatment Targets

Screening Measure BP at every patient visit
Confirm elevated BP at a separate visit

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Systolic (SBP) targets

<140 mm Hg
Lower target (<130) may be appropriate in certain
individuals*
Treatment targets

Diastolic (DBP) targets

<90 mm Hg
Lower target (<80) may be appropriate in certain individuals*

*Younger individuals, people with albuminuria, and/or individuals with hypertension and one or
more additional ASCVD risk factor

Only if the lower target can be achieved without undue treatment burden

Treatment of High Blood Pressure

Individuals with BP >120/80 mm Hg Lifestyle changes (See below)

Individuals with confirmed office BP >140/90 Prompt initiation and timely subsequent
mm Hg titration of pharmacologic therapy (see
below) in addition to lifestyle changes

Older adults Treating to <130/70 mm Hg is not

recommended
SBP <130 has not been shown to improve
CV outcomes
DBP <70 has been associated with
increased mortality

Pregnant individuals Targets of 110-129/65-79 are recommended

to optimize long-term maternal health and
minimize impaired fetal growth

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Pharmacologic Therapy for High Blood Pressure

Regimen to include ACEI or ARB—but never in combination
If either ACEI or ARB is not tolerated, substitute one for the other
If using ACEI, ARB, or diuretic, monitor serum creatinine/eGFR and serum potassium levels

Lifestyle Changes for High Blood Pressure

Weight loss
DASH-style dietary pattern, including:
Reduced sodium intake (<2,300 mg/day)
Increased potassium intake
Increased fruit/vegetable intake (8-10 servings/day)

Moderate alcohol intake

Increased physical activity

Lipid Management
Adults not taking a statin Obtain a lipid profile
At diabetes diagnosis, initial medical
evaluation, and every 5 years thereafter
At initiation of statin therapy and
periodically thereafter

Lifestyle changes Weight loss (if indicated)

Reduced intake of saturated fat, trans fat,
and cholesterol
Increased intake of omega-3 fatty acids,
viscous fiber, and plant stanols/sterols
Increased physical activity

Intensify lifestyle changes and optimize TG ≥150 mg/dL

glycemic control among individuals with HDL-C <40 mg/dL (men), <50 mg/dL
(women)

Individuals with fasting TG ≥500mg/dL Evaluate for secondary causes of

hypertriglyceridemia
Consider medical therapy to reduce
pancreatitis risk

Statin Therapy for Lipid Management

High-intensity statin therapy + lifestyle
Individuals with diabetes and ASCVD* changes

Moderate- or high-intensity statin + lifestyle

Age <40 with diabetes and ASCVD risk factors

Age 40-75 years with diabetes but without Moderate-intensity statin + lifestyle
ASCVD risk factors

Age 40-75 with diabetes and ASCVD risk High-intensity statin + lifestyle
factors

Age >75 with diabetes but without ASCVD risk Moderate- or high-intensity statin + lifestyle
factors†

Moderate- or high-intensity statin + lifestyle

Age >75 with diabetes and ASCVD risk factors

The intensity of statin therapy may require adjustment based on an individual’s response

ASCVD risk factors

LDL-C ≥100 mg/dL (2.6 mmol/L)

High blood pressure
Smoking
Overweight or obesity
Family history of premature ASCVD

*Regardless of age
†Routinely evaluate risk-benefit profile of statin therapy, with down-titration as needed

Combination Therapy for Lipid Management

Statin + ezetimibe
Adding ezetimibe to moderate-intensity statin therapy has been
shown to provide incremental CV benefit compared with
moderate statin therapy along
This combination is a consideration for individuals:
With recent ACS and LDL-C ≥50 mg/dL
Who cannot tolerate a high-intensity statin

Statin + fibrate This combination has not been shown to improve ASCVD
outcomes

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As such, it is not recommended
Statin + fenofibrate may be considered for men with TG ≥204
mg/dL and HDL-C ≤34 mg/dL

Statin + niacin This combination has not been shown to provide additional CV
benefit above statin therapy alone
It may increase the risk for stroke
This combination is not recommended

Statin + PCSK9 inhibitor
36%-59% reductions have been shown with PCSK9 inhibitors on
top of maximal tolerated statin therapy
Combination statin + PCSK9 may be considered as adjunctive
therapy for individuals with diabetes who are at high ASCVD risk
or who are intolerant to a high-intensity statin

Statins & Incident Diabetes

Increased risk of incident diabetes with statin use has been reported1,2
May be limited to individuals with diabetes risk factors

Analysis of initial study3: cardiovascular event rate reduction with statins outweighed risk of
incident diabetes
Even for individuals at highest diabetes risk

Meta-analysis of 13 randomized statin trials:2

Odds ratio of 1.09 for new diabetes diagnosis
Treatment of 255 patients with statins for 4 yrs resulted in 1 additional diabetes case
Simultaneously prevented 5.4 vascular events

Antiplatelet Therapy Recommendations

Aspirin for primary prevention
75-162 mg/day for individuals with type 1 or type 2
diabetes who are at increased ASCVD risk (10-yr risk
>10%)* and not at increased bleeding risk
Aspirin is not recommended for ASCVD prevention in
adults with diabetes who are at low ASCVD risk (10-yr
risk <5%)†
The potential for bleeding in these individuals likely
offsets potential benefits of aspirin

Clinical judgement is required for individuals with

diabetes and multiple other risk factors (10-yr risk
5%-10%)

Aspirin for secondary prevention 75-162 mg/day for individuals with diabetes and a
history of ASCVD

For individuals with ASCVD and a documented aspirin allergy, clopidogrel 75 mg/day should
be used
Dual antiplatelet therapy is reasonable for up to 1 year after ACS

*Includes most men or women with diabetes aged ≥50 yrs with ≥1 add’l major risk factor: family
history of premature ASCVD, hypertension, smoking, dyslipidemia, or albuminuria

Coronary Heart Disease (CHD) Screening and Treatment

Routine coronary artery disease (CAD) screening in asymptomatic

individuals is not recommended

It does not improve outcomes as long as ASCVD risk factors are

treated

Screening Consider investigating for CAD in the presence of:

Atypical cardiac symptoms

Signs or symptoms of associated vascular disease, including
carotid bruits, TIA, stroke, claudiation, or PAD
Electrocardiogram abnormalities

In individuals with known ASCVD

Use aspirin and statin therapy if not contraindicated

Consider therapy with an ACEI to reduce the risk of CV events

In individuals with symptomatic heart failure:

Treatment Do not use TZDs, as these agents are associated with heart
failure

In individuals with type 2 diabetes and stable heart failure:

Metformin may be used if renal function is normal

Metformin therapy should be avoided in unstable or hospitalized
patients with heart failure

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Click slides to view larger.
All slides available for download in the Slide Library.

1. Rajpathak SN, et al. Diabetes Care. 2009;32:1924-1929. 2. Sattar N, et al. Lancet. 2010;375:735-
742. 3. Ridker PM, et al. Lancet. 2012;380:565-571.

ACEI=angiotensin-converting enzyme inhibitor; ACS=acute coronary syndrome; ARB=angiotensin

receptor blocker; ASCVD=atherosclerotic cardiovascular disease; DASH=Dietary Approaches to Stop
Hypertension; PAD=peripheral artery disease; PSCK9 inhibitor=proprotein subtilisin convertase/kexin
type 9 inhibitor; TIA=transient ischemic attack; TZD=thiazolidinedione

Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and
Drug Administration (FDA) unless otherwise noted. Consult individual prescribing information for
approved uses outside of the United States.

January 2016

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