Tag Archives: American Association of Clinical Endocrinologists

Periodic Tests, Treatments, and Goals for PWDs (Persons With Diabetes)

If you don't like your physician, find a new one

If you don’t like your physician, find a new one

So, you’ve got diabetes. You’re trying to deal with it or you wouldn’t be here. You’ve got a heck of a lot of medical information to master.

Unless you have a good diabetes specialist physician on your team, you may not be getting optimal care. Below are some guidelines you may find helpful. The goal is to prevent diabetes complications. Many primary care physicians will not be up-to-date on the guidelines. Don’t hesitate to discuss them with your doctor. Nobody cares as much about your health as you do.

Annual Tests

The American Diabetes Association (ADA) recommends the following items be done yearly (except as noted) in non-pregnant adults with diabetes. (Incidentally, I don’t necessarily agree with all ADA guidelines.) The complete ADA guidelines are available on the Internet.

  • Lipid profile (every two years if results are fine and stable)
  • Comprehensive foot exam
  • Screening test for distal symmetric polyneuropathy: pinprick, vibration, monofilament pressure sense
  • Serum creatinine and estimate of glomerular filtration rate (MDRD equation)
  • Test for albumin in the urine, such as measurement of albumin-to-creatinine ratio in a random spot urine specimen
  • Comprehensive eye exam by an ophthalmologist or optometrist (if exam is normal, every two or three years is acceptable)
  • Hemoglobin A1c at least twice a year, but every three months if therapy has changed or glucose control is not at goal
  • Flu shots

Other Vaccinations, Weight Loss, Diabetic Diet, Prediabetes, Alcohol, Exercise, Etc.

Additionally, the 2013 ADA guidelines recommend:

  • Pneumococcal vaccination. “A one time re-vaccination is recommended for individuals >64 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago.” Also repeat the vaccination after five years for patients with nephrotic syndrome, chronic kidney disease, other immunocompromised states (poor ability to fight infection), or transplantation.
  • Hepatitis B vaccination to unvaccinated adults who are 19 through 59 years of age.
  • Weight loss for all overweight diabetics. “For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to two years).” For those on low-carb diets, monitor lipids, kidney function, and protein consumption, and adjust diabetic drugs as needed. The optimal macronutrient composition of weight loss diets has not been established. (Macronutrients are carbohydrates, proteins, and fats.)
  • “The mix of carbohydrate, protein, and fat may be adjusted to meet the metabolic goals and individual preferences of the person with diabetes.” “It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goal.”
  • “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.”
  • “Monitoring carbohydrate, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control.”
  • Limit alcohol to one (women) or two (men) drinks a day.
  • Limit saturated fat to less than seven percent of calories.
  • During the initial diabetic exam, screen for peripheral arterial disease (poor circulation). Strongly consider calculation of the ankle-brachial index for those over 50 years of age; consider it for younger patients if they have risk factors for poor circulation.
  • Those at risk for diabetes, including prediabetics, should aim for moderate weight loss (about seven percent of body weight) if overweight. Either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to 2 years). Also important is exercise: at least 150 minutes per week of moderate-intensity aerobic activity. “Individuals at risk for type 2 diabetes should be encouraged to achieve the U.S. Department of Agriculture (USDA) recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake).” Limit intake of sugar-sweetened beverages.
  • “Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate), spread over at least 3 days/week with no more than two consecutive days without exercise. In the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week.”
  • Screening for coronary artery disease before an exercise program is depends on the physician judgment on a case-by-case basis. Routine screening is not recommended.
Steve Parker MD, low-carb diet, diabetic diet

Olive, olive oil, and vinegar: classic Mediterranean foods

Obviously, some of my dietary recommendations conflict with ADA guidelines. The experts assembled by the ADA to compose guidelines were well-intentioned, intelligent, and hard-working. The guidelines are supported by 528 scientific journal references. I greatly appreciate the expert panel’s work. We’ve simply reached some different conclusions. By the same token, I’m sure the expert panel didn’t have unanimous agreement on all the final recommendations. I invite you to review the dietary guidelines yourself, discuss with your personal physician, then decide where you stand.

General Blood Glucose Treatment Goals

The ADA in 2013 suggests these therapeutic goals for non-pregnant adults:

  • Fasting blood glucoses: 70 to 130 mg/dl (3.9 to 7.2 mmol/l)
  • Peak glucoses one to two hours after start of meals: under 180 mg/dl (10 mmol/l)
  • Hemoglobin A1C: under 7%
  • Blood pressure: under 140/80 mmHg
  • LDL cholesterol: under 100 mg/dl (2.6 mmol/l). (In established cardiovascular disease: <70 mg/dl or 1.8 mmol/l may be a better goal.)
  • HDL cholesterol: over 40 mg/dl (1.0 mmol/l) for men and over 50 mg/dl (1.3 mmol/l) for women
  • Triglycerides: under 150 mg/dl (1.7 mmol/l)

The American Association of Clinical Endocrinologists (AACE) in 2011 proposed somewhat “tighter” blood sugar goals for non-pregnant adults:

  • Fasting blood glucoses: under 110 mg/dl (6.11 mmol/l)
  • Peak glucoses 2 hours after start of meals: under 140 mg/dl (7.78 mmol/l)
  • Hemoglobin A1C: 6.5% or less

The ADA reminds clinicians, and I’m sure the AACE guys agree, that diabetes control goals should be individualized, based on age and life expectancy of the patient, duration of diabetes, other diseases that are present, individual patient preferences, and whether the patient is able to easily recognize and deal with hypoglycemia. I agree completely.

Steve Parker, M.D.


Filed under Diabetes Complications, Exercise, Fat in Diet, Fiber, Mediterranean Diet, Overweight and Obesity, Prediabetes, Prevention of T2 Diabetes

Oral Drugs for Type 2 Diabetes: Which Are The Best?

A guideline committee established by the American College of Physicians recently reviewed oral medications for treatment of type 2 diabetes.  Assuming blood sugars were still too high after diet and lifestyle modification, the firmest drug recommendations were:

  • Use metformin first.
  • If blood sugars are still too high, add a second agent to metformin.

This was not nearly as helpful as I’d hoped it would be!

The Problem: Too Many Options

We now have 11 classes of drugs for treatment of 26 million diabetics in the United States.  Clinicians are often at a loss as to which drug(s) to recommend for a particular patient.  For most of these drugs, we know very little about the long-term implications, such as effects on overall death rates, diabetes complications, heart attacks, cancer, and strokes. 

I can think of three diabetes drugs once approved by the U.S. Food and Drug Administration, but are now off the market or severely restricted due to serious adverse side effects: phenformin, troglitazone (Rezulin), and rosiglitazone (Avandia).  I fully expect one or more of our current drugs will have a similar fate; only time will tell which ones.

France took pioglitazone off the shelves in 2011 because of a link with bladder cancer.  It’s still available and popular in the U.S.

When you get into multi-drug therapy with two or three different oral drugs, the situation becomes even cloudier.

Some Needles in the Haystack

I reviewed the report from the guideline committee and found just a few clinical pearls to share with you. 

  • They didn’t mention at all the FDA’s recent restrictions on rosiglitazone, so I assume they don’t believe it’s more toxic to the heart than is pioglitazone.
  • Most oral drugs reduce hemoglobin A1c by an average of 1% (absolute decrease).
  • All double-drug regimens were more effective at controlling blood sugars than monotherapy (using only one drug): adding a second drug drops hemoglobin A1c another 1%.
  • “It was difficult to draw conclusions about the comparative effectiveness of type 2 diabetes medications on all-cause mortality, cardiovascular morbidity and mortality, and microvascular outcomes because of low quality or insufficient evidence.”  It was so difficult that they didn’t draw any firm conclusions.  In other words, in terms of overall deaths , heart attacks, heart failure, and strokes, it’s hard to favor some of these drugs over others.  However…
  • Compared to sulfonylureas, metformin was linked to a  lower overall death rate and cardiovascular illness (e.g., heart attacks, heart failure, angina).
  • Sulfonylureas and meglitinides tend to cause more hypoglycemia.
  • Thiazolidinediones are linked to a higher risk of heart failure; they shouldn’t be used in patients who already have serious heart failure.
  • Thiazolidinediones may increase the risk of bone fractures.
  • Metformin helps with loss of excess weight, reduces LDL (bad) cholesterol, and lowers triglycerides.
  • Metformin is cheaper than most other diabetes drugs.
  • For double-drug therapy: “No good evidence supports one combination therapy over another, even though some evidence shows that the combination of metformin with another agent generally tends to have better efficacy [better blood sugar control] than any other monotherapy or combination therapy.”

In contrast to these guidelines, the American Association of Clinical Endocrinology guidelines of  2009  recommend that  the following should be used earlier and more frequently:  GLP-1 agonists (exenatide) and DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin).  Furthermore, sulfonylureas should have a lower priority than in the past. From my limited perspective here in the Sonoran desert, I have no way of knowing how much influence, if any, Big Pharma had over the AACE guidlelines.

My concern about long-term safety of some these drugs compels me to favor carbohydrate restriction, which reduces the overall need for drugs.  Sure, that’s not true for everybody and it may not last forever.  The more carbs you eat, the more drugs you’re likely to need to keep blood sugars in control in an effort to avoid diabetes complications.

Don’t get me wrong; I’m not anti-drug.  As an internist, I prescribe plenty of drugs every day.  They are a major weapon in my armamentarium.  Regardless of the condition I’m treating, I always try to avoid drugs with unknown and potentially serious long-term consequences.

Steve Parker, M.D.

Reference: Qaseem, Amir, et al.  Oral pharmacologic treatment of type 2 diabetes mellitus: A clinical practice guideline from the American College of PhysiciansAnnals of Internal Medicine, 156 (2012): 218-231.

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Filed under Drugs for Diabetes

Which Drug Is Best for Treatment of Type 2 Diabetes?

Physicians now have an amazing array of drug therapies  for control of type 2 diabetes.  Until now, there has been no consensus as to which drugs to use, and when.

The American Association of Clinical Endocrinologists and the American College of Endocrinology have just issued a joint statement with specific drug recommendations.  Their algorithm is quite detailed.  Here are a few highlights you might not know about:

  • Regular human insulin is not recommended
  • NPH insulin is not recommended
  • The following should be used earlier and more frequently:  GLP-1 agonists (exenatide) and DPP-4 inhibitors (sitagliptin and saxagliptin)
  • sulfonylureas are a lower priority
  • metformin is still a key drug

In the U.S., exenatide is sold as Byetta; sitagliptin is Januvia; saxagliptin is Onglyza; metformin is Glucophage (among others). 

If you have type 2 diabetes and are arguing with your physician about optimal drug therapy, this treatment algorithm may be a helpful tie-breaker. 

Steve Parker, M.D.

Reference:  Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology consensus panel on type 2 diabetes mellitus: An algorithm for glycemic controlEndocrine Practice, 15 (2009): 540-559.


Filed under Drugs for Diabetes