2020 ADA guidelines: blood pressure care in adults with diabetes

Here is a concise summary of the 2020 ADA guidelines on the approach of hypertension in patients with diabetes. The authors discuss lifestyle, medications, drug side-effects, and blood pressure (BP) targets. Goals are to achieve BP <130/80, <135/85, and <140/90 mmHg in adults at high risk for ASCVD, gestational diabetes, and low-ASCVD risk, respectively.

Dr. Tashko

2020 ADA Guidelines: Medications for Type 2 Diabetes

The ADA guidelines still recommend Metformin as the first drug for patients with diabetes type 2 (DM2). The advantages of Metformin are its efficacy in lowering A1c, being inexpensive, improving insulin resistance, potential weight loss, not causing hypoglycemia, and having the most extended clinical safety data – since its approval in 1957 in France and 1995 in the U.S.

If the patient has established or risk factors for cardiovascular disease, then a GLP1 agonist with proven CVD benefits is the recommended second-line medication. Examples are Ozempic, Victoza, and Trulicity. However, if a person with DM2 has heart failure or chronic kidney disease ― defined by LVEF <45%, eGFR 30-60, or urinary albuminuria >300 ― an SGLT2 inhibitor should be used. Such medications are Invokana, Jardiance, and Farxiga.

The ADA recommends the following drugs as the third line option: GLP1 agonist if already on Metformin + SGLT2 inhibitor and SGLT2 inhibitor if the patient is taking Metformin + GLP1 agonist. Any of the following agents could be fourth line therapies; sulfonylurea, basal insulin, DDP4 inhibitor, or TZD if heart failure is absent.

The above drug algorithmic guidance is general. The ultimate clinical decision is based on medication tolerability, cost, clinical setting, glucose control, comorbidities, and patient’s preference.


2020 ADA guidelines: Key Revisions

Here you can find the critical modifications in 2020 ADA guidelines. Particular emphasis is placed on pharmacological therapy with GLP-1 agonists or SGLT-2 inhibitors for patients with established cardiovascular disease, heart failure, or chronic kidney disease. Guidelines are published yearly in the month of January.


Review of 2018 ADA guidelines: dyslipidemia in the context of diabetes

ADA recommendations are released each January. Below is a succinct ACP review of guidelines in screening, treatment goals, lifestyle intervention, and drug approach to dyslipidemia in the setting of diabetes mellitus. LDL-cholesterol is still a main target. Charts depict indications and doses of statins, the mainstay therapy to diabetic lipid disorders.


2017 ADA guidelines: dyslipidemia and diabetes

Below you can find ADA recommendations on screening, cardiovascular risks, and treatment of dyslipidemia in the context of diabetes. As always improve lifestyle choices first. If ASCVD likelihood is still high then add medications. Statins are first-line, either of moderate or high intensity. Statin selection would depend on age, CVD status, and contributing factors.

Statin plus PCSK9 inhibitor or statin plus zetia could be used in adults with residual ASCVD risk. Statin plus fenofibrate is no longer advised unless special circumstances are present; severe hypertriglyceridemia or in men with profound metabolic syndrome. Statin plus niacin is also not recommended due to stroke concerns.

For more details, ADA standards are listed below with a slightly modified wording for easier and succinct reading:


2017 ADA guidelines: diabetes during pregnancy

Below you can find ADA standards on proper A1c targets, blood pressure range, retinopathy monitoring and medications used in preexisting and gestational diabetes. The preferred medications during pregnancy are insulin, metformin and glyburide.

Recommendations are listed below with slightly modified wording for easier and succinct reading:


2017 ADA guidelines: metabolic surgery for type 2 diabetes

Obesity is a pro-inflammatory state contributing to insulin resistance and type 2 diabetes. Starting with jejuno-ileal bypass in 1954 by Kremer and intestinal bypass in 1967 by Mason, various techniques of the malabsorption surgery have been developed, researched and applied over the decades. They have shown good results in reducing hyperglycemia, the number of diabetic medications and excessive body weight.

Guidance on the importance and indications of metabolic surgery for type 2 diabetes were published in Diabetes Care, January 2017. Recommendations are listed below with a slightly modified wording for easier and succinct reading:


2017 ADA position statement: hypertension in diabetes

High blood pressure is common in patients with diabetes. Both hypertension and diabetes are independent risk factors for poor cardiovascular outcomes. Obviously the concomitant presence of both HTN and DM in an individual magnifies the chance for CVD events. It is important to screen, diagnose and treat high blood pressure appropriately in someone with diabetes, particularly type 2. 

ADA published a position statement on the subject in Diabetes Care, September 2017. The article is comprehensive in regard to proper diagnosis, clinic vs. home BP measurements, target blood pressure values, life style modifications, pharmacological agent initiation and titration, and barriers to therapy.  Recommendations are listed below with slightly modified wording for easier and succinct reading:


2017 ADA Guidelines: Glucose Targets

Last ADA standards were published in January 2017. You could find below the recommended glucose aims for patients with type 1 and type 2 diabetes. Guidelines offer flexibility on A1c targets from <6.5-8.0% depending on person’s age, life expectancy, polypharmacy, disease duration, hypoglycemia frequency and comorbidities.