For diabetes patients, practical recommendations would be:
- Start moderate-intensity statin therapy if:
- Young — age 20-39 with microvascular complications or long-standing DM.
- Older— age 40-75 without major risk factors.
- Start high-intensity statin ± ezetimibe if the following factors are present with the goal of reducing LDLc ≥50%:
- Multiple risk factors
- ASCVD 10YR ≥20%
- For adults >75, clinician-patient discussion is needed if statin were to be started or continued.
An approximate solidifying recommendation is:
- For patients with severe hypercholesterolemia defined by baseline LDLc ≥190 mg/dL; target LDLc is <100 mg/dL. To achieve this target, patients could receive the following medications in the following order: max statin ± ezetimibe ± BAS ± PCSK9 inhibitor.
- If baseline TGs >300 mg/dL, do not use BAS
- If baseline LDLc is very high, >220 (+30) mg/dL, then target LDLc could be <130 (+30) mg/dL
Below are listed the recommendations of how and when to measure baseline lipid levels. The main determinants are the expected triglyceride values, and family history of premature cardiovascular disease or genetic lipid disorders.
Although current guidelines are an honest attempt in reflecting complex medical evidence from clinical trials, they may not be very practical or user-friendly to general practitioners.
A simplified but reasonable approach to lipid management for secondary ASCVD prevention would be:
- Patients with established clinical ASCVD should achieve LDL-cholesterol <70 mg/dL by using statins ± ezetimibe ± PCSK9 inhibitors.
You can find here key changes in ADA guidelines. They are published in Diabetes Care once yearly in the month of January. Specific topics will be further discussed and posted here. Stay tuned!
This is an update of previous guidelines published in 2010.
We recommend T therapy for men with symptomatic T deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy and involving the patient in decision making.
We suggest that when clinicians institute T therapy, they aim at achieving T concentrations in the mid-normal range during treatment with any of the approved formulations.
Clinicians should monitor men receiving T therapy using a standardized plan that includes: evaluating symptoms, adverse effects, and compliance; measuring serum T and hematocrit concentrations; and evaluating prostate cancer risk during the first year after initiating T therapy.
Cardiovascular disease is the leading cause of death in the United States. Cholesterol anomaly, or dyslipidemia, is a major contributor to atherosclerosis morbidity and mortality. Multi-society new cholesterol guidelines were recently published. They were contributed and endorsed by ACC, AHA, ADA, and NLA, among other national associations. You can find below the key recommendations published in the journal of Circulation, November 2018.
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.
ADA standards are released each January. Here is a succinct ACP review of guidelines in screening, diagnosis, treatment goals, lifestyle intervention, and drug approach to hypertension in the setting of diabetes mellitus. The chart depicts nicely the flow process of how to initiate and intensify the pharmacological therapy.
This is a nice summary of the latest guidelines on diagnosis and management of mineral bone disease induced by chronic kidney disease. Kidney anomaly can be classified functionally via estimated GFR or structurally via proteinuria.
Guidelines emphasize the need for bone density scan, bone biopsy, parathyroid hormone, calcium and phosphorus measures in the right context. Vitamin D analogs and phosphate binders are also discussed. See below for detailed recommendations.
Unlike previous guidelines, the 2017 guideline emphasizes individualized cardiovascular risk assessment and aggressive management of blood pressure at levels of 140/90 mm Hg or higher in patients with a 10-year risk of cardiovascular events of >10%.
Absolute risk is an important determinant of the need for treatment. It’s reasonable to consider more aggressive treatment goals in the highest-risk patients, as SPRINT showed. But while a blood-pressure treatment target of <130/80 mmHg makes sense for high-risk patients, for everyone else it seems more reasonable to continue defining hypertension as a blood pressure of 140/90 mm Hg or higher.
- Normal BP: <120/80 mmHg
- Elevated BP “Pre HTN”: 120-130/<80
- Stage 1 HTN: 130-140/80-90
- Stage 2 HTN: >140/90
New targets for treatment:
- If ASCVD 10-year-risk is <10%, then target BP <140/90
- If ASCVD 10-year-risk is ≥10%, then target BP <130/80
- Established CVD
- AGE>65 and “healthy”