ADA suggests more aggressive lipid, BP and weight targets for diabetes patients in new guideline

USA: The American Diabetes Association (ADA), in a document published as a supplement in Diabetes Care, has suggested new, more aggressive targets for lipid and blood pressure. New guidelines include updates to recommendations around obesity, hypertension, heart failure medication, social determinants of health, and lipid management.

The changes were introduced in the annual ADA Standards of Care in Diabetes — 2023, considered the gold standard for the care of more than 100 million Americans with diabetes and prediabetes. The doctors can access the guidelines via an app. 

Now, a blood pressure (BP) target of less than 130/80 mmHg and low-density lipoprotein (LDL) cholesterol targets below 70 mg/dL or no greater than 55 mg/dL is advised for people with diabetes. The targets are dependent on the cardiovascular risk of the individuals. 

Other modifications for 2023 included a new emphasis on weight loss as a goal of therapy for type 2 diabetes; finerenone use in people with diabetes and CKD (chronic kidney disease); guidance for screening and evaluation of peripheral arterial disease for prevention of amputations; guidance on screening for food insecurity; and use of approved point-of-care A1c tests. 

The American College of Cardiology also endorses the cardiovascular disease and risk management section, which has been for the past six years. The new hypertension definition in diabetes patients is ≥ 130 mmHg systolic or ≥ 80 mmHg diastolic BP, repeated on two measurements at different times. Hypertension in patients with established cardiovascular disease can be diagnosed with one measurement of ≥ 180/110 mmHg. It reached safely, and the goal of treatment now is less than 130/80 mmHg. In 2012, the ADA's relaxation of the systolic target to 140 mmHg invited some controversy. 

There are also new lipid targets in the new Standards. For diabetes patients aged 40-75 years at increased cardiovascular (CV) risk, comprising those with one or more atherosclerotic risk factors. To reduce LDL cholesterol by 50% or more from baseline and to a target of less than 70 mg/dL high-intensity, statin therapy is recommended. This is in contrast to the previous target of 100 mg/dL. The document suggests adding a PCSK9 inhibitor or ezetimibe to maximally tolerated statin therapy to achieve that goal. 

For diabetes patients aged 40-75 having established cardiovascular disease, the document recommends high-intensity statin therapy with the target of a 50% or greater reduction from baseline and an LDL cholesterol level of 55 mg/dL or lower. This is in contrast to the previous 70 mg/dL. 

The lower goal than the previous recommendation is based on strong evidence in the literature. A strong recommendation is made for adding a PCSK9 inhibitor or ezetimibe to maximal statins. 

For diabetic people older than 75, the new Standards recommend continuing to take statins for those already on statins. For those who aren't, it may be reasonable to initiate moderate-intensity statin therapy after discussing the benefits and risks.

To access the full guideline, visit https://diabetesjournals.org/care/issue/46/Supplement_1.