The 2013 Standards of Care
A look at the changes to the type 2 treatment guidelines.
By Wil Dubois
There's a reason why Superman, Spiderman, Wonderwoman, and Zorro aren't physicians. It's not that they aren't smart enough. It's not that they don't care enough. It's that they just don't work well in teams.
Yeah, your doctor isn't the Lone Ranger. And thank goodness for that. The vast majority of modern healthcare providers, even the stubbornly independent ones, know that they can't know it all. To help guide themselves in making medical decisions, they often turn to a disease's Standards of Care.
Wait a sec, what are Standards of Care?
A Standard is a document of established evidence-based interventions, and best cutting-edge expert thought, on treating a given disease or condition that sets out for medical providers what works and what doesn't work. Standards also establish what the treatment targets are for the disease or condition in question.
For years, here in the USA, the American Diabetes Association (ADA) has published the Standards for treating diabetes. It's a living document. As new evidence emerges, the Standards evolve, and they're revised annually by the ADA's multidisciplinary Professional Practice Committee.
This year's Standards, formally called "Standards of Medical Care in Diabetes—2013," were published in January in Diabetes Care, the flagship professional publication for the D-Doc's organization. The Standards mainly provide the recommended treatment for type 2 diabetes, type 1 diabetes, and gestational diabetes; but they also cover a few oddball flavors of diabetes, such as drug-induced diabetes from the treatment of HIV/AIDS—as well as providing guidelines for diabetes treatment in hospitals, and in prisons!
It's a big, wide-ranging, 56-page document that covers everything from how to classify the various flavors of diabetes, to testing and screening, to pharmacological decision trees, to prevention and management of complications, and more. Even smoking and booze are included (drop the smokes and easy-does-it on the alcohol, says the ADA).
Today we'll focus on changes to the diabetes type 2 treatment guidelines for this year.
The big change
For years and years and years the ADA has advocated a one-size-fits all blood sugar target, most recently an A1C goal of less than seven for all type 2s. This year the organization took a sharp left turn, and is advocating personalized A1C targets.
What's your new target? Frankly, it depends on when your funeral is scheduled to be. In general, the older or sicker you are, the higher your A1C can be. The younger, healthier, and more recently diagnosed you are, the lower your A1C should be.
Personally, I've been an advocate of this approach for a long time. Life is too fuzzy to be one-size fits-all rigid. I remember years ago at the clinic I got a frantic call from a home health aide, "Mr. Gonzales is insisting we buy him candy bars! What should we do?" Now I happened to know that Mr. Gonzales was on hospice for aggressive cancer. His funeral was scheduled to be in the next six months. In those days everyone was supposed to have great diabetes control, no matter what, but I was pretty sure the cancer would get him before the diabetes did. "Buy him the candy bars," I told the aide. Standards be damned.
So it's nice to see some flexibility built into the new Standards, which now establish three targets for type 2 adults. For most people, it remains below or around 7%. For younger patients with shorter duration diabetes who don't have cardiovascular disease, 6.5% is the target, if it can be done without hypos. And lastly, around or below 8 for anyone who's not long for this earth, has severe hypos, or has advanced complications.
More test strips
The new Standards come out strongly in favor of increased home testing of blood sugar, especially by insulin users. The Standards clearly spell out that dFolks using both basal and fast-acting insulin should always test before every meal or snack, and "occasionally" after meals and before bedtime. Of course, testing when a low is suspected, and after treating lows, is recommended. The new Standards also state that we should test before we drive. This is a big increase over the previous standards, and is likely to force a change in how health plans currently ration test strips.
Some people have trained diabetes alert dogs that bark and lick their face in the middle of the night when their child is experiencing dangerously high or low blood sugars. I don't have a dog to wake me up. When I sleep past the alarm and forget to test my son's blood sugar, I turn to my go-to guy - a hallucinatory stone-faced murderer. Completely zonked hours after I wanted to wake up and check Charlie, I found myself walking along the...