By Eileen B. Wyner, NP
Bulfinch Medical Group

This week I want to finish reviewing the revisions to the ADA Standards of Care (click here to review Part 1). Please remember that these are guidelines.  Always review your personal health care plan with your health care providers

Immunizations

Many people associate immunizations with childhood, but there are several immunizations that are required throughout the lifespan. I reviewed these in the past (which you can find here), so today I will just address the ADA revisions. Annual influenza and appropriate pneumococcal vaccination is still strongly recommended for all people living with diabetes. Late in 2012 the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices decided to recommend vaccination against hepatitis B virus (HBV) for all people living with diabetes between 19 and 59 years old. People older than 60 are also considered vaccination candidates, but will first need to first be assessed by their providers as the immune response is sometimes decreased in seniors.

The CDC was prompted to make this recommendation after reviewing reports of outbreaks of HBV in long-term care facilities and hospitals where monitoring devices may have been shared by patients.  HBV is a highly contagious disease transmitted through contact with blood and infected bodily fluids. This virus can live for a long period of time on surfaces such as lancet devices, glucometers, and the reservoirs of insulin pens (even when there is no visible blood). This is the reason that these tools shouldn’t be shared with others.

Many people are vaccinated against HBV as this is a required childhood vaccine.  Many professions require this vaccine as well.  I suggest discussing this with your health care provider at your next appointment.

Blood Pressure Control

Well controlled blood pressure is imperative for people living with diabetes and this year the ADA changed their target goal for well controlled blood pressure to <140/<80 (previously <130/<80). This recommendation was developed after reviewing several randomized controlled trials published within the last 5 years demonstrating  little improvement in the reduction of cardiovascular events with the previous target.  Instances when a lower blood pressure goal is appropriate will be determined by the health care provider on an individual basis.

Retinopathy Screening and Treatment

The revised recommendations to this standard have to do with the treatment options for Diabetic Macular Edema (DME), a complication of long term and/or poorly controlled diabetes. DME occurs when damaged blood vessels in the eye leak fluid into the macula, causing swelling and blurry vision. Since 1985 the only treatment available for this condition was laser photocoagulation therapy, which could help reduce the risk of future visual loss but had no effect on damage that had already occurred. In August 2012 the FDA approved Ranibizumab (Lucentis), a medication that is given as a monthly eye injection, for DME treatment.  Studies have shown improvement in vision for people treated with this medication.

Lipid Management

Lowering LDL (“bad” cholesterol) levels with the use of statins has been well documented as a method to reduce cardiovascular events. However, many people have trouble tolerating these medications due to side effects. The ADA is advising  providers work with patients to find a dose or alternative statin  that is better tolerated as the benefits of this therapy is well proven. It is documented that very low, even less than daily, doses of statins can be beneficial.

Diabetes Care in the Hospitalized Patient

The ADA is recommending that patients admitted to the hospital may need some level of screening for diabetes. Providers should consider obtaining an A1C if there is no recent value available and/or  if the patient has any risk factors for diabetes and hyperglycemia while in the hospital.  In the latter case, follow up care needs to be set up to address these results.

There are several more updates and recommendations we did not touch on.  To view the full set of 2013 Clinical Practice Recommendations, click here.