February 1, 2014

2014 ADA Guidelines, My Perspective

This is an analysis from a patient's perspective. I am not saying I am right, but this is the way I read the 2014 ADA guidelines.

Even though I have read the summary of changes, I still see little difference between the 2013 and 2014 guidelines. At least this year there are no claims that testing has changed and apparently all the hoopla raised last year that resulted in no change in testing supply needs by insurance will get no more support. This just shows how much support people with diabetes will receive from the ADA.

Some minor changes were made for gestational diabetes diagnosis and more precise language was put in place for retinopathy exams from 2 to 3 years down to every two years. This is still too general for people above the age of 60. It ought to be every year and more often if any retinopathy is detected.

Other than this, you may read the summary of changes here. I would urge people to read the Medscape article by Dr. Anne Peters here and she covers the evolution of the ADA guidelines in more detail and while I can agree with her, I wish she would have pointed out more weaknesses.

I will quote her response to blood glucose testing for those of us on insulin. “Once you have diagnosed a patient with diabetes, you need to set treatment goals and make a treatment plan. That is fairly standard and is outlined in the standards of care. Somewhat different in the new guidelines is how often patients with diabetes should be monitoring their blood sugar levels.

Patients who are on multiple daily insulin injections or an insulin pump should be monitoring their blood sugar levels as frequently as they need to; in general, this is before meals and snacks, at bedtime, if they are going to drive, if they feel hypoglycemic, and from time to time after eating to get a sense of their postprandial glucose levels. The total is somewhere in the range of 4-10 times (typically 6-8 times) daily.

This frequency is often at variance with what patients are allowed in terms of test strips. I spend a great deal of time trying to get my brittle, older patients with type 1 diabetes the coverage for enough strips. It is important to fight for this because as they get older, people often develop more episodes of hypoglycemia, and we want our patients to have enough strips for testing.”

No one seems supportive of patients on oral diabetes medications and for him or her to be able to self-monitor their blood glucose levels. All anyone wants is to move them over to stronger medications and then to insulin if they HbA1c's trend upward. This may be the best course of treatment if they will not change the blood glucose testing requirements and recommend reduction of carbohydrates to a reasonable level.

No comments: