1. Getting to goal in Diabetes: reviewing the 2016 ADA standards of care Internal Medicine Grand Rounds 2/2/2016 Omar A. Vargas, MD FACP Associate Professor Department of Medicine Southern Illinois University-School of Medicine

2. 3 questions about Diabetes Should all patients be on Statins? What is the Blood Pressure goal? What is the A1C goal?

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6. 6 Main updates for 2016 Aspirin 81mg for women>50 and 1 other risk factor for CVD Statin/ezetimibe if ACS or intolerant to high intensity statin No longer use the term “diabetic”patient Nephropathy changed to diabetic kidney disease A1C goal in pregnancy changed

7. SHOULD ALL PATIENTS WITH DIABETES BE ON STATINS?

8. ADA 2015

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10. 10 AHA/ACC 2013 5

11. 11 Should all Diabetics be on Statins? All older than 40: YES Younger than 40 if high risk or overt CVD High Intensity v.s Moderate Intensity 6

12. 12 Should all Diabetics be on Statins? High intensity (>50% Reduction LDL) if: Overt CVD ASCVD > 7.5% (AHA) Multiple risk factors (ADA)

13. What is the blood pressure goal?

14. <140mmHg <90 mmHg systolic diastolic

15. JNC-8

16. 16 Copyright © 2015 AACE. May not be reprinted in any form without express written permission from AACE. Blood Pressure Targets AACE 2015 GUIDELINES ParameterTreatment Goal Blood pressure General target of: Systolic, mm Hg~130 Diastolic, mm Hg~80 A more intensive goal (such as <120/80 mm Hg) should be considered for some patients, provided the target can be safely reached without adverse effects from medication. More relaxed goals may be considered for patients with complicated comorbidities or those experience adverse medication effects.

17. KDIGO 2012

19. 19 What is the blood pressure goal for a diabetic? LOWER THAN 140/90 SEEMS REASONABLE FOR MOST PATIENTS LOWER THAN 130/80 SEEMS REASONABLE FOR DIABETICS WITH PROTEINURIA >30mg/gCr 3

20. 20 What is the A1C goal? 6

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23. 23 For older adults...

26. 26 What is the A1C goal? LOWER THAN 7% FOR MOST PATIENTS LOWER THAN 6.5% REASONABLE FOR YOUNG, HEALTHY WITHOUT DIABETIC COMPLICATIONS LOWER THAN 8% IF LIMITED LIFE EXPECTANCY, VASCULAR COMPLICATIONS, HYPOGLYCEMIA 3

27. 27 Screening for Diabetes Everybody at 45 years Overweight/obese with 1 more risk factor Asian-americans overweight if BMI>23 No test is preferred DO NOT use POC A1C for screening Check A1C 6 weeks after delivery if GDM Check q 3 years if h/o GDM

28. 28 If Prediabetes... Agressive lifestyle changes Focus on 7% weight loss as target Recheck once a year (at least) Metformin maybe if...Young, BMI>35, other features of metabolic syndrome

29. 29 Immunizations PPSV23 for all Hepatitis B for all 19-59 y/o All other vaccines as per CDC

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31. 31 Thank you...