Be Aware of New Clinical Recommendations on Diabetes, Back Pain, PTSD, Amputation, Opioids

Diabetes Guidelines Don’t Include Specific Pharmacotherapy Advise

By Annette M. Boyle

WASHINGTON —The VA and DoD Evidence-Based Practice Work Group has recently released five updated clinical practice guidelines.

They cover common conditions such as Type 2 diabetes, which affects 25% of veterans, and lower back pain as well as post-traumatic stress disorder and lower limb amputation, which occur more frequently among individuals who have served in the military. In addition, the updates address the current state of research and understanding of the risks of opioid therapy for chronic pain.

The diabetes update differs from previous guidelines because it does not make explicit recommendations for pharmacotherapy.

“Because it is such a rapidly changing field, in a year or two the recommendations could be out of date,” explained James L. Sall, PhD, clinical program specialist, Evidence-Based Practice Program in the VA’s Office of Quality, Safety and Value. Instead, the guidelines encourage clinicians to “refer to the criteria for use published by the VA Pharmacy Benefits Management program and the Department of Defense Pharmacy and Therapeutics Committee.”

While recognizing that new medications and studies will be released during the lifetime of the guideline, the authors did make a few overarching recommendations for pharmacotherapy. They advised starting patients on insulin and non-pharmacological therapy if they have marked symptoms, ketosis, Type 1 diabetes or severe hyperglycemia. Metformin is recommended as a first-line agent in other circumstances unless there are contraindications. The guidelines also note that adding a second agent from another class is typically better than substituting a new agent as dual therapy reduces hyperglycemia through different mechanisms, although clinicians should be careful to combine drugs that have been tested and shown to work well together.

The update also makes strong new recommendations regarding the general approach to Type 2 diabetes care. “The diabetes update emphasized shared decision-making with patients. Research shows that when you involve the patient, while goals may not seem as aggressive, you have more success because the patient feels they have a bigger stake in the goals and in the long haul you have better management of the disease,” Sall told U.S. Medicine. The guideline also advises clinicians to offer patients ongoing self-management education “via various modalities tailored to their preferences, learning needs and abilities.”

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