2019 Guidelines on the management of diabetic patients. A position of Diabetes Poland

Abstract

The 2019 Diabetes Poland guidelines -summary of the most important changes Since 2005, the Diabetes Poland (PTD, Polskie Towarzystwo Diabetologiczne) prepares and publishes annually its guidelines on the management of diabetic patients.The idea of guideline development was first suggested in 2004 by Prof. Jacek Sieradzki who was the president of PTD at that time.The first chairperson of the PTD Guideline Writing Group was Prof. Władysław Grzeszczak who acted in this capacity in 2005-2011, followed by the next president of PTD, in 2011-2015, Prof. Leszek Czupryniak.The guidelines are a product of a team of nearly 50 experts representing numerous medical specialties.They cover multiple key aspects of clinical diabetes care.Guideline chapters were prepared by teams coordinated by their leaders.The goal of this expert teamwork and the resulting guideline publication is to improve prevention, diagnosis, and management of diabetes and its complications in Poland.The PTD guidelines reflect advances in diabetology, including new clinical and experimental study findings, epidemiological observations, and registry data.Thus, some modifications and novel aspects appear every year.However, as the guidelines have always been based on the principles of evidence-based medicine, only minor changes are required, related to new knowledge from reliable research with major implications for clinical practice. Summary of the most important changes to the 2019 PTD guidelinesIn Chapter 2, an updated review of studies of diabetes prevention or delaying its onset indicates that everyone benefits from increased physical activity, regardless of age; however, this intervention is most effective in people over 60.In Chapter 4, in setting therapeutic targets in diabetes, target blood pressure values has been changed from <140/90 mmHg to currently recommended general goal of <130/80 mmHg.It is recommended that in patients aged < 65 years systolic blood pressure should be maintained in the range of 120-129 mmHg, and in patients aged ≥ 65 years systolic blood pressure should be maintained in the range of 130-140 mmHg.In Chapter 5, recommendations for the organization of medical care for patients with diabetes have been updated.The changes implemented reflect joint opinion of diabetologists, family medicine specialists, pediatric diabetologists and endocrinologists as well as nurses and representatives of patient organizations.Chapter 6 has been updated according to the current knowledge.It has been emphasized that optimal weight reduction leading to measurable improvement in glycemic control should be at least 7%.All diabetic patients with overweight or obesity are advised to control portion sizes.Additionally, a recommendation has been included that vegetable fat should be preferred, with the exception of palm and coconut fat.For the first time, vitamin B12 supplementation has been recommended in patients in patients on long-term metformin therapy with confirmed vitamin B12 deficiency.In Chapter 7, recommendations regarding the diagnosis of depression (a condition that occurs frequently in diabetic patients and its presence adversely affects the treatment) include data from the psychometric assessment of the Polish version of the Patient Health Questionnaire PHQ-9 for adults.These data indicate that score > 12 indicates a high risk of depression episode (sensitivity 82%, specificity 89%).Only minor, mostly editorial, changes to clarify the message have been made in Chapter 8 on therapeutic education of patients with diabetes.The therapeutic team has been defined.Apart from the patient and his relatives, it includes a physician, nurse, diabetes educator, dietitian and psychologist.In chapter 9 on the management of adults with diabetes type 1, the results of clinical trials showing the benefits of SGLT-2 inhibitors in this group of patients were taken into account.Combining flozins with insulin therapy may lead to improved glycemic control and weight loss in patients with diabetes type 1.It should be emphasized, however, that SGLT-2 inhibitors have not yet been registered for the supportive treatment of type 1 diabetes.Their use may be associated with the risk of normoglycemic ketoacidosis, especially in the case of a significant reduction in the daily insulin dose.In Chapter 10, changes were made, taking into account the results of randomized clinical trials published last year and new recommendations of the American and European diabetic societies.Metformin remains the drug of choice in the first step of drug treatment.The choice of the drug in the second step should be made considering concomitant diseases, first of all the diagnosed cardiovascular disease and chronic kidney disease,