Results were inconsistent for changes in CVD risk factors such as systolic and diastolic blood pressure , total and low-density lipoprotein cholesterol , and hemoglobin A1C levels .
CONCLUSIONS CDSSs are effective in improving clinician practice s related to screening and other preventive care services , clinical tests , and treatments .
CONTEXT Clinical decision support systems ( CDSSs ) can help clinicians assess cardiovascular disease ( CVD ) risk and manage CVD risk factors by providing tailored assessment s and treatment recommendations based on individual patient data .
The goal of this systematic review was to examine the effectiveness of CDSSs in improving screening for CVD risk factors , practice s for CVD-related preventive care services such as clinical tests and prescribed treatments , and management of CVD risk factors .
Pharmacologic Therapy for Type 2 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes
The American Diabetes Association ( ADA ) first released its St and ards of Medical Care in Diabetes for health professionals in 1989 . These practice guidelines provide an extensive set of evidence -based recommendations that are up date d annually for the diagnosis and management of patients with diabetes . The 2017 St and ards cover all aspects of patient care ( 1 ) ; this guideline synopsis focuses on pharmacologic approaches for patients with type 2 diabetes . Guideline Development and Evidence Grading To develop the 2017 St and ards , the ADA Professional Practice Committee , which comprises physicians , adult and pediatric endocrinologists , diabetes educators , registered dietitians , epidemiologists , and public health experts , systematic ally search ed MEDLINE from 1 January 2016 ( date of last previous search ) to November 2016 . The committee revised recommendations based on the new evidence or , in some cases , to clarify prior ones or match the strength of the wording to the strength of the evidence . It also solicited feedback from the larger clinical community . The recommendations are rated as A , B , C , or E. Those with an A rating are based on large , well- design ed , multicenter clinical trials or high- quality meta-analyses . Recommendations with lower- quality evidence may be equally important and are based on well-conducted cohort studies ( B rating ) or uncontrolled studies ( C rating ) . Those assigned an E rating are consensus recommendations for which there is no evidence from clinical trials , in which clinical trials may be impractical , or in which there is conflicting evidence . The ADA funds development of the St and ards from its general revenues with no industry support or involvement . Details on the methodology , information about the committee members and their conflict-of-interest disclosures , and the complete St and ards can be downloaded at professional.diabetes.org/annals . Pharmacologic Therapy for Type 2 Diabetes : Recommendations Metformin , if not contraindicated and if tolerated , is the preferred initial pharmacologic agent for the treatment of type 2 diabetes ( A rating ) . Long-term use of metformin may be associated with biochemical vitamin B12 deficiency , and periodic measurement of vitamin B12 levels should be considered in patients treated with metformin , especially those with anemia or peripheral neuropathy ( B rating ) . Providers should consider initiating insulin therapy ( with or without additional agents ) in patients with newly diagnosed type 2 diabetes who are symptomatic , have a hemoglobin A1c ( HbA1c ) level of 10 % or greater , or have a blood glucose level of 16.7 mmol/L ( 300 mg/dL ) or greater ( E rating ) . If noninsulin monotherapy at the maximum tolerated dose does not achieve or maintain the HbA1c target after 3 months , adding a second oral agent , a glucagon-like peptide-1 (GLP-1)receptor agonist , or basal insulin should be considered ( A rating ) . For patients with type 2 diabetes who are not achieving glycemic goals , insulin therapy should be instituted without delay ( B rating ) . A patient-centered approach should be used to guide the choice of pharmacologic agents ( E rating ) . Initial Treatment Approach : Metformin Metformin monotherapy should be initiated at the time of diagnosis of type 2 diabetes for most patients unless there are contraindications . It is effective , safe , and inexpensive and may reduce the risk for cardiovascular events and death ( 2 ) . A large meta- analysis ( 3 ) supports the use of metformin monotherapy as first-line therapy . It may be safely used in patients with an estimated glomerular filtration rate as low as 30 mL/min/1.73 m2 ( 4 ) ; the U.S. label of metformin was recently revised to reflect its safety in patients with an estimated glomerular filtration rate of 30 mL/min/1.73 m2 or greater ( 5 ) . Gastrointestinal side effects are common in patients receiving metformin . In the authors ' experience , these side effects can be reduced if metformin monotherapy is started at a dose of 500 mg once or twice daily with food and titrated gradually to the maximum effective dose ( 2 g/d ) . Patients should be advised to stop taking their medication if they experience nausea , vomiting , or dehydration . The Diabetes Prevention Program Outcomes Study found that long-term users of metformin may develop vitamin B12 deficiency . Periodic testing of vitamin B12 levels should be considered in metformin users , especially those with anemia or peripheral neuropathy ( 6 ) . Using Pharmacotherapies Other Than or in Addition to Metformin If the patient does not tolerate or has a contraindication to metformin , another option should be considered . The ADA/European Association for the Study of Diabetes position statement ( 7 ) recommends a patient-centered approach , including assessment of efficacy , hypoglycemia risk , effect on weight , side effects , cost , and patient preferences . A table detailing characteristics of all available glucose-lowering agents in the United States that may guide individualized treatment choices is available in section 8 of the St and ards ( 8) . Tables 1 and 2 depict the costs of antihyperglycemic agents that were extracted from the Red Book ( 9 ) . With so many choices , patients and providers should be able to find a mutually agreeable treatment option . Table 1 . Median Monthly Cost of Maximum Approved Daily Dose of Noninsulin Glucose-Lowering Agents in the United States * Table 2 . Median Cost of Insulins  in the United States , Calculated as the AWP per 1000 Units of Specified Dosage Form/Product * For patients with an HbA1c level of 9 % or greater who are not acutely symptomatic , initiation of dual combination therapy ( Figure 1 ) should be considered to more quickly achieve the target HbA1c level . If the patient has a r and om glucose level of 16.7 mmol/L ( 300 mg/dL ) or greater or an HbA1c level of 10 % or greater and has acute symptoms of polyuria , polydipsia , or weight loss , combination therapy that includes insulin should be considered ( Figure 2 ) . Figure 1 . Antihyperglycemic therapy for type 2 diabetes : general recommendations . The order in the chart was determined by historical availability and the route of administration , with injectables to the right ; it is not meant to denote any specific preference . Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed , with the usual transition moving vertically from top to bottom ( although horizontal movement within therapy stages is also possible , depending on the circumstances ) . Adapted with permission from Inzucchi and colleagues ( 7 ) . DPP-4-i= dipeptidyl peptidase-4 inhibitor ; GI= gastrointestinal ; GLP-1-RA= glucagon-like peptide-1receptor agonist ; GU= genitourinary ; HbA1c= hemoglobin A1c ; HF= heart failure ; SGLT-2-i= sodiumglucose contransporter-2 inhibitor . * See Dieuzeide and colleagues ( 21 ) for description of efficacy and cost categorizations . Usually a basal insulin ( such as neutral protamine Hagedorn , glargine , detemir , or degludec ) . Figure 2 . Combination injectable therapy for type 2 diabetes . Adapted with permission from Inzucchi and colleagues ( 7 ) . GLP-1-RA= glucagon-like peptide-1receptor agonist ; HbA1c= hemoglobin A1c ; SMBG= self-monitored blood glucose . Assessing Response and Deciding to Intensify Therapy Providers should assess whether the HbA1c target has been achieved within approximately 3 months of therapy initiation ( Figure 1 ) ; if it has not , therapy should be intensified ( Figure 2 ) . They should use shared decision making and a patient-centered approach when selecting a second agent . Potential combination therapies include a sulfonylurea , thiazolidinedione , dipeptidyl peptidase-4 ( DPP-4 ) inhibitor , sodiumglucose contransporter-2 ( SGLT-2 ) inhibitor , GLP-1receptor agonist , or basal insulin . Insulin should also be considered as part of any combination regimen for patients with severe hyperglycemia , especially if symptoms or catabolic features ( such as weight loss or ketosis ) are present . Patients should be reassessed within 3 months for achievement of the HbA1c target . Recent Evidence From Cardiovascular Outcomes Trials Major cardiovascular outcomes trials have studied patients with type 2 diabetes and established cardiovascular disease , including EMPA-REG ( Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients ) ( 10 ) and the LEADER ( Liraglutide Effect and Action in Diabetes : Evaluation of Cardiovascular Outcome Results ) trial ( 11 ) . These 2 studies found that , compared with placebo and st and ard treatment , empagliflozin and liraglutide reduced composite outcomes for myocardial infa rct ion , stroke , and cardiovascular death in population s in which most , if not all , patients had established atherosclerotic cardiovascular disease . Whether other agents in the same class as empagliflozin and liraglutide have similar benefits , and whether the treatments benefit patients at lower risk for cardiovascular disease , is unknown . Cardiovascular outcomes trial data for the DPP-4 inhibitors sitagliptin ( 12 ) , saxagliptin ( 13 ) , and alogliptin ( 14 ) showed no statistically significant differences in rates of major cardiovascular events between treatment and placebo groups . Recent Warnings About Pharmacotherapies In May 2015 , the U.S. Food and Drug Administration ( FDA ) issued a warning that SGLT-2 inhibitors may lead to ketoacidosis in the absence of significant hyperglycemia ( termed euglycemic diabetic ketoacidosis ) . Patients who develop symptoms of ketoacidosis  , which may include dyspnea , nausea , vomiting , and abdominal pain  , should stop taking SGLT-2 inhibitors and immediately seek medical attention ( 15 ) . In April 2016 , the FDA also warned that the DPP-4 inhibitors saxagliptin and alogliptin may increase the risk for heart failure , especially in patients with preexisting heart failure or renal impairment ( 16 ) . Insulin Therapy Diabetes is a progressive condition , and many patients with type 2 diabetes eventually require and benefit from insulin therapy . Early patient education about expected disease progression
Results were inconsistent for changes in CVD risk factors such as systolic and diastolic blood pressure , total and low-density lipoprotein cholesterol , and hemoglobin A1C levels .
CONCLUSIONS CDSSs are effective in improving clinician practice s related to screening and other preventive care services , clinical tests , and treatments .
CONTEXT Clinical decision support systems ( CDSSs ) can help clinicians assess cardiovascular disease ( CVD ) risk and manage CVD risk factors by providing tailored assessment s and treatment recommendations based on individual patient data .
The goal of this systematic review was to examine the effectiveness of CDSSs in improving screening for CVD risk factors , practice s for CVD-related preventive care services such as clinical tests and prescribed treatments , and management of CVD risk factors .