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■ FIGURE 3. Glucose-lowering medication in type 2 diabetes: overall approach. For appropriate context, see Figure 1. CV, cardiovascular; CVOTs, cardiovascular outcomes trials; DPP-4i, dipeptidyl peptidase 4 inhibitor; GLP-1 RA, GLP-1 receptor agonist; HbA1c, glycated hemoglobin; HF, heart failure; SGLT2i, SGLT2 inhibitor; SU, sulfo-nylurea; TZD, thiazolidinedione. Adapted from Davies MJ, D’Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:2669–2701.
V O L U M E 3 7, N U M B E R 1 , W I N T E R 2 0 1 9 25
a b r i d g e d s ta n d a r d s o f c a r e 2019
3
■ FIGURE 4. Intensifying to injectable therapies. FRC, fixed-ratio combination; GLP-1 RA, GLP-1 receptor agonist; Hba1c, glycated hemoglobin; iDegLira, insulin degludec/liraglutide; iGlarLixi; insulin glargine/lixsenatide; max, maximum; PPG, postprandial glucose. Adapted from Davies MJ, D’Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:2669–2701.
Copyright 2014 American Medical Association. All rights reserved.
Figure. 2014 Hypertension Guideline Management Algorithm
Adult aged ≥18 years with hypertension
Select a drug treatment titration strategyA. Maximize first medication before adding second orB. Add second medication before reaching maximum dose of first medication orC. Start with 2 medication classes separately or as fixed-dose combination.
Reinforce medication and lifestyle adherence.For strategies A and B, add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB).For strategy C, titrate doses of initial medications to maximum.
Reinforce medication and lifestyle adherence.Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB).
Reinforce medication and lifestyle adherence.
Add additional medication class (eg, β-blocker, aldosterone antagonist, or others) and/or refer to physician with expertise in hypertension management.
Continue current treatment and monitoring.b
Black All racesNonblack
Age ≥60 years
Blood pressure goalSBP <150 mm HgDBP <90 mm Hg
Blood pressure goalSBP <140 mm HgDBP <90 mm Hg
Age <60 years
Blood pressure goalSBP <140 mm HgDBP <90 mm Hg
All agesDiabetes presentNo CKD
Blood pressure goalSBP <140 mm HgDBP <90 mm Hg
All agesCKD present with or without diabetes
At goal blood pressure?
No
Yes
At goal blood pressure?
No
Yes
At goal blood pressure?
No
Yes
YesNo
Initiate thiazide-type diuretic or CCB, alone or in combination.
Initiate thiazide-type diuretic or ACEI or ARB or CCB, alone or in combination.a
Initiate ACEI or ARB, aloneor in combination with other drug class.a
Set blood pressure goal and initiate blood pressure lowering-medication based on age, diabetes, and chronic kidney disease (CKD).
Implement lifestyle interventions(continue throughout management).
Diabetes or CKD presentGeneral population(no diabetes or CKD)
At goal blood pressure?
SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB,calcium channel blocker.
a ACEIs and ARBs should not be used in combination.bIf blood pressure fails to be maintained at goal, reenter the algorithm where
appropriate based on the current individual therapeutic plan.
Clinical Review & Education Special Communication 2014 Guideline for Management of High Blood Pressure
516 JAMA February 5, 2014 Volume 311, Number 5 jama.com
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 05/28/2019
GUIDELINES MADE SIMPLE 2018 Guideline on the Management of Blood CholesterolChol
7
Back to Table of Contents
This tool provides a broad overview of the 2018 Cholesterol Guideline.Please refer to the full guideline document for specific recommendations.
Overview of Primary and Secondary ASCVD Prevention
Y
Y N
N Y N
* Clinical ASCVD consists of acute coronary syndromes, those with history of myocardial infarction, stable or unstable angina or coronary other arterial revascularization, stroke, TIA, or peripheral artery disease including aortic aneurysm, all of atherosclerotic origin.
† Major ASCVD events: Recent ACS, history of MI, history of Ischemic stroke, symptomatic PAD; High-Risk Conditions: ≥65 y of age, heterozygous FH, hx of HF, prior CABG or PCI, DM, HTN, CKD, current smoking, persistently elevated LDL-C≥100 mg/dL.
‡ Risk Enhancers: Family history of premature ASCVD, persistently elevated LDL-C ≥160 mg/dl, chronic kidney disease,metabolic syndrome, conditions speci�c to women (e.g. pre-eclampsia, premature menopause), in�ammatory disease (especially psoriasis, RA, or HIV), ethnicity (e.g. South Asian ancestry), Lipid/biomarkers; persistently elevated triglycerides (≥175 mg/dL), if measured: hs-CRP ≥2.0 mg/L, Lp(a) levels ≥50 mg/dL or ≥125 nmol/l, apoB ≥130 mg/dL especially at higher levels of Lp(a), ABI <0.9.
EVAL
UATE
TH
ERAP
YTR
EATM
ENT
EXPE
CTAT
IONS
Secondary prevention(age 18+)
Primary prevention(age 40-75 y)
Clinical ASCVD*
History of multiple major ASCVD events
or1 major ASCVD event+ multiple high-risk
conditions†
LDL-C≥190 mg/dL
LDL-C70–189 mg/dL
LDL-C<70 mg/dL
Veryhigh risk ASCVD
StableASCVD
Maximaltolerated
statin
Maximaltolerated
statin
Assess lifetime
risk
High- ormoderate-intensity
statin
If LDL-C≥70 mg/dL:
Addingezetimibe isreasonable
If LDL-C≥70 mg/dL
or non-HDL-C
≥100 mg/dL:Adding
PCSK9-I is reasonable following
riskdiscussion
If high intensity
statin:Aim forLDL-C
lowering ≥50%
If moderate intensity
statin:Aim forLDL-C
lowering 30–49%
If LDL-C≥100 mg/dL:
Addingezetimibe isreasonable
If LDL-C ≥100 mg/dL:
PCSK9-Imay be
considered
Moderate-intensity
statin
Aim forLDL-C
lowering 30–49%
If multiple ASCVD risk
factors, 50-75 yof age: High
intensity statin
≥20%HighRisk
≥7.5 to <20%Intermediate
Risk
5 to <7.5%Borderline
Risk
<5%LowRisk
High-intensity
statin
Moderate- intensity
statin
Lifestyleand risk
discussion
Aim forLDL-C
lowering≥50%
Aim forLDL-C
lowering 30–49%
Evaluaterisk
enhancers‡ and coronary
artery calciumscore if
uncertain
Risk discussion for statin bene�t;use risk
enhancers‡
Assess 10-year ASCVD Risk to begin Risk Discussion
Diabetes
Lifestyle; selective moderate
statin
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