FIGURE 3 . Glucose-lowering medication in type 2 diabetes ......based on age, diabetes, and chronic kidney disease (CKD). Implement lifestyle interventions (continue throughout management)

24

C

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ICA

L.D

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ET

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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


Age <60 years


All agesDiabetes presentNo CKD


All agesCKD present with or without diabetes

At goal blood pressure?

No

Yes


No

Yes


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)


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

Documents

FIGURE 3 . Glucose-lowering medication in type 2 diabetes ......based on age, diabetes, and chronic kidney disease (CKD). Implement lifestyle interventions (continue throughout management)