Guideline/Drug Updates and Errata

• The combined assessment of COPD has been changed from an ABCD system to an ABE system, where the previous groups of C and D are combined into one new group (E). Any patient with elevated risk of exacerbations is included in group E.
• The recommendations for initial pharmacologic therapy have been modified to match the new ABE system. Initial treatment by group includes:
• Group A: a bronchodilator (SABA PRN, SAMA PRN, LABA or LAMA)
• Group B: dual therapy (LABA + LAMA)
• Group E: dual therapy (LABA + LAMA) or triple therapy (LABA + LAMA + ICS) if blood eosinophils are ≥ 300 µ/L
• The exacerbation pathway of the Escalation of Treatment algorithm has changed.
• If a patient has high eosinophils (≥ 300 µ/L), escalate to triple therapy (LABA + LAMA + ICS). Dual therapy with LABA + ICS is no longer recommended.
• If eosinophils are < 300 µ/L, escalate to dual bronchodilator therapy (LABA + LAMA).
• If further escalation is needed for patients on dual bronchodilator therapy, an ICS can be considered if eosinophils are ≥ 100 µ/L. There continues to be no role (no proven benefit) of ICS if eosinophils are < 100 µ/L.
• Adding on roflumilast or azithromycin can still be considered as a final step, regardless of eosinophil counts.

The 2023 American Diabetes Association (ADA) Standards of Care update was published. Key changes that could impact testing include:

p. 607: Comprehensive Care, section on Cholesterol Control

• Goal LDL targets are now:
• < 55 mg/dL for patients with ASCVD.
• < 70 mg/dL for patients with high ASCVD risk.
• If these goals are not met with a high-intensity statin (or maximally tolerated dose), add-on agents (ezetimibe or PCSK9 inhibitor) are recommended.

p. 607: Comprehensive Care, section on Diabetic Kidney Disease

• SGLT2 inhibitors are now recommended in patients with an eGFR ≥ 20 mL/min/1.73 m² to reduce CKD progression and cardiovascular events.
• Finerenone is recommended in patients with CKD + albuminuria (in addition to maximum tolerated doses of an ACE inhibitor or ARB and an SGLT2 inhibitor).

p. 607: Comprehensive Care, section on Blood Pressure Control

• Goal blood pressure is now < 130/80 mmHg for all patients.

p. 608: Treatment for Type 2 Diabetes and Treatment Algorithm

• GLP-1 agonists and SGLT2 inhibitors are first-line for cardiorenal comorbidities, with or without metformin (i.e., metformin does not need to be the first drug selected).
• Tirzepatide (Mounjaro), a GLP-1/GIP agonst, was added as a treatment option. It has high efficacy for both glycemic control and weight loss.