quinta-feira, 18 de setembro de 2008

rastreamento para diabetes em hipertensos

USPSTF Recommends Screening for Diabetes in Adults With Elevated Blood Pressure
Posted 09/11/2008
Richard Saitz, MD, MPH, FACP, FASAMAuthor Information
The U.S. Preventive Services Task Force (USPSTF) has been releasing new and updated guidelines periodically. The USPSTF grades each of its recommendations according to a system described on the USPSTF website.
In 2003, the USPSTF concluded that the evidence was insufficient to recommend screening asymptomatic adults for type 2 diabetes, but it did recommend diabetes screening for adults with hypertension or hyperlipidemia. In updated recommendations, the task force suggests screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or higher. Recommendation: B (the USPSTF recommends that clinicians provide this service). It also concludes that evidence still is insufficient to assess the benefits and harms of diabetes screening in adults with blood pressure lower than 135/80 mm Hg. Recommendation: I (evidence is insufficient to assess the balance of benefits and harms; if the service is offered [e.g., based on clinical considerations], patients should understand that uncertainty exists about benefits and harms).
The USPSTF guideline cites the American Diabetes Association recommendation that measurement of fasting plasma glucose (≥126 mg/dL, repeated for confirmation) be the test of choice for diagnosing diabetes. In an evidence review, the task force identified no studies that showed whether screening asymptomatic individuals for diabetes altered health outcomes. However, fair evidence suggests that lifestyle and pharmacologic interventions can slow progression of prediabetes to type 2 diabetes. Evidence also suggests that lowering blood pressure (even below conventional targets) lowers the occurrence of cardiovascular events among people with diabetes and hypertension. For people with diabetes, but without hypertension, intensive glycemic control attenuates progression of microvascular disease among those identified clinically, but whether early identification of diabetes by screening and early treatment provide a long-term benefit over waiting until clinical diagnosis occurs is unclear. The short-term harms of diabetes screening (e.g., anxiety) are small, although the USPSTF notes that harms associated with screening and labeling large segments of the population as having diabetes might be unknown.
The American Diabetes Association recommends diabetes screening in middle-aged or older people (>45) and screening in younger people who have risk factors. But recommendations from generalist organizations (e.g., American Academy of Family Physicians diabetes screening guideline) are similar to those of the USPSTF. So, should we screen for diabetes in adults who don´t have blood pressures of 135/80 mm Hg or higher? The best evidence suggests that we should not, unless it will make a difference in management (e.g., in decisions about lipid-lowering therapy) or unless symptoms of diabetes are evident

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