• Embed Doc
  • Copy Link
  • Readcast
  • Collections
  • CommentGo Back
Download
 
 
What’s
 
New 
 
Clinical 
 
Practice
 
Recommendations
 
2009
 
 American
 
Diabetes
 
 Association
 
The following are the changes in Clinical Practice Recommendations 2009:
 Revisions Additions
•
 
Testing for type 2 diabetes in children
•
 
Diabetes Prevention
•
 
Glucose Monitoring
•
 
Glycemic Control
 
•
 
Hypertension management
•
 
Dyslipidemia management
•
 
Antiplatelet agents
•
 
Coronary heart disease
•
 
Retinopathy
•
 
Neuropathy
•
 
Foot Care
•
 
Vaccination
•
 
Specific populations
•
 
Diabetes care in hospital
•
 
Bariatric Surgery Section
•
 
Discharge Planning Section
 Revisions 2009TESTING FOR TYPE 2 DIABETES IN CHILDREN:
•
 
In the "Testing for type 2 diabetes in children" section, small-for-gestational-age birthweight has been added to the list of conditions associated with insulin resistance.
•
 
Testing should begin at age 10 years or at onset of puberty, if puberty occurs at a youngerage, and should be repeated every 3 years.
DIABETES PREVENTION:
•
 
In the "Prevention/delay of type 2 diabetes" section, the recommendation has beenrevised to clarify that one-time counseling is not adequate.
•
 
Patients with impaired glucose tolerance or impaired fasting glucose should be referred toan effective ongoing support program for weight loss of 5–10% of body weight and forincreasing physical activity to at least 150 min per week of moderate activity such aswalking.
 
 
GLUCOSE MONITORING:
•
 
For patients using less frequent insulin injections, noninsulin therapies, or medicalnutrition therapy and physical therapy alone, self-monitoring of blood glucose (SMBG)may be useful as a guide to the success of therapy.
•
 
In the "Glucose monitoring" section, continuous glucose monitoring (CGM) has beenrevised with recommendations.
o
 
CGM in conjunction with intensive insulin regimens can be a useful tool to lowerA
1C
in selected adults (aged 25 years) with type 1 diabetes.
o
 
Although the evidence for A
1C
lowering is less strong in children, teens, andyounger adults, CGM may be helpful in these groups. Success correlates withadherence to ongoing use of the device.
o
 
CGM may be a supplemental tool to SMBG in those with hypoglycemiaunawareness and/or frequent hypoglycemic episodes.
•
 
Correlation of A
1C
with average glucose has been revised to reflect the correlation fromthe ADAG (A
1C
Derived Average Glucose) study as follows:
A
1C
(%)Mean Plasma Glucose
mg/dL mmol/L
6
126 7.0
7
154 8.6
8
183 10.2
9
212 11.8
10
240 13.4
11
269 14.9
12
298 16.5
GLYCEMIC CONTROL:
•
 
The "Glycemic control" section has been extensively revised based on new evidence andincludes the following recommendations.
o
 
Lowering A
1C
to below or around 7% has been shown to reduce microvascularand neuropathic complications of type 1 and type 2 diabetes. Therefore, formicrovascular disease prevention, the A
1C
goal for nonpregnant adults in generalis <7%.
o
 
In type 1 and type 2 diabetes, randomized controlled trials of intensive versusstandard glycemic control have not shown a significant reduction incardiovascular disease (CVD) outcomes during the randomized portion of thetrials. Long-term follow-up of the Diabetes Control and Complications Trial(DCCT) and the UK Prospective Diabetes Study (UKPDS) cohorts suggests thattreatment to A
1C
targets below or around 7% in the years soon after the diagnosisof diabetes is associated with long-term reduction in risk of macrovasculardisease. Until more evidence becomes available, the general goal of <7% appears
 
 
reasonable for many adults for macrovascular risk reduction.
o
 
Subgroup analyses of clinical trials such as the DCCT and UKPDS and themicrovascular evidence from the Action in Diabetes and Vascular Disease:Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial suggest asmall but incremental benefit in microvascular outcomes with A
1C
values closer tonormal. Therefore, for selected individual patients, providers might reasonablysuggest even lower A
1C
goals than the general goal of <7%, if this can beachieved without significant hypoglycemia or other adverse effects of treatment.Such patients might include those with short duration of diabetes, long lifeexpectancy, and no significant CVD.
o
 
Conversely, less stringent A
1C
goals than the general goal of <7% may beappropriate for patients with a history of severe hypoglycemia, limited lifeexpectancy, advanced micro- or macrovascular complications, and extensivecomorbid conditions and those with longstanding diabetes in whom the generalgoal is difficult to attain despite diabetes self-management education, appropriateglucose monitoring, and effective doses of multiple glucose-lowering agentsincluding insulin.
o
 
The level of evidence for a medical nutrition therapy recommendation has beenchanged.
 
Intake of 
trans
fat should be minimized. (Earlier recommendation wasbased on an expert consensus or clinical experience while the presentrecommendation has supportive evidence from a well-conducted cohortstudy).
HYPERTENSION MANAGEMENT:
•
 
Pharmacologic therapy for patients with diabetes and hypertension should be with a regimenthat includes either an ACE inhibitor or an angiotensin receptor blocker. If one class is nottolerated, the other should be substituted. If needed to achieve blood pressure targets, athiazide diuretic should be added to those with an estimated glomerular filtration rate (GFR)30 ml/min per 1.73 m
2
and a loop diuretic for those with an estimated GFR <30 ml/min per1.73 m
2
.
•
 
Glomerular filtration rate (GFR) cut points for use of thiazide or loop diuretics have beenrevised (see above).
DYSLIPIDEMIA/LIPID MANAGEMENT:
•
 
Several dyslipidemia recommendations have been revised.
o
 
If drug-treated patients do not reach the above targets on maximal tolerated statintherapy, a reduction in LDL cholesterol of 30–40% from baseline is an alternativetherapeutic goal. If targets are not reached on maximally tolerated doses of statins,combination therapy using statins and other lipid-lowering agents (e.g. niacin,fenofibrate, ezetimibe, and bile acid sequestrants) may be considered to achieve lipidtargets but have not been evaluated in outcome studies for either CVD outcomes orsafety.
of 00

Leave a Comment

You must be to leave a comment.
Submit
Characters: ...
You must be to leave a comment.
Submit
Characters: ...