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ADA Evidence Grading System of Clinical Recommendations I. II. III. I,. ,. ,I. ,II. ,III. I0. 0. Classification and Diagnosis esting for Dia!etes in Asym"tomatic #atients Detection and Diagnosis of Gestational Dia!etes &ellit's (GD&) #revention-Delay of y"e $ Dia!etes Dia!etes Care #revention and &anagement of Dia!etes Com"lications Assessment of Common Comor!id Conditions Dia!etes Care in S"ecific #o"'lations Dia!etes Care in S"ecific Settings Strategies for Im"roving Dia!etes Care
Slide No.
3 4-11 1$-1% 1*-1+ $.-$$ $3-*4 *%-1./ 1.+-11. 111-131 13$-14. 141-14*
ADA Evi en!e "#a in$ S%ste& fo# Clini!al Re!o&&en ations
1evel of Evidence A Descri"tion Clear or s'""ortive evidence from ade2'ately "o3ered 3ell-cond'cted4 generali5a!le4 randomi5ed controlled trials Com"elling none6"erimental evidence 7 C S'""ortive evidence from 3ell-cond'cted co8ort st'dies or case-control st'dy S'""ortive evidence from "oorly controlled or 'ncontrolled st'dies Conflicting evidence 3it8 t8e 3eig8t of evidence s'""orting t8e recommendation E E6"ert consens's or clinical e6"erience
ADA. Diabetes Care $.1393*(s'""l 1):S1$9 a!le 1.
Classifi!ation of Diabetes
y"e 1 dia!etes
;-cell destr'ction
y"e $ dia!etes
#rogressive ins'lin secretory defect
AIn t8e a!sence of 'ne2'ivocal 8y"erglycemia4 res'lt s8o'ld !e confirmed !y re"eat testing. ADA. I. Classification and Diagnosis. Diabetes Care $.1393*(s'""l 1):S139 a!le $.
AIn t8e a!sence of 'ne2'ivocal 8y"erglycemia4 res'lt s8o'ld !e confirmed !y re"eat testing. ADA. I. Classification and Diagnosis. Diabetes Care $.1393*(s'""l 1):S139 a!le $.
AIn t8e a!sence of 'ne2'ivocal 8y"erglycemia4 res'lt s8o'ld !e confirmed !y re"eat testing. ADA. I. Classification and Diagnosis. Diabetes Care $.1393*(s'""l 1):S139 a!le $.
$-8 "lasma gl'cose in t8e @%-g <G 14.E1++ mg-d1 (@./E11.. mmol-1): IG
OR
A1C %.@E*.4>
A?or all t8ree tests4 risB is contin'o's4 e6tending !elo3 t8e lo3er limit of a range and !ecoming dis"ro"ortionately greater at 8ig8er ends of t8e range.
(7)
ADA. II. esting for Dia!etes in Asym"tomatic #atients. Diabetes Care $.1393*(s'""l 1):S13.
C#ite#ia fo# Testin$ fo# Diabetes in As%&-to&ati! A .lt In ivi .als /10
1. Testing should be considered in all adults who are overweight (BMI 25 kg/m2 ! and have additional risk "actors#
#8ysical inactivity ?irst-degree relative 3it8 dia!etes Dig8-risB race-et8nicity (e.g.4 African American4 1atino4 Native American4 Asian American4 #acific Islander) Comen 38o delivered a !a!y 3eig8ing G+ l! or 3ere diagnosed 3it8 GD& Dy"ertension (=14.-+. mmDg or on t8era"y for 8y"ertension)
AAt-risB 7&I may !e lo3er in some et8nic gro'"s. ADA. esting for Dia!etes in Asym"tomatic #atients. Diabetes Care $.1393*(s'""l 1):S149 a!le 4.
DD1 c8olesterol level H3% mg-d1 (..+. mmol-1) and-or a triglyceride level G$%. mg-d1 ($./$ mmol-1) Comen 3it8 "olycystic ovary syndrome (#C<S) A1C =%.@>4 IG 4 or I?G on "revio's testing <t8er clinical conditions associated 3it8 ins'lin resistance (e.g.4 severe o!esity4 acant8osis nigricans) Distory of C,D
C#ite#ia fo# Testin$ fo# Diabetes in As%&-to&ati! A .lt In ivi .als /20
2' In t8e a!sence of criteria (risB factors on "revio's slide)4 testing for dia!etes s8o'ld !egin at age 4% years 3' If res'lts are normal4 testing s8o'ld !e re"eated at least at 3-year intervals4 3it8 consideration of more fre2'ent testing de"ending on initial res'lts (e.g.4 t8ose 3it8 "redia!etes s8o'ld !e tested yearly)4 and risB stat's
ADA. esting for Dia!etes in Asym"tomatic #atients. Diabetes Care $.1393*(s'""l 1):S149 a!le 4.
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.1393*(s'""l 1):S1%.
?ollo3-'" co'nseling im"ortant for s'ccess (7) 7ased on cost-effectiveness of dia!etes "revention4 t8ird-"arty "ayers s8o'ld cover s'c8 "rograms (E)
In t8ose 3it8 "redia!etes4 monitor for develo"ment of dia!etes ann'ally (E) Screen for and treat modifia!le risB factors for C,D (7)
E &acrovasc'lar: CDD4 cere!rovasc'lar disease4 #AD E <t8er: "syc8osocial "ro!lemsA4 dental diseaseA
ASee a""ro"riate referrals for t8ese categories. ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@9 a!le @.
ASee a""ro"riate referrals for t8ese categories. ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@9 a!le @.
&anagement "lan s8o'ld recogni5e dia!etes self-management ed'cation (DS&E) and on-going dia!etes s'""ort
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@.
8ese estimates are !ased on ADAG data of L$4@.. gl'cose meas'rements over 3 mont8s "er A1C meas'rement in %.@ ad'lts 3it8 ty"e 14 ty"e $4 and no dia!etes. 8e correlation !et3een A1C and average gl'cose 3as ..+$. A calc'lator for converting A1C res'lts into estimated average gl'cose (eAG)4 in eit8er mg-d1 or mmol-14 is availa!le at 8tt":--"rofessional.dia!etes.org-eAG. ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1+9 a!le /.
Gerstein DC4 et al4 for t8e Action to Control Cardiovasc'lar RisB in Dia!etes St'dy Gro'". N Engl J Med $../93%/:$%4%-$%%+.
#atel A4 et al4. for t8e AD,ANCE Colla!orative Gro'". N Engl J Med $../93%/:$%*.-$%@$.
AIndivid'ali5e goals !ased on t8ese val'es. ;#ost"randial gl'cose meas'rements s8o'ld !e made 1E$ 8 after t8e !eginning of t8e meal4 generally "eaB levels in "atients 3it8 dia!etes. ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$19 a!le +.
7enefits s'stained at 4 years$ Do3ever4 trial 8alted after 11 years of follo3-'" !eca'se t8ere 3as no significant difference in "rimary cardiovasc'lar o'tcome !et3een 3eig8t loss4 standard care gro'"
14 $. 1ooB ADEAD Researc8 Gro'". Diabetes Care. $..@93.:13@4-13/3 and Arch Intern Med. $.1.91@.:1%**E1%@%9 8tt":--333.ni8.gov-ne3s-8ealt8-oct$.1$-niddB-1+.8tm.
&'lti"le dr'g t8era"y (t3o or more agents at ma6imal doses) generally re2'ired to ac8ieve 7# targets (7) Administer one or more anti8y"ertensive medications at !edtime (A)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S$+.
?or "atients at lo3er risB (e.g.4 3it8o't overt C,D4 H4. years of age) (C)
Consider statin t8era"y in addition to lifestyle t8era"y if 1D1 c8olesterol remains G1.. mg-d1 In t8ose 3it8 m'lti"le C,D risB factors
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S31.
riglyceride levels H1%. mg-d1 (1.@ mmol-1)4 DD1 c8olesterol G4. mg-d1 (1.. mmol-1) in men and G%. mg-d1 (1.3 mmol-1) in 3omen4 are desira!le (C)
Do3ever4 1D1 c8olesterolEtargeted statin t8era"y remains t8e "referred strategy (A)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S31.
A&ore or less stringent glycemic goals may !e a""ro"riate for individ'al "atients. Goals s8o'ld !e individ'ali5ed !ased on: d'ration of dia!etes4 age-life e6"ectancy4 comor!id conditions4 Bno3n C,D or advanced microvasc'lar com"lications4 8y"oglycemia 'na3areness4 and individ'al "atient considerations. M7ased on "atient c8aracteristics and res"onse to t8era"y4 8ig8er or lo3er systolic !lood "ress're targets may !e a""ro"riate. NIn individ'als 3it8 overt C,D4 a lo3er 1D1 c8olesterol goal of H@. mg-d1 (1./ mmol-1)4 'sing a 8ig8 dose of statin4 is an o"tion. ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S339 a!le 1..
In "atients in t8ese age gro'"s 3it8 m'lti"le ot8er risB factors (1.-year risB %E1.>)4 clinical K'dgment is re2'ired (E)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S33.
Com!ination t8era"y 3it8 as"irin (@%E1*$ mg-day) and clo"idogrel (@% mg-day)
Reasona!le for '" to a year after an ac'te coronary syndrome (7)
AIf not contraindicated. ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S34.
Red'ction of "rotein intaBe may im"rove meas'res of renal f'nction ('rine al!'min e6cretion rate4 G?R) (7)
o ../E1.. g-Bg !ody 3t "er day in t8ose 3it8 dia!etes4 earlier stages of CJD o ../ g-Bg !ody 3t "er day in later stages of CJD
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S34-S3%.
ADistorically4 ratios !et3een 3. and $++ 8ave !een called microal!'min'ria and t8ose 3.. or greater 8ave !een called macroal!'min'ria (or clinical al!'min'ria). ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%9 a!le 11.
Stage 1 $ 3 4 %
Descri"tion Jidney damageA 3it8 normal or increased G?R Jidney damageA 3it8 mildly decreased G?R &oderately decreased G?R Severely decreased G?R Jidney fail're
=>3 4 glomerular "iltration rate <idne+ damage de"ined as abnormalities on )athologic. urine. blood. or imaging tests' ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%-S3*9 a!le 1$.
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3@9 a!le 139 Ada"ted from 8tt":--333.Bidney.org-"rofessionals-JD<RI-g'idelineSdia!etes-.
C8ile retinal "8otogra"8y may serve as a screening tool for retino"at8y4 it is not a s'!stit'te for a com"re8ensive eye e6am
#erform com"re8ensive eye e6am at least initially and at intervals t8ereafter as recommended !y an eye care "rofessional (E)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3*.
&edications for relief of s"ecific sym"toms related to D#N4 a'tonomic ne'ro"at8y are recommended
Im"rove 2'ality of life of t8e "atient (E)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3@.
Refer "atients to foot care s"ecialists for ongoing "reventive care4 life-long s'rveillance (C)
SmoBers 1oss of "rotective sensation or str'ct'ral a!normalities Distory of "rior lo3er-e6tremity com"lications
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3/.
Refer "atients 3it8 significant cla'dication or a "ositive A7I for f'rt8er vasc'lar assessment (C)
Consider e6ercise4 medications4 s'rgical o"tions
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3/.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4.-S41.
Confirmed4 elevated ACR on t3o additional 'rine s"ecimens from different days
reat 3it8 an ACE in8i!itor4 titrated to normali5ation of al!'min e6cretion (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.
If target 7# is not reac8ed 3it8 3E* mont8s of lifestyle intervention4 consider "8armacologic treatment (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.
Goal of treatment
7lood "ress're consistently H13.-/. mmDg or !elo3 t8e +.t8 "ercentile for age4 se64 and 8eig8t4 38ic8ever is lo3er (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.
If 1D1 c8olesterol val'es are 3it8in acce"ted risB levels (H1.. mg-d1 U$.* mmol-1V)
Re"eat li"id "rofile every % years (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4$.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4$.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S43.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S44.
D'ring a "eriod of sta!le 8ealt84 diagnosis of C?RD can !e made in "atients 3it8 cystic fi!rosis according to 's'al gl'cose criteria (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4%.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4%.
ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4%.
&ore stringent targets may !e a""ro"riate in sta!le "atients 3it8 "revio's tig8t glycemic control 1ess stringent targets may !e a""ro"riate in t8ose 3it8 severe comor!idities (E)
ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4*.
ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4*.
If 8y"erglycemia is doc'mented and "ersistent4 consider treating s'c8 "atients to t8e same glycemic goals as "atients 3it8 Bno3n dia!etes (E)
ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4*.
#atients 3it8 8y"erglycemia 3it8o't a diagnosis of dia!etes: doc'ment "lans for follo3-'" testing and care at disc8arge (E)
ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4*.
ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4*.
ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4*.
ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1393*(s'""l 1):S4+-S%..
ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1393*(s'""l 1):S%..
Strategies incl'de
E6"licit goal setting 3it8 "atients Identifying and addressing !arriers to care Integrating evidence-!ased g'idelines Incor"orating care management teams
ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1393*(s'""l 1):S%..