STANDARDS OF MEDICAL CARE IN DIABETES2013

Table of Contents
Section
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.

I' CLASSIFICATION AND DIA"NOSIS

Classifi!ation of Diabetes
y"e 1 dia!etes
;-cell destr'ction

y"e $ dia!etes
#rogressive ins'lin secretory defect

<t8er s"ecific ty"es of dia!etes

Genetic defects in ;-cell f'nction4 ins'lin action Diseases of t8e e6ocrine "ancreas Dr'g- or c8emical-ind'ced

Gestational dia!etes mellit's (GD&)

ADA. I. Classification and Diagnosis. Diabetes Care $.1393*(s'""l 1):S11.

C#ite#ia fo# t(e Dia$nosis of Diabetes

A1C =*.%>
OR

?asting "lasma gl'cose (?#G) =1$* mg-d1 (@.. mmol-1)

OR

$-8 "lasma gl'cose =$.. mg-d1 (11.1 mmol-1) d'ring an <G

OR

A random "lasma gl'cose =$.. mg-d1 (11.1 mmol-1)

ADA. I. Classification and Diagnosis. Diabetes Care $.1393*(s'""l 1):S139 a!le $.

C#ite#ia fo# t(e Dia$nosis of Diabetes

A1C =*.%> 8e test s8o'ld !e "erformed in a la!oratory 'sing a met8od t8at is NGS# certified and standardi5ed to t8e DCC assayA

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 $.

C#ite#ia fo# t(e Dia$nosis of Diabetes

?asting "lasma gl'cose (?#G) =1$* mg-d1 (@.. mmol-1) ?asting is defined as no caloric intaBe for at least / 8A

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 $.

C#ite#ia fo# t(e Dia$nosis of Diabetes

$-8 "lasma gl'cose =$.. mg-d1 (11.1 mmol-1) d'ring an <G 8e test s8o'ld !e "erformed as descri!ed !y t8e CD<4 'sing a gl'cose load containing t8e e2'ivalent of @% g an8ydro's gl'cose dissolved in 3aterA

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 $.

C#ite#ia fo# t(e Dia$nosis of Diabetes

In a "atient 3it8 classic sym"toms of 8y"erglycemia or 8y"erglycemic crisis4 a random "lasma gl'cose =$.. mg-d1 (11.1 mmol-1)

ADA. I. Classification and Diagnosis. Diabetes Care $.1393*(s'""l 1):S139 a!le $.

)#e iabetes* IF"+ I"T+ In!#ease A1C

Categories of increased risB for dia!etes ("redia!etes)A ?#G 1..E1$% mg-d1 (%.*E*.+ mmol-1): I?G
OR

$-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.

ADA. I. Classification and Diagnosis. Diabetes Care $.1393*(s'""l 1):S139 a!le 3.

II' TESTIN" FOR DIABETES IN AS,M)TOMATIC )ATIENTS

Re!o&&en ations* Testin$ fo# Diabetes in As%&-to&ati! )atients

Consider testing over3eig8t-o!ese ad'lts (7&I =$% Bg-m$) and 38o 8ave one or more additional risB factors
In t8ose 3it8o't risB factors4 !egin testing at age 4% years (7)

If tests are normal

Re"eat testing at least at 3-year intervals (E)

Fse A1C4 ?#G4 or $-8 @%-g <G In t8ose 3it8 "redia!etes

(7)

Identify and4 if a""ro"riate4 treat ot8er C,D risB factors (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.

III' DETECTION AND DIA"NOSIS OF "ESTATIONAL DIABETES MELLIT1S /"DM0

Re!o&&en ations* Dete!tion an Dia$nosis of "DM /10

Screen for 'ndiagnosed ty"e $ dia!etes at t8e first "renatal visit in t8ose 3it8 risB factors4 'sing standard diagnostic criteria (7) In "regnant 3omen not "revio'sly Bno3n to 8ave dia!etes4 screen for GD& at $4E$/ 3eeBsI gestation4 'sing a @%-g <G and s"ecific diagnostic c't "oints (7)

ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.1393*(s'""l 1):S1%.

Re!o&&en ations* Dete!tion an Dia$nosis of "DM /20

Screen 3omen 3it8 GD& for "ersistent dia!etes at *E1$ 3eeBs "ost"art'm4 'sing <G 4 non"regnancy diagnostic criteria (E) Comen 3it8 a 8istory of GD& s8o'ld 8ave lifelong screening for t8e develo"ment of dia!etes or "redia!etes at least every 3 years (7) Comen 3it8 a 8istory of GD& fo'nd to 8ave "redia!etes s8o'ld receive lifestyle interventions or metformin to "revent dia!etes (A)
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.1393*(s'""l 1):S1%.

S!#eenin$ fo# an Dia$nosis of "DM

#erform a @%-g <G 4 3it8 "lasma gl'cose meas'rement fasting and at 1 and $ 84 at $4E$/ 3eeBs of gestation in 3omen not "revio'sly diagnosed 3it8 overt dia!etes #erform <G in t8e morning after an overnig8t fast of at least / 8 GD& diagnosis: 38en any of t8e follo3ing "lasma gl'cose val'es are e6ceeded
E ?asting =+$ mg-d1 (%.1 mmol-1) E 1 8 =1/. mg-d1 (1... mmol-1) E $ 8 =1%3 mg-d1 (/.% mmol-1)
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.1393*(s'""l 1):S1%9 a!le *.

I2' )RE2ENTION3DELA, OF T,)E 2 DIABETES

Re!o&&en ations* )#evention3Dela% of T%-e 2 Diabetes

Refer "atients 3it8 IG (A)4 I?G (E)4 or A1C %.@E*.4> (E) to ongoing s'""ort "rogram
argeting 3eig8t loss of @> of !ody 3eig8t At least 1%. min-3eeB moderate "8ysical activity

?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)

ADA. I,. #revention-Delay of y"e $ Dia!etes. Diabetes Care $.1393*(s'""l 1):S1*.

Re!o&&en ations* )#evention3Dela% of T%-e 2 Diabetes

Consider metformin for "revention of ty"e $ dia!etes if IG (A)4 I?G (E)4 or A1C %.@E*.4> (E)
Es"ecially for t8ose 3it8 7&I G3% Bg-m$4 age H*. years4 and 3omen 3it8 "rior GD& (A)

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)

ADA. I,. #revention-Delay of y"e $ Dia!etes. Diabetes Care $.1393*(s'""l 1):S1*.

2' DIABETES CARE

Diabetes Ca#e* Initial Eval.ation

A com"lete medical eval'ation s8o'ld !e "erformed to
E Classify t8e dia!etes E Detect "resence of dia!etes com"lications E Revie3 "revio's treatment4 risB factor control in "atients 3it8 esta!lis8ed dia!etes E Assist in form'lating a management "lan E #rovide a !asis for contin'ing care

#erform la!oratory tests necessary to eval'ate eac8 "atientIs medical condition

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1*.

Co&-onents of t(e Co&-#e(ensive Diabetes Eval.ation /10

&edical 8istory (1) Age and c8aracteristics of onset of dia!etes (e.g.4 DJA4 asym"tomatic la!oratory finding) Eating "atterns4 "8ysical activity 8a!its4 n'tritional stat's4 and 3eig8t 8istory9 gro3t8 and develo"ment in c8ildren and adolescents Dia!etes ed'cation 8istory Revie3 of "revio's treatment regimens and res"onse to t8era"y (A1C records)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@9 a!le @.

Co&-onents of t(e Co&-#e(ensive Diabetes Eval.ation /20

&edical 8istory ($) C'rrent treatment of dia!etes4 incl'ding medications4 medication ad8erence and !arriers t8ereto4 meal "lan4 "8ysical activity "atterns4 and readiness for !e8avior c8ange Res'lts of gl'cose monitoring and "atientIs 'se of data DJA fre2'ency4 severity4 and ca'se Dy"oglycemic e"isodes
E Dy"oglycemia a3areness E Any severe 8y"oglycemia: fre2'ency and ca'se

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@9 a!le @.

Co&-onents of t(e Co&-#e(ensive Diabetes Eval.ation /30

&edical 8istory (3) Distory of dia!etes-related com"lications
E &icrovasc'lar: retino"at8y4 ne"8ro"at8y4 ne'ro"at8y
Sensory ne'ro"at8y4 incl'ding 8istory of foot lesions A'tonomic ne'ro"at8y4 incl'ding se6'al dysf'nction and gastro"aresis

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 @.

Co&-onents of t(e Co&-#e(ensive Diabetes Eval.ation /40

#8ysical e6amination (1) Deig8t4 3eig8t4 7&I 7lood "ress're determination4 incl'ding ort8ostatic meas'rements 38en indicated ?'ndosco"ic e6aminationA 8yroid "al"ation SBin e6amination (for acant8osis nigricans and ins'lin inKection sites)

ASee a""ro"riate referrals for t8ese categories. ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@9 a!le @.

Co&-onents of t(e Co&-#e(ensive Diabetes Eval.ation /50

#8ysical e6amination ($) Com"re8ensive foot e6amination
EIns"ection E #al"ation of dorsalis "edis and "osterior ti!ial "'lses E #resence-a!sence of "atellar and Ac8illes refle6es E Determination of "ro"rioce"tion4 vi!ration4 and monofilament sensation

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@9 a!le @.

Co&-onents of t(e Co&-#e(ensive Diabetes Eval.ation /60

1a!oratory eval'ation A1C4 if res'lts not availa!le 3it8in "ast $E3 mont8s If not "erformed-availa!le 3it8in "ast year
E ?asting li"id "rofile4 incl'ding total4 1D14 and DD1 c8olesterol and triglycerides E 1iver f'nction tests E est for 'rine al!'min e6cretion 3it8 s"ot 'rine al!'min-to-creatinine ratio E Ser'm creatinine and calc'lated G?R E 8yroid-stim'lating 8ormone in ty"e 1 dia!etes4 dysli"idemia4 or 3omen over age %. years
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@9 a!le @.

Co&-onents of t(e Co&-#e(ensive Diabetes Eval.ation /70

Referrals Eye care "rofessional for ann'al dilated eye e6am ?amily "lanning for 3omen of re"rod'ctive age Registered dietitian for &N Dia!etes self-management ed'cation Dentist for com"re8ensive "eriodontal e6amination &ental 8ealt8 "rofessional4 if needed

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@9 a!le @.

Diabetes Ca#e* Mana$e&ent

#eo"le 3it8 dia!etes s8o'ld receive medical care from a team t8at may incl'de
#8ysicians4 n'rse "ractitioners4 "8ysicianIs assistants4 n'rses4 dietitians4 "8armacists4 mental 8ealt8 "rofessionals In t8is colla!orative and integrated team a""roac84 essential t8at individ'als 3it8 dia!etes ass'me an active role in t8eir care

&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@.

Diabetes Ca#e* "l%!e&i! Cont#ol

3o "rimary tec8ni2'es availa!le for 8ealt8 "roviders and "atients to assess effectiveness of management "lan on glycemic control
#atient self-monitoring of !lood gl'cose (S&7G)4 or interstitial gl'cose A1C

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@.

Re!o&&en ations* "l.!ose Monito#in$ /10

#atients on m'lti"le-dose ins'lin (&DI) or ins'lin "'m" t8era"y s8o'ld do S&7G (7)
At least "rior to meals and snacBs <ccasionally "ost"randially At !edtime #rior to e6ercise C8en t8ey s's"ect lo3 !lood gl'cose After treating lo3 !lood gl'cose 'ntil t8ey are normoglycemic #rior to critical tasBs s'c8 as driving

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@.

Re!o&&en ations* "l.!ose Monito#in$ /20

C8en "rescri!ed as "art of a !roader ed'cational conte6t4 S&7G res'lts may !e 8el"f'l to g'ide treatment decisions and-or "atient self-management for "atients 'sing less fre2'ent ins'lin inKections or nonins'lin t8era"ies (E) C8en "rescri!ing S&7G4 ens're t8at "atients receive ongoing instr'ction and reg'lar eval'ation of S&7G tec8ni2'e and S&7G res'lts4 as 3ell as t8eir a!ility to 'se S&7G data to adK'st t8era"y (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1*.

Re!o&&en ations* "l.!ose Monito#in$ /30

Contin'o's gl'cose monitoring (CG&) 3it8 intensive ins'lin regimens 'sef'l tool to lo3er A1C in selected ad'lts (age =$% years) 3it8 ty"e 1 dia!etes (A) Evidence for A1C-lo3ering less strong in c8ildren4 teens4 and yo'nger ad'lts9 8o3ever4 CG& may !e 8el"f'l9 s'ccess correlates 3it8 ad8erence to device 'se (C) CG& may !e a s'""lemental tool to S&7G in t8ose 3it8 8y"oglycemia 'na3areness and-or fre2'ent 8y"oglycemic e"isodes (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@-S1/.

Re!o&&en ations* A1C

#erform A1C test at least t3ice yearly in "atients meeting treatment goals (and 8ave sta!le glycemic control) (E) #erform A1C test 2'arterly in "atients 38ose t8era"y 8as c8anged or 38o are not meeting glycemic goals (E) Fse of "oint-of-care (#<C) testing for A1C "rovides t8e o""ort'nity for more timely treatment c8anges (E)

ADA. ,. Dia!etes Care. Diabetes Care $.1$93%(s'""l 1):S1/.

Co##elation of A1C 8it( Ave#a$e "l.!ose /A"0

&ean "lasma gl'cose A1C (>) * @ / + 1. 11 1$ mg-d1 1$* 1%4 1/3 $1$ $4. $*+ $+/ mmol-1 @.. /.* 1..$ 11./ 13.4 14.+ 1*.%

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 /.

Re!o&&en ations* "l%!e&i! "oals in A .lts /10

1o3ering A1C to !elo3 or aro'nd @> 8as !een s8o3n to red'ce microvasc'lar com"lications and4 if im"lemented soon after t8e diagnosis of dia!etes4 is associated 3it8 long-term red'ction in macrovasc'lar disease (7) 8erefore4 a reasona!le A1C goal for many non"regnant ad'lts is H@> (7)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1+.

Re!o&&en ations* "l%!e&i! "oals in A .lts /20

#roviders mig8t reasona!ly s'ggest more stringent A1C goals (s'c8 as H*.%>) for selected individ'al "atients4 if t8is can !e ac8ieved 3it8o't significant 8y"oglycemia or ot8er adverse effects of treatment (C) A""ro"riate "atients mig8t incl'de t8ose 3it8 s8ort d'ration of dia!etes4 long life e6"ectancy4 and no significant C,D (C)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1+.

Re!o&&en ations* "l%!e&i! "oals in A .lts /30

1ess stringent A1C goals (s'c8 as H/>) may !e a""ro"riate for "atients 3it8 (7)
E Distory of severe 8y"oglycemia4 limited life e6"ectancy4 advanced microvasc'lar or macrovasc'lar com"lications4 e6tensive comor!id conditions E 8ose 3it8 longstanding dia!etes in 38om t8e general goal is diffic'lt to attain des"ite dia!etes self-management ed'cation4 a""ro"riate gl'cose monitoring4 and effective doses of m'lti"le gl'cose lo3ering agents incl'ding ins'lin

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1+.

Intensive "l%!e&i! Cont#ol an Ca# iovas!.la# O.t!o&es* ACCORD

*rimar+ ,utcome# -on"atal MI. non"atal stroke. /01 death
234%'5% (%'6&78'%9!

$2%%& New England Journal of Medicine' (sed with )ermission'

Gerstein DC4 et al4 for t8e Action to Control Cardiovasc'lar RisB in Dia!etes St'dy Gro'". N Engl J Med $../93%/:$%4%-$%%+.

Intensive "l%!e&i! Cont#ol an Ca# iovas!.la# O.t!o&es* AD2ANCE

*rimar+ ,utcome# Microvascular )lus macrovascular (non"atal MI. non"atal stroke. /01 death!
234%'5% (%'&27%'5&!

$2%%& New England Journal of Medicine' (sed with )ermission'

#atel A4 et al4. for t8e AD,ANCE Colla!orative Gro'". N Engl J Med $../93%/:$%*.-$%@$.

Intensive "l%!e&i! Cont#ol an Ca# iovas!.la# O.t!o&es* 2ADT

*rimar+ ,utcome# -on"atal MI. non"atal stroke. /01 death. hos)itali:ation "or heart "ailure. revasculari:ation
234%'&& (%'6978'%5!

$2%%5 New England Journal of Medicine' (sed with )ermission'

D'cB3ort8 C4 et al.4 for t8e ,AD Investigators. N Engl J Med $..+93*.:1$+-13+.

"l%!e&i! Re!o&&en ations fo# Non-#e$nant A .lts 8it( Diabetes /10

A1C #re"randial ca"illary "lasma gl'cose H@..>A @.E13. mg-d1A (3.+E@.$ mmol-1)

#eaB "ost"randial H1/. mg-d1A ca"illary "lasma gl'coseM (H1... mmol-1)

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 +.

"l%!e&i! Re!o&&en ations fo# Non-#e$nant A .lts 8it( Diabetes /20

Goals s8o'ld !e individ'ali5ed !ased on
ED'ration of dia!etes EAge-life e6"ectancy EComor!id conditions EJno3n C,D or advanced microvasc'lar com"lications EDy"oglycemia 'na3areness EIndivid'al "atient considerations

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$19 a!le +.

"l%!e&i! Re!o&&en ations fo# Non-#e$nant A .lts 8it( Diabetes /30

&ore or less stringent glycemic goals may !e a""ro"riate for individ'al "atients #ost"randial gl'cose may !e targeted if A1C goals are not met des"ite reac8ing "re"randial gl'cose goals

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$19 a!le +.

Re!o&&en ations* Ins.lin T(e#a-% fo# T%-e 1 Diabetes /10

&ost "eo"le 3it8 ty"e 1 dia!etes
S8o'ld !e treated 3it8 &DI inKections (3E4 inKections "er day of !asal and "randial ins'lin) or contin'o's s'!c'taneo's ins'lin inf'sion (CSII) (A) S8o'ld !e ed'cated in 8o3 to matc8 "randial ins'lin dose to car!o8ydrate intaBe4 "remeal !lood gl'cose4 and antici"ated activity (E)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$1.

Re!o&&en ations* Ins.lin T(e#a-% fo# T%-e 1 Diabetes /20

&ost "eo"le 3it8 ty"e 1 dia!etes s8o'ld 'se ins'lin analogs to red'ce 8y"oglycemia risB (A) Consider screening t8ose 3it8 ty"e 1 dia!etes for ot8er a'toimm'ne diseases (t8yroid4 vitamin 71$ deficiency4 celiac) as a""ro"riate (7)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$1.

Re!o&&en ations* T(e#a-% fo# T%-e 2 Diabetes /10

&etformin4 if not contraindicated and if tolerated4 is t8e "referred initial "8armacological agent for ty"e $ dia!etes (A) In ne3ly diagnosed ty"e $ dia!etic "atients 3it8 marBedly sym"tomatic and-or elevated !lood gl'cose levels or A1C4 consider ins'lin t8era"y4 3it8 or 3it8o't additional agents4 from t8e o'tset (E)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$$.

Re!o&&en ations* T(e#a-% fo# T%-e 2 Diabetes /20

If nonins'lin monot8era"y at ma6imal tolerated dose does not ac8ieve or maintain t8e A1C target over 3E* mont8s4 add a second oral agent4 a G1#-1 rece"tor agonist4 or ins'lin (A)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$$.

Re!o&&en ations* T(e#a-% fo# T%-e 2 Diabetes /30

A "atient-centered a""roac8 s8o'ld !e 'sed to g'ide c8oice of "8armacological agents9 considerations incl'de efficacy4 cost4 "otential side effects4 effects on 3eig8t4 comor!idities4 8y"oglycemia risB4 and "atient "references (E) D'e to t8e "rogressive nat're of ty"e $ dia!etes4 ins'lin t8era"y is event'ally indicated for many "atients 3it8 ty"e $ dia!etes (7)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$$.

Re!o&&en ations* Me i!al N.t#ition T(e#a-% /MNT0

Individ'als 38o 8ave "redia!etes or dia!etes s8o'ld receive individ'ali5ed &N as needed to ac8ieve treatment goals4 "refera!ly "rovided !y a registered dietitian familiar 3it8 t8e com"onents of dia!etes &N (A) 7eca'se &N can res'lt in cost-savings and im"roved o'tcomes (7)4 &N s8o'ld !e ade2'ately covered !y ins'rance and ot8er "ayers (E)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$$.

Loo9 A:EAD /A!tion fo# :ealt( in Diabetes0* T#ial :alte Ea#l%

Intensive lifestyle intervention res'lted in1
Average /.*> 3eig8t loss Significant red'ction of A1C Red'ction in several C,D risB factors

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.

Re!o&&en ations* Diabetes Self;Mana$e&ent E .!ation+ S.--o#t

#eo"le 3it8 dia!etes s8o'ld receive DS&E according to National Standards for Dia!etes Self-&anagement Ed'cation and S'""ort at diagnosis and as needed t8ereafter (7) Effective self-management4 2'ality of life are Bey o'tcomes of DS&E9 s8o'ld !e meas'red4 monitored as "art of care (C) DS&E s8o'ld address "syc8osocial iss'es4 since emotional 3ell-!eing is associated 3it8 "ositive o'tcomes (C)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$4.

Re!o&&en ations* Diabetes Self;Mana$e&ent E .!ation+ S.--o#t

DS&E and DS&S "rograms are a""ro"riate ven'es for "eo"le 3it8 "redia!etes to receive ed'cation and s'""ort to develo" and maintain !e8aviors t8at can "revent or delay t8e onset of dia!etes (C) 7eca'se DS&E can res'lt in cost-savings and im"roved o'tcomes (7)4 DS&E s8o'ld !e reim!'rsed !y t8ird-"arty "ayers (E)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$4.

Re!o&&en ations* )(%si!al A!tivit%

Advise "eo"le 3it8 dia!etes to "erform at least 1%. min-3eeB of moderate-intensity aero!ic "8ysical activity (%.E@.> of ma6im'm 8eart rate)4 s"read over at least 3 days "er 3eeB 3it8 no more t8an $ consec'tive days 3it8o't e6ercise (A) In a!sence of contraindications4 ad'lts 3it8 ty"e $ dia!etes s8o'ld !e enco'raged to "erform resistance training at least t3ice "er 3eeB (A)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$4.

Re!o&&en ations* )s%!(oso!ial Assess&ent an Ca#e

<ngoing "art of medical management of dia!etes (E) #syc8osocial screening-follo3-'": attit'des a!o't dia!etes4 medical management-o'tcomes e6"ectations4 affect-mood4 2'ality of life4 reso'rces4 "syc8iatric 8istory (E) C8en self-management is "oor4 screen for "syc8osocial "ro!lems: de"ression4 dia!etes-related an6iety4 eating disorders4 cognitive im"airment (7)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$%-S$*.

Re!o&&en ations* :%-o$l%!e&ia /10

Individ'als at risB for 8y"oglycemia s8o'ld !e asBed a!o't sym"tomatic and asym"tomatic 8y"oglycemia at eac8 enco'nter (C) Gl'cose (1%E$. g) "referred treatment for conscio's individ'al 3it8 8y"oglycemia (E) Gl'cagon s8o'ld !e "rescri!ed for all individ'als at significant risB of severe 8y"oglycemia and caregivers-family mem!ers instr'cted in administration (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$*.

Re!o&&en ations* :%-o$l%!e&ia /20

Dy"oglycemia 'na3areness or one or more e"isodes of severe 8y"oglycemia s8o'ld trigger re-eval'ation of t8e treatment regimen (E) Ins'lin-treated "atients 3it8 8y"oglycemia 'na3areness or an e"isode of severe 8y"oglycemia
Advised to raise glycemic targets to strictly avoid f'rt8er 8y"oglycemia for at least several 3eeBs4 to "artially reverse 8y"oglycemia 'na3areness4 and to red'ce risB of f't're e"isodes (A)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$*.

Re!o&&en ations* :%-o$l%!e&ia /30

<ngoing assessment of cognitive f'nction is s'ggested 3it8 increased vigilance for 8y"oglycemia !y t8e clinician4 "atient4 and caregivers if lo3 cognition and-or declining cognition is fo'nd (7)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$*.

Re!o&&en ations* Ba#iat#i! S.#$e#%

Consider !ariatric s'rgery for ad'lts 3it8 7&I =3% Bg-m$ and ty"e $ dia!etes (7) After s'rgery4 life-long lifestyle s'""ort and medical monitoring is necessary (7) Ins'fficient evidence to recommend s'rgery in "atients 3it8 7&I H3% Bg-m$ o'tside of a researc8 "rotocol (E) Cell-designed4 randomi5ed controlled trials com"aring o"timal medical-lifestyle t8era"y needed to determine long-term !enefits4 cost-effectiveness4 risBs (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$@.

Re!o&&en ations* I&&.ni<ation /10

#rovide infl'en5a vaccine ann'ally to all dia!etic "atients =* mont8s of age (C) Administer "ne'mococcal "olysacc8aride vaccine to all dia!etic "atients =$ years (C)
<ne-time revaccination recommended for t8ose G*4 years "revio'sly imm'ni5ed at H*% years if administered G% years ago <t8er indications for re"eat vaccination: ne"8rotic syndrome4 c8ronic renal disease4 imm'nocom"romised states

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$/.

Re!o&&en ations* I&&.ni<ation /20

Administer 8e"atitis 7 vaccination to 'nvaccinated ad'lts 3it8 dia!etes 38o are aged 1+ t8ro'g8 %+ years (C) Consider administering 8e"atitis 7 vaccination to 'nvaccinated ad'lts 3it8 dia!etes 38o are aged =*. years (C)

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$/.

2I' )RE2ENTION AND MANA"EMENT OF DIABETES COM)LICATIONS

Ca# iovas!.la# Disease /C2D0 in In ivi .als 8it( Diabetes

C,D is t8e maKor ca'se of mor!idity4 mortality for t8ose 3it8 dia!etes Common conditions coe6isting 3it8 ty"e $ dia!etes (e.g.4 8y"ertension4 dysli"idemia) are clear risB factors for C,D Dia!etes itself confers inde"endent risB 7enefits o!served 38en individ'al cardiovasc'lar risB factors are controlled to "revent-slo3 C,D in "eo"le 3it8 dia!etes
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S$/-$+.

Re!o&&en ations* :%-e#tension3Bloo )#ess.#e Cont#ol

Screening and diagnosis 7lood "ress're s8o'ld !e meas'red at every ro'tine visit #atients fo'nd to 8ave elevated !lood "ress're s8o'ld 8ave !lood "ress're confirmed on a se"arate day (7)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S$/-S$+.

Re!o&&en ations* :%-e#tension3Bloo )#ess.#e Cont#ol

Goals #eo"le 3it8 dia!etes and 8y"ertension s8o'ld !e treated to a systolic !lood "ress're goal of H14. mmDg (7) 1o3er systolic targets4 s'c8 as H13. mmDg4 may !e a""ro"riate for certain individ'als4 s'c8 as yo'nger "atients4 if it can !e ac8ieved 3it8o't 'nd'e treatment !'rden (C) #atients 3it8 dia!etes s8o'ld !e treated to a diastolic !lood "ress're H/. mmDg (7)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S$+.

Re!o&&en ations* :%-e#tension3Bloo )#ess.#e Cont#ol

reatment (1) #atients 3it8 a !lood "ress're (7#) G1$.-/. mmDg s8o'ld !e advised on lifestyle c8anges to red'ce 7# (7) #atients 3it8 confirmed 7# =14.-/. mmDg s8o'ld4 in addition to lifestyle t8era"y4 8ave "rom"t initiation and timely s'!se2'ent titration of "8armacological t8era"y to ac8ieve 7# goals (7)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S$+.

Re!o&&en ations* :%-e#tension3Bloo )#ess.#e Cont#ol

reatment ($) 1ifestyle t8era"y for elevated 7# (7)
Ceig8t loss if over3eig8t DASD-style dietary "attern incl'ding red'cing sodi'm4 increasing "otassi'm intaBe &oderation of alco8ol intaBe Increased "8ysical activity

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S$+.

Re!o&&en ations* :%-e#tension3Bloo )#ess.#e Cont#ol

reatment (3) #8armacological t8era"y for "atients 3it8 dia!etes and 8y"ertension (C)
A regimen t8at incl'des eit8er an ACE in8i!itor or angiotensin II rece"tor !locBer9 if one class is not tolerated4 s'!stit'te t8e ot8er

&'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 $.1393*(s'""l 1):S$+.

Re!o&&en ations* :%-e#tension3Bloo )#ess.#e Cont#ol

reatment (4) If ACE in8i!itors4 AR7s4 or di'retics are 'sed4 Bidney f'nction4 ser'm "otassi'm levels s8o'ld !e monitored (E) In "regnant "atients 3it8 dia!etes and c8ronic 8y"ertension4 !lood "ress're target goals of 11.E1$+-*%E@+ mmDg are s'ggested in interest of long-term maternal 8ealt8 and minimi5ing im"aired fetal gro3t89 ACE in8i!itors4 AR7s4 contraindicated d'ring "regnancy (E)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S$+.

Re!o&&en ations* D%sli-i e&ia3Li-i Mana$e&ent /10

Screening In most ad'lt "atients4 meas're fasting li"id "rofile at least ann'ally (7) In ad'lts 3it8 lo3-risB li"id val'es (1D1 c8olesterol H1.. mg-d14 DD1 c8olesterol G%. mg-d14 and triglycerides H1%. mg-d1)4 li"id assessments may !e re"eated every $ years (E)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S31.

Re!o&&en ations* D%sli-i e&ia3Li-i Mana$e&ent /20

reatment recommendations and goals (1) o im"rove li"id "rofile in "atients 3it8 dia!etes4 recommend lifestyle modification (A)4 foc'sing on
Red'ction of sat'rated fat4 trans fat4 c8olesterol intaBe Increased n-3 fatty acids4 visco's fi!er4 "lant stanols-sterols Ceig8t loss (if indicated) Increased "8ysical activity

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S31.

Re!o&&en ations* D%sli-i e&ia3Li-i Mana$e&ent /30

reatment recommendations and goals ($) Statin t8era"y s8o'ld !e added to lifestyle t8era"y4 regardless of !aseline li"id levels
3it8 overt C,D (A) 3it8o't C,D G4. years of age 38o 8ave one or more ot8er C,D risB factors (A)

?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.

Re!o&&en ations* D%sli-i e&ia3Li-i Mana$e&ent /40

reatment recommendations and goals (3) In individ'als 3it8o't overt C,D
#rimary goal is an 1D1 c8olesterol H1.. mg-d1 ($.* mmol-1) (7)

In individ'als 3it8 overt C,D

1o3er 1D1 c8olesterol goal of H@. mg-d1 (1./ mmol-1)4 'sing a 8ig8 dose of a statin4 is an o"tion (7)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S31.

Re!o&&en ations* D%sli-i e&ia3Li-i Mana$e&ent /50

reatment recommendations and goals (4) If targets not reac8ed on ma6imal tolerated statin t8era"y
Alternative t8era"e'tic goal: red'ce 1D1 c8olesterol L3.E4.> from !aseline (7)

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.

Re!o&&en ations* D%sli-i e&ia3Li-i Mana$e&ent /60

reatment recommendations and goals (%) Com!ination t8era"y 8as !een s8o3n not to "rovide additional cardiovasc'lar !enefit a!ove statin t8era"y alone and is not generally recommended (A) Statin t8era"y is contraindicated in "regnancy (7)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S31.

Re!o&&en ations* "l%!e&i!+ Bloo )#ess.#e+ Li-i Cont#ol in A .lts

A1C 7lood "ress're 1i"ids: 1D1 c8olesterol H@..>A H14.-/. mmDgM H1.. mg-d1 (H$.* mmol-1)N Statin t8era"y for t8ose 3it8 8istory of &I or age G4.O or ot8er risB factors

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..

Re!o&&en ations* Anti-latelet A$ents /10

Consider as"irin t8era"y (@%E1*$ mg-day) (C)
As a "rimary "revention strategy in t8ose 3it8 ty"e 1 or ty"e $ dia!etes at increased cardiovasc'lar risB (1.-year risB G1.>) Incl'des most men G%. years of age or 3omen G*. years of age 38o 8ave at least one additional maKor risB factor
?amily 8istory of C,D Dy"ertension SmoBing Dysli"idemia Al!'min'ria
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3$-S33.

Re!o&&en ations* Anti-latelet A$ents /20

As"irin s8o'ld not !e recommended for C,D "revention for ad'lts 3it8 dia!etes at lo3 C,D risB4 since "otential adverse effects from !leeding liBely offset "otential !enefits (C)
1.-year C,D risB H%>: men H%. and 3omen H*. years of age 3it8 no maKor additional C,D risB factors

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.

Re!o&&en ations* Anti-latelet A$ents /30

Fse as"irin t8era"y (@%E1*$ mg-day)
Secondary "revention strategy in t8ose 3it8 dia!etes 3it8 a 8istory of C,D (A)

?or "atients 3it8 C,D and doc'mented as"irin allergy

Clo"idogrel (@% mg-day) s8o'ld !e 'sed (7)

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)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S33-S34.

Re!o&&en ations* S&o9in$ Cessation

Advise all "atients not to smoBe or 'se to!acco "rod'cts (A) Incl'de smoBing cessation co'nseling and ot8er forms of treatment as a ro'tine com"onent of dia!etes care (7)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S34.

Re!o&&en ations* Co#ona#% :ea#t Disease S!#eenin$

In asym"tomatic "atients4 ro'tine screening for CAD is not recommended4 as it does not im"rove o'tcomes as long as C,D risB factors are treated (A)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S34.

Re!o&&en ations* Co#ona#% :ea#t Disease T#eat&ent /10

o red'ce risB of cardiovasc'lar events in "atients 3it8 Bno3n C,D4 consider
ACE in8i!itor (C) As"irinA (A) Statin t8era"yA (A)

In "atients 3it8 a "rior &I

;-!locBers s8o'ld !e contin'ed for at least $ years after t8e event (7)

AIf not contraindicated. ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S34.

Re!o&&en ations* Co#ona#% :ea#t Disease T#eat&ent /20

Avoid t8ia5olidinedione treatment in "atients 3it8 sym"tomatic 8eart fail're (C) &etformin 'se in "atients 3it8 sta!le CD?
Indicated if renal f'nction is normal (C) S8o'ld !e avoided in 'nsta!le or 8os"itali5ed "atients 3it8 CD? (C)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S34.

Re!o&&en ations* Ne-(#o-at(%

o red'ce t8e risB or slo3 t8e "rogression of ne"8ro"at8y
<"timi5e gl'cose control (A) <"timi5e !lood "ress're control (A)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S34-S3%.

Re!o&&en ations* Ne-(#o-at(% S!#eenin$

Assess 'rine al!'min e6cretion ann'ally (7)
In ty"e 1 dia!etic "atients 3it8 dia!etes d'ration of =% years In all ty"e $ dia!etic "atients at diagnosis

&eas're ser'm creatinine at least ann'ally (E)

In all ad'lts 3it8 dia!etes regardless of degree of 'rine al!'min e6cretion Ser'm creatinine s8o'ld !e 'sed to estimate G?R and stage level of c8ronic Bidney disease4 if "resent
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S34.

Re!o&&en ations* Ne-(#o-at(% T#eat&ent /10

Non"regnant "atient 3it8 modestly elevated (3.-$++ mg-day) (C) or 8ig8er levels (=3.. mg-day) (A) of 'rinary al!'min e6cretion
Fse eit8er ACE in8i!itors or AR7s

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%.

Re!o&&en ations* Ne-(#o-at(% T#eat&ent /20

C8en ACE in8i!itors4 AR7s4 or di'retics are 'sed4 monitor ser'm creatinine and "otassi'm levels for t8e develo"ment of increased creatinine or c8anges in "otassi'm (E) Reasona!le to contin'e monitoring 'rine al!'min e6cretion to assess !ot8 res"onse to t8era"y and disease "rogression (E) C8en estimated G?R is H*. m1-min1.@3 m$4 eval'ate and manage "otential com"lications of CJD (E)
ADA. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%.

Re!o&&en ations* Ne-(#o-at(% T#eat&ent /30

Consider referral to a "8ysician e6"erienced in care of Bidney disease (7)
Fncertainty a!o't etiology of Bidney disease Diffic'lt management iss'es Advanced Bidney disease

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%.

Definitions of Abno#&alities in Alb.&in E=!#etion

S"ot collection (Pg-mg creatinine) H3. =3.

Category Normal Increased 'rinary al!'min e6cretionA

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.

Sta$es of C(#oni! >i ne% Disease

G?R (m1-min "er 1.@3 m$ !ody s'rface area) =+. *.E/+ 3.E%+ 1%E$+ H1% or dialysis

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 $.1393*(s'""l 1):S3%-S3*9 a!le 1$.

Mana$e&ent of C>D in Diabetes /10

G?R All "atients 4%-*. Recommended Qearly meas'rement of creatinine4 'rinary al!'min e6cretion4 "otassi'm Referral to ne"8rology if "ossi!ility for nondia!etic Bidney disease e6ists Consider dose adK'stment of medications &onitor eG?R every * mont8s &onitor electrolytes4 !icar!onate4 8emoglo!in4 calci'm4 "8os"8or's4 "arat8yroid 8ormone at least yearly Ass're vitamin D s'fficiency Consider !one density testing Referral for dietary co'nselling
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-.

Mana$e&ent of C>D in Diabetes /20

G?R 3.-44 Recommended &onitor eG?R every 3 mont8s &onitor electrolytes4 !icar!onate4 calci'm4 "8os"8or's4 "arat8yroid 8ormone4 8emoglo!in4 al!'min 3eig8t every 3E* mont8s Consider need for dose adK'stment of medications H3. Referral to ne"8rologist

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-.

Re!o&&en ations* Retino-at(%

o red'ce t8e risB or slo3 t8e "rogression of retino"at8y
<"timi5e glycemic control (A) <"timi5e !lood "ress're control (A)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3*.

Re!o&&en ations* Retino-at(% S!#eenin$ /10

Initial dilated and com"re8ensive eye e6amination !y an o"8t8almologist or o"tometrist
Ad'lts and c8ildren aged 1. years or older 3it8 ty"e 1 dia!etes
Cit8in % years after dia!etes onset (7)

#atients 3it8 ty"e $ dia!etes

S8ortly after diagnosis of dia!etes (7)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%.

Re!o&&en ations* Retino-at(% S!#eenin$ /20

S'!se2'ent e6aminations for ty"e 1 and ty"e $ dia!etic "atients (7)
S8o'ld !e re"eated ann'ally !y an o"8t8almologist or o"tometrist

1ess fre2'ent e6ams (every $E3 years) (7)

&ay !e considered follo3ing one or more normal eye e6ams

&ore fre2'ent e6aminations re2'ired if retino"at8y is "rogressing (7)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%-S3*.

Re!o&&en ations* Retino-at(% S!#eenin$ /30

Dig8-2'ality f'nd's "8otogra"8s
Can detect most clinically significant dia!etic retino"at8y (E)

Inter"retation of t8e images

#erformed !y a trained eye care "rovider (E)

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*.

Re!o&&en ations* Retino-at(% S!#eenin$ /40

Comen 3it8 "ree6isting dia!etes 38o are "lanning "regnancy or 38o 8ave !ecome "regnant (7)
Com"re8ensive eye e6amination Co'nseled on risB of develo"ment and-or "rogression of dia!etic retino"at8y

Eye e6amination s8o'ld occ'r in t8e first trimester (7)

Close follo3-'" t8ro'g8o't "regnancy ?or 1 year "ost"art'm

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3*.

Re!o&&en ations* Retino-at(% T#eat&ent /10

#rom"tly refer "atients 3it8 any level of mac'lar edema4 severe N#DR4 or any #DR
o an o"8t8almologist Bno3ledgea!le and e6"erienced in management4 treatment of dia!etic retino"at8y (A)

1aser "8otocoag'lation t8era"y is indicated (A)

o red'ce risB of vision loss in "atients 3it8
Dig8-risB #DR Clinically significant mac'lar edema Some cases of severe N#DR

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3*.

Re!o&&en ations* Retino-at(% T#eat&ent /20

Anti-vasc'lar endot8elial gro3t8 factor (,EG?) t8era"y is indicated for dia!etic mac'lar edema (A) #resence of retino"at8y
Not a contraindication to as"irin t8era"y for cardio"rotection4 as t8is t8era"y does not increase t8e risB of retinal 8emorr8age (A)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3*.

Re!o&&en ations* Ne.#o-at(% S!#eenin$+ T#eat&ent /10

All "atients s8o'ld !e screened for distal symmetric "olyne'ro"at8y (D#N) (7)
At diagnosis of ty"e $ dia!etes and % years after diagnosis of ty"e 1 dia!etes At least ann'ally t8ereafter 'sing sim"le clinical tests

Electro"8ysiological testing rarely needed

E6ce"t in sit'ations 38ere clinical feat'res are aty"ical (E)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3@.

Re!o&&en ations* Ne.#o-at(% S!#eenin$+ T#eat&ent /20

Screening for signs and sym"toms of cardiovasc'lar a'tonomic ne'ro"at8y
S8o'ld !e instit'ted at diagnosis of ty"e $ dia!etes and % years after t8e diagnosis of ty"e 1 dia!etes S"ecial testing rarely needed9 may not affect management or o'tcomes (E)

&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@.

Re!o&&en ations* Foot Ca#e /10

?or all "atients 3it8 dia!etes4 "erform an ann'al com"re8ensive foot e6amination to identify risB factors "redictive of 'lcers and am"'tations (7)
Ins"ection Assessment of foot "'lses est for loss of "rotective sensation: 1.-g monofilament "l's testing any one of
,i!ration 'sing 1$/-D5 t'ning forB #in"ricB sensation AnBle refle6es ,i!ration "erce"tion t8res8old
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3/.

Re!o&&en ations* Foot Ca#e /20

1--e# -anel o "erform t8e 1.-g monofilament test4 "lace t8e device "er"endic'lar to t8e sBin4 3it8 "ress're a""lied 'ntil t8e monofilament !'cBles Dold in "lace for 1 second and t8en release Lo8e# -anel 8e monofilament test s8o'ld !e "erformed at t8e 8ig8lig8ted sites 38ile t8e "atientIs eyes are closed
7o'lton AT&4 et al. Diabetes Care. $../931:1*@+-1*/%.

Re!o&&en ations* Foot Ca#e /30

#rovide general foot self-care ed'cation (7) Fse m'ltidisci"linary a""roac8
Individ'als 3it8 foot 'lcers4 8ig8-risB feet9 es"ecially "rior 'lcer or am"'tation (7)

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/.

Re!o&&en ations* Foot Ca#e /40

Initial screening for "eri"8eral arterial disease (#AD) (C)
Incl'de a 8istory for cla'dication4 assessment of "edal "'lses Consider o!taining an anBle-!rac8ial inde6 (A7I)9 many "atients 3it8 #AD are asym"tomatic

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/.

2II' ASSESSMENT OF COMMON COMORBID CONDITIONS

Re!o&&en ations* Assess&ent of Co&&on Co&o#bi Con itions

?or "atients 3it8 risB factors4 signs or sym"toms4 consider assessment and treatment for common dia!etes-associated conditions (7) Common comor!idities for 38ic8 increased risB is associated 3it8 dia!etes
Dearing im"airment <!str'ctive slee" a"nea ?atty liver disease 1o3 testosterone in men #eriodontal disease
ADA. ,II. Assessment of Common Comor!id Conditions. Diabetes Care. $.1393*(s'""l 1):S3+9 a!le 14.

Certain cancers ?ract'res Cognitive im"airment De"ression

2III' DIABETES CARE IN S)ECIFIC )O)1LATIONS

Re!o&&en ations* )e iat#i! "l%!e&i! Cont#ol /T%-e 1 Diabetes0

As is t8e case for all c8ildren4 c8ildren 3it8 dia!etes or "redia!etes s8o'ld !e enco'raged to engage in at least *. min'tes of "8ysical activity eac8 day (7) Consider age 38en setting glycemic goals in c8ildren and adolescents 3it8 ty"e 1 dia!etes (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4.-S41.

Re!o&&en ations* )e iat#i! Ne-(#o-at(% /T%-e 1 Diabetes0

Ann'al screening for microal!'min'ria4 3it8 a random s"ot 'rine sam"le for al!'min-to-creatinine (ACR) ratio (7)
Consider once c8ild is 1. years of age and 8as 8ad dia!etes for % years

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.

Re!o&&en ations* )e iat#i! :%-e#tension /T%-e 1 Diabetes0 /10

&eas're !lood "ress're (7#) at eac8 ro'tine visit9 confirm 8ig8-normal 7# or 8y"ertension on a se"arate day (7) reat 8ig8-normal 7# (systolic or diastolic consistently a!ove +.t8 "ercentile for age4 se64 and 8eig8t) 3it8
Dietary intervention9 e6ercise aimed at 3eig8t control and increased "8ysical activity

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.

Re!o&&en ations* )e iat#i! :%-e#tension /T%-e 1 Diabetes0 /20

#8armacologic treatment of 8y"ertension
Systolic or diastolic !lood "ress're consistently a!ove t8e +%t8 "ercentile for age4 se64 and 8eig8t Or Consistently G13.-/. mmDg4 if +%> e6ceeds t8at val'e

Initiate treatment as soon as diagnosis is confirmed (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.

Re!o&&en ations* )e iat#i! :%-e#tension /T%-e 1 Diabetes0 /30

ACE in8i!itors
Consider for initial treatment of 8y"ertension4 follo3ing a""ro"riate re"rod'ctive co'nseling d'e to "otential teratogenic effects (E)

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.

Re!o&&en ations* )e iat#i! D%sli-i e&ia /T%-e 1 Diabetes0 /10

Screening (1) If family 8istory of 8y"erc8olesterolemia or a cardiovasc'lar event !efore age %% years4 or if family 8istory is 'nBno3n
#erform fasting li"id "rofile on c8ildren G$ years of age soon after diagnosis (after gl'cose control 8as !een esta!lis8ed)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.

Re!o&&en ations* )e iat#i! D%sli-i e&ia /T%-e 1 Diabetes0 /20

Screening ($) If family 8istory is not of concern
Consider first li"id screening at "'!erty (=1. years) (E)

All c8ildren diagnosed 3it8 dia!etes at or after "'!erty

#erform fasting li"id "rofile soon after diagnosis (after gl'cose control 8as !een esta!lis8ed) (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.

Re!o&&en ations* )e iat#i! D%sli-i e&ia /T%-e 1 Diabetes0 /30

Screening (3) ?or !ot8 age-gro'"s4 if li"ids are a!normal
Ann'al monitoring is reasona!le

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.

Re!o&&en ations* )e iat#i! D%sli-i e&ia /T%-e 1 Diabetes0 /40

reatment Initial t8era"y: o"timi5e gl'cose control4 &N 'sing Ste" $ ADA diet aimed at decreasing dietary sat'rated fat (E) G age 1. years4 statin reasona!le in t8ose (after &N and lifestyle c8anges) 3it8
1D1 c8olesterol G1*. mg-d1 (4.1 mmol-1) or 1D1 c8olesterol G13. mg-d1 (3.4 mmol-1) and one or more C,D risB factors (E)

Goal: 1D1 c8olesterol H1.. mg-d1 ($.* mmol-1) (E)

&N Wmedical n'trition t8era"y ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.

Re!o&&en ations* )e iat#i! Retino-at(% /T%-e 1 Diabetes0

?irst o"8t8almologic e6amination
<!tain once c8ild is =1. years of age9 8as 8ad dia!etes for 3E% years (7)

After initial e6amination

Ann'al ro'tine follo3-'" generally recommended 1ess fre2'ent e6aminations may !e acce"ta!le on advice of an eye care "rofessional (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4$.

Re!o&&en ations* )e iat#i! Celia! Disease /T%-e 1 Diabetes0 /10

C8ildren 3it8 ty"e 1 dia!etes
Screen for celiac disease !y meas'ring tiss'e transgl'taminase or antiendomysial anti!odies4 3it8 doc'mentation of normal total ser'm IgA levels4 soon after t8e diagnosis of dia!etes (E)

Re"eat testing in c8ildren 3it8

Gro3t8 fail're ?ail're to gain 3eig8t4 3eig8t loss Diarr8ea4 flat'lence4 a!dominal "ain4 or signs of mala!sor"tion ?re2'ent 'ne6"lained 8y"oglycemia or deterioration in glycemic control (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4$.

Re!o&&en ations* )e iat#i! Celia! Disease /T%-e 1 Diabetes0 /20

Asym"tomatic c8ildren 3it8 "ositive anti!odies
Refer to a gastroenterologist for eval'ation 3it8 "ossi!le endosco"y and !io"sy (E)

C8ildren 3it8 !io"sy-confirmed celiac disease

#lace on a gl'ten-free diet Cons'lt 3it8 a dietitian e6"erienced in managing !ot8 dia!etes and celiac disease (7)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4$.

Re!o&&en ations* )e iat#i! :%-ot(%#oi is& /T%-e 1 Diabetes0

C8ildren 3it8 ty"e 1 dia!etes
Screen for t8yroid "ero6idase4 t8yroglo!'lin anti!odies soon after diagnosis (E)

8yroid-stim'lating 8ormone ( SD) concentrations

&eas're after meta!olic control esta!lis8ed
If normal4 rec8ecB every 1E$ years9 or If "atient develo"s sym"toms of t8yroid dysf'nction4 t8yromegaly4 or an a!normal gro3t8 rate (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S43.

Re!o&&en ations* T#ansition f#o& )e iat#i! to A .lt Ca#e

As teens transition into emerging ad'lt8ood4 8ealt8 care "roviders and families m'st recogni5e t8eir many v'lnera!ilities (7) and "re"are t8e develo"ing teen4 !eginning in early to mid adolescence and at least 1 year "rior to t8e transition (E) 7ot8 "ediatricians and ad'lt 8ealt8 care "roviders s8o'ld assist in "roviding s'""ort and linBs to reso'rces for t8e teen and emerging ad'lt (7)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S43.

Re!o&&en ations* )#e!on!e-tion Ca#e /10

A1C levels s8o'ld !e as close to normal as "ossi!le (@>) in an individ'al "atient !efore conce"tion is attem"ted (7) Starting at "'!erty4 incor"orate "reconce"tion co'nseling in ro'tine dia!etes clinic visit for all 3omen of c8ild!earing "otential (C) Comen 3it8 dia!etes contem"lating "regnancy s8o'ld !e eval'ated and4 if indicated4 treated for dia!etic retino"at8y4 ne"8ro"at8y4 ne'ro"at8y4 C,D (7)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S44.

Re!o&&en ations* )#e!on!e-tion Ca#e /20

&edications s8o'ld !e eval'ated "rior to conce"tion4 since dr'gs commonly 'sed to treat dia!etes and its com"lications may !e contraindicated or not recommended in "regnancy4 incl'ding statins4 ACE in8i!itors4 AR7s4 and most nonins'lin t8era"ies (E) Since many "regnancies are 'n"lanned4 consider "otential risBs-!enefits of medications contraindicated in "regnancy in all 3omen of c8ild!earing "otential9 co'nsel accordingly (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S44.

Re!o&&en ations* Ol e# A .lts /10

?'nctional4 cognitively intact older ad'lts 3it8 significant life e6"ectancies s8o'ld receive dia!etes care 'sing goals develo"ed for yo'nger ad'lts (E) Glycemic goals for t8ose not meeting t8e a!ove criteria may !e rela6ed 'sing individ'al criteria4 !'t 8y"erglycemia leading to sym"toms or risB of ac'te 8y"erglycemic com"lications s8o'ld !e avoided in all "atients (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S44.

Re!o&&en ations* Ol e# A .lts /20

reat ot8er cardiovasc'lar risB factors 3it8 consideration of t8e time frame of !enefit and t8e individ'al "atient (E) reatment of 8y"ertension is indicated in virt'ally all older ad'lts9 li"id4 as"irin t8era"y may !enefit t8ose 3it8 life e6"ectancy e2'al to time frame of "rimary-secondary "revention trials (E) Individ'ali5e screening for dia!etes com"lications 3it8 attention to t8ose leading to f'nctional im"airment (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S44.

Re!o&&en ations* C%sti! Fib#osis; Relate Diabetes /CFRD0 /10

Ann'al screening for C?RD 3it8 <G s8o'ld !egin !y age 1. years in all "atients 3it8 cystic fi!rosis 38o do not 8ave C?RD (7)
Fse of A1C as a screening test for C?RD is not recommended (7)

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%.

Re!o&&en ations* C%sti! Fib#osis; Relate Diabetes /CFRD0 /20

#atients 3it8 C?RD s8o'ld !e treated 3it8 ins'lin to attain individ'ali5ed glycemic goals (A) Ann'al monitoring for com"lications of dia!etes is recommended4 !eginning % years after t8e diagnosis of C?RD (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4%.

I?' DIABETES CARE IN S)ECIFIC SETTIN"S

Re!o&&en ations* Diabetes Ca#e in t(e :os-ital /10

All "atients 3it8 dia!etes admitted to t8e 8os"ital s8o'ld 8ave t8eir dia!etes clearly identified in t8e medical record (E) All "atients 3it8 dia!etes s8o'ld 8ave an order for !lood gl'cose monitoring4 3it8 res'lts availa!le to all mem!ers of t8e 8ealt8 care team (E)

ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4%.

Re!o&&en ations* Diabetes Ca#e in t(e :os-ital /20

Goals for !lood gl'cose levels
Critically ill "atients: Initiate ins'lin t8era"y for treatment of "ersistent 8y"erglycemia starting at a t8res8old of no greater t8an 14.-1/. mg-d1 (@./E1. mmol-1) (A) &ore stringent goals4 s'c8 as 11.-14. mg-d1 (*.1E@./ mmol-1) may !e a""ro"riate for selected "atients4 if ac8ieva!le 3it8o't significant 8y"oglycemia (C) Critically ill "atients re2'ire an I, ins'lin "rotocol 3it8 demonstrated efficacy4 safety in ac8ieving desired gl'cose range 3it8o't increasing risB for severe 8y"oglycemia (E)
ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4%.

Re!o&&en ations* Diabetes Ca#e in t(e :os-ital /30

Goals for !lood gl'cose levels
Noncritically ill "atients: No clear evidence for s"ecific !lood gl'cose goals If treated 3it8 ins'lin4 "remeal !lood gl'cose targets (if safely ac8ieved)
Generally H14. mg-d1 (@./ mmol-1) 3it8 random !lood gl'cose H1/. mg-d1 (1... mmol-1)

&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*.

Re!o&&en ations* Diabetes Ca#e in t(e :os-ital /40

Sc8ed'led s'!c'taneo's ins'lin 3it8 !asal4 n'tritional4 and correction com"onents is t8e "referred met8od for ac8ieving and maintaining gl'cose control in non-critically ill "atients (C)

ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4*.

Re!o&&en ations* Diabetes Ca#e in t(e :os-ital /50

Initiate gl'cose monitoring in any "atient not Bno3n to !e dia!etic 38o receives t8era"y associated 3it8 8ig8-risB for 8y"erglycemia
Dig8-dose gl'cocorticoid t8era"y4 initiation of enteral or "arenteral n'trition4 or ot8er medications s'c8 as octreotide or imm'nos'""ressive medications (7)

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*.

Re!o&&en ations* Diabetes Ca#e in t(e :os-ital /60

A 8y"oglycemia management "rotocol s8o'ld !e ado"ted and im"lemented !y eac8 8os"ital or 8os"ital system (E) <!tain A1C for all "atients (E)
If res'lts 3it8in "revio's $E3 mont8s 'navaila!le Cit8 dia!etes risB factors 38o e68i!it 8y"erglycemia

#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*.

Diabetes Ca#e in t(e :os-ital* NICE;S1"AR St. % /10

1argest randomi5ed controlled trial to date ested effect of tig8t glycemic control (target /1E1./ mg-d1) on o'tcomes among *41.4 critically ill "artici"ants &aKority (G+%>) re2'ired mec8anical ventilation

ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4*.

Diabetes Ca#e in t(e :os-ital* NICE;S1"AR St. % /20

In !ot8 s'rgical-medical "atients4 +.-day mortality significantly 8ig8er in intensively treated vs conventional gro'" (target 144E1/. mg-d1)
Severe 8y"oglycemia more common (*./> vs ..%>9 PH....1) ?indings strongly s'ggest may not !e necessary to target !lood gl'cose levels H14. mg-d19 8ig8ly stringent target of H11. mg-d1 may !e dangero's

ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4*.

?' STRATE"IES FOR IM)RO2IN" DIABETES CARE

Re!o&&en ations* St#ate$ies fo# I&-#ovin$ Diabetes Ca#e /10

Care s8o'ld !e aligned 3it8 com"onents of t8e C8ronic Care &odel to ens're "rod'ctive interactions !et3een a "re"ared "roactive "ractice team and an informed activated "atient (A) C8en feasi!le4 care systems s8o'ld s'""ort team-!ased care4 comm'nity involvement4 "atient registries4 and em!edded decision s'""ort tools to meet "atient needs (7)

ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1393*(s'""l 1):S4+-S%..

Re!o&&en ations* St#ate$ies fo# I&-#ovin$ Diabetes Ca#e /20

reatment decisions s8o'ld !e timely and !ased on evidence-!ased g'idelines t8at are tailored to individ'al "atient "references4 "rognoses4 and comor!idities (7) A "atient-centered comm'nication style s8o'ld !e em"loyed t8at incor"orates "atient "references4 assesses literacy and n'meracy4 and addresses c'lt'ral !arriers to care (7)

ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1393*(s'""l 1):S%..

Ob@e!tive 1* O-ti&i<e )#ovi e# an Tea& Be(avio#

Care team s8o'ld "rioriti5e timely4 a""ro"riate intensification of lifestyle and-or "8armace'tical t8era"y
#atients 38o 8ave not ac8ieved !eneficial levels of !lood "ress're4 li"id4 or gl'cose control

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%..

Ob@e!tive 2* S.--o#t )atient Be(avio# C(an$e

Im"lement a systematic a""roac8 to s'""ort "atient !e8avior c8ange efforts
a) Dealt8y lifestyle: "8ysical activity4 8ealt8y eating4 non'se of to!acco4 3eig8t management4 effective co"ing !) Disease self-management: medication taBing and management4 self-monitoring of gl'cose and !lood "ress're 38en clinically a""ro"riate c) #revention of dia!etes com"lications: self-monitoring of foot 8ealt84 active "artici"ation in screening for eye4 foot4 and renal com"lications4 and imm'ni5ations
ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1393*(s'""l 1):S%..

Ob@e!tive 3* C(an$e t(e S%ste& of Ca#e

8e most s'ccessf'l "ractices 8ave an instit'tional "riority for "roviding 8ig8 2'ality of care
7asing care on evidence-!ased g'idelines E6"anding t8e role of teams and staff Redesigning t8e "rocesses of care Im"lementing electronic 8ealt8 record tools Activating and ed'cating "atients Identifying and-or develo"ing comm'nity reso'rces and "'!lic "olicy t8at s'""orts 8ealt8y lifestyles Alterations in reim!'rsement
ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1393*(s'""l 1):S%..