P O S I T I O N SETD

ATI TEO
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Clinical Diabetes Papers In Press, published online December 15, 2016

Standards of Medical Care in Diabetes—2017
Abridged for Primary Care Providers
American Diabetes Association

T
he American Diabetes Associa- PROMOTING HEALTH AND
tion’s (ADA’s) Standards of Med- REDUCING DISPARITIES IN
ical Care in Diabetes is updated POPULATIONS
and published annually in a supple-
Recommendations
ment to the January issue of Diabetes
• Treatment plans should align
Care. The ADA’s Professional Practice
with the Chronic Care Model,
Committee, comprised of physicians,
emphasizing productive interac-
diabetes educators, registered dieti-
tions between a prepared proactive
tians, and public health experts, de-
practice team and an informed
velops the Standards. Formerly called
Clinical Practice Recommendations, the activated patient. A
Standards includes the most current • When feasible, care systems
evidence-based recommendations for should support team-based care,
diagnosing and treating adults and community involvement, patient
children with all forms of diabetes. registries, and decision support
ADA’s grading system uses A, B, C, tools to meet patient needs. B
or E to show the evidence level that Diabetes and Population
supports each recommendation. Health
• A—Clear evidence from well-con- Clinical practice guidelines are key
ducted, generalizable randomized to improving population health;
controlled trials that are ade- however, for optimal outcomes, di-
quately powered abetes care must be individualized
• B —Supportive evidence from for each patient. Thus, efforts to im-
well-conducted cohort studies prove population health will require
• C —Supportive evidence from a combination of systems-level and
poorly controlled or uncontrolled patient-level approaches. With such
studies an integrated approach in mind, the
• E —Expert consensus or clinical ADA highlights the importance of
This is an abridged version of the experience
American Diabetes Association Position
patient-centered care, defined as care
Statement: Standards of Medical Care that is respectful of and responsive to
in Diabetes—2017. Diabetes Care This is an abridged version of the individual patient preferences, needs,
2017;40(Suppl. 1):S1–S138. current Standards containing the
and values and ensuring that patient
The complete 2017 Standards supplement, evidence-based recommendations
including all supporting references, is values guide all clinical decisions.
most pertinent to primary care. The
available at professional.diabetes.org/
standards. tables and figures have been renum- Care Delivery Systems
DOI: 10.2337/cd16-0067 bered from the original document Despite the many advances in diabe-
to match this version. The complete tes care, 33–49% of patients still do
©2017 by the American Diabetes Association.
Readers may use this article as long as the work
2017 Standards of Care document, not meet targets for glycemic, blood
is properly cited, the use is educational and not including all supporting references, pressure, or cholesterol control, and
for profit, and the work is not altered. See http://
creativecommons.org/licenses/by-nc-nd/3.0
is available at professional.diabetes. only 14% meet targets for all three
for details. org/standards. measures while also avoiding smok-

C L I N I C A L D I A B E T E S 1

P O S I T I O N S TAT E M E N T

Clinical Diabetes Papers In Press, published online December 15, 2016
ing. Certain segments of the popu- TABLE. 1. Criteria for the Diagnosis of Diabetes
lation, such as young adults and pa-
FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at
tients with complex comorbidities, least 8 h.*
financial or other social hardships,
and/or limited English proficiency, OR
face particular challenges to care. 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT. The test
Even after adjusting for these factors, should be performed as described by the World Health Organization,
using a glucose load containing the equivalent of 75 g anhydrous glucose
the persistent variability in the quality dissolved in water.*
of diabetes care across providers and
OR
practice settings indicates that sub-
stantial system-level improvements A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory
using a method that is NGSP certified and standardized to the Diabetes
are still needed. Control and Complications Trial assay.*
Chronic Care Model OR
Numerous interventions to improve In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis,
adherence to the recommended a random plasma glucose ≥200 mg/dL (11.1 mmol/L).
standards have been implemented. *In the absence of unequivocal hyperglycemia, results should be confirmed
However, a major barrier to optimal by repeat testing.
care is a delivery system that is often
fragmented, lacks clinical information are fundamental to the success- and change the societal determinants
capabilities, duplicates services, and is ful implementation of the CCM. of these problems.
poorly designed for the coordinated Collaborative, multidisciplinary
delivery of chronic care. The Chronic Recommendations
teams are best suited to provide care
Care Model (CCM) takes these fac- • Providers should assess social
for people with chronic conditions
tors into consideration and is an ef- context, including potential food
such as diabetes and to facilitate
fective framework for improving the insecurity, housing stability, and
patients’ self-management.
quality of diabetes care. financial barriers, and apply that
Strategies for System-Level information to treatment deci-
Six Core Elements
Improvement sions. A
The CCM includes six core elements
Optimal diabetes management re- • Patients should be referred to local
to optimize the care of patients with
chronic disease: quires an organized, systematic ap- community resources when avail-
1. Delivery system design (moving
proach and the involvement of a co- able. B
from a reactive to a proactive care ordinated team of dedicated health • Patients should be provided with
delivery system where planned care professionals working in an en- self-management support from
visits are coordinated through a vironment where patient-centered, lay health coaches, navigators, or
team-based approach) high-quality care is a priority. Three community health workers when
2. Self-management support objectives to achieve this include: available. A
3. Decision support (basing care • Optimizing provider and team
CLASSIFICATION AND
on evidence-based, effective care behavior
DIAGNOSIS OF DIABETES
guidelines) • Supporting patient self-manage-
Diabetes can be classified into the fol-
4. Clinical information systems ment
lowing general categories:
(using registries that can provide • Changing the care system
1. Type 1 diabetes (due to auto-
patient-specific and popula- Tailoring Treatment to Reduce immune β-cell destruction,
tion-based support to the care Disparities usually leading to absolute insu-
team)
Social determinants of health can be lin deficiency)
5. Community resources and pol-
defined as the economic, environmen- 2. Type 2 diabetes (due to a pro-
icies (identifying or developing
tal, political, and social conditions in gressive loss of β-cell insulin
resources to support healthy
lifestyles) which people live and are responsible secretion frequently on the back-
6. Health systems (to create a qual-
for a major part of health inequality ground of insulin resistance)
worldwide. Given the tremendous 3. Gestational diabetes mellitus
ity-oriented culture)
burden that obesity, unhealthy eat- (GDM) (diabetes diagnosed in
Redefining the roles of the health ing, physical inactivity, and smoking the second or third trimester
care delivery team and empow- place on the health of patients with of pregnancy that is not clearly
ering patient self-management diabetes, efforts are needed to address overt diabetes prior to gestation)

2 CLINICAL.DIABETESJOURNALS.ORG

physician. Pacific Islander) evaluations.g. Other specific types. Lifestyle management and psy- TABLE 3. smoking cessation coun- Diabetes may be diagnosed based on • Screening to assess prediabetes seling. physi- • Women with polycystic ovary syndrome cian assistants. Patients should • Family planning for women of reproductive age be referred for diabetes self-manage- ment education (DSME). dietitians. with consideration of more frequent testing depending on and health care team should formu- initial results (e. E • Confirm the diagnosis and classify C L I N I C A L D I A B E T E S 3 .7% (39 mmol/mol). B The components of the comprehen- detect individuals with prediabetes • Testing for prediabetes and type 2 sive diabetes medical evaluation are (Table 2). Patients should receive monogenic forms of diabetes Prediabetes recommended preventive care ser- vices (e.g. podiatrists.. Testing should be considered in overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) adults who have one or more of the COMPREHENSIVE following risk factors: MEDICAL EVALUATION • A1C ≥5.4% (39–47 mmol/mol). Criteria for Testing for Diabetes or Prediabetes in The American Diabetes Association Asymptomatic Adults Risk Test is an additional option for screening. Referrals for Initial Care Management chosocial care are the cornerstones of • Eye care professional for annual dilated eye exam diabetes management. 2-hr OGTT of 140–199 overweight or obese and who have A complete medical evaluation should mg/dL (7. published online December 15. Comprehensive Medical • To test for prediabetes. If results are normal. for diabetes. Individuals with diabetes 2. pharmacists. a b r i d g e d s ta n d a r d s o f c a r e Clinical Diabetes Papers In Press. or impaired AND ASSESSMENT OF fasting glucose on previous testing COMORBIDITIES • First-degree relative with diabetes The comprehensive medical evalua- • High-risk race/ethnicity (e. 2016 TABLE 2.7–6. care from a team that may include ide level >250 mg/dL (2. plasma glucose criteria—either the and risk for future diabetes with and podiatric referrals. acanthosis nigricans) fessionals. nurses. if indicated concerns if indicated. People • Hypertension (≥140/90 mmHg or on therapy for hypertension) with diabetes should receive health • HDL cholesterol level <35 mg/dL (0. FPG. and ophthalmological.g. Asian American.0 mmol/L). which in- risk status.90 mmol/L) and/or a triglycer. including Type 2 Diabetes and sary (Table 3). Native tion includes the initial and ongoing American.9 children and adolescents who are Recommendations mmol/L). immunizations and cancer Diagnostic Tests for Diabetes Recommendations screening). Clinicians fasting plasma glucose (FPG) or the an informal assessment of risk should ensure that individuals with 2-h plasma glucose value after a 75-g factors or validated tools should diabetes are appropriately screened be considered in asymptomatic for complications and comorbidities. cludes lifestyle management. Latino..6–6. and engagement of the pa- • History of CVD tient throughout the process. and A1C are equally Evaluation for and diagnose diabetes and to appropriate. must assume an active role in their care. family. 1. 3.. testing should be repeated at a minimum of 3-year intervals. dental. and mental health pro- severe obesity. diabetes • Registered dietitian for MNT self-management support (DSMS). The patient. B — or A1C (Table 1). • DSME and DSMS medical nutrition therapy (MNT). exer- • Physical inactivity cise specialists.g. • Dentist for comprehensive dental and periodontal examination and psychosocial/emotional health • Mental health professional. dentists. or A1C two or more additional risk factors be performed at the initial visit to of 5. Prediabetes is defined as diabetes should be considered in listed in Table 4. those with prediabetes should be tested yearly) and late the management plan. The same tests are used to screen OGTT. testing should begin at age 45 years. For all patients. oral glucose tolerance test (OGTT) adults. assessment of complica- • Women who were diagnosed with GDM tions.8–11. impaired glucose tolerance.. nurse practitioners. FPG of 100–125 mg/dL (5. African American. Additional referrals should be arranged as neces- 4. • Other clinical conditions associated with insulin resistance (e. management of comorbid con- ditions.82 mmol/L) physicians.

anxiety. including orthostatic measurements when indicated • Fundoscopic examination • Thyroid palpation • Skin examination (e. and HDL cholesterol and triglycerides. asymptomatic laboratory finding) • Eating patterns. review contraception and preconception planning Physical examination • Height. autonomic. cerebrovascular disease. 2016 TABLE 4.g. and neuropathy (sensory. published online December 15. nephropathy. as needed ❍❍ Liver function tests ❍❍ Spot urinary albumin–to–creatinine ratio ❍❍ Serum creatinine and eGFR ❍❍ Thyroid-stimulating hormone in patients with type 1 diabetes *The comprehensive medical evaluation should all ideally be done on the initial visit. and peripheral arterial disease • For women with child-bearing capacity. including sexual dysfunction and gastroparesis) • Macrovascular complications: coronary heart disease.ORG .. and substance use • DSME and DSMS history and needs • Review of previous treatment regimens and response to therapy (A1C records) • Assess medication-taking behaviors and barriers to medication adherence • Results of glucose monitoring and patient’s use of data • DKA frequency. for acanthosis nigricans and insulin injection or infusion set insertion sites) • Comprehensive foot examination: ❍❍ Inspection ❍❍ Palpation of dorsalis pedis and posterior tibial pulses ❍❍ Presence/absence of patellar and Achilles reflexes ❍❍ Determination of proprioception. diabetic ketoacidosis [DKA]. severity. and monofilament sensation Laboratory evaluation • A1C. and BMI. logistical. weight. weight history.DIABETESJOURNALS. sleep behaviors (pattern and duration). vibration.. growth and pubertal development in children and adolescents • Blood pressure determination.g. LDL. and physical activity habits. including history of foot lesions.P O S I T I O N S TAT E M E N T Clinical Diabetes Papers In Press. 4 CLINICAL. nutritional status. awareness. but if time is limited different components can be done as appropriate on follow-up visits **Refer to the ADA position statement “Psychochsocial Care for People With Diabetes” for additional details on diabetes-specific screening measures. including total. and cause • Hypoglycemia episodes. alcohol consumption. if results not available within the past 3 months • If not performed/available within the past year: ❍❍ Fasting lipid profile. and support resources • History of tobacco use. Components of the Comprehensive Diabetes Medical Evaluation* Medical history • Age and characteristics of onset of diabetes (e. frequency. and disordered eating using validated and appropriate measures** • Screen for diabetes distress using validated and appropriate measures** • Screen for psychosocial problems and other barriers to diabetes self-management such as limited financial. nutrition education and behavioral support history and needs • Complementary and alternative medicine use • Presence of common comorbidities and dental disease • Screen for depression. and causes • History of increased blood pressure and abnormal lipids • Microvascular complications: retinopathy.

cancer screenings and to reduce their in men with diabetes compared with mendations. and especially with central obesity. control remains unclear. and some diagnoses are con- Recommendations Age-specific hip fracture risk is signifi. waist circumference. C diabetes may be as high as 23%. administer the pneumococ- of diabetes at baseline significantly apnea. Recommendations links is scarce. C modifiable cancer risk factors (obesity. B thyroid disease and celiac disease (relative risk 1. • Begin patient engagement in the and bladder. but in type 2 dia- Cancer • Review previous treatment and betes. Obstructive Sleep Apnea ride vaccine (PPSV23).to 10-fold) with obesity. clinicians and their patients with diabetes (weight loss. and may be more prevalent in people unvaccinated adults with diabetes tive analysis. and vascular de. odontal disease adversely affects di- Comorbidities cellular carcinoma.to mid-frequen- • Develop a plan for continuing ty. At age ≥65 ple >60 years of age. The evidence that tes- of age. but obesity is a major confounder. B tes-related factors such as underlying ple with diabetes than in those with- Immunization disease physiology or diabetes treat. of vaccine PPSV23 at least 1 year mentia compared with rates in those The prevalence of obstructive sleep after PCV13 and at least 5 years with normal glucose tolerance. is more common in peo- care. followed by another dose Alzheimer’s disease.3) and type 2 the disease. 2016 diabetes. obesi. Elevations of hepatic transaminase breathing may be as high as 58%. fatty liver disease. and recent guidelines recommended for all people with cantly increased risk and rate of cog. of dementia. Symptoms. established diabetes. do not recommend testing or treating diabetes who are 2–64 years of age nitive decline and an increased risk men without symptoms. although evidence for these or vascular disease. age-matched men without diabetes. In a prospec. out. Interventions that abetes outcomes. breast. abetes ranges across diagnostic cate- Autoimmune Diseases Fractures gories. and triglyceride levels and lower Periodontal disease is more severe dose series of hepatitis B vaccine to HDL cholesterol levels. C higher BMI. an increased risk of hip fracture Diabetes is associated with increased risk factor control in patients with is seen despite higher bone mineral risk of cancers of the liver. although evidence Besides assessing diabetes-related improve metabolic abnormalities in for treatment benefits on diabetes complications. a risk factor for cardiovascu- cal conjugate vaccine (PCV13) at increased the age. both clinical C L I N I C A L D I A B E T E S 5 . colon/rectum. both in high- plan. and physical inactivity) or diabe. perhaps due to neuropathy and/ ments. pancreas. nated adults with diabetes who concentrations are associated with are aged 19–59 years. published online December 15. siderably more common in people • Consider screening patients with cantly increased in people with both with diabetes than for those without type 1 diabetes for autoimmune type 1 (relative risk 6. Periodontal Disease • Consider administering three.and sex-adjust. are significantly least 1 year after vaccination with ed incidence of all-cause dementia. Hearing Impairment formulation of a care management sult from shared risk factors between Hearing impairment. cy ranges. higher (4. apnea in the population with type 2 after the last dose of PPSV23. The association may re.7) diabetes in both • Detect diabetes complications and soon after diagnosis. C Dementia tosterone replacement affects out- • Vaccination against pneumonia is Diabetes is associated with a signifi. B diabetes and cancer (older age. the presence Age-adjusted rates of obstructive sleep years. lar disease (CVD). with pneumococcal polysaccha.and sex-appropriate Mean levels of testosterone are lower according to age-related recom. and treatment with Psychosocial Disorders with diabetes and may complicate specific drugs for hyperglycemia or Prevalence of clinically significant dyslipidemia) are also beneficial for psychopathology in people with di- management. frequency and low. E endometrium. patients need to be aware of com- mon comorbidities that affect people glycemic control. Type 1 diabetes is associated potential comorbid conditions. C associated with incident nonalcoholic Current evidence suggests that peri- chronic liver disease and with hepato. comes is mixed. Low Testosterone in Men children and adults with diabetes ommended age. and • Administer three-dose series of Fatty Liver Disease the prevalence of any sleep disordered hepatitis B vaccine to unvacci. enza is recommended for all Treatment in asymptomatic men is people with diabetes ≥6 months Cognitive Impairment/ controversial. • Annual vaccination against influ. diabetes was significantly with diabetes than in those without. In a 15-year prospective study of community-dwelling peo. who are ≥60 years of age. a b r i d g e d s ta n d a r d s o f c a r e Clinical Diabetes Papers In Press. E sexes. density. physical inactivity. Patients with diabetes • Provide routine vaccinations for should be encouraged to undergo rec. and smoking). PPSV23. E with osteoporosis.

At diagnosis plications or when there are significant changes in medical • In accordance with the national 2. and psychosocial care. dread. B all people with diabetes should needs • Referrals for treatment of depres. cation. should hunger/caloric intake. Annually for assessment of edu- status. self-care behaviors. B a review of the medical regimen is should therefore be able to tailor • People with hypoglycemic recommended to identify poten. menting and sustaining skills and ence self-management dence-based treatment approaches behaviors needed for ongoing 4.P O S I T I O N S TAT E M E N T Clinical Diabetes Papers In Press. been defined when the need for screening measures. treatment team. B self-management must be addressed. • DSME and DSMS should be worries regarding diabetes com. taking medications. and ability (health conditions. ing behavior. • Consider screening for disor. DSME and DSMS similar evidence-based interven. for depressive symptoms Four critical time points have with age-appropriate depression tal aspect of diabetes care. basic living needs) arise that influ- interpersonal therapy. published online December 15. nutrition. that interfere with a in conjunction with collaborative self-management. distinct from a psychological disorder. an eating disorder. Refer for treatment if anxiety is and physical activity. B • Because DSME and DSMS can be treated using Blood Glucose Serious Mental Illness improve outcomes and reduce Awareness Training (or another costs B . when hyperglycemia and weight or irrational thoughts and/or show • DSME and DSMS programs loss are unexplained based on have the necessary elements in anxiety symptoms such as avoid- self-reported behaviors related to their curricula to delay or prevent ance behaviors. tes. E of hypoglycemia and reduce fear prescribed atypical antipsychotic of hyperglycemia. When transitions in care occur 6 CLINICAL. B and DSMS are to support informed Depression • Incorporate monitoring of diabetes decision-making. and active collabo- • Providers should consider annual goals in people with diabetes and ration with the health care team to screening of all patients with serious mental illness. When new complicating factors sion should be made to mental the knowledge. A • Effective self-management and Diabetes distress is very common and improved clinical outcomes. especially those with a status. their content when prevention of unawareness. B DSME and DSMS • Beginning at diagnosis of com. insulin injections or or disrupted patterns of eating. 2016 and subclinical. consider assessment for standards for DSME and DSMS. and in DSMS to assist with imple. both at diagno- person’s ability to carry out diabetes care with the patient’s diabetes sis and as needed thereafter. patient-centered. B improve clinical outcomes. and plications. A and those who express fear. Recommendations should be adequately reimbursed tion) to help re-establish awareness • Annually screen people who are by third-party payers. referrals made as needed: Recommendations 1. In addition. participate in DSME to facilitate 3. B responsive to individual patient infusion. with a positive screen. and quality of Anxiety Disorders Recommendations life are key goals of DSME and • Providers should consider reeval. B with fear of hypoglycemia. needs. effective manner. and quality of life in a cost- LIFESTYLE MANAGEMENT self-reported history of depres. skills. or other evi. recognizing DSME and DSMS should be eval- that further evaluation will be physical activity. meal plan. or using cognitive behavioral therapy. preferences. DSME and DSMS programs present. DSMS that should be measured Recommendations uating the treatment regimen of and monitored as part of routine • Consider screening for anxiety people with diabetes who present care. or social withdrawal. respectful. emotional factors. Recommendations self-care activities into treatment problem-solving. uated by the medical care provider necessary for individuals who have and/or multidisciplinary team. which can co-occur tial treatment-related effects on diabetes is the desired goal. A medications for prediabetes or The overall objectives of DSME diabetes. health diabetes. the development of type 2 diabe- behaviors. Lifestyle management is a fundamen- sion. and in- cludes DSME and DSMS. Disordered Eating Behavior health status. and/or hypoglycemia that interfere dered or disrupted eating using with self-management behaviors and should help guide clinical validated screening measures decisions. and emotional depression. C in people exhibiting anxiety or with symptoms of disordered eat. nutrition.ORG . excessive repetitive medication dosing. physical lim- health providers with experience necessary for diabetes self-care itations. and values.DIABETESJOURNALS. smoking cessation.

or who are elderly and prone to hypoglycemia. E improved outcomes (e. A TABLE CONTINUED ON P. fats. • Carbohydrate intake from whole grains. vegetables. published online December 15. DASH.. education on how to use carbohydrate counting and. • People with diabetes and those at risk should avoid sugar-sweetened B. and proteins for people with diabetes. preferably provided by a registered A nutrition therapy dietitian. MNT should be adequately reimbursed by insurance and other payers. and plant-based diets. A and DHA) and nuts and seeds (ALA) is recommended to prevent or treat CVD B. • A simple and effective approach to glycemia and weight management B emphasizing portion control and healthy food choices may be more helpful for those with type 2 diabetes who are not taking insulin. especially those containing sugars. A. • A variety of eating patterns are acceptable for the management of type B 2 diabetes and prediabetes including the Mediterranean diet. Therefore. and B dairy products. carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia. an eating plan emphasizing elements of a Mediterranean-style diet rich in monounsaturated fats may improve glucose metabolism and lower CVD risk and can be an effective alternative to a diet low in total fat but relatively high in carbohydrates. legumes. A1C reduction) A. E Energy balance • Modest weight loss achievable by the combination of reduction of A caloric intake and lifestyle modification benefits overweight or obese adults with type 2 diabetes and also those with prediabetes. a b r i d g e d s ta n d a r d s o f c a r e Clinical Diabetes Papers In Press.g. fruits. ingested protein appears to increase B insulin response without increasing plasma glucose concentrations. • For people with type 1 diabetes and those with type 2 diabetes who are A prescribed a flexible insulin therapy program. is recommended for all people with type 1 or type 2 diabetes. who have limited health literacy or numeracy. macronutri- distribution ent distribution should be individualized while keeping total caloric and metabolic goals in mind. MNT Recommendations Topic Recommendations Evidence Rating Effectiveness of • An individualized MNT program. more nutrient-dense food choices. such as fatty fish (EPA B. Eating patterns • Because there is no single ideal dietary distribution of calories among E and macronutrient carbohydrates. • Because diabetes nutrition therapy can result in cost savings B and B. with an emphasis on foods higher in fiber and lower in glycemic load. however. 8 → C L I N I C A L D I A B E T E S 7 . A Protein • In individuals with type 2 diabetes. in some cases. • Eating foods rich in long-chain Ω-3 fatty acids. should be advised over other sources. • For individuals whose daily insulin dosing is fixed. 2016 TABLE 5. evidence does not support a beneficial role for Ω-3 dietary supplements. having a consistent B pattern of carbohydrate intake with respect to time and amount can result in improved glycemic control and a reduced risk of hypoglycemia. Dietary fat • Whereas data on the ideal total dietary fat content for people with B diabetes are inconclusive. A beverages to control weight and reduce their risk for CVD and fatty liver disease B and should minimize their consumption of foods with added sugar that have the capacity to displace healthier. fat and protein gram estimation to determine mealtime insulin dosing can improve glycemic control. Intervention programs to facilitate this process are recommended.

Education and awareness regarding the recognition and management of delayed hypoglycemia are warranted. C Exercise in the Presence pattern for individuals with diabe. C Recommendations • Flexibility training and balance or proprioceptive sensation during • Children and adolescents with training are recommended 2−3 physical activity. with preferences to increase flexibility. Yoga and tai chi may For many individuals with diabe.DIABETESJOURNALS. muscle-strengthening. should deficit or provide ~1. modest weight min/week) of vigorous-intensity or may be contraindicated because of the loss. particularly in those type 1 or type 2 diabetes or predi. and plant-based diets ate-to-vigorous intensity activity If proliferative diabetic retinopathy or are all examples of healthful eating per week. 2016 TABLE 5. Sodium • As for the general population. infection. times/week for older adults with with more severe neuropathy. Nonnutritive sweeteners are generally safe to use within the defined acceptable daily intake levels. published online December 15. the most challenging part of the ous intensity aerobic activity.200–1. a thorough assess- glucose benefits. joint destruction with some forms of individual's baseline body weight. Therefore. Retinopathy (DASH) diet. herbs. Consultation has been shown to improve glyce. and there may be safety concerns regarding the long-term use of antioxidant supplements such as vitamins E and C and carotene. However. day or more of moderate or vigor. and Charcot kcal/day for men. although further restriction may be indicated for those with both diabetes and hypertension. muscular strength. with an ophthalmologist prior to en- mic control and to reduce the need • Adults with type 1 C or type 2 gaging in an intense exercise regimen for glucose-lowering medications. sustaining weight loss can sessions/week of resistance exercise Peripheral Neuropathy be challenging. C and herbal minerals. then vigorous-in- trition recommendations. and particularly those er pain threshold in the extremities achieve a 500–750 kcal/day energy with type 2 diabetes. Non-nutritive • The use of nonnutritive sweeteners has the potential to reduce overall B Sweeteners caloric and carbohydrate intake if substituted for caloric sweeteners and without compensation by intake of additional calories from other food sources. Nutrition Therapy abetes should engage in 60 min/ diabetes. defined as sustained reduc. The Mediterranean diet.P O S I T I O N S TAT E M E N T Clinical Diabetes Papers In Press. Alcohol • Adults with diabetes who drink alcohol should do so in moderation C (no more than one drink per day for adult women and no more than two drinks per day for adult men). fit individuals. and balance. for younger and more physically or retinal detachment. Weight loss can be on nonconsecutive days. • Alcohol consumption may place people with diabetes at increased B risk for hypoglycemia. B breakdown. or spices can improve outcomes in people with supplements diabetes who do not have underlying deficiencies. interval training may be sufficient risk of triggering vitreous hemorrhage tion of 5% of initial body weight. particularly in ment should be done to ensure that Physical Activity neuropathy does not alter kinesthetic adults with type 2 diabetes. Dietary type 2 B diabetes should engage Complications of Diabetes Approaches to Stop Hypertension in 150 min or more of moder. C to eat and following a food plan. See Table 5 for specific nu. B diabetes should engage in 2−3 may be appropriate. 7 5. be included based on individual tes. with no more than 2 nopathy is present. adjusted for the Prolonged sitting should be inter. and bone-strengthening activities There is not a one-size-fits-all eating included at least 3 days/week. TABLE continued from p. • Most adults with with type 1 C or of Specific Long-Term tes. MNT Recommendations Topic Recommendations Evidence Rating Micronutrients • There is no clear evidence that dietary supplementation with vitamins. spread over at least 3 severe nonproliferative diabetic reti- patterns.500–1. especially if they are taking insulin or insulin secretagogues. rupted every 30 min for blood exercise. In overweight and obese patients Shorter durations (minimum 75 tensity aerobic or resistance exercise with type 2 diabetes.300 mg/day. Decreased pain sensation and a high- attained with lifestyle programs that • All adults.ORG . days/week.800 in daily sedentary behavior. people with diabetes should limit sodium B consumption to <2. 8 CLINICAL. consecutive days without activity. treatment plan is determining what vigorous.500 kcal/ decrease the amount of time spent result in an increased risk of skin day for women and 1. MNT Recommendations.

gluca. A cemia and adjusting medications health outcomes and health-re. at bedtime. when to prescribe SMBG different timing of SMBG or con- development of diabetes in those and at what testing frequency are less tinuous glucose monitoring. effective (∼58% risk reduction after patient’s monitoring technique. also supports a correlation between low-up may include. is suggested for those with predi. and prior to critical Psychosocial Issues of type 2 diabetes should be con. • Providers should consider assess. SMBG is es. • Screening for and treatment of (particularly prandial insulin doses). Self-monitoring of blood glucose (SMBG) frequency and timing • Point-of-care testing for A1C pro- ommended. E visit. as well as has demonstrated long-term safety as • Perform the A1C test at least two cognitive capacities. anxiety. and thiazolidinediones have ment for symptoms of diabetes A1C Testing been shown to decrease incident dia- distress. those <60 years of and assess whether glycemic targets patient-centered approach and age. general and diabe. B Recommendations sidered in those with prediabetes. A blood glucose until they are nor- of diabetes care. at periodic intervals. published online December 15. orlistat. A modifiable risk factors for CVD MNT. ≥ 35 kg/m 2. available 3 years). tasks such as driving. Other with prediabetes is suggested. B vides the opportunity for more • Consider screening older adults should be dictated by patients’ spe- cific needs and goals. B SMBG frequency and meeting A1C limited to. or life circumstances. and/or those with rising A1C can be useful in preventing hypogly- tes. a b r i d g e d s ta n d a r d s o f c a r e Clinical Diabetes Papers In Press. both tes-related quality of life. Intensive lifestyle modification pro. timely treatment changes. cosidase inhibitors. after treating low treatment as a routine component 150 min/week. grams have been shown to be very and user-dependent. and psychiatric his. For patients in whom A1C and sion. E (aged ≥65 years) with diabetes for cognitive impairment and depres. pecially important for patients treat. using pharmacologic therapy for diabetes times a year in patients who are patient-appropriate standardized meeting treatment goals (and who prevention. when they suspect low counseling and other forms of (such as brisk walking) to at least blood glucose. lated quality of life. clinicians should consider PREVENTION OR DELAY OF and hyperglycemia. attitudes about the targets. SMBG accuracy is instrument- cal management and outcomes. expectations for medi. B • Metformin therapy for prevention moglycemic. measures of chronic glycemia such C L I N I C A L D I A B E T E S 9 . and validated tools at the initial have stable glycemic control). occasionally postprandially. and GLYCEMIC TARGETS • Perform the A1C test quarterly when there is a change in disease. B ed with insulin to monitor for and measured blood glucose appear dis- prevent asymptomatic hypoglycemia crepant. and women with prior GDM. E gon-like peptide 1 (GLP-1) receptor uated at each routine visit. Evaluate each affect or mood. A or e-cigarettes. depression. E established. Evidence • Psychosocial screening and fol. changed or who are not meeting Control Including caregivers and family glycemic goals. pharmacologic initially and at regular intervals resources (financial. with the goals of optimizing despite lifestyle intervention. in patients whose therapy has Assessment of Glycemic treatment. SMBG allows patients to evaluate • Psychosocial care should be especially for those with a BMI their individual responses to therapy integrated with a collaborative. α-glu. are being achieved. and physical activity. For patients on the possibilities of hemoglobinopathy TYPE 2 DIABETES nonintensive insulin regimens such as or altered red blood cell turnover and Recommendations those with type 2 diabetes using bas. prior • Include smoking cessation erate-intensity physical activity to exercise. E members in this assessment is rec. social. and agents including metformin. frequency of SMBG should be reeval- tory. Metformin Recommendations disordered eating. the options of more frequent and/or • At least annual monitoring for the al insulin. and betes to various degrees. illness. but are not abetes. Results of SMBG provided to all people with diabe. E body weight and increase mod. In addition. agonists. The ongoing need for and emotional). thereafter. 2016 Smoking Cessation: Tobacco • Patients with prediabetes should Recommendation and e-Cigarettes be referred to an intensive • Most patients using intensive behavioral lifestyle intervention insulin regimens (multiple-dose Recommendations program modelled on the Diabetes insulin or insulin pump therapy) • Advise all patients not to use ciga- Prevention Program to achieve should perform SMBG prior to rettes and other tobacco products and maintain 7% loss of initial meals and snacks.

Fifteen minutes after hypoglycemia should trigger and type 2 diabetes. or no significant CVD.e. however optimal treatment. 2016 as fructosamine are available.. type expected treatment efforts excellent self-care capabilities poor self-care capabilities 2 diabetes treated with lifestyle or metformin only. or Recommendations family members of these individ- The complete 2017 Standards of • Individuals at risk for hypogly.P O S I T I O N S TAT E M E N T Clinical Diabetes Papers In Press. those toward the right suggest less stringent efforts. uals should know where it is and Care includes additional goals for cemia should be asked about when and how to administer it. Once SMBG • Insulin-treated patients with disease-specific factors (Figure 1). returns to normal. dations include blood glucose levels cemia. to prevent recurrence of hypogly- complications.0 mmol/L). for the treatment of hypoglycemia A1C targets of <7% (53 mmol/mol) C in people unable or unwilling to has been shown to reduce micro. a short duration of diabetes.38:140–149.5% [48 mmol/mol]) Relevant comorbidities for selected individual patients if absent few / mild severe this can be achieved without sig- Established vascular nificant hypoglycemia or other complications absent few / mild severe adverse effects of treatment (i. or long-standing that appear to correlate with achieve. ment of an A1C of ≤7% (53 mmol/ for all individuals at increased ficult to achieve despite DSME. B Caregivers. The recommen. but Approach to the Management of Hyperglycemia their linkage to average glucose and Patient / Disease Features More stringent A1C 7% Less stringent their prognostic significance are not Risks potentially associated as clear as for A1C. Appropriate Potentially modifiable patients might include those with Patient attitude and highly motivated. in type 1 diabetes. the treatment imen. defined as blood glucose Hypoglycemia and effective doses of multiple <54 mg/dL (3. Depicted are patient and disease factors used to determine optimal as <8% [64 mmol/mol]) may be A1C targets. nonadherent. children and pregnant women. symptomatic and asymptomatic The use of glucagon is indicated Glycemic control achieved using hypoglycemia at each encounter. polypharmacy). adherent. published online December 15. school personnel. mortality. • Hypoglycemia unawareness or after long-term follow-up of people bohydrate that contains glucose one or more episodes of severe treated early in the course of type 1 may be used. insulin. A Life expectancy • Providers might reasonably sug. long life expec. although any form of car.DIABETESJOURNALS. vascular complications of diabetes. C readily available limited • Less stringent A1C goals (such ■ FIGURE 1. if SMBG shows contin.ORG . less motivated. E based on several patient-specific and should be repeated. individuals with hypoglycemia limited to health care profession- There is evidence for cardiovascular (glucose alert value of ≤70 mg/ als. so it is The 2017 Standards of Care provides glucose-lowering agents. a new classification of hypoglycemia. reevaluation of the treatment reg- A1C targets should be individualized ued hypoglycemia. consume carbohydrates by mouth. Adapted history of severe hypoglycemia. including available should it be needed. extensive comor. with hypoglycemia and other drug adverse effects A1C Goals low high Recommendations Usually not modifiable • A reasonable A1C goal for many Disease duration newly diagnosed long-standing nonpregnant adults is <7% (53 mmol/mol). advanced microvascular or macrovascular provided in Table 6. long short gest more stringent A1C goals (such as <6. mol). with permission from Inzucchi et al. E benefit of intensive glycemic control dL). glycemia. risk of clinically significant hypo- appropriate glucose monitoring. • Glucose (15–20 g) is the pre. E bid conditions. • Glucagon should be prescribed diabetes in whom the goal is dif. Resources and support system tancy. Diabetes Care 2015. the individual hypoglycemia unawareness or an Recommended glycemic targets are should consume a meal or snack episode of clinically significant 10 CLINICAL. ferred treatment for conscious Glucagon administration is not and. limited life expectancy. Characteristics and predicaments toward the left justify more stringent appropriate for patients with a efforts to lower A1C.

0 mmol/L) *More or less stringent glycemic goals may be appropriate for individual patients. minimize the THE TREATMENT OF TYPE 2 physical activity. In Asian Americans. Recommendations increased vigilance for hypoglyce. Recommendations Providers should advise over. declining cognition is found. long-term risks of the medications. B high intensity (≥16 sessions in E OBESITY MANAGEMENT FOR 6 months) and focus on diet. E gression from prediabetes to type 2 • Diets should be individualized. A populations. To strictly avoid hypoglycemia for maintain weight loss. 2016 TABLE 6. and behavioral medications for comorbid con- DIABETES strategies to achieve a 500–750 ditions that are associated with Obesity management can delay pro. modest and sustained weight content are equally effective in with type 2 diabetes and a BMI achieving weight loss. A for glucose-lowering medications.4–7. Potential benefits must loss has been shown to improve gly- • For patients who achieve short. be weighed against the potential cemic control and to reduce the need term weight loss goals. A obese patients with type 2 diabe- caregivers if low cognition and/or • Such interventions should be tes. A • Diet. physical activity.†Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals. and at least several weeks to partially grams must incorporate long-term Behavioral Therapy reverse hypoglycemia unawareness comprehensive weight mainte- and reduce the risk of future epi. patient. A weight gain. Summary of Glycemic Recommendations for Many Nonpregnant Adults With Diabetes A1C <7. • Metabolic surgery should be rec- weight and obese patients that higher sity lifestyle interventions that use ommended to treat type 2 diabetes BMIs increase the risk of CVD and very-low-calorie diets (≤800 kcal/ in appropriate surgical candidates all-cause mortality. Physical Activity. Recommendations nance counseling. the medication should should be calculated and docu. • To achieve weight loss of >5%. In over. • Whenever possible. BMI and encourage ongoing moni. and behav- Pharmacotherapy • Ongoing assessment of cogni. carbohydrate. any time. regardless of the level of glycemic C L I N I C A L D I A B E T E S 11 . • Weight loss medications may diabetes and may be beneficial in the eating patterns that provide the be effective as adjuncts to diet. day) or total meal replacements with a BMI ≥40 kg/m 2 (BMI Providers should assess each may be prescribed for carefully ≥37. and patients with type 2 diabetes ready medications for overweight or to achieve weight loss. continued tive medications or treatment consumption of a reduced-calorie approaches should be considered. generally peak levels in patients with diabetes. Postprandial glucose measurements should be made 1–2 h after the beginning of the meal. scribed for overweight and obese • When choosing glucose-lowering mia by the clinician. hypoglycemia should be advised loss and jointly determine weight loss titioners in medical care settings to raise their glycemic targets to goals and intervention strategies. age/life expectancy. Such programs should loss after 3 months or if there are Recommendation provide at least monthly contact any safety or tolerability issues at • At each patient encounter. short-term (3-month) high-inten. and behavioral weight and obese patients with type 2 in protein. B or more frequently). A cutoff points to define overweight els of physical activity (200–300 and obesity are lower than in other Metabolic Surgery min/week). with close medical monitoring. such pro- Diet. the BMI diet. kcal/day energy deficit. published online December 15. toring of body weight (weekly be discontinued and alterna- mented in the medical record. (≥1-year) comprehensive weight • If a patient’s response to weight Assessment maintenance programs should be loss medications is <5% weight prescribed. a b r i d g e d s ta n d a r d s o f c a r e Clinical Diabetes Papers In Press.0% (53 mmol/mol)* Preprandial capillary plasma glucose 80–130 mg/dL* (4. known CVD or advanced microvascular com- plications. consider their effect on weight. and participation in high lev. A ≥27 kg/m2. ioral therapy designed to achieve tive function is suggested with >5% weight loss should be pre. comorbid conditions.2 mmol/L) Peak postprandial capillary plasma glucose † <180 mg/dL* (10. B sodes.5 kg/m2 in Asian Americans) patient’s readiness to achieve weight selected patients by trained prac. same caloric restriction but differ physical activity. hypoglycemia unawareness. Goals should be individualized based on duration of diabetes. and fat counseling for selected patients diabetes. and individual patient considerations. treatment of type 2 diabetes.

are symptomatic and/or have an is inadequately controlled despite ing greater reductions in CVD risk A1C ≥10% (86 mmol/mol) and/ lifestyle and optimal medical ther. E • Metabolic surgery should be con.4 kg/m2 in Asian confer additional health benefits in diagnosed type 2 diabetes who Americans) when hyperglycemia randomized controlled trials. assess their need for ongoing men. cardiovascular risk factors shorter duration of diabetes (e. 2016 control or complexity of glu. should be treated with multiple choice of pharmacologic agents. A Recommendations • A patient-centered approach oral or injectable medications (including insulin). be delayed. a inadequately controlled despite Type 1 Diabetes GLP-1 receptor agonist.5–37. family history of premature 12 CLINICAL. Beyond improving glycemia. odic measurement of vitamin B12 diabetes. a second oral agent. or years of age. if not contraindicated emphasizing drugs commonly used surgery should be evaluated to in the United States and/or Europe. B smoking. costs of diabetes.DIABETESJOURNALS. sclerotic cardiovascular disease tional professional societies.0–39. C pump therapy). cost. especially least annually. includ. <8 levels should be considered in met. These risk factors in- glycemic control are consistently asso. weight. A of life. suicidal ideation.4 kg/m2 in Asian Americans) if hyperglycemia is Pharmacologic Therapy for oral agent. C A bidity and mortality for individuals • Long-term use of metformin may with diabetes and is the largest con- Several GI operations promote be associated with biochemical tributor to the direct and indirect dramatic and durable improvement vitamin B12 deficiency. insulin therapy should not ent and nutritional status must be insulin analogs to reduce hypo. E therapy and combination therapy • People who undergo metabolic Recommendations • Metformin. Younger age. • Individuals with type 1 diabetes to reduce cardiovascular and all- B Surgery should be postponed in who have been successfully using cause mortality when added to patients with a history of alcohol CSII should have continued access standard care.7 mmol/L). and peri. significant to this therapy after they turn 65 are investigating the cardiovascu- depression. insulin and patient preferences. prandial insulin doses to carbo. in those with anemia or peripheral clude hypertension. potential side effects. published online December 15. Ongoing studies or substance abuse. should be systematically assessed at years). E because they have been shown hensive mental health assessment. E lar benefits of other agents in these other mental health conditions drug classes. • If noninsulin monotherapy at PHARMACOLOGIC maximum tolerated dose does not sidered for adults with type 2 APPROACHES TO achieve or maintain the A1C tar- diabetes and a BMI of 30. B Pharmacologic Therapy for until these conditions have been Type 2 Diabetes Figure 2 and Figure 3 outline mono- fully addressed. and if tolerated. ASCVD is the leading cause of mor- changes after surgery. empaglif lozin or • People presenting for metabolic glucose levels. • Consider educating individuals suboptimally controlled type 2 erative management of metabolic with type 1 diabetes on matching diabetes and established athero- surgery by national and interna. In all patients with of type 2 diabetes. E gastrointestinal (GI) surgery. apy (with or without additional adults with a BMI of 35. B • Most people with type 1 diabetes should be used to guide the • Metabolic surgery should be per.9 GLYCEMIC TREATMENT get after 3 months.ORG . B provided to patients after surgery. remission and/or lower risk of recid. dL (16. glycemia risk. nonuse of insulin.. dyslipidemia. and anticipated liraglutide should be considered surgery should receive a compre.P O S I T I O N S TAT E M E N T Clinical Diabetes Papers In Press. add a second kg/m2 (27. physical activity. the management of diabetes and ous insulin infusion (CSII. A • For patients with type 2 diabetes • Long-term lifestyle support and • Most individuals with type 1 who are not achieving glycemic routine monitoring of micronutri. A • In patients with long-standing according to guidelines for postop. • Consider initiating insulin ther- cose-lowering regimens and in ivism. C hydrate intake. with multidisciplinary teams who including prandial and basal hypoglycemia risk. impact on understand and are experienced in insulin or continuous subcutane. premeal blood (ASCVD). ciated with higher rates of diabetes neuropathy. or basal optimal medical control by either insulin. is the preferred tal health services to help them initial pharmacologic agent for CVD AND RISK MANAGEMENT adjust to medical and psychosocial the treatment of type 2 diabetes. formed in high-volume centers daily injection (MDI) therapy Considerations include efficacy.0–34. and better formin-treated patients.9 metabolic surgery has been shown to agents) in patients with newly kg/m2 (32. diabetes should use rapid-acting goals. factors and enhancements in quality or blood glucose levels ≥300 mg/ apy.g.5–32.

dehydration.& disease-specific factors): Triple Therapy Metformin + Lifestyle Management Sulfonylurea + Thiazolidinedione + DPP-4 inhibitor + SGLT2 inhibitor + GLP-1 receptor agonist + Insulin (basal) + TZD SU SU SU SU TZD or DPP-4-i or DPP-4-i or TZD or TZD or TZD or DPP-4-i or SGLT2-i or SGLT2-i or SGLT2-i or DPP-4-i or SGLT2-i or SGLT2-i or GLP-1-RA or GLP-1-RA or Insulin§ or GLP-1-RA or Insulin§ or GLP-1-RA or Insulin§ or Insulin§ or Insulin§ If A1C target not achieved after approximately 3 months of triple therapy and patient (1) on oral combination. thiazolidinedione. add basal insulin or (3) on optimally titrated basal insulin. Combination Injectable Therapy (See Figure 3) ■ FIGURE 2. Diabetes Care 2015. B based blood pressure >140/90 among U. a b r i d g e d s ta n d a r d s o f c a r e Clinical Diabetes Papers In Press. (2) on GLP-1 RA. fxs rare GU. detemir. gastrointestinal. Metformin therapy should be maintained.2). SU.& disease-specific factors): Dual Therapy Metformin + Lifestyle Management Sulfonylurea Thiazolidinedione DPP-4 inhibitor SGLT2 inhibitor GLP-1 receptor agonist Insulin (basal) EFFICACY* high high intermediate intermediate high highest HYPO RISK moderate risk low risk low risk low risk low risk high risk WEIGHT gain gain neutral loss loss gain SIDE EFFECTS hypoglycemia edema. individuals at high risk of CVD risk factors are addressed simultane. GLP-1 RA. fxs. <140 mmHg and a diastolic blood pharmacologic therapy to achieve Blood Pressure Control pressure goal of 90 mmHg. such as 130/80 based blood pressure >160/100 C L I N I C A L D I A B E T E S 13 . Monotherapy Metformin Lifestyle Management EFFICACY* high HYPO RISK low risk WEIGHT neutral/loss SIDE EFFECTS GI/lactic acidosis COSTS* low If A1C target not achieved after approximately 3 months of monotherapy. proceed to 3-drug combination (order not meant to denote any specific preference — choice dependent on a variety of patient. may be appropriate for Large benefits are seen when multiple sured at every routine visit. proceed to 2-drug combination (order not meant to denote any specific preference — choice dependent on a variety of patient. mmHg. TZD. add GLP-1 RA or mealtime insulin. The order in the chart was determined by historical availability and the route of administration. depending on the circumstances). HF. HF. while other oral agents may be discontinued on an individual basis to avoid unnecessarily complex or costly regimens (i. geni- tourinary. and albuminuria. adults with diabetes have • Most patients with diabetes and mmHg should. C of 10-year coronary heart disease risk pressure confirmed on a separate • Patients with confirmed office- day. SGLT2 inhibitor. fractures. or patient is markedly symptomatic. glargine. *See original source for description of efficacy categorization. Patients found to have elevated if they can be achieved without ously. in addition to improved significantly over the past hypertension should be treated to lifestyle therapy. with injectables to the right. DPP-4-i. consider Combination Injectable Therapy (See Figure 8. blood glucose is greater than or equal to 300 mg/dl. • Blood pressure should be mea. consider Dual Therapy. GLP-1 receptor agonist. §Usually a basal insulin (NPH. it is not meant to denote any specific pref- erence. with the usual transition moving vertically from top to bottom (although horizontal movement within therapy stages is also possible. There is evidence that measures blood pressure should have blood undue treatment burden. Hypo. GI.38:140–149.e. A • Lower systolic and diastolic blood • Patients with confirmed office- Recommendations pressure targets. Antihyperglycemic therapy in type 2 diabetes: general recommendations. A1C is greater than or equal to 10%. Adapted with permission from Inzucchi et al. degludec). adding a fourth antihyperglycemic agent). published online December 15. coronary disease. heart failure. sulfonylurea. fxs GI hypoglycemia COSTS* low low high high high high If A1C target not achieved after approximately 3 months of dual therapy. hypoglycemia. A blood pressure goals. have prompt decade and that ASCVD morbidity a systolic blood pressure goal of initiation and timely titration of and mortality have decreased. 2016 Start with Monotherapy unless: A1C is greater than or equal to 9%.S. SGLT2-i. GU. move to basal insulin or GLP-1 RA. DPP-4 inhibitor. Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed.

if no clear reason for hypo.3 mmol/L] for women). improve ASCVD outcomes and should be substituted. If A1C <8%. into ⅔ AM. units. if no clear reason reduce the risk of pancreatitis.0 mmol/L] for men. advance to 3rd injection mg/dL [1. C address cause. ê If A1C not controlled.7 mmol/L]) by 2–4 units or 10–20% and/or low HDL cholesterol (<40 If A1C not controlled. A • For patients treated with an ACE and every 5 years thereafter.3 mmol/L) and 14 CLINICAL. E fenofibrate may be considered for creatinine/estimated glomerular • Obtain a lipid profile at initiation men with both triglyceride level filtration rate (eGFR) and serum of statin therapy and periodically ≥204 mg/dL (2. 0.3 mmol/L) and should be con- of alcohol intake. fasting patient response to medication blood glucose. ⅓ PM or ½ AM. B also in patients with diabetes and ment for hyperytension in patients history of ASCVD who cannot with diabetes and urine albu. U. providers may by 2–4 units or 10–20% need to adjust intensity of sta- tin therapy based on individual ■ FIGURE 3. consider combination injectable therapy and cholesterol intake. serum more frequently if indicated. and increased sidered for these patients A and is the recomended first-line treat- physical activity. E Start: 10 U/day or 0. lifestyle inter. GLP-1 receptor agonist. <50 mg/dL [1.1 U/kg. supper) glyceride levels ≥500 mg/dL (5. moderation (1. hypoglycemia.. hypo. is generally not recommended.DIABETESJOURNALS. ê corresponding dose for hypo. cholesterol levels). ½ PM patients with diabetes. viscous fiber. A vention consists of weight loss. and increase in physical insulin injection before largest meal Add GLP-1 RA insulin twice daily (before breakfast and supper) activity should be recommended Start: 4 units. B at an initial medical evaluation. published online December 15. (e. tolerability. E ≥300 mg/g creatinine A or UACR • In adults not taking statins. lunch. • The addition of ezetimibe to mod- lifestyle therapy. have prompt ini. reduced sodium and increased and LDL cholesterol ≥50 mg/dL cated for blood pressure treatment potassium intake. or However.other noninsulin agent monitor the response to therapy and inform adherence.P O S I T I O N S TAT E M E N T Clinical Diabetes Papers In Press. B erate-intensity statin therapy has tiation and timely titration of two • For patients with blood pressure been shown to provide additional drugs to reduce CVD events in >120/80 mmHg.1 U/kg. including recent acute coronary syndrome the maximum tolerated dose indi. 0. or diuretic. Lipid Management tolerate high-intensity statin ther- min-to-creatinine ratio (UACR) Recommendations apy. LDL Adapted with permission from Inzucchi et al. GLP-1 RA. or 10% If not tolerated or A1C Start: Divide current basal dose to improve the lipid profile in basal dose. and plant stanols/sterols Add 1 rapid-acting Change to premixed intake. Diabetes Care 2015.1–0. E mmHg should.g. therapy with statin and inhibitor. a DASH. side effects. weight loss (if indicated). Combination injectable therapy for type 2 diabetes. if no clear reason insulin regimen for hypo. B If one reasonable to obtain a lipid profile fibrate) has not been shown to class is not tolerated. it is • Combination therapy (statin/ 30–299 mg/g creatinine. or 10% basal dose/meal. if no clear reason patients with elevated triglyceride address cause. advance to basal-bolus If A1C not controlled.ORG . FBG. the other at the time of diabetes diagnosis. 2016 thereafter because it may help to Initiate Basal Insulin Usually with metformin +/. itored. consider For hypo: Determine and changing to alternative address cause. A ê basal by same amount change to 2 injection Adjust: é dose by 1–2 units or insulin regimen Adjust: é dose by 1–2 units or 10–15% once or twice weekly • Intensify lifestyle therapy and 10–15% once or twice weekly until SMBG target reached until SMBG target reached For hypo: Determine and optimize glycemic control for If goals not met. with moderate-intensity statin • An ACE inhibitor or an angio. consider Adjust: é doses by 1–2 units or 10–15% once or twice weekly to causes of hypertriglyceridemia changing to alternative 10–15% once or twice weekly to achieve SMBG target insulin regimen achieve SMBG target and consider medical therapy to For hypo: Determine and For hypo: Determine and address cause. Add ≥2 rapid-acting Change to premixed C insulin injections before analog insulin 3 times daily • For patients with fasting tri- meals (‘basal-bolus’) (breakfast. increase in omega-3 fatty acids. ê corresponding dose by 2–4 units or 10–20% • In clinical practice. cardiovascular benefit compared patients with diabetes. in addition to potassium levels should be mon. therapy alone for patients with tensin receptor blocker (ARB) at style dietary pattern. evaluate for secondary consider ê basal by same amount Adjust: é dose(s) by 1–2 units or If goals not met. ê corresponding dose for hypo. trans fat. If A1C <8%. reduc- dose by 4 units or 10–20% tion of saturated fat.7 Start: 4 units. if no clear reason for hypo. consider target not reached. ARB. Start: Add additional injection before lunch mmol/L).2 U/kg/day Adjust: 10–15% or 2–4 units once or twice weekly to reach FBG target • Lifestyle modification focusing on For hypo: Determine & address cause.38:140–149. ê corresponding dose by 2–4 units or 10–20% levels (≥150 mg/dL [1. if overweight or obese.

and family history of premature ASCVD. B tion strategy in those with type heart failure. B sider ACE inhibitor therapy C to • At least once a year. treated. and con. cemia has been shown in large. 1 or type 2 diabetes who are at treatment should not be used. routine the goal of achieving near-normogly- Recommendations screening for coronary artery dis. A cin) has not been shown to provide increased cardiovascular risk. **ASCVD risk factors include LDL cholesterol ≥100 mg/dL (2. C MICROVASCULAR lines high. high blood pressure. and in all patients with • Consider aspirin therapy (75–162 the event. albuminuria. A vascular complications. chronic kidney disease. in all patients with type 2 B continued for at least 2 years after diabetes. A factor (family history of premature should be avoided in unstable or ASCVD. B C L I N I C A L D I A B E T E S 15 . spot UACR) sonable for up to 1 year after an events. published online December 15. or albuminuria) and for statin and combination therapy tive heart failure. 2016 TABLE 7. Coronary Heart Disease CARE Antiplatelet Agents Recommendations Intensive diabetes management with • In asymptomatic patients. A • For patients with ASCVD and • In patients with known ASCVD. This • In patients with type 2 diabetes additional cardiovascular benefit includes most men or women with with stable congestive heart fail- above statin therapy alone and diabetes aged ≥50 years who have ure.3 mmol/L) Moderate plus ezetimibe or in patients with a history of ASCVD who cannot tolerate high-dose statins *In addition to lifestyle therapy. smoking. randomized studies to delay day) as a secondary prevention it does not improve outcomes as strategy in those with diabetes and the onset and progression of micro- long as ASCVD risk factors are a history of ASCVD. metformin may be used if may increase the risk of stroke and at least one additional major risk eGFR remains >30 mL/min but is not generally recommended. Table 7 provides recommendations hospitalized patients with conges- dyslipidemia. infarction. reduce the risk of cardiovascular nary albumin (e. B are not at increased risk of bleed- in people with diabetes. Recommendations be used. assess uri- • Dual antiplatelet therapy is rea. Diabetic Kidney Disease documented aspirin allergy.3 mmol/L) Moderate plus ezetimibe or in patients with a history of ASCVD who cannot tolerate high-dose statins >75 None Moderate ASCVD risk factors Moderate or high ASCVD High ACS and LDL cholesterol ≥50 mg/dL (1. Table 8 out. ing. thiazolidinedione • Combination therapy (statin/nia.6 mmol/L). hypertension. • In patients with symptomatic (0. HDL cholesterol level ≤34 mg/dL mg/day) as a primary preven.9 mmol/L). use aspirin and statin therapy (if clopidogrel (75 mg/day) should not contraindicated) A.and moderate-intensity COMPLICATIONS AND FOOT statin therapy.g. a b r i d g e d s ta n d a r d s o f c a r e Clinical Diabetes Papers In Press. Recommendations for Statin and Combination Treatment in People With Diabetes Age (years) Risk Factors Recommended Statin Intensity* <40 None None ASCVD risk factor(s)** Moderate or high ASCVD High 40–75 None Moderate ASCVD risk factors High ASCVD High ACS and LDL cholesterol ≥50 mg/dL (1. and eGFR in patients with type acute coronary syndrome and may • In patients with prior myocardial 1 diabetes with a duration of ≥5 have benefits beyond this period.. smoking. B comorbid hypertension. pro- • Use aspirin therapy (75–162 mg/ ease is not recommended because spective. β-blockers should be years.

S. B to reduce CVD mortality and slow • Optimize blood pressure and • Either pregabalin or duloxetine are chronic kidney disease (CKD) serum lipid control to reduce the recommended as initial pharma- progression. examinations will be required • Optimize glucose control to states that metformin is contraindi. Foot Care U.73 m2. agement of CKD in people with testing to identify feet at risk of UACR determined for two of three diabetes are summarized in Table 9. B High-Intensity Statin Therapy Moderate-Intensity Statin Therapy • If there is no evidence of retinop- (Lowers LDL cholesterol by ≥50%) (Lowers LDL cholesterol by 30 to <50%) athy for one or more annual eye • Atorvastatin 40–80 mg • Atorvastatin 10–20 mg exams and glycemia is well con- • Rosuvastatin 20–40 mg • Rosuvastatin 5–10 mg trolled. A and vibration sensation using a also require dose adjustment or dis. A mL/min/1. B patients with kidney disease for whom should have an initial dilated and • All patients with diabetes should metformin treatment should be con. • Optimize glycemic control to 1 diabetes A and to slow the pro- Blood pressure levels <140/90 reduce the risk or slow the pro. then *Once-daily dosing.73 m2. sensation (for small-fiber function) UACR >300 mg/g creatinine and/ Other glucose-lowering medications or eGFR <60 mL/min/1. either the diagnosis of type 1 diabetes for patients with an eGFR <45 mL/ an ACE inhibitor or an ARB and at least annually thereafter.73 m2. A ing may require modification. 128-Hz tuning fork (for large-fi- Screening for albuminuria can continuation at low eGFR. visit.DIABETESJOURNALS. If any level of • Simvastatin 20–40 mg diabetic retinopathy is present. then exams every 2 years may be considered.P O S I T I O N S TAT E M E N T Clinical Diabetes Papers In Press. • In nonpregnant patients with type 2 diabetes and 5 years after metformin should not be initiated diabetes and hypertension. The revised FDA guidance by an ophthalmologist or optom. comprehensive eye examination have their feet inspected at every sidered.to Diabetic Retinopathy • Optimize glucose control to pre- 6-month period should be abnormal vent or delay the development of before considering a patient to have Recommendations neuropathy in patients with type albuminuria. and metformin should is recommended for those with • Assessment for distal symmetric be temporarily discontinued at the modestly elevated UACR (30–299 polyneuropathy should include time of or before iodinated contrast a careful history and assessment mg/g creatinine) B. more frequently B reduce the risk or slow the progres. 2016 TABLE 8. to reduce the risk or slow the the benefits and risks of continuing • All patients should be assessed for progression of diabetic kidney treatment should be reassessed when diabetic peripheral neuropathy disease. ber function). risk or slow the progression of dia. and is strongly imaging procedures in patients with recommended for those with of either temperature or pinprick an eGFR of 30–60 mL/min/1. • Pravastatin 40–80 mg subsequent dilated retinal exam- • Lovastatin 40 mg inations should be repeated at least • Fluvastatin XL 80 mg annually by an ophthalmologist or • Pitavastatin 2–4 mg optometrist. If retinopathy is pro- gressing or sight-threatening.73 m 2.ORG . cologic treatments for neuropathic With reduced eGFR. gression of neuropathy in patients mmHg in diabetes are recommended gression of diabetic retinopathy. published online December 15. eGFR should be • Optimize blood pressure control Recommendations monitored while taking metformin. A pain in diabetes. All patients should be most easily performed by UACR Recommendations for the man. A with type 2 diabetes. High. ulceration and amputation. recommending use of eGFR within 5 years after the onset of evaluation each year to identify instead of serum creatinine to guide diabetes. cated in patients with an eGFR <30 Neuropathy sion of diabetic kidney disease. drug dos. have annual 10-g monofilament in a random spot urine collection. The • Adults with type 1 diabetes should have an initial dilated and com.73 m2.and Moderate-Intensity Statin Therapy* etrist at the time of the diabetes diagnosis. Food and Drug Administration (FDA) revised guidance for the use prehensive eye examination by an Recommendations metformin in diabetic kidney disease ophthalmologist or optometrist • Perform a comprehensive foot in 2016. C 16 CLINICAL. B risk factors for ulcers and ampu- treatment and expanding the pool of • Patients with type 2 diabetes tations. A (DPN) starting at diagnosis of eGFR falls to <45 mL/min/1. betic retinopathy. B min/1. B specimens collected within a 3.

parathyroid hormone. Charcot foot. and vascular assessment. serum creatinine. numbness) and protective sensation. with diabetes. C angioplasty or vascular surgery. • Refer patients who smoke or who adults might reasonably be and renal disease and assess cur. B • Refer for dietary counseling • Hypoglycemia should be avoided 30–44 • Monitor eGFR every 3 months in older adults with diabetes. with Charcot foot. therapy may benefit those with a with foot ulcers and high-risk feet cal. including those with severe in most older adults. published online December 15. functional. amputation). relaxed using individual criteria. assessment lifelong surveillance. C tions should be individualized in of foot deformities. ized in older adults considering OLDER ADULTS ment as appropriate. C All patients • Yearly measurement of UACR. B tic footwear is recommended for • Treatment of hypertension to indi- • Patients who are ≥50 years of age high-risk patients with diabe. Lipid- • A multidisciplinary approach is Recommendations lowering therapy and aspirin recommended for individuals • Consider the assessment of medi. B risk factors should be individual- referred for further vascular assess. dialysis patients and those similar to those developed for amputation. or younger adults. burning. abnormal find- basic and instrumental activities ings on renal ultrasound. (e. or • Treatment of other cardiovascular absent pedal pulses should be history of amputation. foot deformities. hemoglobin. B least yearly • Older adults (≥65 years of age) • Assure vitamin D sufficiency with diabetes should be consid- • Vaccinate against hepatitis B virus ered a high-priority population for depression screening and treat- • Consider bone density testing ment. by adjusting glycemic targets and albumin. • Screening for geriatric syndromes and potassium may be appropriate in older adults 45–60 • Refer to a nephrologist if possibility for nondiabetic experiencing limitations in their kidney disease exists (duration of type 1 diabetes <10 years. rent symptoms of neuropathy tremity complications. prior ulcers.73 m2) for diabetes management. It • Monitor electrolytes. Particular attention assessment (10-g monofilament self-care education to all patients should be paid to complications testing). 2016 TABLE 9. bicarbonate. B that would lead to functional including pulses in the legs and • The use of specialized therapeu. C medications • Annual screening for early detec- • Monitor eGFR every 6 months tion of mild cognitive impairment • Monitor electrolytes. and social life expectancy at least equal to the C L I N I C A L D I A B E T E S 17 . C the time frame of benefit. C of claudication or decreased or neuropathy. abnormalities. of daily living because they may rapid fall in eGFR. neurological • Provide general preventive foot older adults. clau. bicarbonate. a b r i d g e d s ta n d a r d s o f c a r e Clinical Diabetes Papers In Press. or active urinary sediment on affect diabetes self-management urine microscopic examination) and be related to health-related • Consider the need for dose adjustment of quality of life. C • The examination should include for ongoing preventive care and • Screening for diabetes complica- inspection of the skin.. and weight every 3–6 months pharmacologic interventions. or dementia is indicated for adults calcium. have a history of prior lower-ex. persistent albuminuria. retinopathy. hemoglobin. impairment. or peripheral arte. and parathyroid hormone at ≥65 years of age. Management of CKD in Diabetes geriatric domains in older adults to provide a framework to determine eGFR Recommended Management targets and therapeutic approaches (mL/min/1. should be assessed and managed phosphorus. phosphorus. B • Consider the need for dose adjustment of • Older adults who are cognitively medications and functionally intact and have <30 • Refer to a nephrologist significant life expectancy may receive diabetes care with goals • Obtain a history of ulceration. loss of but hyperglycemia leading to (pain. resistant hypertension. mental. B rial disease to foot care specialists avoided in all patients. calcium.g. B • Glycemic goals for some older cigarette smoking. structural symptoms or risk of acute hyper- vascular disease (leg fatigue. C feet. glycemic complications should be dication). vidualized target levels is indicated and any patients with symptoms tes.

Recommendations statement “Management of Diabetes sideration when setting and prioritiz. cial issues and family stresses that older adults with diabetes. hypoglycemia (blood glucose ≤70 health professionals. B conditions (e. and coexisting ological differences related to sexual rate days.. • Blood pressure should be measured ventions are likely to apply to older uration. E nursing homes and skilled nursing years of age) should receive cultur.P O S I T I O N S TAT E M E N T Clinical Diabetes Papers In Press. see ADA’s position must take this heterogeneity into con.e. preferably the intensity of lipid management mg/dL [3. to physical growth and sexual mat. preconception appropriate. Support Services to be initiated after reproductive Treatment in Skilled Nursing counseling and implementation Facilities and Nursing Homes Recommendations of effective birth control due to Management of diabetes is unique in • Youth with type 1 diabetes and the potential teratogenic effects of the long-term care (LTC) setting (i.g. Similarly. The maturity are all essential in develop. and neurologi. and changes in diabetes man. at each routine visit. Alert strategies should be in place for priate referrals to trained mental apy may be appropriate. E LTC are especially vulnerable to follow-up care. pressure confirmed on three sepa- hypoglycemia. parents/caregivers (for patients <18 both drug classes. ability to provide self-care. renal status).. • Assess for the presence of auto- in Long-Term Care and Skilled ing treatment goals (Table 10). nutritional considerations. cologic treatment of hypertension. and height) or hypertension Pharmacologic Therapy well as possible adverse neurocogni. E However.9 mmol/L]) and hypergly. Blood pressure measurements staff and caregivers. management and provide appro- necessary. published online December 15. immune conditions associated Nursing Facilities. sex. experienced in childhood diabe- can be relaxed. cal vulnerability to hypoglycemia and pressure ≥90th percentile for age. and and monitoring pharmacologic ther- (DKA). 2016 time frame of primary prevention Older adults with diabetes in • At diagnosis and during routine or secondary intervention trials. height) should have elevated blood apy in older adults. Individualization of health ally sensitive and developmentally pressure consistently <90th per- care is important for all patients. cost. end-of-life girls of childbearing potential.ORG . hyperglycemia (in young children). practical guidance is needed and DSMS according to national for both medical providers and LTC standards at diagnosis and rou. management and support.DIABETESJOURNALS. as sex. ADOLESCENTS develop. tinely thereafter. and physi. E of lipid-lowering therapy may be [13.” Older adults with diabetes are with type 1 diabetes soon after likely to benefit from control of CHILDREN AND the diagnosis and if symptoms other cardiovascular risk factors. A ties to improve the management of care. E Evidence is strong for treatment of Children and adolescents with diabe- hypertension. Providers use or withdrawal of medications.5% (58 mmol/ The care of older adults with diabetes mol) is recommended across all in people with advanced disease can is complicated by their clinical and pediatric age-groups. pressure (systolic or diastolic blood prevention trials. counseling should be incorporated • Consider diabetes education for special attention should be given to into routine diabetes care for all the staff of long-term care facili. strict proportionately higher number of could affect adherence to diabetes blood pressure control may not be complications and comorbidities. and withdrawal of ther. Glycemic Control older adults with diabetes. assess psychoso- • When palliative care is needed in hypoglycemia because of their dis. E For patients in the LTC setting.9 mmol/L]). E agement with respect to advanced disease. developmental stages. Attention to family dynam. changes in insulin sensitivity related Recommendations although the benefits of these inter. (systolic or diastolic blood pressure Special care is required in prescribing tive effects of diabetic ketoacidosis ≥95th percentile for age. • ACE inhibitors or ARBs should be patient’s living situation must be con- ing and implementing an optimal considered for the initial pharma- sidered because it may affect diabetes diabetes regimen. Factors include ics. and height. • The goal of treatment is blood facilities). There is less evidence tes have unique aspects of care such as Hypertension for lipid-lowering and aspirin therapy. B should be determined using the 18 CLINICAL. and withdrawal cemia (blood glucose >250 mg/dL tes. sex. Acknowledging the limited Recommendations Treatment Goals benefit of intensive glycemic control • An A1C goal of <7. appropriate individualized DSME centile for age. E guide A1C goals and determine the functional heterogeneity. • Starting at puberty. Children adults whose life expectancies equal supervision in the child care and found to have high-normal blood or exceed the time frames of clinical school environment. For Autoimmune Conditions caring for older adults with diabetes more information.

such as stage 3–4 congestive heart failure or oxygen-dependent lung disease.” we mean at least three. hyperglycemic hyperosmolar syndrome. tion more so than ate-to-severe cognitive primary) impairment or 2+ ADL dependencies) This represents a consensus framework for considering treatment goals for glycemia. The patient characteristic categories are general concepts. 2016 (mg/dL [mmol/L]) Healthy (few coexisting Longer remaining life <7.a b r i d g e d s ta n d a r d s o f c a r e C L I N I C A L D I A B E T E S 19 TABLE 10. blood pressure.2) 90–150 (5. tolerated or 2+ instrumental hypoglycemia vulnera- ADL impairments or bility.0) <140/90 Statin unless con- (multiple coexisting ing life expectancy. a patient’s health status and preferences may change over time.0 (64) 90–150 (5.0–7. CKD requiring dialysis.5 (58) 90–130 (5. depression. stage 3 or worse CKD. Not every patient will clearly fall into a particular category. but many patients may have five or more.5% (69 mmol/mol) equates to an estimated average glucose of ~200 mg/dL (11.1) <150/90 Consider likelihood poor health (LTC or expectancy makes of benefit with statin end-stage chronic benefit uncertain (secondary preven- illnesses** or moder. and stroke.6–10.3) 100–180 (5. traindicated or not chronic illnesses* high treatment burden. *Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis.5† (69) 100–180 (5.3) <140/90 Statin unless con- chronic illnesses. fall risk mild-to-moderate cog- nitive impairment) Very complex/ Limited remaining life <8. activities of daily living. or uncontrolled metastatic cancer. ‡A lower A1C goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden. ADL. emphysema. published online December 15. falls. Blood Pressure.0) 110–200 (6. intact expectancy traindicated or not cognitive and function. and Dyslipidemia in Older Adults With Diabetes Patient Rationale Reasonable A1C Fasting or Bedtime Glucose Blood Pressure Lipids Characteristics/ Goal Preprandial (mg/dL [mmol/L]) (mmHg) Health Status Glucose (% [mmol/mol])‡ Clinical Diabetes Papers In Press.6–10.1–11.5% (69 mmol/mol) are not rec- ommended because they may expose patients to more frequent higher glucose values and the acute risks from glycosuria. tolerated al status) Complex/intermediate Intermediate remain. <8.0–8. By “multiple. cancer. Additionally. incontinence. . and dyslipidemia in older adults with diabetes. congestive heart failure.1 mmol/L). **The presence of a single end-stage chronic illness. Framework for Considering Treatment Goals for Glycemia.0–8. Consideration of patient and caregiver preferences is an important aspect of treatment individualization. myocardial infarction. hypertension. †A1C of 8. dehydration. Looser A1C targets >8. may cause significant symptoms or impairment of functional status and significantly reduce life expectancy. and poor wound healing.

1 should be prescribed and used statins) should be avoided in sexu- mmol/L) or LDL cholesterol >130 until a woman is prepared and ally active women of childbearing mg/dL (3.P O S I T I O N S TAT E M E N T Clinical Diabetes Papers In Press. 20 CLINICAL. A (<100 mg/dL [2. examinations. but the for UACR should be considered should occur before pregnancy target may be relaxed to <7% (53 once a child has had type 1 diabe. <6% Recommendations the risk of development and/or (42 mmol/mol) may be optimal if • Annual screening for albuminuria progression of diabetic retinop.4 mmol/L) and one or ready to become pregnant. and caudal after puberty has started. may cemic targets. ACE inhibitors and LDL cholesterol >160 mg/dL (4. • Potentially teratogenic medica- lifestyle changes. this can be achieved without sig- with a random spot urine sample athy. • The goal of therapy is an LDL of congenital anomalies. once glyburide. when used to treat • If lipids are abnormal. preconception Management of Diabetes in years is reasonable. A age who are not using reliable con- more CVD risk factors. E tion for treating hyperglycemia in not been reached within 3–6 months. • Fasting and postprandial SMBG implementation of effective birth mic control as close to normal as is are recommended in both GDM control due to the potential tera. initiated • Preconception counseling should traception. whichever is earlier. If IN PREGNANCY induce ovulation. Less frequent be added if needed to achieve gly- modification and increased exer. 2016 appropriate size cuff and with the • After the initial examination. by the eye care provider. the Pregnancy into routine diabetes care for all addition of a statin is suggested in girls of childbearing potential. microcephaly. prehensive eye examination is especially anencephaly. every 2 years. but both cross the placenta Recommendations sive foot exam for a child at the to the fetus. with metformin likely • Obtain a fasting lipid profile on start of puberty or at age ≥10 crossing to a greater extent than children ≥10 years of age soon after years. A Recommendations patients who. Recommendations regression directly proportional to el- ever is earlier. should be implemented for 3–6 be acceptable on the advice of an • Insulin is the preferred medica- months. GDM recommended at age ≥10 years or congenital heart disease. despite MNT and • Family planning should be dis. E type 2 diabetes who are planning glucose preprandially. B Nephropathy pregnancy or who have become • The A1C target in pregnancy is pregnant should be counseled on 6–6. to reduce the risk nancy to achieve glycemic control. E • Metformin. which. and may suffice for treatment for child seated and relaxed. E for 5 years. B Retinopathy every trimester and for 1 year post- partum as indicated by degree of Preconception Counseling Recommendations retinopathy and as recommended Observational studies show an in- • An initial dilated and com. once a youth has had • Lifestyle change is an essential evations in A1C during the first 10 type 1 diabetes for 3–5 years.DIABETESJOURNALS. All oral agents lack diabetes diagnosis (after glucose the youth has had type 1 diabetes long-term safety data. published online December 15. including dietary ally recommended.ORG .6 • Women with preexisting type 1 or diabetes should also test blood mmol/L). A cise. If target blood pressure has eye care professional. continue to have cussed and effective contraception tions (e. Medications should modifications. Lifestyle annual routine follow-up is gener. placenta to a measurable extent. annual MANAGEMENT OF DIABETES polycystic ovary syndrome and monitoring is reasonable. Dilated eye examinations nificant hypoglycemia. A control has been established).6 mmol/L]). need not be con- LDL cholesterol values are tinued once pregnancy has been within the accepted risk levels Preexisting Diabetes confirmed. B creased risk of diabetic embryopathy.5% (42–48 mmol/mol). a Recommendations lipid profile repeated every 3–5 General Principles for the • Starting at puberty. and then mmol/mol) if necessary to prevent tes for 5 years. or in the first trimester..5% and preexisting diabetes in preg- togenic effects of statins. E counseling should be incorporated • After the age of 10 years. B after reproductive counseling and address the importance of glyce. E (48 mmol/mol). used. ideally A1C <6. B patients should be monitored hypoglycemia. safely possible. Neuropathy GDM because it does not cross the pharmacotherapy should be initiated. many women. B Some women with preexisting cholesterol value <100 mg/dL (2. Recommendations Metformin and glyburide may be Dyslipidemia • Consider an annual comprehen. B component of GDM management weeks of pregnancy.g.

preferred treatment for noncriti. Women with mg/dL (<7. a b r i d g e d s ta n d a r d s o f c a r e Clinical Diabetes Papers In Press.8 mmol/L) able at no cost through the ADA. hormone. Once insulin therapy is started. lus-correction insulin regimen is A glucose value ≤70 mg/dL (3. • Intravenous (IV) insulin infusions • Hyperglycemia: >140 mg/dL es tailored for adolescents are avail. FPG. insulin injections should align with thresholds).) • Basal insulin or a basal-plus-bo- should be tested for persistent diabe. and HIV testing. insulin is the preferred treatment every 1–3 years thereafter if the 4. prepregnancy BMI. The ommended for the majority of High-quality care can often be en- medication list should be reviewed for critically ill patients A and non. • The treatment regimen should be is being used. Antihyperglycemic Agents in Because GDM is associated with and correction components is the Hospitalized Patients increased maternal risk for diabe. • Insulin therapy should be initi- Considerations on Admission blood typing.8 mmol/L) may be preexisting diabetic retinopathy will appropriate for selected patients. women with GDM tional details on the new criteria.9 mmol/L). mmol/L) may be used as an alert partum with a 75-g OGTT using the critically ill patients with poor value and as a threshold for further nonpregnancy criteria as outlined in oral intake or those who are tak. idated written or computerized • Hypoglycemia: <54 mg/dL (3. or cemia should be established for patients. • More stringent goals such as <140 standards. should be administered using val. • Sole use of sliding-scale insulin circumstances. in the inpatient hospital setting is men may be continued. a previous home regi- with frequency of testing depend. thyroid-stimulating mg/dL (7. 10] for addi- existing undiagnosed type 2 or even fluctuations and insulin dose. creatinine. Episodes of hypo. (See the section on infusion rate based on glycemic Hypoglycemia [p. E type 1 diabetes. prescription of prenatal ated for treatment of persistent Initial admission documentation vitamins (with at least 400 µg of folic hyperglycemia starting at a thresh- should state that the patient has type acid). prehensive eye exam. C to basal insulin at 60–80% of the C L I N I C A L D I A B E T E S 21 . as formed in the prior 3 months.0 mmol/L) is rec- adverse outcomes. published online December 15. glycemia in the hospital should be meals and bedtime or be given every DIABETES CARE IN THE documented in the medical record 4–6 hours if no meals are taken or if and tracked. A1C. Ongoing evaluation may or hospital system. titration of insulin regimens. A for glycemic control. and UACR. but in certain to 12-week 75-g OGTT is normal. Basal-bolus cose-lowering medication during implemented by each hospital regimens that include correction dos- pregnancy. be used for many noncritical-care glycemic test (e. Glycemic Targets in need close monitoring during preg. C Abnormalities Preconception counseling resourc. A Insulin Therapy family history. good nutritional intake. nutritional. • A hypoglycemia management IV insulin protocols should be used and need for insulin or oral glu. B well as Pap smear. impairment. ing on other risk factors. ing nothing by mouth. and critically ill patients.. regimen with basal. 2016 Preconception counseling visits with diabetes or hyperglycemia • There should be a structured should include rubella. the section on classification and diag.0 mmol/L). In most instances in the hospital set- tes. protocol should be adopted and for critically ill patients. discharge plan tailored to the indi- atitis B virus.g. E continuous enteral/parenteral therapy HOSPITAL. 1 or type 2 diabetes or no history of ing if indicated. hep.0 protocols that allow for pre. including death. C sets consistent with quality assurance patients should be referred for a com. A plan for es and account for oral intake may be performed with any recommended preventing and treating hypogly. Scheduled subcutaneous 75-g OGTT using nonpregnant each patient. and smoking cessation counsel. women should also be tested cally ill hospitalized patients with ting. as long as this can be achieved Hospitalized Patients nancy to ensure that retinopathy does without significant hypoglyce. the preferred treatment for non. including strongly discouraged. old ≥180 mg/dL (10. sured by the use of structured order potentially teratogenic drugs.8–10. a diabetes. mia. cervical cultures. NURSING HOME. Converting • Perform an A1C for all patients mg/dL (3. mmol/L) or severe cognitive Postpartum Care defined adjustments in the insulin Because GDM may represent pre. Both hyperglycemia and Diabetes-specific testing should target glucose range of 140–180 hypoglycemia are associated with include A1C. Standard Definition of Glucose not progress. An insulin nosis of diabetes above. B vidual patient with diabetes. (7. AND SKILLED NURSING reviewed and changed as necessary Subcutaneous insulin should be FACILITY to prevent further hypoglycemia administered 1–2 hours before IV Recommendations when a blood glucose value is ≤70 insulin is discontinued.9 tes or prediabetes at 4–12 weeks post. admitted to the hospital if not per. syphilis.

L. including social determinants Amy Butts. along with appropriate in Diabetes—2017 was created by ADA’s lar hyperglycemic state. Chair. MD. Kalyani. MPAS. PA-C. the section above on older adults with CRNP. MD. Salt Lake City. Psychosocial factors should be con. hold any oral hypoglyce. Joshua J. VA. MD. CPsychol. mic agents. statements. ND. FACP (Co-Chair). PhD. FACE. FACE. thanks to Jay Shubrook. Eric On the morning of surgery or a within 1 month of discharge is ad. FNP-BC. DIABETES ADVOCACY with staff support from Erika Gebel Berg. DO.* mmol/L). Factors to prevent re. and glucocor. vised for all patients having hyper. of long-acting analog or pump basal communication with outpatient pro. Donald fore discharge. and This abridged version of the ADA posi- tion statement Standards of Medical Care teral feedings. MEd. Perioperative Care of care. FASCP. MS. and address personal food preferenc. and Neil Skolnik. provide adequate skilled nursing facilities. The term “ADA diet” is no longer Advocacy Position Statements PhD. CDE. with staff support from viders either directly or via structured Sarah Bradley. Cherrington. PharmD. 2016 daily infusion dose has been shown Transition From the Acute Care and Driving” and “Diabetes and to be effective. DO. supplies. A registered dietitian can serve For a list of ADA advocacy position Uelmen.P O S I T I O N S TAT E M E N T Clinical Diabetes Papers In Press. with special ticoid therapy. NPH insulin dose or 60–80% doses contact may also be needed. Andrea L. R. Florez. *Subgroup leaders. es. PharmD. as patient needs change. Sacha used. H. MNT in the Hospital admissions need to be considered. CDTC. Vallejo. Jenkintown. beginning at admission and update plete 2017 Standards. Ian de Boer. Clear Abingdon. McAuliffe-Fogarty. Sandra procedure. Premixed insulins are Setting Employment. Tailor a structured discharge plan (“Diabetes Advocacy”) of the com- pital use. MPH (Co-Chair).4–10. CDE. Acknowledgments Care for guidance on enteral/paren. Neumiller. calories to meet metabolic demands. including “Diabetes MD. Monitor blood glucose every provided by Florence M.* Suneil Koliwad. Primary Care Advisory Group. James J. Johnson. Rhinehart. CDE. MD. MD. Melinda Maryniuk.” refer to Section 15 not routinely recommended for hos. Herman. Coustan. Editorial assistance was insulin. An outpatient follow-up visit Chamberlain. published online December 15. MD. education at the time of discharge. Hope Feldman.0 cols for resuming them 1–2 days be. prescriptions. hospital discharge summaries facil- 4–6 hours while a patient is taking The full Standards of Medical Care in itates safe transitions to outpatient nothing by mouth and dose with care. MB. FAPhA. Jaffa. BC-ADM.* diabetes regarding long-term care and glycemic control. MPH. Hermes J. Tucson. RD. Andrew S. MHS. there should be proto. UT. ment. give half of the patient’s glycemia in the hospital. Continuing FACP. 22 CLINICAL. MD. FACP. It is import- Standards for Special Situations ant that patients be provided with Refer to the full 2017 Standards of appropriate durable medical equip. medications. MD. The goals of MNT are to optimize PhD. MD. Primary Care Advisory Group. DKA and hyperosmo. and Robert Ratner. PA.ORG . PhD. Grand Forks.DIABETESJOURNALS. CDE. BCh. AZ. CDE. MD. MPH. Alicia H. CA. R.* and Joseph Wolfsdorf. MPH. Sheri Colberg-Ochs. MD. See Robert James Dudl. MD. CDE. PhD. Leal. as an inpatient team member. If oral medications are held in Diabetes—2017 was developed by the ADA’s Professional Practice Committee: William short-acting insulin as needed with the hospital. RDN. sidered. Rita a target of 80–180 mg/dL (4.