ADA 2016 Summary PDF

2016 American Diabetes Association (ADA) Diabetes Guidelines 1
Summary Recommendations from NDEI

2016 American Diabetes Association (ADA) Diabetes Guidelines

Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care.
2016;39(suppl 1):S1-S106. Available here.
Refer to source document for full recommendations, including level of evidence rating.
1. Diabetes Diagnosis
Criteria for Diabetes Diagnosis: 4 options

FPG ≥126 mg/dL (7.0 mmol/L)*
Fasting is defined as no caloric intake for ≥8 hours
2-hr PG ≥200 mg/dL (11.1 mmol/L) during OGTT (75-g)*
Using a glucose load containing the equivalent of 75g anhydrous glucose dissolved in water
A1C ≥6.5% (48 mmol/mol)*
Performed in a lab using NGSP-certified method and standardized to DCCT assay
Random PG ≥200 mg/dL (11.1 mmol/L)
In individuals with symptoms of hyperglycemia or hyperglycemic crisis
*In the absence of unequivocal hyperglycemia results should be confirmed using repeat testing
• No clear clinical diagnosis? Immediately repeat the same test using a new blood sample.
• Same test with same or similar results? Diagnosis confirmed.
• Different tests above diagnostic threshold? Diagnosis confirmed.
• Discordant results from two separate tests? Repeat the test with a result above diagnostic cut-point.
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The National Diabetes Education Initiative® (NDEI®) is sponsored by Ashfield Healthcare Communications, Lyndhurst, NJ.

Copyright © 2016 Ashfield Healthcare Communications. All rights reserved.

Testing for Type 2 Diabetes and Prediabetes in Asymptomatic Adults

Type 2 diabetes screening should be performed in adults of any age who are overweight or obese, and who have one or
more diabetes risk factor (See Diabetes Risk Factors)
• Testing should begin at age 45
• If test is normal? Repeat it at least every 3 years (See Diabetes Risk Factors):
Screening for prediabetes can be done using A1C, FPG, or 2-hr PG after 75-g OGTT criteria
• CVD risk factors should be identified and treated
• Testing may be considered in children and adolescents who are overweight or obese and have two or more risk
factors for diabetes (See Diabetes Risk Factors)
Type 2 Diabetes Risk Factors

• Physical inactivity
• First-degree relative with diabetes
• High-risk race/ethnicity
• Women who delivered a baby >9 lb or were diagnosed with GDM
• HDL-C <35 mg/dL ± TG >250 mg/dL
• Hypertension (≥140/90 mm Hg or on therapy)
• A1C ≥5.7%, IGT, or IFG on previous testing
• Conditions associated with insulin resistance: severe obesity, acanthosis
nigricans, PCOS
• History of CVD



Categories of Increased Risk for Diabetes (Prediabetes)

FPG 2-hr PG A1C
100-125 mg/dL 140-199 mg/dL 5.7-6.4%
(5.6-6.9 mmol/L) (7.8-11.0 mmol/L) (39-46 mmol/mol)
Impaired fasting glucose (IFG) Impaired glucose tolerance (IGT)
For all tests, risk is continuous, extending below lower limit of range
and becoming disproportionately greater at higher ends of range
Screening Children for Type 2 Diabetes and Prediabetes

Consider screening for type 2 diabetes and prediabetes for all children who are overweight* and have two or more of the
following risk factors:
• Family history of type 2 diabetes in a first- or second-degree relative
• Native American, African American, Latino, Asian American, or Pacific Islander descent
• Signs of insulin resistance or conditions associated with insulin resistance†
• Maternal history of diabetes or GDM during the child’s gestation
Test every 3 years using A1C beginning at age 10 or onset of puberty
*BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% ideal weight
†Acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, or small-for-gestational-age birth weight
Children defined as age <18 years



Screening for Gestational Diabetes Mellitus (GDM)

Pregnant women with risk factors Test for undiagnosed type 2 at first prenatal visit using stansard
diagnostic criteria
Pregnant women without known prior diabetes Test for GDM at 24-28 weeks
Women with GDM Screen for persistent diabetes 6-12 wks postpartum using OGTT
and standard diagnostic criteria
Women with a history of GDM Lifelong screening for diabetes or prediabetes every ≥3 yrs
Women with a history of GDM and prediabetes Lifestyle interventions or metformin for diabetes prevention
• Women with diabetes in the first trimester have type 2 diabetes
• GDM is diagnosed in the second or third trimester and not clearly associated with type 1 or type 2 diabetes
Screening is recommended at 24-48 weeks in women who were not previously diagnosed with overt diabetes
One-step diagnosis strategy Two-step diagnosis strategy
• Perform 75-g OGTT with plasma glucose Step 1:
measurement
• Test in the morning after the patient has fasted for • Perform a 50-g nonfasting GLT with plasma measurement at
≥8 hours 1 hour
• Repeat test at 1 and 2 hours after initial • If PG measured 1 hour after the load is
measurement ≥140 mg/dL (7.8 mmol/L), proceed to 100-g OGTT
Diagnosis is confirmed when PG levels meet or Step 2:
exceed: • Perform 100-g OGTT while patient is fasting
• Fasting 92 mg/dL (5.1 mmol/L) Diagnosis is confirmed when two or more PG levels meet or
• 1 hr: 180 mg/dL (10.0 mmol/L) exceed:
• 2 hr: 153 mg/dL (8.5 mmol/L)
• Fasting: 95 mg/dL or 105 mg/dL (5.3/5.8)
• 1 hr: 180 mg/dL or 190 mg/dL (10.0/10.6)
• 2 hr: 155 mg/dL or 165 mg/dL (8.6/9.2)
• 3 hr: 140 mg/dL or 145 mg/dL (7.8/8.0)



Screening for Type 1 Diabetes

There are two manifestations of type 1 diabetes:
• Immune-mediated diabetes, previously called “insulin-dependent diabetes” or “juvenile-onset diabetes”, is due to
cellular-mediated autoimmune destruction of beta-cells
• Idiopathic type 1 diabetes largely has no known cause with no evidence of beta-cell autoimmunity
Blood glucose is preferred over A1C to diagnose acute onset of type 1 diabetes with symptoms of hyperglycemia
Inform relatives of individuals with type 1 diabetes of the opportunity to be tested
• Testing should occur only in the setting of a clinical research study
BMI=body mass index; FPG=fasting plasma glucose; GDM=gestational diabetes mellitus; HDL-C=high-density lipoprotein
cholesterol; OGTT=oral glucose tolerance test; PG=plasma glucose; TG=triglycerides
Download the full 2016 ADA diabetes guidelines slide set

http://ndei.org/dsl/mainpage.aspx




2. Glycemic Targets
Blood Glucose Targets for Non-Pregnant Adults With Diabetes

A1C <7.0% (53 mmol/L)
Preprandial capillary PG 80-130 mg/Dl (4.4-7.2 mmol/L)
Peak postprandial capillary PG <180 mg/dL* (10.0 mmol/L)
More or less stringent targets may be appropriate for individual patients
if achieved without significant hypoglycemia or adverse events
More stringent (<6.5%) Less stringent (<8.0%)
• Short diabetes duration • Severe hypoglycemia history
• Long life expectancy • Limited life expectancy
• Type 2 diabetes treated with lifestyle or metformin • Advanced microvascular or macrovascular complications
only • Extensive comorbidities
• No significant CVD/vascular complications • Long-term diabetes in whom general A1C targets are difficult
to attain
Targets may be individualized based on:
• Age/life expectancy
• Comorbid conditions
• Diabetes duration
• Hypoglycemia status
• Individual patient considerations
Lowering A1C below or around 7.0% has been shown to reduce:
• Microvascular complications



• Macrovascular disease (if implemented soon after diagnosis)

• Mortality (individuals with type 1 diabetes only)
*
Postprandial glucose measurements should be made 1-2 hours after the beginning of the meal
Management of Hypoglycemia
Ask at-risk patients about symptomatic and asymptomatic hypoglycemia at each encounter
Glucose (15-20 g) is the preferred treatment of hypoglycemia for conscious patients
• 15 minutes after treatment, repeat if SMBG shows continued hypoglycemia
• When SMBG is normal, the patient should consume a meal or snack to prevent hypoglycemia recurrence
Glucagon may be prescribed for all individuals who are at risk for severe hypoglycemia
If an individual has hypoglycemia unawareness or an episode of severe hypoglycemia:
• Re-evaluate the treatment regimen
• In patients treated with insulin, raise glycemic targets for several weeks to partially reverse hypoglycemia unawareness
and reduce the recurrence of hypoglycemia
For individuals with low or declining cognition, continually assess cognitive function with increased vigilance for
hypoglycemia
PG=plasma glucose; SMBG=self-monitoring of blood glucose





3. Type 2 Diabetes Prevention
Strategies for Preventing or Delaying Type 2 Diabetes

Individuals with prediabetes: Refer these individuals to a behavioral counseling program targeting
IGT, IFG, or A1C 5.7-6.4% intensive diet and physical activity to achieve:
• 7% of body weight loss
• Increased physical activity, targeting at least 150 minutes per week
(moderate activity
*
Consider metformin therapy for type 2 diabetes prevention in individuals with prediabetes, especially
in the presence of:
• BMI >35 kg/m2
• Age <60 years
• Women who have had gestational diabetes
Monitoring at least once per year is recommended for all individuals with prediabetes
Screen for and treat modifiable CVD risk factors:
• Obesity
• Hypertension
• Dyslipidemia
Diabetes self-management education (DSME) and diabetes self-management support (DSMS) are appropriate for all
individuals with prediabetes for type 2 diabetes prevention or delay
*
Metformin is not FDA approved in the United States for type 2 diabetes prevention
BMI=body mass index; CVD=cardiovascular disease; IFG=impaired fasting glucose; IGT=impaired glucose tolerance




4. Pharmacologic Therapy for Type 2 Diabetes Management
Pharmacologic Therapy Recommendations

Lifestyle changes should be the first-line therapy for most individuals with type 2 diabetes
When lifestyle changes alone have not achieved or • Add metformin
maintained glycemic goals • Preferred initial pharmacologic therapy if
tolerated and not contraindicated*
For newly diagnosed individuals who are markedly • Consider insulin therapy with or without other
symptomatic and/or have elevated glucose levels agents
or A1C
If noninsulin monotherapy (OAD) at maximal • Add:
tolerated dose(s) does not achieve or maintain A1C • A second oral agent or
target over 3 months • A GLP-1 receptor agonist or
• Basal insulin
Due to the progressive nature of type 2 diabetes, insulin is eventually needed Insulin therapy should not be delayed



Choice of Pharmacologic Therapy

The choice of pharmacologic therapy should be based on a patient-centered approach with consideration of the following:
• Efficacy
• Cost
• Potential side effects
• Effects on weight
• Comorbidities
• Hypoglycemia risk
• Patient preferences
*Metformin is contraindicated in individuals with:
• Renal disease or renal dysfunction (e.g., as suggested by serum creatinine levels ≥1.5 mg/dL (males), ≥1.4 mg/dL
(females) or abnormal creatinine clearance) which may also result from conditions such as cardiovascular collapse
(shock), acute myocardial infarction, and septicemia
• Known hypersensitivity to Metformin hydrochloride
• Acute or chronic metabolic acidosis, including diabetic ketoacidosis, with or without coma. Diabetic ketoacidosis should
be treated with insulin

OAD=oral antidiabetic drugs
Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug Administration (FDA) unless otherwise
noted. Consult individual prescribing information for approved uses outside of the United States.





5. Pharmacologic Therapy for Type 1 Diabetes
Pharmacologic Therapy for Type 1 Diabetes Management

Insulin therapy is the mainstay for individuals with type 1 diabetes
• Treat with multiple-dose insulin injections* or continuous subcutaneous insulin infusion (CSII)
• Match prandial insulin to carbohydrate intake, premeal glucose, and anticipate physical activity
• Use insulin analogs to reduce the risk of hypoglycemia
• Consider using sensor-augmented low glucose suspend threshold pump in patients with frequent nocturnal
hypoglycemia and/or hypoglycemia unawareness
Non-insulin agents Investigational agents†
• Pramlinitide (amylin analog) • Metformin + insulin
• Delays gastric emptying • May reduce insulin requirements and improve
• Blunts pancreatic secretion of glucagon metabolic control in obese/overweight with poor
• Enhances satiety glycemic control
• Induces weight loss • Incretins
• Lowers insulin dose • GLP-1 receptor agonists
• Use only in adults • DPP-4 inhibitors
• SGLT2 inhibitors
*
3-4 injections/day of basal and prandial insulin)
†
Not FDA approved for the treatment of type 1 diabetes in the United States




6. Insulin & Glucose Monitoring
Self-monitoring of blood glucose (SMBG)

Encourage individuals receiving multiple dose insulin or insulin pump therapy to perform SMBG:
• Prior to meals and snacks
• Occasionally after meals (postprandially)
• At bedtime
• Prior to exercise
• When low blood glucose is suspected
• After treating low blood glucose until normoglycemia is achieved
• Prior to critical tasks, such as driving
SMBG results may be useful for guiding treatment and/or self-management for individuals using less frequent insulin
injections or noninsulin therapies
• It is important to provide ongoing instruction and regular evaluation of SMBG technique, results, and the patient’s ability
to use the data to adjust therapy
Continuous Glucose Monitoring (CGM)
CGM is useful for A1C lowering in select adults (aged ≥25 yrs) with type 1 diabetes who require intensive insulin:
• The technique may be useful among children, teens, and younger adults*
• Success is related with adherence to ongoing use
CGM may be a useful supplement to SMBG among individuals with hypoglycemia unawareness and/or frequent
hypoglycemic episodes
*
Evidence for A1C lowering is less strong in these populations




7. Lifestyle Changes
Medical Nutrition Therapy (MNT)
The ADA acknowledges that there is no one-size-fits-all eating pattern for individuals with type 2 diabetes.
MNT is recommended for all individuals with type 1 and type 2 diabetes as part of an overall treatment plan, preferably
provided by a registered dietitian skilled in diabetes MNT
Goals of MNT:
• A healthful eating pattern to improve overall health, specifically:
• Achievement and maintenance of weight goals
• Attainment of individualized glycemic, blood pressure, and lipid goals
• Type 2 diabetes prevention or delay
• Attain individualized glycemic, blood pressure, and lipid goals
• Achieve and maintain body weight goals
• Delay or prevent diabetes complications
Physical Activity
Adults with diabetes
Exercise programs should include:
• ≥150 min/wk moderate-intensity aerobic activity (50%-70% max heart rate), spread over
≥3 days/wk with no more than 2 consecutive days without exercise
• Resistance training ≥2 times/wk (in absence of contraindications)*
• Reduce sedentary time = break up >90 minutes spent sitting
Evaluate patients for contraindications prohibiting certain types of exercise before recommending exercise program†



Consider age and previous level of physical activity

Children with diabetes or prediabetes
• ≥60 min physical activity/day
*Adults with type 2 diabetes
†
Eg, uncontrolled hypertension, severe autonomic or peripheral neuropathy, history of foot lesions, unstable proliferative
retinopathy
Physical Activity in Individuals With Hypoglycemia

• If an individual is taking insulin and/or insulin secretagogues, physical activity can cause hypoglycemia if medication
dose or carb consumption is not altered
• Added carbohydrate should be ingested when pre-exercise glucose is <100 mg/dL (5.6 mmol/L)
Physical Activity in Individuals With Diabetes Complications

Retinopathy • Proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy
• Vigorous aerobic or resistance exercise may be contraindicated
Autonomic neuropathy • Can increase the risk for exercise-induced injury
• All individuals with autonomic neuropathy should undergo cardiac investigation before
beginning more-intense-than-usual physical activity
Peripheral neuropathy • Decreased pain sensation and a higher pain threshold in the extremities cause increased
risk of skin breakdown and infection
• All individuals with neuropathy should wear proper footwear and examine feet daily for
lesions
• Individuals with foot injury or open sores are restricted to non–weight-bearing activity
Albuminuria and • Physical activity can acutely increase urinary protein excretion
nephropathy • There is no evidence that vigorous-intensity exercise increases the progression of diabetic
kidney disease
• No restrictions are necessary for individuals with diabetic kidney disease




8. Management of Obesity in Individuals With Type 2 Diabetes
Obesity Management
• Management of obesity has been shown to delay the progression from prediabetes to type 2 diabetes
• It may also be beneficial for treating type 2 diabetes
• Modest and sustained weight loss has been shown to improve glycemic control and reduce the need for glucose-
lowering medications
General Recommendations
Calculate BMI at each patient encounter to determine the presence of overweight or obesity
Advise patients that higher BMI increases the risk for CVD and mortality
Assess the patient’s readiness to achieve weight loss
• With the patient, determine weight loss goals and the treatment strategy
Lifestyle Changes for Obesity Management

Diet, physical activity, and behavior therapy designed to achieve 5% weight loss are recommended for overweight and
obese individuals with type 2 diabetes who are motivated to lose weight
• High-intensity interventions (eg, 16 or more sessions within 6 months
• Focus on diet, physical activity, and behavioral strategies to achieve a 500-750 kcal/day deficit
Recommendations for individuals who achieve short-term weight loss:
• Prescribe a long-term (more than 1 year) comprehensive weight management program
• Make contact with the patient at least monthly, with ongoing monitoring of body weight thereafter
• Prescribe a reduced-calorie diet



• Encourage high levels of physical activity (200-300 mins/wk)

To achieve short-term weight loss, recommend:
• Short-term (3-month) high-intensity lifestyle interventions that use low-calorie diets (fewer than
800 kcal/day)
• Long-term comprehensive weight management counseling to maintain weight loss
Pharmacologic Therapy for Obesity Management

Glucose-lowering medications may affect weight in individuals with type 2 diabetes who are overweight or obese
• Consider the effects of antihyperglycemic medications on weight before prescribing
• Minimize where possible the medications for comorbid conditions that are associated with weight gain
Among selected individuals with type 2 diabetes and BMI ≥27 kg/m2:
• Weight loss medications may be effective as adjuncts to diet, physical activity, and behavioral counseling
• The potential benefits of these medications must be balanced against potential risks
If an individual who was prescribed weight loss medications does not lose >5% body weight after 3 months, or
experiences safety or tolerability issues:
• Discontinue the medication
• Use an alternative medication or treatment approach
Bariatric Surgery in Type 2 Diabetes

Bariatric surgery may be considered for adults with type 2 diabetes whose BMI is >35 kg/m2
• In particular in individuals in whom their diabetes or associated comorbidities are difficult to control with lifestyle and
pharmacologic therapy
• Lifelong support and monitoring are necessary
There is insufficient evidence to recommend bariatric surgery for individuals with BMI ≤35 kg/m2 outside of a research
protocol
Advantages of bariatric surgery Disadvantages of bariatric surgery
• Achieves near or complete normalization of glycemia • Costly
2 years after surgery*1 • Outcomes are variable based on the procedure and experience
• Younger age, shorter diabetes duration, lower A1C, of the surgeon
higher insulin levels, and non-use of insulin are • Long term:
associated with higher post-surgery remission rates • Dumping syndrome



• Vitamin and mineral deficiencies

• Osteoporosis
• Severe hypoglycemia from insulin hypersecretion
• Increased risk for substance abuse
*
Among 72% of subjects compared with 16% control subjects treated with lifestyle
and pharmacologic therapy
BMI=body mass index






9. Cardiovascular Disease (CVD) and Diabetes
Blood Pressure (Hypertension) Management & Treatment Targets

Screening • Measure BP at every patient visit
• Confirm elevated BP at a separate visit
Systolic (SBP) targets
• <140 mm Hg
Treatment targets • Lower target (<130) may be appropriate in certain individuals*
Diastolic (DBP) targets
• <90 mm Hg
• Lower target (<80) may be appropriate in certain individuals*
*
Younger individuals, people with albuminuria, and/or individuals with hypertension and one or more additional ASCVD
risk factor
• Only if the lower target can be achieved without undue treatment burden




Treatment of High Blood Pressure

Individuals with BP >120/80 mm Hg • Lifestyle changes (See below)
Individuals with confirmed office BP >140/90 mm • Prompt initiation and timely subsequent titration of pharmacologic
Hg therapy (see below)in addition to lifestyle changes
Older adults • Treating to <130/70 mm Hg is not recommended
• SBP <130 has not been shown to improve CV outcomes
• DBP <70 has been associated with increased mortality
Pregnant individuals • Targets of 110-129/65-79 are recommended to optimize long-term
maternal health and minimize impaired fetal growth
Pharmacologic Therapy for High Blood Pressure

• Regimen to include ACEI or ARB—but never in combination
• If either ACEI or ARB is not tolerated, substitute one for the other
• If using ACEI, ARB, or diuretic, monitor serum creatinine/eGFR and serum potassium levels
Lifestyle Changes for High Blood Pressure

• Weight loss
• DASH-style dietary pattern, including:
• Reduced sodium intake (<2,300 mg/day)
• Increased potassium intake
• Increased fruit/vegetable intake (8-10 servings/day)
• Moderate alcohol intake
• Increased physical activity



Lipid Management
Adults not taking a statin • Obtain a lipid profile
• At diabetes diagnosis, initial medical evaluation, and every 5
years thereafter
• At initiation of statin therapy and periodically thereafter
Lifestyle changes • Weight loss (if indicated)
• Reduced intake of saturated fat, trans fat, and cholesterol
• Increased intake of omega-3 fatty acids, viscous fiber, and plant
stanols/sterols
• Increased physical activity
Intensify lifestyle changes and optimize glycemic • TG ≥150 mg/dL
control among individuals with • HDL-C <40 mg/dL (men), <50 mg/dL (women
Individuals with fasting TG ≥500mg/dL • Evaluate for secondary causes of hypertriglyceridemia
• Consider medical therapy to reduce pancreatitis risk
Statin Therapy for Lipid Management

Individuals with diabetes and ASCVD* • High-intensity statin therapy + lifestyle changes
Age <40 with diabetes and ASCVD risk factors • Moderate- or high-intensity statin + lifestyle
Age 40-75 years with diabetes but without ASCVD • Moderate-intensity statin + lifestyle
risk factors
Age 40-75 with diabetes and ASCVD risk factors • High-intensity statin + lifestyle
Age >75 with diabetes but without ASCVD risk • Moderate- or high-intensity statin + lifestyle
†
factors
Age >75 with diabetes and ASCVD risk factors • Moderate- or high-intensity statin + lifestyle
The intensity of statin therapy may require adjustment based on an individual’s response



ASCVD Risk Factors

• LDL-C ≥100 mg/dL (2.6 mmol/L)
• High blood pressure
• Smoking
• Overweight or obesity
• Family history of premature ASCVD
*
Regardless of age
†
Routinely evaluate risk-benefit profile of statin therapy, with down-titration as needed
Combination Therapy for Lipid Management

Statin + ezetimibe • Adding ezetimibe to moderate-intensity statin therapy has been shown to provide
incremental CV benefit compared with moderate statin therapy along
• This combination is a consideration for individuals:
• With recent ACS and LDL-C ≥50 mg/dL
• Who cannot tolerate a high-intensity statin
Statin + fibrate • This combination has not been shown to improve ASCVD outcomes
• As such, it is not recommended
• Statin + fenofibrate may be considered for men with
TG ≥204 mg/dL and HDL-C ≤34 mg/dL
Statin + niacin • This combination has not been shown to provide additional CV benefit above statin therapy
alone
• It may increase the risk for stroke
• This combination is not recommended
Statin + PCSK9 inhibitor • 36%-59% reductions have been shown with PCSK9 inhibitors on top of maximal tolerated
statin therapy
• Combination statin + PCSK9 may be considered as adjunctive therapy for individuals with
diabetes who are at high ASCVD risk or who are intolerant to a high-intensity statin



Statins & Incident Diabetes

• Increased risk of incident diabetes with statin use has been reported1,2
• May be limited to individuals with diabetes risk factors
• Analysis of initial study3: cardiovascular event rate reduction with statins outweighed risk of incident diabetes
• Even for individuals at highest diabetes risk
• Meta-analysis of 13 randomized statin trials:2
• Odds ratio of 1.09 for new diabetes diagnosis
• Treatment of 255 patients with statins for 4 yrs resulted
in 1 additional diabetes case
• Simultaneously prevented 5.4 vascular events
Antiplatelet Therapy Recommendations

Aspirin for primary • 75-162 mg/day for individuals with type 1 or type 2 diabetes who are at increased
prevention ASCVD risk (10-yr risk >10%)* and not at increased bleeding risk
• Aspirin is not recommended for ASCVD prevention in adults with diabetes who are at low
ASCVD risk (10-yr risk <5%)†
• The potential for bleeding in these individuals likely offsets potential benefits of aspirin
• Clinical judgement is required for individuals with diabetes and multiple other risk factors
(10-yr risk 5%-10%)
Aspirin for secondary • 75-162 mg/day for individuals with diabetes and a history of ASCVD
prevention
• For individuals with ASCVD and a documented aspirin allergy, clopidogrel 75 mg/day should be used
• Dual antiplatelet therapy is reasonable for up to 1 year after ACS
*
Includes most men or women with diabetes aged ≥50 yrs with ≥1 add’l major risk factor: family history of premature
ASCVD, hypertension, smoking, dyslipidemia, or albuminuria



Coronary Heart Disease (CHD) Screening and Treatment

Routine coronary artery disease (CAD) screening in asymptomatic individuals is not recommended
• It does not improve outcomes as long as ASCVD risk factors are treated
Consider investigating for CAD in the presence of:

Screening • Atypical cardiac symptoms
• Signs or symptoms of associated vascular disease, including carotid bruits, TIA, stroke, claudiation, or
PAD
• Electrocardiogram abnormalities
In individuals with known ASCVD
• Use aspirin and statin therapy if not contraindicated
• Consider therapy with an ACEI to reduce the risk of CV events
Treatment In individuals with symptomatic heart failure:

• Do not use TZDs, as these agents are associated with heart failure
In individuals with type 2 diabetes and stable heart failure:

• Metformin may be used if renal function is normal
• Metformin therapy should be avoided in unstable or hospitalized patients with heart failure





10. Microvascular Complications and Foot Care
Diabetic Kidney Disease (Nephropathy) Screening and Treatment

Screening Annually measure urinary albumin and eGFR in:
• Patients with type 1 diabetes with ≥5-year duration
• Patients with type 2 diabetes starting at diagnosis
• All patients with hypertension
For individuals with nondialysis-dependent diabetic kidney disease:
• Dietary protein intake should be 0.8 g/kg of body weight/day
For individuals on dialysis:
• Higher levels of protein intake should be considered
ACEI or ARB is recommended for treating nonpregnant individuals with diabetes and modestly
elevated urinary albumin excretion (30-299 mg/d)
Treatment • This is strongly recommended for individuals with urinary albumin excretion ≥300 mg/d and/or
eGFR <60 mL/min/1.73m2
Periodically monitor serum creatinine and potassium levels when ACEIs, ARBs, or diuretics are used
for treatment
Monitor urinary albumin-to-creatinine ratio in individuals with albuminuria treated with an ACEI
or ARB
ACEI or ARB treatment is not recommended for primary prevention of diabetic kidney disease in
individuals with diabetes who have normal blood pressure, urinary albumin-to-creatinine ratio, and
eGFR
If eGFR is <60 mL/min/1.73m2



• Evaluate and manage potential complications of chronic kidney disease
If eGFR is <30 mL/min/1.73m2

• Refer for evaluation of renal replacement treatment
Refer to a physician experienced in the care of kidney disease for uncertainty regarding cause
of kidney disease, difficult management issues, or rapidly progressing disease
eGFR 45-60 • Refer to a nephrologist if the possibility exists for nondiabetic kidney
2
mL/min/1.73m disease
• Consider the need for dose adjustment of medications
• Monitor eGFR, electrolytes, bicarbonate, calcium, phosphorous,
Management parathyroid hormone, hemoglobin, albumin, and weight every 6 months
• Assure vitamin D sufficiency
• Consider bone density testing
• Refer for dietary counseling
eGFR 30-44 • Monitor eGFR every 3 months
2
mL/min/1.73m • Monitor eGFR, electrolytes, bicarbonate, calcium, phosphorous,
parathyroid hormone, hemoglobin, albumin, and weight every 3 months
• Consider the need for dose adjustment of medications
eGFR 30-44 • Refer to a nephrologist
2
mL/min/1.73m
Retinopathy Screening and Treatment

Screening
Optimize glucose, BP, and lipid control to reduce the risk or slow the progression of retinopathy
Adults with type 1 diabetes Initial dilated and comprehensive eye exam within 5 years of diabetes onset
Adults with type 2 diabetes Initial dilated and comprehensive eye exam at the time of diabetes
diagnosis
No evidence of retinopathy for one or Consider exams every 2 years
more annual eye exam
Any evidence of retinopathy present Subsequent dilated retinal exam for type 1 or type 2 repeated at least



annually
Retinopathy progressive or sight More frequent dilated retinal exams are recommended
threatening
Eye exams should occur prior to Thereafter, monitor every trimester and for 1 year postpartum as indicated
pregnancy or in the first trimester by degree of retinopathy
Treatment
• Refer individuals with macular edema, severe NPDR, or any PDR to an ophthalmologist
• Laser photocoagulation therapy indicated to reduce the risk of vision loss in high-risk PDR and severe NPDR
• Intravitreal injections of antivascular endothelial growth factor are indicated for center-involved diabetic macular edema
• The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection
Neuropathy Screening and Treatment

Screen all patients for diabetic peripheral neuropathy
• Type 2 diabetes: at diagnosis
• Type 1 diabetes: 5 yrs after diagnosis and at least annually thereafter
Assessment should include careful history, 10-g monofilament testing, and one or more of the
Screening following:
• Pinprick
• Temperature
• Vibration sensation
Symptoms of autonomic neuropathy should be assessed in individuals with microvascular and
neuropathic complications
Optimize glucose control to:
• Type 1: prevent or delay neuropathy onset
Treatment • Type 2: slow neuropathy progression
Assess and treat patients to reduce pain related to DPN and symptoms of autonomic neuropathy



Foot Care Recommendations

All individuals with diabetes • Annual foot exam to identify risk factors predictive of ulcers and
amputations
• Assessment of foot deformities, skin inspection, neurological exam, vascular
assessment (pulses)
• Provide foot self-care education
All individuals with insensate feet, foot • Examine feet at every patient visit
deformities, or history of foot ulcers
Patients with foot ulcers, high-risk feet • Use a multidisciplinary approach
(previous ulcer or amputation), or
peripheral artery disease
Symptoms of claudication or decreased • Refer for ankle-brachial index and further vascular assessment
or absent pedal pulses
Patients who smoke or have a history of • Refer to foot care specialist for ongoing preventive care
prior lower-extremity complications, loss
of sensation, structural abnormalities, or
peripheral artery disease
ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; eGFR=estimated glomerular filtration

rate; NPDR=nonproliferative diabetic retinopathy; PDR=proliferative diabetic retinopathy





11. Diabetes in Pregnancy (Gestational Diabetes—GDM)
Screening for Gestational Diabetes Mellitus (GDM)

Pregnant women with risk factors Test for undiagnosed type 2 at first prenatal visit using stansard
diagnostic criteria
Pregnant women without known prior diabetes Test for GDM at 24-28 weeks
Women with GDM Screen for persistent diabetes 6-12 wks postpartum using OGTT
and standard diagnostic criteria
Women with a history of GDM Lifelong screening for diabetes or prediabetes every ≥3 yrs
Women with a history of GDM and prediabetes Lifestyle interventions or metformin for diabetes prevention
• Women with diabetes in the first trimester have type 2 diabetes
• GDM is diagnosed in the second or third trimester and not clearly associated with type 1 or type 2 diabetes
Screening is recommended at 24-48 weeks in women who were not previously diagnosed with overt diabetes
One-step diagnosis strategy Two-step diagnosis strategy
• Perform 75-g OGTT with plasma glucose Step 1:
measurement
• Test in the morning after the patient has fasted for • Perform a 50-g nonfasting GLT with plasma measurement at
≥8 hours 1 hour
• Repeat test at 1 and 2 hours after initial • If PG measured 1 hour after the load is
measurement ≥140 mg/dL (7.8 mmol/L), proceed to 100-g OGTT
Diagnosis is confirmed when PG levels meet or Step 2:



exceed: • Perform 100-g OGTT while patient is fasting
• Fasting 92 mg/dL (5.1 mmol/L) Diagnosis is confirmed when two or more PG levels meet or
• 1 hr: 180 mg/dL (10.0 mmol/L)
exceed:
• 2 hr: 153 mg/dL (8.5 mmol/L)
• Fasting: 95 mg/dL or 105 mg/dL (5.3/5.8)
• 1 hr: 180 mg/dL or 190 mg/dL (10.0/10.6)
• 2 hr: 155 mg/dL or 165 mg/dL (8.6/9.2)
• 3 hr: 140 mg/dL or 145 mg/dL (7.8/8.0)
Glycemic Targets in Pregnancy

Pregestational diabetes Gestational diabetes mellitus (GDM)
Fasting ≤90 mg/dL ≤95 mg/dL
(5.0 mmol/L) (5.3 mmol/L)
1-hr postprandial ≤130-140 mg/dL ≤140 mg/dL
(7.2-7.8 mmol/L) (7.8 mmol/L)
2-hr postprandial ≤120 mg/dL ≤120 mg/dL
(6.7 mmol/L) (6.7 mmol/L)
A1C 6.0-6.5% (42-48 mmol/L) recommended
<6.0% may be optimal as pregnancy progresses
Achieve without hypoglycemia
Recommendations for Pregestational Diabetes

Pregestational type 1 and type 2 diabetes confer greater maternal and fetal risk than GDM
• Spontaneous abortion
• Fetal anomalies
• Preeclampsia
• Intrauterine fetal demise
• Macrosomia
• Neonatal hypoglycemia
• Neonatal hyperbilirubinemia



Diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life
Maintain A1C levels as close to normal as is safely possible
• Ideally, A1C <6.5% (48 mmol/L) without hypoglycemia
Discuss family planning
• Prescribe effective contraception until woman is prepared to become pregnant
Women with preexisting type 1 or type 2 diabetes
• Counsel on the risk of development and/or progression of diabetic retinopathy
• Perform eye exams before pregnancy or in first trimester; monitor every trimester and for 1 year postpartum
Management of Pregestational Diabetes

Insulin is the preferred medication for pregestational type 1 and type 2 diabetes not adequately controlled with diet,
exercise, and metformin
Insulin* management during pregnancy is complex
• Requires frequent titration to match changing requirements
• Referral to specialized center recommended
Women with type 1 diabetes are at high risk for hypoglycemia
• Hypoglycemia education important before and during pregnancy to prevent hypoglycemia
Women with type 1 diabetes are at risk for ketoacidosis
• At lower blood glucose levels than in the nonpregnant state
• Provide education on prevention and treatment of diabetic ketoacidosis
Women with type 2 diabetes are at risk for obesity
• Recommended weight gain during pregnancy: 15-25 lb overweight, 10-20 lb obese
• Glycemic control easier to achieve than in type 1 but can require higher insulin doses
Targets:
• Fasting ≤90 mg/dL (5.0 mmol/L)
• 1-hr postprandial ≤130-140 mg/dL (7.2-7.8 mmol/L)
• 2-hr postprandial ≤120 mg/dL (6.7 mmol/L
*
Most insulins are category B; glargine, glulisine, and degludec are category C



Recommendations for Gestational Diabetes Mellitus (GDM)

GDM increases the risk of macrosomia, birth complications, and maternal diabetes after pregnancy
• Risks increase with progressive hyperglycemia
• Risk may be reduced with diet, physical activity, and lifestyle counseling
Lifestyle management
• Medical nutrition, physical activity, weight management
Pharmacologic therapy
• Insulin* is first line
• Requires frequent titration to match changing requirements
• Referral to specialized center recommended
• Sulfonylureas:
• May be inferior to insulin and metformin due to increased risk of neonatal hypoglycemia and macrosomia
• No long-term safety data
• Metformin
• May be preferable to insulin for maternal health if can control hyperglycemia
• May increase risk of prematurity
• Lower hypoglycemia & weight gain
• Long-term outcomes in offspring not known
*
Most insulins are category B; glargine, glulisine, and degludec are category C
Recommendations for Postpartum Follow-Up in Women With GDM

An oral glucose tolerance test (OGTT) is recommended at the 6- to 12-week postpartum visit
GDM is associated with increased maternal risk for type 2 diabetes
• Test women with GDM every 1-3 years if her 6- to 12-wk OGTT is normal
• The frequency of screening is based on the presence of risk factors: family history,
pre-pregnancy BMI, or need for insulin or OAD medications during pregnancy
• Ongoing screening may be done with any glycemic test (A1C, fasting plasma glucose, OGTT) using nonpregnancy cut
points
Metformin and intensive lifestyle changes prevent or delay progression to type 2 diabetes



Managing Hypertension During Pregnancy

Target BP for pregnancy complicated by diabetes • SBP: 110-129 mm Hg
• DBP: 65-79 mm Hg
Antihypertensive medications
Safe medications Unsafe medications (contraindicated)
• Methyldopa • ACEIs
• Labetalol • ARBs
• Diltiazem
• Clonidine
• Prazosin
ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; BMI=body mass index; DBP=diastolic
blood pressure; OAD=oral antidiabetic drug; SBP=systolic blood pressure





12. In-Patient Glycemia
Diabetes Care in the Hospital

Insulin is preferred method for glycemic control in the hospital setting
• Exclusive use of SSI is strongly discouraged
Recommendations for diabetes care of patients in the ICU (critical care):
• Intravenous insulin shown to be the best method for achieving glycemic targets
• Administer using validated written or computerized protocols that allow for predefined adjustments in infusion rate
based on glycemic fluctuations and insulin dose
Recommendations for diabetes care of patients in noncritical care settings:
• Scheduled subcutaneous insulin injections that align with meals and bedtime*
• Insulin regimen with basal, nutritional, and correction components (basal-bolus) for individuals with good nutritional
intake
• Basal plus correction insulin regimen for individuals with poor oral intake or who are NPO
The safety and efficacy of noninsulin therapies are being studied
*
Or every 4-6 hrs if no meals or if continuous enteral/parenteral therapy being used
Glycemic Targets for Critically Ill Individuals

Insulin is the preferred method for achieving glycemic control for diabetes care in the hospital
Recommendations for critically ill individuals with persistent hyperglycemia:
• Initiate insulin starting at ≤180 mg/dL (10.0 mmol/L)
• Once insulin is started, a target glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) is recommended for most patients
More stringent targets may be appropriate for certain patients providing a lower target does not confer increased



hypoglycemia risk
• 110-140 mg/dL (6.1-7.8 mmol/L)
A hypoglycemia management protocol should be established for each patient:
• A plan for prevention and treatment of hypoglycemia should be developed
• All episodes of hypoglycemia should be documented and tracked
• The treatment plan should be reviewed and changed when glucose is <70 mg/dL (3.9 mmol/L)
Glycemic Targets for Noncritically Ill Individuals

• Glucose target of 140-180 mg/dL (7.8-10.0 mmol/L) is recommended for most
• A lower target (<140 mg/dL) may be appropriate for individuals with a prior history of successful tight glycemic control
and who are clinically stable
• Higher ranges may be appropriate for individuals who are terminally ill, have severe comorbidities, or are in in-patient
care settings where frequent glucose monitoring is not feasible
Recommendations for Perioperative Care

Target glucose range for perioperative period:
• 80-180 mg/dL (4.4-10.0 mmol/L)
Perioperative risk assessment for individuals at high risk for ischemic heart disease and those with autonomic neuropathy
or renal failure
On the morning of the procedure, withhold OADs and give half of the NPH dose or full doses of long-acting analog or
pump basal insulin
Monitor blood glucose every 4-6 hours while NPO and dose with short-acting insulin as needed
NPH=neutral protamine hagedorn; NPO=nothing by mouth; OADs=oral antidiabetes drugs; SSI=sliding scale insulin





13. Diabetes Care for Older Adults

General Recommendations for Diabetes Care of Older Adults
Individuals aged ≥65 with diabetes are a high-priority population for depression screening and treatment
Avoid hypoglycemia
• Screen for and manage by adjusting glycemic targets and pharmacologic interventions
Functional and cognitively intact older adults with long life expectancy
• Provide diabetes care with goals similar to those for younger adults
Glycemic goals may be relaxed based in selected individuals
• But avoid hyperglycemia leading to symptoms or risk of acute hyperglycemic complications
Individualize screening for diabetes complications
• Pay close attention to complications leading to functional impairment
Treat other CV risk factors
• Hypertension treatment indicated for all
• Lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the timeframe of primary
and secondary prevention trials




Pharmacologic Therapy Considerations for Older Adults

Cost May be a significant factor due to polypharmacy
Metformin • First-line agent for older adults
• Contraindicated in patients with renal insufficiency or significant heart failure
TZDs • Use cautiously in individuals with, or at risk for, heart failure
• Associated with fractures
Sulfonylureas • Can cause hypoglycemia
Insulin • Use with caution
secretagogues • Glyburide contraindicated in older adults
Insulin*
GLP-1 receptor • Few side effects
*
agonists • Cost may be a barrier
DPP-4 inhibitors
SGLT2 inhibitors • Oral administration may be convenient
• Limited long-term experience despite initial safety and efficacy
*
Injectable agent—requires that patients or caregivers have good visual and motor skills, cognitive ability






14. Diabetes Care for Children and Adolescents
Screening Children for Type 2 Diabetes and Prediabetes

Consider screening for type 2 diabetes and prediabetes for all children who are overweight* and have two or more of the
following risk factors:
• Family history of type 2 diabetes in a first- or second-degree relative
• Native American, African American, Latino, Asian American, or Pacific Islander descent
• Signs of insulin resistance or conditions associated with insulin resistance†
• Maternal history of diabetes or GDM during the child’s gestation
Test every 3 years using A1C beginning at age 10 or onset of puberty
*BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% ideal weight
†Acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, or small-for-gestational-age birth weight
Children defined as age <18 years

Glycemic Targets for Children and Adolescents With Type 1 Diabetes
Consider a risk-benefit assessment, including hypoglycemia risk, when individualizing
glycemic targets for children and adolescents with type 1 diabetes
A1C target <7.5%
(58 mmol/L)
A lower A1C target (<7.0%) is reasonable if it can be achieved without
excessive hypoglycemia
Plasma glucose before meals 90-130 mg/dL



(preprandial) (5.0-7.2 mmol/L)

Plasma glucose at bedtime and overnight 90-150 mg/dL
(5.0-8.3 mmol/L)
Glucose goals should be modified in children with frequent hypoglycemiaor hypoglycemia unawareness
If the child is taking basal-bolus therapy, measure postprandial glucose when there is a discrepancy between preprandial
glucose values and A1C levels, and to assess preprandial insulin doses

Managing Microvascular Complications in Children and Adolescents With Type 1 Diabetes

Nephropathy
Screening • Annual albuminuria screen with a random spot urine sample for ACR with 5-yr diabetes diabetes
duration
• Measure eGFR at initial evaluation and then based on age, diabetes duration, and treatment
Treatment/Follow- • ACEI* titrated to normalization of albumin excretion if elevated ACR
Up (>30 mg/g) confirmed with 2 of 3 urine samples
• Obtain samples over 6-month interval after efforts to improve glycemic control and normalize
BP
Retinopathy
Screening • Initial dilated and comprehensive eye exam at age ≥10 yrs or post-puberty onset (whichever
occurs first) in children with diabetes duration of 3-5 years
Neuropathy
Screening • Consider annual comprehensive foot exam at age ≥10 yrs or post-puberty onset (whichever
occurs first) in children with diabetes duration of 3-5 years
*
ACEIs are not approved by the U.S. Food and Drug Administration (FDA) for treatment of nephropathy.
Not all ACEIs are indicated for use in children/adolescents by the FDA. Refer to full prescribing information for indications
and uses in pediatric populations.



Managing High Blood Pressure in Children and Adolescents With Type 1 Diabetes
Screening • Measure BP at every visit
• Confirm elevated BP at separate visit
• High-normal BP* or hypertension†: confirm BP on 3 separate days
Treatment High-normal BP*
• Lifestyle changes (diet & physical activity) aimed at weight
control
• If target BP is not achieved within Initial pharmacologic
3-6 months, initiate pharmacologic therapy therapy:
Hypertension †
ACEI or ARB‡
• Initiate lifestyle changes and pharmacologic therapy
BP target: Consistently <90th percentile for age, gender, and height
*
SBP or DBP consistently ≥90th percentile for age, , and height
†
SBP or DBP consistently ≥95th percentile for age, gender, and height
‡
Provide counseling regarding potential teratogenic effects
Not all ACEIs and ARBs are indicated for use in children/adolescents by the U.S. Food and Drug Administration (FDA).
Refer to full prescribing information for indications and uses in pediatric populations.
Managing Dyslipidemia in Children and Adolescents With Type 1 Diabetes

Screening Obtain a fasting lipid profile in children aged ≥10 years soon after diagnosis*
Abnormal lipids? LDL-C <100 mg/dL?
• Annual monitoring • Repeat lipid panel every 3-5 years
Treatment Initial therapy
• Optimize glucose control and medical nutrition therapy (MNT)†
• Starting at age 10, a statin§ can be initiated in individuals with:
• LDL-C >160 mg/dL or >130 mg/dL (4.1 mmol/L or 3.4 mmol/L)
• ≥1 CVD risk factor despite lifestyle and MNT
LDL-C target: LDL-C <100 mg/dL (<2.6 mmol/L)
*When glucose levels are well controlled
†
Using Step 2 AHA diet to decrease saturated fat intake
‡
Statins are approved by the U.S. Food and Drug Administration for treatment of heterozygous familial



hypercholesterolemia in children and adolescents. Not all statins are FDA approved for use under the age of 10 yrs;
statins should generally not be used in children with type 1 diabetes before age 10. Refer to full prescribing information
for indications and uses in pediatric populations. For postpubertal girls, pregnancy prevention is important as statins are
contraindicated in pregnancy.
Screening for Autoimmunities in Children and Adolescents With Type 1 Diabetes

Hypothyroidism
Soon after type 1 diabetes diagnosis Consider screening for
• Antithyroid peroxidase antibodies
• Antithyroglobulin antibodies
Measure TSH soon after diagnosis and after glucose control has been
established
• Reassess every 1-2 yrs if normal
Celiac disease
Screen soon after type 1 diabetes diagnosis by measuring tissue transglutaminase or deamidated gliadin antibodies, with
documentation of normal total serum IgA levels
Candidates for testing • Family history of celiac disease
• Failure to grow or gain weight
• Weight loss
• Diarrhea or flatulence
• Abdominal pain
• Signs of malabsorption
• Repeated hypoglycemia of unknown cause or decline in glycemic control
Biopsy confirms diagnosis Place child on gluten-free diet and refer to dietitian



Recommendations for Monogenic Diabetes Syndromes in Children and Adolescents

Neonatal diabetes Maturity-onset diabetes of the young
• Monogenic form of diabetes with onset • Inherited autosomal dominant pattern
in the first 6 months of life • Impaired insulin secretion with minimal or no defects in insulin action
A diagnosis of monogenic diabetes should be considered in children with:
• Diabetes diagnosed within first 6 months of life
• Strong family history of diabetes but without typical features
• Mild fasting hyperglycemia*, especially if young and non-obese
• Diabetes with negative diabetes-associated antibodies without typical type 2 diabetes clinical features
Recommendations:
• Genetic testing for all children diagnosed in first 6 months of life
• Consider MODY with mild stable fasting hyperglycemia, multiple family members with diabetes not characteristic of
type 1 or 2
• Consider referring individuals with diabetes not characteristic of type 1 or type 2
and occurring in successive generations to a specialist
*
100-150 mg/dL (5.5-8.5 mmol/L)
ACEI=angiotensin-converting enzyme inhibitor; ACR=albumin-to-creatinine ratio; ARB=angiotensin-receptor

blockerBP=blood pressure; eGFR=estimated glomerular filtration rate; MNT=medical nutrition therapy; TSH=thyroid-
stimulating hormone






15. Psychosocial Assessment and Care

Psychological and Social Assessments
Include psychological & social assessments as part of diabetes management
Psychosocial screening and follow-up may include:
• Attitudes about diabetes
• Expectations for medical management and outcomes
• Mood
• Quality of life
• Financial, social, emotional resources
• Psychiatric history
Screen for and treat depression in older adults (≥65 yrs) with diabetes
Routinely screen for depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment
Stepwise collaborative care approach to manage depression for patients with comorbidities
Refer patients who exhibit these symptoms/behaviors to a mental health professional:
• Disregard for medical regimen
• Depression
• Self-harm potential
• Stress
• Debilitating anxiety
• Eating disorder
• Cognitive function signaling impaired judgment



Recommendations for Individuals With Cognitive Dysfunction

Intensive glucose control is not recommended for the improvement of poor cognitive function
Tailor glycemic therapy to avoid significant hypoglycemia
in individuals with:
• Poor cognitive function
• Severe hypoglycemia
In individuals with diabetes who are at high CV risk:
• CV benefits of statin therapy outweigh the risk of cognitive dysfunction
Second-generation antipsychotic medication prescribed:
• Monitor changes in weight, glycemic control, cholesterol levels
• Reassess treatment regimen if significant changes






16. Immunization & Vaccinations

Immunization Recommendations
Provide routine vaccinations for children and adults with diabetes according to age-related recommendations
Influenza vaccine Annually in all patients with diabetes aged ≥6 mos
Pneumococcal polysaccharide • All patients with diabetes aged ≥2 yrs
vaccine 23 (PPSV23) • Routinely in patients with diabetes aged ≥65 yrs
Pneumococcal conjugate vaccine 13 • Routinely in patients with diabetes aged ≥65 yrs
(PCV13)
Hepatitis B vaccine • All adults with diabetes







17. Recommendations for Individuals With HIV

Recommendations for Individuals With HIV
Individuals with HIV who are taking ART are a higher risk for developing prediabetes and diabetes
Screen for diabetes and prediabetes with a fasting glucose level:
• Prior to starting ART
• 3 months after starting or changing ART
Initial screen normal?
• Check fasting glucose each year
Prediabetes identified?
• Measure glucose levels every 3-6 months for diabetes progression
• Weight loss via diet and physical activity may reduce progression
Diabetes diagnosed?
• Preventive health measures to reduce the risk of microvascular and macrovascular complications

ART=antiretroviral therapy; HIV=human immunodeficiency virus





18. Cystic-Fibrosis Related Diabetes
Recommendations for Individuals With Cystic Fibrosis

Screening • Annually using OGTT
• Begin by age 10 in patients with cystic fibrosis who do not have CFRD
• A1C not recommended as screening test
Diagnosis • Use usual glucose criteria during period of stable health
Treatment CFRD: • CF & IGT (no diabetes):
• Insulin to achieve Consider prandial insulin
individualized glycemic to maintain weight
targets
Annual monitoring for Start 5 years after CFRD diagnosis
diabetes complications

CF=cystic fibrosis; CFRD=cystic fibrosis-related diabetes; IGT=impaired glucose tolerance; OGTT=oral glucose tolerance
test




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2016 American Diabetes Association (ADA) Diabetes Guidelines 1

Summary Recommendations from NDEI

2016 American Diabetes Association (ADA) Diabetes Guidelines

Criteria for Diabetes Diagnosis: 4 options

Testing for Type 2 Diabetes and Prediabetes in Asymptomatic Adults

Type 2 Diabetes Risk Factors

Categories of Increased Risk for Diabetes (Prediabetes)

Screening Children for Type 2 Diabetes and Prediabetes

Screening for Gestational Diabetes Mellitus (GDM)

Screening for Type 1 Diabetes

Download the full 2016 ADA diabetes guidelines slide set

2016 American Diabetes Association (ADA) Diabetes Guidelines

Blood Glucose Targets for Non-Pregnant Adults With Diabetes

• Macrovascular disease (if implemented soon after diagnosis)

PG=plasma glucose; SMBG=self-monitoring of blood glucose

Download the full 2016 ADA diabetes guidelines slide set

2016 American Diabetes Association (ADA) Diabetes Guidelines

3. Type 2 Diabetes Prevention

Strategies for Preventing or Delaying Type 2 Diabetes

2016 American Diabetes Association (ADA) Diabetes Guidelines

4. Pharmacologic Therapy for Type 2 Diabetes Management

Pharmacologic Therapy Recommendations

Choice of Pharmacologic Therapy

Download the full 2016 ADA diabetes guidelines slide set

2016 American Diabetes Association (ADA) Diabetes Guidelines

5. Pharmacologic Therapy for Type 1 Diabetes

Pharmacologic Therapy for Type 1 Diabetes Management

2016 American Diabetes Association (ADA) Diabetes Guidelines

6. Insulin & Glucose Monitoring

Self-monitoring of blood glucose (SMBG)

2016 American Diabetes Association (ADA) Diabetes Guidelines

Consider age and previous level of physical activity

Physical Activity in Individuals With Hypoglycemia

Physical Activity in Individuals With Diabetes Complications

2016 American Diabetes Association (ADA) Diabetes Guidelines

8. Management of Obesity in Individuals With Type 2 Diabetes

Lifestyle Changes for Obesity Management

• Encourage high levels of physical activity (200-300 mins/wk)

Pharmacologic Therapy for Obesity Management

Bariatric Surgery in Type 2 Diabetes

• Vitamin and mineral deficiencies

BMI=body mass index

Download the full 2016 ADA diabetes guidelines slide set

2016 American Diabetes Association (ADA) Diabetes Guidelines

9. Cardiovascular Disease (CVD) and Diabetes

Blood Pressure (Hypertension) Management & Treatment Targets

Download the full 2016 ADA diabetes guidelines slide set

Treatment of High Blood Pressure

Pharmacologic Therapy for High Blood Pressure

Lifestyle Changes for High Blood Pressure

Statin Therapy for Lipid Management

ASCVD Risk Factors

Combination Therapy for Lipid Management

Statins & Incident Diabetes

Antiplatelet Therapy Recommendations

Coronary Heart Disease (CHD) Screening and Treatment

Consider investigating for CAD in the presence of:

Treatment In individuals with symptomatic heart failure:

In individuals with type 2 diabetes and stable heart failure:

Download the full 2016 ADA diabetes guidelines slide set

2016 American Diabetes Association (ADA) Diabetes Guidelines

10. Microvascular Complications and Foot Care

Diabetic Kidney Disease (Nephropathy) Screening and Treatment