2013 American Diabetes Association Standards of Care for Diabetes

Brief Summary of Screening and Diagnosis of Type 2 Diabetes and Its Complications

DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013

Sutter Health Sacramento Sierra Region Diabetes Management Committee March 2013

Screening for Diabetes

Use any of the following • HbA1c
• Fasting glucose
• 2 hour 75gm Glucose Tolerance Test (OGTT)

Screen adults Screen teens

Every 3 years starting at age 45 for all adults or starting at Every 3 years starting at age 10 (or at onset of
age 18 if overweight and one or more additional risk factors puberty) if overweight and two or more risk factors
Diagnosis of Pre-Diabetes
Use any of the following* • HbA1c of 5.7–6.4%
• Fasting glucose 100-125 (Impaired Fasting Glucose IFT)
• 2 hour 75 gram Glucose Tolerance Test (OGTT) 140-200 (Impaired Glucose Tolerance IGT)
*For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately
greater at higher ends of the range.

ADA treatment guidelines for pre-diabetes

• Screen for and treat other modifiable cardiovascular disease (CVD) risk factors
• Refer to an effective ongoing support program for weight loss of 7% of body weight and increase in physical activity to at least 150
min/week of moderate activity such as walking
• Encourage USDA recommended amount of dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one half of
grain intake) and limit sugar sweetened beverages
• Consider Metformin in those who are at very high risk for developing diabetes:
IGT, IFG, or A1C 5.7–6.4% especially for those with BMI >35 kg/m2, age <60 years, and women with prior GDM
• Re-test for diabetes annually

Diagnosis of Diabetes
Use any of the following
(repeat x 1 to confirm)
Diabetes Goals
• HbA1c ≥ 6.5%
• Fasting glucose ≥ 126 mg/dl
• 2 hr 75 gram Glucose Tolerance Test (OGTT) ≥ 200 mg/dl.
• Random plasma glucose ≥ 200 mg/dl in a patient with classic symptoms of
hyperglycemia or hyperglycemic crisis
Approach to Individualizing Glycemic Goals

Figure and notes below from article Management of Hyperglycemia in Type 2

A1C Frequency Diabetes: A Patient-Centered Approach. Position Statement of the American

Diabetes Association (ADA) and the European Association for the Study of

• Every 6 months if meeting goals and Diabetes (EASD). Inzucchi, SE et al. Diabetes Care June 2012 vol. 35 no. 6 1364-1379

stable glycemic control

• Every 3 months if therapy has changed
or who are not meeting glycemic goals

A1C Goal (individualized)

• Goal < 7.0 is general goal
• Goal < 8.0 may be appropriate if
o Longstanding diabetes
o Limited life expectancy
o Known CVD or advanced complications
o Extensive co-morbid conditions
o Difficult to control despite use of insulin
o Severe hypoglycemia

• Goal < 6.5 may be appropriate if

o Achievable without significant
hypoglycemia or adverse effects
of treatment.
o Short duration of diabetes Depiction of the elements of decision making used to determine appropriate efforts to achieve glycemic targets.
o Long life expectancy Greater concerns about a particular domain are represented by increasing height of the ramp. Thus,
characteristics/predicaments toward the left justify more stringent efforts to lower HbA1c, whereas those toward the
o No significant CVD right are compatible with less stringent efforts. Where possible, such decisions should be made in conjunction with
the patient, reflecting his or her preferences, needs, and values. This “scale” is not designed to be applied rigidly but
to be used as a broad construct to help guide clinical decisions. Adapted with permission from Ismail-Beigi et al.
2013 American Diabetes Association Standards of Care for Diabetes, page 2 of 4
Brief Summary of Screening and Diagnosis of Type 2 Diabetes and Its Complications
DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013
Sutter Health Sacramento Sierra Region Diabetes Management Committee March 2013

Blood Glucose Goals

General Goal (adjust to correlate with A1C goals*):
• Premeal 70-130 mg/dl
• Postmeal (peak 1-2 hours) <180 mg/dl
*Note that each increase in A1C by 1% correlates with an increase in glucose of approximately 30 mg/dl

Correlation between A1C and glucose:

A1C Estimated Average Glucose
(%) (eAG)
6 126
7 154
8 183
9 212
10 240
11 269
12 298

NOTE: For all patients, regardless of goals, strive to:

• Avoid hypoglycemia
• Avoid high glucose levels that cause acute symptoms or increase risk for acute complications of hyperglycemia

Blood Pressure
Goal
• SBP < 140 mmHg Lower systolic targets, such as < 130 mmHg, may be appropriate for certain individuals, such
as younger patients, if can be achieved without undue treatment burden.
• DBP < 80 mmHg
Treatment
• Lifestyle changes
o Recommend lifestyle changes if BP ≥ 120/80.
o Reduce sodium intake (<1,500 mg/day), reduce excess body weight, increase consumption of fruits,
vegetables and low-fat dairy products (DASH diet), avoid excessive alcohol, and increase activity levels.
• Medication
o Recommend prompt initiation and timely titration of medication if BP ≥ 140/80
o Use ACE inhibitor or ARB. If one of those two classes is not tolerated, the other should be substituted.
o Use other classes of medications as needed. Note taking ≥ 2 medications is often necessary to reach
target.
o Make sure at least one medication is taken at bedtime
o Consider evaluation for secondary causes of HTN if target not achieved on 3 classes of medication
(including diuretic)
Cholesterol
Goal
• LDL < 100 for those who do not have overt CVD*
• LDL < 70 who do have overt CVD*
• TG < 150
• HDL > 40 men, > 50 in women
*attempt to reduce LDL 30-40% with high dose statin if unable to reach LDL goal or if LDL only minimally
elevated at initiation of therapy.
Treatment
• LIfestyle - reduce saturated fat, cholesterol, and trans unsaturated fat intake and increase omega-3 fatty acids,
viscous fiber (such as in oats, legumes, citrus), and plant stanols/sterols, weight loss (if indicated), increased
physical activity, smoking cessation, and glycemic control.
• STATIN is the preferred pharmacologic treatment strategy and should be started (regardless of baseline lipid) if:
• over 40 years old with one or more CVD risk factors (family history of CVD, hypertension, smoking,
dyslipidemia, or albuminuria)

• overt CVD, multiple risk factors for CVD, or long standing diabetes

• LDL above goal after lifestyle therapy

• If very high TG, then consider fibric acid derivative, niacin, or fish oil to reduce the risk of acute pancreatitis
 2013 American Diabetes Association Standards of Care for Diabetes, page 3 of 4
Brief Summary of Screening and Diagnosis of Type 2 Diabetes and Its Complications
DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013
Sutter Health Sacramento Sierra Region Diabetes Management Committee March 2013

Nephropathy
General recommendation:
• Optimize BP and glucose control to reduce the risk or slow the progression of nephropathy

Screening

• Assess urine albumin excretion annually (urine albumin-to-creatinine ratio in random spot urine)
o Normal < 30, Elevated ≥ 30 (2 out of 3 samples over 3-6 month period)
• Check serum creatinine annually and estimate GFR and stage the level if chronic kidney disease

Treatment and referral recommendations:

• See SMF Chronic Kidney Disease guidelines (which are consistent with the ADA standards of care)

Antiplatelet agents (2010 position statement of the ADA, AHA, and American College of Cardiology Foundation)
Aspirin IS recommended (75–162 mg/day) in:
• Those with 10-year risk CV risk > 10%, which includes most men > 50 years old, women > 60 years old with at least
one additional major CVD risk (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria) (primary
prevention)
• Known CVD (secondary prevention)

Aspirin IS NOT recommended in:

• Those with 10-year CVD risk < 5%, such as men <50 years old and women <60 years old with no major additional
CVD risk factors
Use clopidogrel (75 mg/day) if documented aspirin allergy

Coronary Heart Disease Screening

In asymptomatic patients, routine screening for CAD is not recommended, as it does not improve outcomes as long as
CVD risk factors are treated
Immunizations
Influenza vaccine annually to all diabetic patients ≥ 6 months of age
Pneumococcal polysaccharide vaccine once to all diabetic patients ≥ 2 years
• One-time revaccination recommended for those > 64 years previously immunized at < 65 years

if administered > 5 years ago

Hepatitis B vaccination to all adult unvaccinated diabetes patients 19-59 years old (and consider Hepatitis B vaccine for
patients ≥ 60 years old as well)
Smoking cessation
Advise all patients not to smoke. Include smoking cessation counseling and other forms of treatment as a routine
component of diabetes care.
Foot Care
Annual comprehensive foot exam including
• Inspection
• Assessment of foot pulses
• Assessment for Loss of Protective Sensation (LOPS):

10 g monofilament plus any of following:

– Vibration using 128-Hz tuning fork

– Pinprick sensation
– Ankle reflexes
– Vibration perception threshold

Consider specialized foot care if

• Loss of Protective Sensation (LOPS) and structural abnormalities

• Tobacco smokers
• Prior lower extremity complications

Retinopathy
Annual exam by ophthalmologist or optometrist
 2013 American Diabetes Association Standards of Care for Diabetes, page 4 of 4
Brief Summary of Screening and Diagnosis of Type 2 Diabetes and Its Complications
DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013

Sutter Health Sacramento Sierra Region Diabetes Management Committee March 2013

Common Diabetes-Associated Conditions

The ADA now includes general information about the following diseases or conditions that occur at rates higher than those
without diabetes. The ADA recommends taking this information in consideration when assessing for and treating the
conditions. The following information is provided directly from the ADA Standards of Medical Care in Diabetes—2013:
Hearing impairment
• “Hearing impairment, both high frequency and low/mid frequency, is more common in people with diabetes,
perhaps due to neuropathy and/or vascular disease.”
Obstructive sleep apnea
• “Age-adjusted rates of obstructive sleep apnea, a risk factor for CVD, are significantly higher (4- to 10-fold) with
obesity, especially with central obesity, in men and women.”
Fatty liver disease
• “Unexplained elevation of hepatic transaminase concentrations is significantly associated with higher BMI, waist
circumference, triglycerides, and fasting insulin, and with lower HDL cholesterol.” “In a prospective analysis,
diabetes was significantly associated with incident nonalcoholic chronic liver disease and with hepatocellular
carcinoma.”
Low testosterone in men
• “Mean levels of testosterone are lower in men with diabetes compared with age-matched men without diabetes,
but obesity is a major confounder.”
• “The issue of treatment in asymptomatic men is controversial. The evidence for effects of testosterone
replacement on outcomes is mixed, and recent guidelines suggest that screening and treatment of men without
symptoms is not recommended.”*
*Note: In men with diabetes who are symptomatic for possible hypogonadism, consider checking a free or bioavailable morning
testosterone if the total morning testosterone is low (uptodate.com/contents/clinical-features-and-diagnosis-of-male-hypogonadism)
Periodontal disease
• “Periodontal disease is more severe, but not necessarily more prevalent, in patients with diabetes than those
without.”
Cancer
• “Diabetes (possibly only type 2 diabetes) is associated with increased risk of cancers of the liver, pancreas,
endometrium, colon/ rectum, breast, and bladder.”
Fractures
• “Age-matched hip fracture risk is significantly increased in both type 1 (summary RR 6.3) and type 2 diabetes
(summary RR 1.7) in both sexes.”
• “It is appropriate to assess fracture history and risk factors in older patients with diabetes and recommend BMD
testing if appropriate for the patient’s age and sex.”
• “For at-risk patients, it is reasonable to consider standard primary or secondary prevention strategies (reduce risk
factors for falls, ensure adequate calcium and vitamin D intake, avoid use of medications that lower BMD, such as
glucocorticoids) and to consider pharmacotherapy for high-risk patients.
• “For patients with type 2 diabetes with fracture risk factors, avoiding use of TZDs is warranted.”

Cognitive impairment
• “Diabetes is associated with significantly increased risk of cognitive decline, a greater rate of cognitive decline,
and increased risk of dementia.”
Depression
• “Depression is highly prevalent in people with diabetes and is associated with worse outcomes.”