Professional Documents
Culture Documents
The American Diabetes Association’s (ADA’s) Standards of health (SDOH)—often out of direct control of the
of Medical Care in Diabetes (the Standards) is updated individual and potentially representing lifelong risk—
and published annually in a supplement to the January contribute to medical and psychosocial outcomes and
issue of Diabetes Care. The Standards are developed by must be addressed to improve all health outcomes.
the ADA’s multidisciplinary Professional Practice Com-
Patient-centered care is defined as care that considers Telemedicine may increase access to care for people
individual patient comorbidities and prognoses; is with diabetes. Increasingly, evidence suggests that vari-
respectful of and responsive to patient preferences, ous telemedicine modalities may be effective at reduc-
needs, and values; and ensures that patient values ing A1C in people with type 2 diabetes compared with
guide all clinical decisions. Further, social determinants or in addition to usual care. Interactive strategies that
https://doi.org/10.2337/cd22-as01
©2022 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational
and not for profit, and the work is not altered. More information is available at https://diabetesjournals.org/journals/pages/license.
10 D IA B E TE SJ OUR N A L S.OR G/ C L IN IC A L
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facilitate communication between providers and Type 1 diabetes (due to autoimmune b-cell destruc-
patients appear more effective. tion, usually leading to absolute insulin deficiency
including latent autoimmune diabetes of adulthood)
Behaviors and Well-Being Type 2 diabetes (due to a progressive loss of b-cell
insulin secretion frequently on the background of
Successful diabetes care requires a systematic approach
insulin resistance)
to supporting patients’ behavior-change efforts, includ- Specific types of diabetes due to other causes, e.g.,
ing high-quality diabetes self-management education monogenic diabetes syndromes (such as neonatal
and support (DSMES). diabetes and maturity-onset diabetes of the young),
diseases of the exocrine pancreas (such as cystic
Tailoring Treatment for Social Context
fibrosis and pancreatitis), and drug- or chemical-
Recommendations induced diabetes (such as with glucocorticoid use,
1.5 Assess food insecurity, housing insecurity/ in the treatment of HIV/AIDS, or after organ
TABLE 2.2/2.5 Criteria for the Screening and Diagnosis of Prediabetes and Diabetes
Prediabetes Diabetes
A1C 5.7–6.4% (39–47 mmol/mol)* $6.5% (48 mmol/mol)†
Fasting plasma glucose 100–125 mg/dL (5.6–6.9 mmol/L)* $126 mg/dL (7.0 mmol/L)†
2-hour plasma glucose during 75-g OGTT 140–199 mg/dL (7.8–11.0 mmol/L)* $200 mg/dL (11.1 mmol/L)†
Adapted from Tables 2.2 and 2.5 in the complete 2022 Standards of Care. *For all three tests, risk is continuous, extending below the lower
limit of the range and becoming disproportionately greater at the higher end of the range. †In the absence of unequivocal hyperglycemia,
diagnosis requires two abnormal test results from the same sample or in two separate samples ‡Only diagnostic in a patient with classic
symptoms of hyperglycemia or hyperglycemic crisis.
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TABLE 2.3 Criteria for Screening for Diabetes or Prediabetes in Asymptomatic Adults
1. Testing should be considered in adults with overweight or obesity (BMI $25 kg/m2 or $23 kg/m2 in Asian Americans) who have one or more
of the following risk factors:
First-degree relative with diabetes
High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
History of CVD
Hypertension ($140/90 mmHg or on therapy for hypertension)
HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)
Women with polycystic ovary syndrome
Physical inactivity
Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
2. Patients with prediabetes (A1C $5.7% [39 mmol/mol], impaired glucose tolerance, or impaired fasting glucose]) should be tested yearly.
3. Women who were diagnosed with GDM should have lifelong testing at least every 3 years.
5. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on
initial results and risk status.
and type 2 diabetes risk through an informal assess- Certain medications such as glucocorticoids, thiazide
ment of risk factors or with an assessment tool, such diuretics, some HIV medications, and atypical antipsy-
as the ADA’s risk test (diabetes.org/socrisktest) is chotics are known to increase the risk of diabetes and
recommended. should be considered when deciding whether to
screen.
Marked discrepancies between measured A1C and
plasma glucose levels should prompt consideration that
the A1C assay may not be reliable for that individual,
3. PREVENTION OR DELAY OF TYPE 2 DIABETES
and one should consider using an A1C assay without
AND ASSOCIATED COMORBIDITIES
interference or plasma blood glucose criteria for diagno- Recommendation
sis. (An updated list of A1C assays with interferences is 3.1 Monitor for the development of type 2 diabetes in
available at ngsp.org/interf.asp.) those with prediabetes at least annually, modified
If the patient has a test result near the margins of the based on individual risk/benefit assessment. E
diagnostic threshold, the clinician should follow the
Lifestyle Behavior Change for Diabetes
patient closely and repeat the test in 3–6 months. If
Prevention
using the oral glucose tolerance test (OGTT), fasting
or carbohydrate restriction 3 days prior to the test Recommendations
should be avoided, as it can falsely elevate glucose 3.2 Refer adults with overweight/obesity at high risk
levels. of type 2 diabetes, as typified by the Diabetes
TABLE 2.4 Risk-Based Screening for Type 2 Diabetes or Prediabetes in Asymptomatic Children and Adolescents in a
Clinical Setting
Screening should be considered in youth* who have overweight ($85th percentile) or obesity ($95th percentile) A and who have one or more
additional risk factors based on the strength of their association with diabetes:
Maternal history of diabetes or GDM during the child’s gestation A
Family history of type 2 diabetes in first- or second-degree relative A
Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) A
Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary
syndrome, or small-for-gestational-age birth weight) B
*After the onset of puberty or after 10 years of age, whichever occurs earlier. If tests are normal, repeat testing at a minimum of 3-year inter-
vals, or more frequently if BMI is increasing or risk factor profile deteriorating, is recommended. Reports of type 2 diabetes before age 10
years exist, and this can be considered with numerous risk factors.
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Prevention Program (DPP), to an intensive life- evidence base. However, no agents have been approved
style behavior change program consistent with by the U.S. Food and Drug Administration (FDA) for
the DPP to achieve and maintain 7% loss of initial diabetes prevention.
body weight, and increase moderate-intensity
physical activity (such as brisk walking) to at
Prevention of Vascular Disease and Mortality
least 150 minutes/week. A
3.3 A variety of eating patterns can be considered Recommendation
to prevent diabetes in individuals with pre- 3.8 Prediabetes is associated with heightened cardio-
diabetes. B vascular (CV) risk; therefore, screening for and
3.5 Based on patient preference, certified technology- treatment of modifiable risk factors for cardiovas-
assisted diabetes prevention programs may be cular disease (CVD) are suggested. B
effective in preventing type 2 diabetes and should
be considered. B
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intensity aerobic activity, with vigorous muscle- to decreased pain sensation. They should wear proper
strengthening and bone-strengthening activities footwear and examine their feet daily to detect
at least 3 days/week. C lesions early. Anyone with a foot injury or open sore
5.28 Most adults with type 1 C and type 2 B diabetes should be restricted to non–weight-bearing activities.
should engage in 150 minutes or more of moder- Diabetes is associated with autonomic neuropathy,
ate- to vigorous-intensity aerobic activity per which can increase the risk of exercise-induced
week, spread over at least 3 days/week, with no injury or adverse events through decreased cardiac
more than 2 consecutive days without activity. responsiveness to exercise, postural hypotension,
Shorter durations (minimum 75 minutes/week) impaired thermoregulation, and greater susceptibil-
of vigorous-intensity or interval training may be ity to hypoglycemia.
sufficient for younger and more physically fit
individuals. Smoking Cessation: Tobacco and e-Cigarettes
5.29 Adults with type 1 C and type 2 B diabetes should
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are not met and/or at the onset of diabetes com- year in patients who are meeting treatment goals
plications. B (and who have stable glycemic control). E
6.2 Assess glycemic status at least quarterly and as
Diabetes distress refers to significant negative psy- needed in patients whose therapy has recently
chological reactions related to emotional burdens changed and/or who are not meeting glycemic
and worries specific to an individual’s experience in goals. E
having to manage a severe, complicated, and
demanding chronic disease such as diabetes. The Glucose Assessment by CGM
constant behavioral demands of diabetes self-man-
Recommendations
agement and the potential or actuality of disease pro-
gression are directly associated with reports of 6.3 Standardized, single-page glucose reports from
diabetes distress. CGM devices with visual cues, such as the ambula-
tory glucose profile (AGP), should be considered as
2. Percentage of time CGM device is active (recommend 70% of data from 14 days)
3. Mean glucose
4. GMI
6. TAR: % of readings and time >250 mg/dL (>13.9 mmol/L) Level 2 hyperglycemia
7. TAR: % of readings and time 181–250 mg/dL (10.1–13.9 mmol/L) Level 1 hyperglycemia
9. TBR: % of readings and time 54–69 mg/dL (3.0–3.8 mmol/L) Level 1 hypoglycemia
10. TBR: % of readings and time <54 mg/dL (<3.0 mmol/L) Level 2 hypoglycemia
%CV, percentage coefficient of variation; TAR, time above range; TBR, time below range. *Some studies suggest that lower %CV targets
(<33%) provide additional protection against hypoglycemia for those receiving insulin or sulfonylureas. Adapted from Battelino T, Danne T,
Bergenstal RM, et al. Diabetes Care 2019;42:1593–1603.
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AGP is a summary of glucose values from the report period, with median (50%) and other percentiles shown as if they occurred in a single day.
350
mg/dL
95%
75%
250
50%
25%
180
Target
Range
70 5%
54
0
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
180
70
180
70
FIGURE 6.1 Key points included in standard AGP report. Reprinted from Holt RIG, DeVries JH, Hess-Fischl A, et al. Diabetes Care
2021;44:2589–2625.
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in data interpretation and treatment decision-making. 6.11 Glucagon should be prescribed for all individuals
Table 6.2 summarizes CGM-derived metrics for assess- at increased risk of level 2 or 3 hypoglycemia, so
ment and glycemic management. that it is available should it be needed. Care-
givers, school personnel, or family members pro-
viding support to these individuals should know
Glycemic Goals
where it is and when and how to administer it.
Recommendations Glucagon administration is not limited to health
6.5a An A1C goal for many nonpregnant adults of care professionals. E
<7% (53 mmol/mol) without significant hypogly- 6.12 Hypoglycemia unawareness or one or more epi-
cemia is appropriate. A sodes of level 3 hypoglycemia should trigger
6.5b If using AGP/GMI to assess glycemia, a parallel hypoglycemia avoidance education and reevalua-
goal for many nonpregnant adults is TIR of tion and adjustment of the treatment regimen to
>70% with time below range <4% and time decrease hypoglycemia. E
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Intermittently scanned CGM (isCGM) CGM systems that measure glucose levels continuously but only
display glucose values when swiped by a reader or a smartphone
Professional CGM CGM devices that are placed on the patient in the provider’s office (or
with remote instruction) and worn for a discrete period of time
(generally 7–14 days). Data may be blinded or visible to the
person wearing the device. The data are used to assess glycemic
patterns and trends. These devices are not fully owned by the
patient—they are clinic-based devices, as opposed to the patient-
owned rtCGM or isCGM CGM devices.
8. OBESITY AND WEIGHT MANAGEMENT FOR Table 8.1 summarizes treatment options for overweight
THE PREVENTION AND TREATMENT OF TYPE 2 and obesity in type 2 diabetes.
DIABETES
Strong evidence exists that obesity management can
Diet, Physical Activity, and Behavioral Therapy
delay the progression from prediabetes to type 2 diabe- Recommendations
tes and is highly beneficial in the treatment of type 2 8.5 Diet, physical activity, and behavioral therapy to
diabetes. Modest weight loss improves glycemic control achieve and maintain $5% weight loss is recom-
and reduces the need for glucose-lowering medications, mended for most people with type 2 diabetes and
and more intensive dietary energy restriction can sub- overweight or obesity. Additional weight loss usu-
stantially reduce A1C and fasting glucose and promote ally results in further improvements in control of
sustained diabetes remission through at least 2 years. diabetes and CV risk. B
Metabolic surgery strongly improves glycemic control 8.6 Such interventions should include a high frequency of
and often leads to remission of diabetes, improved qual- counseling ($16 sessions in 6 months) and focus on
ity of life, improved CV outcomes, and reduced dietary changes, physical activity, and behavioral strate-
mortality. gies to achieve a 500–750 kcal/day energy deficit. A
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8.9 Evaluate systemic, structural, and socioeconomic months’ use) or if there are significant safety or
factors that may impact dietary patterns and food tolerability issues, consider discontinuation of
choices, such as food insecurity and hunger, the medication and evaluate alternative medica-
access to healthful food options, cultural circum- tions or treatment approaches. A
stances, and SDOH. C
8.10 For those who achieve weight loss goals, long-term Approved Weight Loss Medications
($1 year) weight maintenance programs are rec- Nearly all FDA-approved medications for weight loss have
ommended when available. Such programs should, been shown to improve glycemic control in patients with
at minimum, provide monthly contact and support, type 2 diabetes and delay progression to type 2 diabetes
recommend ongoing monitoring of body weight in patients at risk. Medications approved by the FDA for
(weekly or more frequently) and other self-monitor- the treatment of obesity are summarized in Table 8.2 in
ing strategies, and encourage regular physical activ- the complete 2022 Standards of Care.
ity (200–300 minutes/week). A
TABLE 8.1 Treatment Options for Overweight and Obesity in Type 2 Diabetes
BMI Category, kg/m2
Treatment 25.0–26.9 (or 23.0–24.9*) 27.0–29.9 (or 25.0–27.4*) $30.0 (or $27.5*)
Diet, physical activity, and behavioral counseling † † †
Pharmacotherapy † †
Metabolic surgery †
*Recommended cut points for Asian-American individuals (expert opinion). †Treatment may be indicated for select motivated patients.
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especially for those with severe hypoglycemia or 9.9 Among individuals with type 2 diabetes who have
hypoglycemia unawareness. E established ASCVD or indicators of high CV risk,
established CKD, or HF, an SGLT2 inhibitor and/or
9. PHARMACOLOGIC APPROACHES TO GLP-1 receptor agonist with demonstrated CVD
GLYCEMIC TREATMENT benefit (Table 9.2 and Figure 9.3) is recommended
as part of the glucose-lowering regimen and com-
Pharmacologic Therapy for Adults With Type 1 prehensive CV risk reduction, independent of A1C
Diabetes and in consideration of patient-specific factors. A
See “9. Pharmacologic Approaches to Glycemic 9.10 In patients with type 2 diabetes, a GLP-1 receptor
Treatment” in the complete 2022 Standards of Care for agonist is preferred to insulin when possible. A
detailed information on pharmacologic approaches to 9.11 If insulin is used, combination therapy with a GLP-1
type 1 diabetes management in adults. receptor agonist is recommended for greater effi-
cacy and durability of treatment effect. A
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TABLE 9.2 Drug-Specific and Patient Factors to Consider When Selecting Antihyperglycemic Treatment in Adults With Type 2 Diabetes
24
CV effects Renal effects
Weight
Efficacy (60) Hypoglycemia Cost Oral/SQ Additional considerations
change (109)
ASCVD HF Progression of DKD Dosing/use considerations*
Metformin High No Neutral Potential Neutral Low Oral Neutral Contraindicated with eGFR Gastrointestinal side effects common
2
(potential for benefit <30 mL/min/1.73 m (diarrhea, nausea)
modest loss) Potential for B12 deficiency
GLP-1 RAs High No Loss Benefit: dulaglutide†, Neutral High SQ; oral Benefit on renal end FDA Black Box: Risk of thyroid C-cell
(semaglutide)
See labels for renal dose
liraglutide†, points in CVOTs, tumors in rodents; human relevance
considerations of individual
semaglutide (SQ)† driven by albuminuria not determined (liraglutide,
agents
outcomes: liraglutide, dulaglutide, exenatide
semaglutide (SQ), No dose adjustment for extended release, semaglutide)
Neutral: exenatide dulaglutide dulaglutide, liraglutide, Gl side effects common
once weekly, semaglutide (nausea, vomiting, diarrhea)
ABRIDGED STANDARDS OF CARE 2022
DPP-4 inhibitors Intermediate No Neutral Neutral Potential risk: High Oral Neutral Renal dose adjustment Pancreatitis has been reported in clinical
saxagliptin required (sitagliptin, trials but causality has not been
saxagliptin, alogliptin); established. Discontinue if pancreatitis
can be used in renal is suspected.
impairment
Joint pain
No dose adjustment
required for linagliptin
Thiazolidinediones High No Gain Potential benefit: Increased risk Low Oral Neutral No dose adjustment FDA Black Box: Congestive heart
pioglitazone required failure (pioglitazone, rosiglitazone)
Generally not Fluid retention (edema; heart
recommended in renal failure)
impairment due to Benefit in NASH
potential for Risk of bone fractures
fluid retention Bladder cancer (pioglitazone)
LDL cholesterol (rosiglitazone)
Sulfonylureas High Yes Gain Neutral Neutral Low Oral Neutral Glyburide: generally not FDA Special Warning on increased
(2nd generation) recommended in chronic risk of cardiovascular mortality
kidney disease based on studies of an older
Glipizide and glimepiride: sulfonylurea (tolbutamide)
initiate conservatively to
avoid hypoglycemia
Insulin Human High Yes Neutral SQ; Neutral Lower insulin doses Injection site reactions
Gain Neutral Low (SQ)
insulin inhaled required with a Higher risk of hypoglycemia with
decrease in eGFR; titrate human insulin (NPH or premixed
Analogs per clinical response formulations) vs. analogs
High SQ
*For agent-specific dosing recommendations, please refer to the manufacturers’ prescribing information. †FDA-approved for CVD benefit. ‡FDA-approved for HF indication. §FDA-approved
for CKD indication. CVOT, cardiovascular outcomes trial; DPP-4, dipeptidyl peptidase 4; GLP-1 RA, glucagon-like peptide 1 receptor agonist; NASH, nonalcoholic steatohepatitis; SQ, sub-
D IA B E TE SJ OUR N A L S.OR G/ C L IN IC A L
cutaneous; T2D, type 2 diabetes.
25
cotransporter 2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione.
cause of morbidity and mortality from CVD. Studies show 10.5 For individuals with diabetes and hypertension
HF (with preserved ejection fraction [HFpEF] or reduced at lower risk for CVD (10-year ASCVD risk
ejection fraction [HFrEF]) is twofold higher in people <15%), treat to a blood pressure target of
with diabetes compared to those without. <140/90 mmHg. A
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10.30 In adults with moderate hypertriglyceridemia and low bleeding risk to prevent major adverse
(fasting or nonfasting triglycerides 175–499 cardiovascular (MACE) events. A
mg/dL), clinicians should address and treat 10.38 Combination therapy with aspirin plus low-dose
lifestyle factors (obesity and metabolic syn- rivaroxaban should be considered for patients
drome), secondary factors (diabetes, chronic with stable CAD and/or PAD and low bleeding
liver or kidney disease and/or nephrotic syn- risk to prevent major adverse limb and CV
drome, hypothyroidism), and medications events. A
that raise triglycerides. C 10.39 Aspirin therapy (75–162 mg/day) may be con-
10.31 In patients with ASCVD or other CV risk factors on sidered as a primary prevention strategy in
a statin with controlled LDL cholesterol but elevated those with diabetes who are at increased CV
triglycerides (135–499 mg/dL), the addition of ico- risk, after a comprehensive discussion with the
sapent ethyl can be considered to reduce CV patient on the benefits versus the comparable
risk. A increased risk of bleeding. A
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reduction in the risk of adverse CV and kid- mL/min/1.73 m2 should be monitored twice
ney events. A annually to guide therapy. B
10.43 In patients with type 2 diabetes and estab-
lished HFrEF, an SGLT2 inhibitor with proven Treatment
benefit in this patient population is recom- Recommendations
mended to reduce risk of worsening HF and
11.2 Optimize glucose control to reduce the risk or
CV death. A
10.44 In patients with known ASCVD, particularly CAD, slow the progression of CKD. A
11.3a For patients with type 2 diabetes and DKD, use
ACE inhibitor or ARB therapy is recommended to
of an SGLT2 inhibitor in patients with an eGFR
reduce the risk of CV events. A
$25 mL/min/1.73 m2 and urinary albumin
10.45 In patients with prior myocardial infarction,
$300 mg/g creatinine is recommended to
b-blockers should be continued for 3 years
reduce CKD progression and CV events. A
after the event. B
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reduced eGFR in the absence of signs or symptoms of 12. RETINOPATHY, NEUROPATHY, AND FOOT
other primary causes of kidney damage. Two of three CARE
specimens of UACR collected within a 3- to 6-month Diabetic Retinopathy
period should be abnormal before considering a
Recommendations
patient to have albuminuria. eGFR should be calcu-
lated from serum creatinine using a validated for- 12.1 Optimize glycemic control to reduce the risk or
mula. The Chronic Kidney Disease Epidemiology slow the progression of diabetic retinopathy. A
Collaboration (CKD-EPI) equation is generally 12.2 Optimize blood pressure and serum lipid control
preferred. to reduce the risk or slow the progression of dia-
betic retinopathy. A
Interventions Screening
Selection of Glucose-Lowering Medications for Patients
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For more information about treatment of proliferative 12.24 The examination should include inspection of
diabetic retinopathy, see “12. Retinopathy, Neuropathy, the skin, assessment of foot deformities, neuro-
and Foot Care” in the complete 2022 Standards of logical assessment (10-g monofilament testing
Care. with at least one other assessment: pinprick,
temperature, vibration), and vascular assess-
ment, including pulses in the legs and feet. B
Neuropathy
12.25 Patients with symptoms of claudication or
Screening decreased or absent pedal pulses should be
Recommendations referred for ankle-brachial index and for further
12.15 All patients should be assessed for diabetic periph- vascular assessment as appropriate. C
eral neuropathy starting at diagnosis of type 2 dia- 12.26 A multidisciplinary approach is recommended
betes and 5 years after the diagnosis of type 1 for individuals with foot ulcers and high-risk
feet (e.g., dialysis patients and those with Char-
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TABLE 13.1 Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older
Adults With Diabetes
Fasting or
Patient Reasonable A1C Preprandial Bedtime
Characteristics/ Goal, % Glucose, mg/dL Glucose, mg/dL Blood Pressure,
Health Status Rationale (mmol/mol)‡ (mmol/L) (mmol/L) mmHg Lipids
Healthy (few Longer remaining <7.0–7.5 (53–58) 80–130 (4.4–7.2) 80–180 <140/90 Statin unless
coexisting chronic life expectancy (4.4–10.0) contraindicated
illnesses, intact or not tolerated
cognitive and
functional status)
Complex/ Intermediate <8.0 (64) 90–150 (5.0–8.3) 100–180 <140/90 Statin unless
intermediate remaining life (5.6–10.0) contraindicated
Very complex/poor Limited remaining Avoid reliance on 100–180 110–200 <150/90 Consider
health (LTC or life expectancy A1C; glucose (5.6–10.0) (6.1–11.1) likelihood of
end-stage chronic makes benefit control decisions benefit with
illnesses** or uncertain should be based statin
moderate-to- on avoiding
severe cognitive hypoglycemia and
impairment or 2+ symptomatic
ADL impairments) hyperglycemia
This table represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults
with diabetes. The patient characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consid-
eration of patient and caregiver preferences is an important aspect of treatment individualization. Additionally, a patient’s health status and
preferences may change over time. ADL, activities of daily living. ‡A lower A1C goal may be set for an individual if achievable without recur-
rent or severe hypoglycemia or undue treatment burden. *Coexisting chronic illnesses are conditions serious enough to require medications
or lifestyle management and may include arthritis, cancer, HF, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse
CKD, myocardial infarction, and stroke. “Multiple” means at least three, but many patients may have five or more. **The presence of a single
end-stage chronic illness, such as stage 3–4 HF or oxygen-dependent lung disease, CKD requiring dialysis, or uncontrolled metastatic cancer,
may cause significant symptoms or impairment of functional status and significantly reduce life expectancy. Adapted from Kirkman MS, Bris-
coe VJ, Clark N, et al. Diabetes Care 2012;35:2650–2664.
complications in older adults should be individualized and diabetes onset may help to maintain cognitive function
periodically revisited, as the results of screening tests may in older adults. However, studies examining the effects
impact targets and therapeutic approaches. of intensive glycemic and blood pressure control to
achieve specific targets have not demonstrated a reduc-
Neurocognitive Function tion in brain function decline.
Recommendation
13.3 Screening for early detection of mild cognitive Hypoglycemia
impairment or dementia should be performed Recommendations
for adults 65 years of age or older at the initial
13.4 Because older adults with diabetes have a greater
visit and annually as appropriate. B
risk of hypoglycemia than younger adults, epi-
People with diabetes have higher incidences of all-cause sodes of hypoglycemia should be ascertained and
dementia, Alzheimer disease, and vascular dementia addressed at routine visits. B
than people with normal glucose tolerance. Ongoing 13.5 For older adults with type 1 diabetes, CGM
studies are evaluating whether preventing or delaying should be considered to reduce hypoglycemia. A
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Older adults are at higher risk of hypoglycemia for many reduction in appetite that can be problematic for some
reasons, including insulin deficiency necessitating insulin older adults. See Figure 9.3 for general recommenda-
therapy and progressive renal insufficiency. Glycemic tar- tions regarding glucose-lowering treatment for adults
gets and pharmacologic regimens may need to be adjusted with type 2 diabetes and Table 9.2 for patient- and
to minimize the occurrence of hypoglycemic events. drug-specific factors to consider when selecting glucose-
Patients and their caregivers should be routinely queried lowering agents.
about hypoglycemia and hypoglycemia unawareness.
Many older adults with diabetes struggle to maintain
the frequent BGM and insulin injection regimens they
Treatment Goals
previously followed. MDI insulin therapy may be too
Providers caring for older adults with diabetes must complex for older patients with advanced diabetes
take clinical, cognitive, and functional heterogeneity complications, life-limiting coexisting chronic illnesses, or
into consideration when setting and prioritizing treat-
limited functional status. Simplification of the insulin
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Overall, palliative care should promote comfort, symp- Consideration of the sociocultural context and efforts to
tom control, prevention (e.g., of pain, hypoglycemia, personalize diabetes management are of critical impor-
hyperglycemia, and dehydration), and preservation of tance to minimize barriers to care, enhance adherence,
dignity and quality of life. and maximize response to treatment.
34 D IA B E TE SJ OUR N A L S.OR G/ C L IN IC A L
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ABRIDGED STANDARDS OF CARE 2022
15.24 Screen women with a recent history of GDM at 16.5 More stringent goals, such as 110–140 mg/dL
4–12 weeks postpartum using the 75-g OGTT (6.1–7.8 mmol/L), may be appropriate for
and clinically appropriate nonpregnancy diag- selected patients if they can be achieved without
nostic criteria. B significant hypoglycemia. C
15.25 Women with a history of GDM found to have
prediabetes should receive intensive lifestyle Hyperglycemia in hospitalized patients is defined as
interventions and/or metformin to prevent dia- blood glucose levels >140 mg/dL (7.8 mmol/L). Glu-
betes. A cose levels persistently above this level should receive
15.26 Women with a history of GDM should have life- prompt conservative interventions to correct the hyper-
long screening for the development of type 2 glycemia, such as changes to diet or medications caus-
diabetes or prediabetes every 1–3 years. B ing hyperglycemia.
15.27 Women with a history of GDM should seek pre- Hypoglycemia in the hospital is classified the same as in
conception screening for diabetes and precon-
36 D IA B E TE SJ OUR N A L S.OR G/ C L IN IC A L
AMERICAN DIABETES ASSOCIATION
VO L UM E 40 , N U MB E R 1, W IN TE R 20 22 37
ABRIDGED STANDARDS OF CARE 2022
38 D IA B E TE SJ OUR N A L S.OR G/ C L IN IC A L