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STANDARDS OF MEDICAL CARE IN DIABETES2012

Table of Contents
Section
ADA Evidence Grading System of Clinical Recommendations I. II. III. I,. ,. ,I. ,II. ,III. I1. 1. Classification and Diagnosis esting for Dia!etes in Asym"tomatic #atients Detection and Diagnosis of Gestational Dia!etes &ellit's (GD&) #revention-Delay of y"e $ Dia!etes Dia!etes Care #revention and &anagement of Dia!etes Com"lications Assessment of Common Comor!id Conditions Dia!etes Care in S"ecific #o"'lations Dia!etes Care in S"ecific Settings Strategies for Im"roving Dia!etes Care

Slide No.
3 4-11 1$-1% 1*-1+ $.-$1 $$-*/ *0-11$ 113-114 11%-13% 13*-144 14%-1%.

ADA Eviden e !"adin# S$ste% fo" Clini al Re o%%endations


2evel of Evidence A Descri"tion Clear or s'""ortive evidence from ade3'ately "o4ered 4ell-cond'cted5 generali6a!le5 randomi6ed controlled trials Com"elling none7"erimental evidence 8 C S'""ortive evidence from 4ell-cond'cted co9ort st'dies or case-control st'dy S'""ortive evidence from "oorly controlled or 'ncontrolled st'dies Conflicting evidence 4it9 t9e 4eig9t of evidence s'""orting t9e recommendation E E7"ert consens's or clinical e7"erience
ADA. Diabetes Care $.1$:3%(s'""l 1);S1$. a!le 1.

I& CLASSIFICATION AND DIA!NOSIS

Classifi ation of Diabetes


y"e 1 dia!etes
<-cell destr'ction

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

=t9er s"ecific ty"es of dia!etes


Genetic defects in <-cell f'nction5 ins'lin action Diseases of t9e e7ocrine "ancreas Dr'g- or c9emical-ind'ced

Gestational dia!etes mellit's


ADA. I. Classification and Diagnosis. Diabetes Care $.1$:3%(s'""l 1);S11.

C"ite"ia fo" t'e Dia#nosis of Diabetes


A1C >*.%?
OR

@asting "lasma gl'cose (@#G) >1$* mg-d2 (/.. mmol-2)


OR

$-9 "lasma gl'cose >$.. mg-d2 (11.1 mmol-2) d'ring an =G


OR

A random "lasma gl'cose >$.. mg-d2 (11.1 mmol-2)


ADA. I. Classification and Diagnosis. Diabetes Care $.1$:3%(s'""l 1);S1$. a!le $.

C"ite"ia fo" t'e Dia#nosis of Diabetes


A1C >*.%? 9e test s9o'ld !e "erformed in a la!oratory 'sing a met9od t9at is NGS# certified and standardi6ed to t9e DCC assayA

AIn t9e a!sence of 'ne3'ivocal 9y"erglycemia5 res'lt s9o'ld !e confirmed !y re"eat testing. ADA. I. Classification and Diagnosis. Diabetes Care $.1$:3%(s'""l 1);S1$. a!le $.

C"ite"ia fo" t'e Dia#nosis of Diabetes


@asting "lasma gl'cose (@#G) >1$* mg-d2 (/.. mmol-2) @asting is defined as no caloric intaBe for at least 0 9A

AIn t9e a!sence of 'ne3'ivocal 9y"erglycemia5 res'lt s9o'ld !e confirmed !y re"eat testing. ADA. I. Classification and Diagnosis. Diabetes Care $.1$:3%(s'""l 1);S1$. a!le $.

C"ite"ia fo" t'e Dia#nosis of Diabetes


$-9 "lasma gl'cose >$.. mg-d2 (11.1 mmol-2) d'ring an =G 9e test s9o'ld !e "erformed as descri!ed !y t9e CD=5 'sing a gl'cose load containing t9e e3'ivalent of /% g an9ydro's gl'cose dissolved in 4aterA

AIn t9e a!sence of 'ne3'ivocal 9y"erglycemia5 res'lt s9o'ld !e confirmed !y re"eat testing. ADA. I. Classification and Diagnosis. Diabetes Care $.1$:3%(s'""l 1);S1$. a!le $.

C"ite"ia fo" t'e Dia#nosis of Diabetes


In a "atient 4it9 classic sym"toms of 9y"erglycemia or 9y"erglycemic crisis5 a random "lasma gl'cose >$.. mg-d2 (11.1 mmol-2)

ADA. I. Classification and Diagnosis. Diabetes Care $.1$:3%(s'""l 1);S1$. a!le $.

("ediabetes) IF!* I!T* In "eased A1C


Categories of increased risB for dia!etes ("redia!etes)A @#G 1..E1$% mg-d2 (%.*E*.+ mmol-2); I@G
OR

$-9 "lasma gl'cose in t9e /%-g =G 14.E1++ mg-d2 (/.0E11.. mmol-2); IG


OR

A1C %./E*.4?
A@or all t9ree tests5 risB is contin'o's5 e7tending !elo4 t9e lo4er limit of a range and !ecoming dis"ro"ortionately greater at 9ig9er ends of t9e range.

ADA. I. Classification and Diagnosis. Diabetes Care $.1$:3%(s'""l 1);S13. a!le 3.

II& TESTIN! FOR DIABETES IN AS+M(TOMATIC (ATIENTS

Re o%%endations) Testin# fo" Diabetes in As$%,to%ati (atients


Consider testing over4eig9t-o!ese ad'lts (8&I >$% Bg-m$) 4it9 one or more additional risB factors
In t9ose 4it9o't risB factors5 !egin testing at age 4% years (8)

If tests are normal


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

Fse A1C5 @#G5 or $-9 /%-g =G (8) In t9ose 4it9 increased risB for f't're dia!etes
Identify and5 if a""ro"riate5 treat ot9er C,D risB factors (8)

ADA. II. esting in Asym"tomatic #atients. Diabetes Care $.1$:3%(s'""l 1);S13.

C"ite"ia fo" Testin# fo" Diabetes in As$%,to%ati Ad-lt Individ-als .1/


1. Testing should be considered in all adults who are overweight (BMI 25 kg/m2 ! and who have one or more additional risk "actors#
#9ysical inactivity @irst-degree relative 4it9 dia!etes Dig9-risB race-et9nicity (e.g.5 African American5 2atino5 Native American5 Asian American5 #acific Islander) Comen 49o delivered a !a!y 4eig9ing G+ l! or 4ere diagnosed 4it9 GD& Dy"ertension (>14.-+. mmDg or on t9era"y for 9y"ertension)
AAt-risB 8&I may !e lo4er in some et9nic gro'"s. ADA. esting in Asym"tomatic #atients. Diabetes Care $.1$:3%(s'""l 1);S14. a!le 4.

DD2 c9olesterol level H3% mg-d2 (..+. mmol-2) and-or a triglyceride level G$%. mg-d2 ($.0$ mmol-2) Comen 4it9 "olycystic ovarian syndrome (#C=S) A1C >%./?5 IG 5 or I@G on "revio's testing =t9er clinical conditions associated 4it9 ins'lin resistance (e.g.5 severe o!esity5 acant9osis nigricans) Distory of C,D

C"ite"ia fo" Testin# fo" Diabetes in As$%,to%ati Ad-lt Individ-als .2/


2& In t9e a!sence of criteria (risB factors on "revio's slide)5 testing for dia!etes s9o'ld !egin at age 4% years 0& If res'lts are normal5 testing s9o'ld !e re"eated at least at 3-year intervals5 4it9 consideration of more fre3'ent testing de"ending on initial res'lts (e.g.5 t9ose 4it9 "redia!etes s9o'ld !e tested yearly)5 and risB stat's

ADA. esting in Asym"tomatic #atients. Diabetes Care $.1$:3%(s'""l 1);S14. a!le 4.

III& DETECTION AND DIA!NOSIS OF !ESTATIONAL DIABETES MELLIT1S .!DM/

Re o%%endations) Dete tion and Dia#nosis of !DM .1/


Screen for 'ndiagnosed ty"e $ dia!etes at t9e first "renatal visit in t9ose 4it9 risB factors5 'sing standard diagnostic criteria (8) In "regnant 4omen not "revio'sly Bno4n to 9ave dia!etes5 screen for GD& at $4E$0 4eeBsI gestation5 'sing a /%-g =G and s"ecific diagnostic c't "oints (8)

ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.1$:3%(s'""l 1);S1%.

Re o%%endations) Dete tion and Dia#nosis of !DM .2/


Screen 4omen 4it9 GD& for "ersistent dia!etes at *E1$ 4eeBsI "ost"art'm5 'sing a test ot9er t9an A1C (E) Comen 4it9 a 9istory of GD& s9o'ld 9ave lifelong screening for t9e develo"ment of dia!etes or "redia!etes at least every 3 years (8) Comen 4it9 a 9istory of GD& fo'nd to 9ave "redia!etes s9o'ld receive lifestyle interventions or metformin to "revent dia!etes (A)
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.1$:3%(s'""l 1);S1%.

S "eenin# fo" and Dia#nosis of !DM


#erform a /%-g =G 5 4it9 "lasma gl'cose meas'rement fasting and at 1 and $ 95 at $4E$0 4eeBsI gestation in 4omen not "revio'sly diagnosed 4it9 overt dia!etes #erform =G in t9e morning after an overnig9t fast of at least 0 9 GD& diagnosis; 49en any of t9e follo4ing "lasma gl'cose val'es are e7ceeded
E @asting >+$ mg-d2 (%.1 mmol-2) E 1 9 >10. mg-d2 (1... mmol-2) E $ 9 >1%3 mg-d2 (0.% mmol-2)
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.1$:3%(s'""l 1);S1%. a!le *.

I2& (RE2ENTION3DELA+ OF T+(E 2 DIABETES

Re o%%endations) ("evention3Dela$ of T$,e 2 Diabetes


Refer "atients 4it9 IG (A)5 I@G (E)5 or A1C %./E*.4? (E) to ongoing s'""ort "rogram
argeting 4eig9t loss of /? of !ody 4eig9t At least 1%. min-4eeB moderate "9ysical activity

@ollo4-'" co'nseling im"ortant for s'ccess (8) 8ased on cost-effectiveness of dia!etes "revention5 t9ird-"arty "ayers s9o'ld cover s'c9 "rograms (E) Consider metformin for "revention of ty"e $ dia!etes if IG (A)5 I@G (E)5 or A1C %./E*.4? (E)
Es"ecially for t9ose 4it9 8&I G3% Bg-m$5 age H*. years5 and 4omen 4it9 "rior GD& (A)

In t9ose 4it9 "redia!etes5 monitor for develo"ment of dia!etes ann'ally (E)


ADA. I,. #revention-Delay of y"e $ Dia!etes. Diabetes Care $.1$:3%(s'""l 1);S1*.

2& DIABETES CARE

Diabetes Ca"e) Initial Eval-ation


A com"lete medical eval'ation s9o'ld !e "erformed to
E Classify t9e dia!etes E Detect "resence of dia!etes com"lications E Revie4 "revio's treatment5 glycemic control in "atients 4it9 esta!lis9ed dia!etes E Assist in form'lating a management "lan E #rovide a !asis for contin'ing care

#erform la!oratory tests necessary to eval'ate eac9 "atientIs medical condition

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1*.

Co%,onents of t'e Co%,"e'ensive Diabetes Eval-ation .1/


&edical 9istory (1) Age and c9aracteristics of onset of dia!etes (e.g.5 DJA5 asym"tomatic la!oratory finding) Eating "atterns5 "9ysical activity 9a!its5 n'tritional stat's5 and 4eig9t 9istory: gro4t9 and develo"ment in c9ildren and adolescents Dia!etes ed'cation 9istory Revie4 of "revio's treatment regimens and res"onse to t9era"y (A1C records)

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1/. a!le /.

Co%,onents of t'e Co%,"e'ensive Diabetes Eval-ation .2/


&edical 9istory ($) C'rrent treatment of dia!etes5 incl'ding medications and medication ad9erence5 meal "lan5 "9ysical activity "atterns5 and readiness for !e9avior c9ange Res'lts of gl'cose monitoring and "atientIs 'se of data DJA fre3'ency5 severity5 and ca'se Dy"oglycemic e"isodes
E Dy"oglycemia a4areness E Any severe 9y"oglycemia; fre3'ency and ca'se

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1/. a!le /.

Co%,onents of t'e Co%,"e'ensive Diabetes Eval-ation .0/


&edical 9istory (3) Distory of dia!etes-related com"lications
E &icrovasc'lar; retino"at9y5 ne"9ro"at9y5 ne'ro"at9y
Sensory ne'ro"at9y5 incl'ding 9istory of foot lesions A'tonomic ne'ro"at9y5 incl'ding se7'al dysf'nction and gastro"aresis

E &acrovasc'lar; CDD5 cere!rovasc'lar disease5 #AD E =t9er; "syc9osocial "ro!lemsA5 dental diseaseA

ASee a""ro"riate referrals for t9ese categories. ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1/. a!le /.

Co%,onents of t'e Co%,"e'ensive Diabetes Eval-ation .4/


#9ysical e7amination (1) Deig9t5 4eig9t5 8&I 8lood "ress're determination5 incl'ding ort9ostatic meas'rements 49en indicated @'ndosco"ic e7aminationA 9yroid "al"ation SBin e7amination (for acant9osis nigricans and ins'lin inKection sites)

ASee a""ro"riate referrals for t9ese categories. ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1/. a!le /.

Co%,onents of t'e Co%,"e'ensive Diabetes Eval-ation .5/


#9ysical e7amination ($) Com"re9ensive foot e7amination
EIns"ection E #al"ation of dorsalis "edis and "osterior ti!ial "'lses E #resence-a!sence of "atellar and Ac9illes refle7es E Determination of "ro"rioce"tion5 vi!ration5 and monofilament sensation

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1/. a!le /.

Co%,onents of t'e Co%,"e'ensive Diabetes Eval-ation .6/


2a!oratory eval'ation A1C5 if res'lts not availa!le 4it9in "ast $E3 mont9s If not "erformed-availa!le 4it9in "ast year
E @asting li"id "rofile5 incl'ding total5 2D25 and DD2 c9olesterol and triglycerides E 2iver f'nction tests E est for 'rine al!'min e7cretion 4it9 s"ot 'rine al!'min-to-creatinine ratio E Ser'm creatinine and calc'lated G@R E 9yroid-stim'lating 9ormone in ty"e 1 dia!etes5 dysli"idemia5 or 4omen over age %. years
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1/. a!le /.

Co%,onents of t'e Co%,"e'ensive Diabetes Eval-ation .7/


Referrals Eye care "rofessional for ann'al dilated eye e7am @amily "lanning for 4omen of re"rod'ctive age Registered dietitian for &N Dia!etes self-management ed'cation Dentist for com"re9ensive "eriodontal e7amination &ental 9ealt9 "rofessional5 if needed

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1/. a!le /.

Diabetes Ca"e) Mana#e%ent


#eo"le 4it9 dia!etes s9o'ld receive medical care from a "9ysician-coordinated team
#9ysicians5 n'rse "ractitioners5 "9ysicianIs assistants5 n'rses5 dietitians5 "9armacists5 mental 9ealt9 "rofessionals In t9is colla!orative and integrated team a""roac95 essential t9at individ'als 4it9 dia!etes ass'me an active role in t9eir care

&anagement "lan s9o'ld recogni6e dia!etes self-management ed'cation (DS&E) and on-going dia!etes s'""ort
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1*.

Diabetes Ca"e) !l$ e%i Cont"ol


4o "rimary tec9ni3'es availa!le for 9ealt9 "roviders and "atients to assess effectiveness of management "lan on glycemic control
#atient self-monitoring of !lood gl'cose (S&8G)5 or interstitial gl'cose A1C

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1*.

Re o%%endations) !l- ose Monito"in# .1/


Self-monitoring of !lood gl'cose (S&8G) s9o'ld !e carried o't t9ree or more times daily for "atients 'sing m'lti"le ins'lin inKections or ins'lin "'m" t9era"y (8) @or "atients 'sing less fre3'ent ins'lin inKections5 nonins'lin t9era"ies5 or medical n'trition t9era"y (&N ) alone5 S&8G may !e 'sef'l as a g'ide to management (E)

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1*.

Re o%%endations) !l- ose Monito"in# .2/


o ac9ieve "ost"randial gl'cose targets5 "ost"randial S&8G may !e a""ro"riate (E) C9en "rescri!ing S&8G5 ens're "atients receive initial instr'ction in5 and ro'tine follo4-'" eval'ation of5 S&8G tec9ni3'e and t9eir a!ility to 'se data to adK'st t9era"y (E)

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1*.

Re o%%endations) !l- ose Monito"in# .0/


Contin'o's gl'cose monitoring (CG&) 4it9 intensive ins'lin regimens 'sef'l tool to lo4er A1C in selected ad'lts (age >$% years) 4it9 ty"e 1 dia!etes (A) Evidence for A1C-lo4ering less strong in c9ildren5 teens5 and yo'nger ad'lts: 9o4ever5 CG& may !e 9el"f'l: s'ccess correlates 4it9 ad9erence to device 'se (C) CG& may !e a s'""lemental tool to S&8G in t9ose 4it9 9y"oglycemia 'na4areness and-or fre3'ent 9y"oglycemic e"isodes (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1*-S1/.

Re o%%endations) A1C
#erform A1C test at least t4ice yearly in "atients meeting treatment goals (and 9ave sta!le glycemic control) (E) #erform A1C test 3'arterly in "atients 49ose t9era"y 9as c9anged or 49o are not meeting glycemic goals (E) Fse of "oint-of-care (#=C) testing for A1C "rovides t9e o""ort'nity for more timely treatment c9anges (E)

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S10.

Co""elation of A1C 8it' Ave"a#e !l- ose .A!/


&ean "lasma gl'cose A1C (?) * / 0 + 1. 11 1$ mg-d2 1$* 1%4 103 $1$ $4. $*+ $+0 mmol-2 /.. 0.* 1..$ 11.0 13.4 14.+ 1*.%

9ese estimates are !ased on ADAG data of L$5/.. gl'cose meas'rements over 3 mont9s "er A1C meas'rement in %./ ad'lts 4it9 ty"e 15 ty"e $5 and no dia!etes. 9e correlation !et4een A1C and average gl'cose 4as ..+$. A calc'lator for converting A1C res'lts into estimated average gl'cose (eAG)5 in eit9er mg-d2 or mmol-25 is availa!le at 9tt";--"rofessional.dia!etes.org-Gl'coseCalc'lator.as"7. ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S10. a!le 0.

Re o%%endations) !l$ e%i !oals in Ad-lts .1/


2o4ering A1C to !elo4 or aro'nd /? 9as !een s9o4n to red'ce microvasc'lar com"lications and5 if im"lemented soon after t9e diagnosis of dia!etes5 is associated 4it9 long-term red'ction in macrovasc'lar disease 9erefore5 a reasona!le A1C goal for many non"regnant ad'lts is H/? (8)

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S10-1+.

Re o%%endations) !l$ e%i !oals in Ad-lts .2/


#roviders mig9t reasona!ly s'ggest more stringent A1C goals (s'c9 as H*.%?) for selected individ'al "atients5 if t9is can !e ac9ieved 4it9o't significant 9y"oglycemia or ot9er adverse effects of treatment A""ro"riate "atients mig9t incl'de t9ose 4it9 s9ort d'ration of dia!etes5 long life e7"ectancy5 and no significant C,D (C)

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1+.

Re o%%endations) !l$ e%i !oals in Ad-lts .0/


2ess stringent A1C goals (s'c9 as H0?) may !e a""ro"riate for "atients 4it9 (8)
E Distory of severe 9y"oglycemia5 limited life e7"ectancy5 advanced microvasc'lar or macrovasc'lar com"lications5 e7tensive comor!id conditions E 9ose 4it9 longstanding dia!etes in 49om t9e general goal is diffic'lt to attain des"ite dia!etes self-management ed'cation5 a""ro"riate gl'cose monitoring5 and effective doses of m'lti"le gl'cose lo4ering agents incl'ding ins'lin

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1+.

Intensive !l$ e%i Cont"ol and Ca"diovas -la" O-t o%es) ACCORD
*rimar+ ,utcome# -on"atal MI. non"atal stroke. /01 death
234%'5% (%'6&78'%9!

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

Gerstein DC5 et al5 for t9e Action to Control Cardiovasc'lar RisB in Dia!etes St'dy Gro'". N Engl J Med $..0:3%0;$%4%-$%%+.

Intensive !l$ e%i Cont"ol and Ca"diovas -la" O-t o%es) AD2ANCE
*rimar+ ,utcome# Microvascular )lus macrovascular (non"atal MI. non"atal stroke. /01 death!
234%'5% (%'&27%'5&!

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

#atel A5 et al5. for t9e AD,ANCE Colla!orative Gro'". N Engl J Med $..0:3%0;$%*.-$%/$.

Intensive !l$ e%i Cont"ol and Ca"diovas -la" O-t o%es) 2ADT
*rimar+ ,utcome# -on"atal MI. non"atal stroke. /01 death. hos)itali:ation "or heart "ailure. revasculari:ation
234%'&& (%'6978'%5!

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

D'cB4ort9 C5 et al.5 for t9e ,AD Investigators. N Engl J Med $..+:3*.;1$+-13+.

!l$ e%i Re o%%endations fo" Non,"e#nant Ad-lts 8it' Diabetes .1/


A1C #re"randial ca"illary "lasma gl'cose H/..?A /.E13. mg-d2A (3.+E/.$ mmol-2)

#eaB "ost"randial H10. mg-d2A ca"illary "lasma gl'coseM (H1... mmol-2)

AIndivid'ali6e goals !ased on t9ese val'es. ;#ost"randial gl'cose meas'rements s9o'ld !e made 1E$ 9 after t9e !eginning of t9e meal5 generally "eaB levels in "atients 4it9 dia!etes. ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$.. a!le +.

!l$ e%i Re o%%endations fo" Non,"e#nant Ad-lts 8it' Diabetes .2/


Goals s9o'ld !e individ'ali6ed !ased on
ED'ration of dia!etes EAge-life e7"ectancy EComor!id conditions EJno4n C,D or advanced microvasc'lar com"lications EDy"oglycemia 'na4areness EIndivid'al "atient considerations

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$.. a!le +.

!l$ e%i Re o%%endations fo" Non,"e#nant Ad-lts 8it' Diabetes .0/


&ore- or less-stringent glycemic goals may !e a""ro"riate for individ'al "atients #ost"randial gl'cose may !e targeted if A1C goals are not met des"ite reac9ing "re"randial gl'cose goals

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$.. a!le +.

Re o%%ended T'e"a,$ fo" T$,e 1 Diabetes) T'"ee Co%,onents


Fse of m'lti"le-dose ins'lin inKections (3E4 inKections-day of !asal and "randial ins'lin) or contin'o's s'!c'taneo's ins'lin inf'sion (CSII) &atc9ing "randial ins'lin to car!o9ydrate intaBe5 "remeal !lood gl'cose5 and antici"ated activity @or many "atients (es"ecially if 9y"oglycemia is a "ro!lem)5 'se of ins'lin analogs
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$1.

Re o%%endations) T'e"a,$ fo" T$,e 2 Diabetes .1/


At t9e time of ty"e $ dia!etes diagnosis5 initiate metformin t9era"y along 4it9 lifestyle interventions5 'nless metformin is contraindicated (A) In ne4ly diagnosed ty"e $ dia!etes "atients 4it9 marBedly sym"tomatic and-or elevated !lood gl'cose levels or A1C5 consider ins'lin t9era"y5 4it9 or 4it9o't additional agents5 from t9e o'tset (E)

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$1.

Re o%%endations) T'e"a,$ fo" T$,e 2 Diabetes .2/


If nonins'lin monot9era"y at ma7imal tolerated dose does not ac9ieve or maintain t9e A1C target over 3E* mont9s5 add a second oral agent5 a G2#-1 rece"tor agonist5 or ins'lin (E)

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$1.

Nonins-lin T'e"a,ies fo" 9$,e"#l$ e%ia in T$,e 2 Diabetes .1/


Class Com"o'nd &ec9anism Action(s) 8ig'anides &etformin Activates A&#-Binase De"atic gl'cose "rod'ction Intestinal gl'cose a!sor"tion Ins'lin action No 4eig9t gain No 9y"oglycemia Red'ction in cardiovasc'lar events and mortality (FJ#DS f-')

Advantages

Disadvantages Gastrointestinal side effects (diarr9ea5 a!dominal cram"ing) 2actic acidosis (rare) ,itamin 81$ deficiency Contraindications; red'ced Bidney f'nction Cost 2o4
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.

Nonins-lin T'e"a,ies fo" 9$,e"#l$ e%ia in T$,e 2 Diabetes .2/


Class Com"o'nd S'lfonyl'reas ($nd generation) Gli!enclamide-Gly!'ride Gli"i6ide Glicla6ide Glime"iride
#

&ec9anism Action(s) Advantages

Closes JA

c9annels on <-cell "lasma mem!ranes

Ins'lin secretion Generally 4ell tolerated Red'ction in cardiovasc'lar events and mortality (FJ#DS f-') Relatively gl'cose-inde"endent stim'lation of ins'lin secretion; Dy"oglycemia5 incl'ding e"isodes necessitating 9os"ital admission and ca'sing deat9 Ceig9t gain &ay !l'nt myocardial isc9emic "reconditioning 2o4 Od'ra!ilityP 2o4
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.

Disadvantages

Cost

Nonins-lin T'e"a,ies fo" 9$,e"#l$ e%ia in T$,e 2 Diabetes .0/


Class Com"o'nd &ec9anism Action(s) Advantages Disadvantages &eglitinides Re"aglinide Nateglinide Closes JA
#

c9annels on <-cell "lasma mem!ranes

Ins'lin secretion Accent'ated effects aro'nd meal ingestion Dy"oglycemia5 4eig9t gain &ay !l'nt myocardial isc9emic "reconditioning Dosing fre3'ency &edi'm

Cost

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.

Nonins-lin T'e"a,ies fo" 9$,e"#l$ e%ia in T$,e 2 Diabetes .4a/


Class Com"o'nd &ec9anism Action(s) Advantages 9ia6olidinediones (Glita6ones) #ioglita6one Activates t9e n'clear transcri"tion factor ##AR- #eri"9eral ins'lin sensitivity No 9y"oglycemia DD2 c9olesterol riglycerides Ceig9t gain Edema Deart fail're 8one fract'res

Disadvantages

Cost

Dig9

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.

Nonins-lin T'e"a,ies fo" 9$,e"#l$ e%ia in T$,e 2 Diabetes .4b/


Class Com"o'nd &ec9anism Action(s) Advantages Disadvantages 9ia6olidinediones (Glita6ones) Rosiglita6one Activates t9e n'clear transcri"tion factor ##AR- #eri"9eral ins'lin sensitivity No 9y"oglycemia 2D2 c9olesterol Ceig9t gain Edema Deart fail're 8one fract'res Increased cardiovasc'lar events (mi7ed evidence) @DA 4arnings on cardiovasc'lar safety Contraindicated in "atients 4it9 9eart disease Dig9

Cost

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.

Nonins-lin T'e"a,ies fo" 9$,e"#l$ e%ia in T$,e 2 Diabetes .5/


Class Com"o'nd &ec9anism Action(s) Advantages Disadvantages Q-Gl'cosidase in9i!itors Acar!ose &iglitol In9i!its intestinal Q-gl'cosidase Intestinal car!o9ydrate digestion (and consec'tively5 a!sor"tion) slo4ed Nonsystemic medication #ost"randial gl'cose Gastrointestinal side effects (gas5 flat'lence5 diarr9ea) Dosing fre3'ency &edi'm

Cost

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.

Nonins-lin T'e"a,ies fo" 9$,e"#l$ e%ia in T$,e 2 Diabetes .6/


Class Com"o'nd &ec9anism Action(s) G2#-1 rece"tor agonists (incretin mimetics) E7enatide 2iragl'tide Activates G2#-1 rece"tors (<-cells-endocrine "ancreas: !rain-a'tonomo's nervo's system Ins'lin secretion (gl'cose-de"endent) Gl'cagon secretion (gl'cose-de"endent) Slo4s gastric em"tying Satiety Ceig9t red'ction #otential for im"roved <-cell mass-f'nction

Advantages Disadvantages

Gastrointestinal side effects (na'sea5 vomiting5 diarr9ea) Cases of ac'te "ancreatitis o!served C-cell 9y"er"lasia-med'llary t9yroid t'mors in animals (liragl'tide) InKecta!le 2ong-term safety 'nBno4n Dig9
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$3. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.

Cost

Nonins-lin T'e"a,ies fo" 9$,e"#l$ e%ia in T$,e 2 Diabetes .7/


Class Com"o'nd D##-4 in9i!itors (incretin en9ancers) Sitagli"tin ,ildagli"tin Sa7agli"tin 2inagli"tin

&ec9anism Action(s)

In9i!its D##-4 activity5 "rolongs s'rvival of endogeno'sly released incretin 9ormones Active G2#-1 concentration Active GI# concentration Ins'lin secretion Gl'cagon secretion No 9y"oglycemia Ceig9t One'tralityP =ccasional re"orts of 'rticaria-angioedema Cases of "ancreatitis o!served 2ong-term safety 'nBno4n Dig9
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$3. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.

Advantages Disadvantages

Cost

Nonins-lin T'e"a,ies fo" 9$,e"#l$ e%ia in T$,e 2 Diabetes .:/


Class Com"o'nd &ec9anism Action(s) Advantages Disadvantages 8ile acid se3'estrants Colesevelam 8inds !ile acids-c9olesterol FnBno4n No 9y"oglycemia 2D2 c9olesterol Consti"ation riglycerides &ay interfere 4it9 a!sor"tion of ot9er medications Dig9

Cost

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$3. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.

Nonins-lin T'e"a,ies fo" 9$,e"#l$ e%ia in T$,e 2 Diabetes .;/


Class Com"o'nd &ec9anism Action(s) Advantages Disadvantages Do"amine-$ agonists 8romocri"tine Activates do"aminergic rece"tors Alters 9y"ot9alamic reg'lation of meta!olism Ins'lin sensitivity No 9y"oglycemia Di66iness-synco"e Na'sea @atig'e R9initis 2ong-term safety 'nBno4n

Cost

&edi'm

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$3. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.

Re o%%endations) Medi al N-t"ition T'e"a,$ .MNT/


Individ'als 49o 9ave "redia!etes or dia!etes s9o'ld receive individ'ali6ed &N as needed to ac9ieve treatment goals5 "refera!ly "rovided !y a registered dietitian familiar 4it9 t9e com"onents of dia!etes &N (A) 8eca'se &N can res'lt in cost-savings and im"roved o'tcomes (8)5 &N s9o'ld !e ade3'ately covered !y ins'rance and ot9er "ayers (E)

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$1.

Loo< A9EAD .A tion fo" 9ealt' in Diabetes/) One=+ea" Res-lts


Intensive lifestyle intervention res'lted in1
Average 0.*? 4eig9t loss Significant red'ction of A1C Red'ction in several C,D risB factors

8enefits s'stained at 4 years$ @inal res'lts of 2ooB ADEAD to "rovide insig9t into effects of long-term 4eig9t loss on im"ortant clinical o'tcomes

1. 2ooB ADEAD Researc9 Gro'". Diabetes Care. $../:3.;13/4-1303: $. 2ooB ADEAD Researc9 Gro'". Arch Intern Med. 2%8%<86%#85==8565.

Re o%%endations) Diabetes Self=Mana#e%ent Ed- ation .DSME/


#eo"le 4it9 dia!etes s9o'ld receive DS&E according to national standards and dia!etes self-management s'""ort at diagnosis and as needed t9ereafter (8) Effective self-management5 3'ality of life are Bey o'tcomes of DS&E: s9o'ld !e meas'red5 monitored as "art of care (C) DS&E s9o'ld address "syc9osocial iss'es5 since emotional 4ell-!eing is associated 4it9 "ositive o'tcomes (C) 8eca'se DS&E can res'lt in cost-savings and im"roved o'tcomes (8)5 DS&E s9o'ld !e reim!'rsed !y t9ird-"arty "ayers (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$4.

Re o%%endations) ('$si al A tivit$


Advise "eo"le 4it9 dia!etes to "erform at least 1%. min-4eeB of moderate-intensity aero!ic "9ysical activity (%.E/.? of ma7im'm 9eart rate)5 s"read over at least 3 days "er 4eeB 4it9 no more t9an $ consec'tive days 4it9o't e7ercise (A) In a!sence of contraindications5 "eo"le 4it9 ty"e $ dia!etes s9o'ld !e enco'raged to "erform resistance training at least t4ice "er 4eeB (A)

ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$%.

Re o%%endations) (s$ 'oso ial Assess%ent and Ca"e


=ngoing "art of medical management of dia!etes (E) #syc9osocial screening-follo4-'"; attit'des a!o't dia!etes5 medical management-o'tcomes e7"ectations5 affect-mood5 3'ality of life5 reso'rces5 "syc9iatric 9istory (E) C9en self-management is "oor5 screen for "syc9osocial "ro!lems; de"ression5 dia!etes-related an7iety5 eating disorders5 cognitive im"airment (C)
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$*.

Re o%%endations) 9$,o#l$ e%ia


Gl'cose (1%E$. g) "referred treatment for conscio's individ'al 4it9 9y"oglycemia (E) Gl'cagon s9o'ld !e "rescri!ed for all individ'als at significant risB of severe 9y"oglycemia and caregivers-family mem!ers instr'cted in administration (E) 9ose 4it9 9y"oglycemia 'na4areness or one or more e"isodes of severe 9y"oglycemia s9o'ld raise glycemic targets to red'ce risB of f't're e"isodes (8)
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$/.

Re o%%endations) Ba"iat"i S-"#e"$


Consider !ariatric s'rgery for ad'lts 4it9 8&I G3% Bg-m$ and ty"e $ dia!etes (8) After s'rgery5 life-long lifestyle s'""ort and medical monitoring is necessary (8) Ins'fficient evidence to recommend s'rgery in "atients 4it9 8&I H3% Bg-m$ o'tside of a researc9 "rotocol (E) Cell-designed5 randomi6ed controlled trials com"aring o"timal medical-lifestyle t9era"y needed to determine long-term !enefits5 cost-effectiveness5 risBs (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$/.

Re o%%endations) I%%-ni>ation
#rovide infl'en6a vaccine ann'ally to all dia!etic "atients >* mont9s of age (C) Administer "ne'mococcal "olysacc9aride vaccine to all dia!etic "atients >$ years (C)
=ne-time revaccination recommended for t9ose G*4 years "revio'sly imm'ni6ed at H*% years if administered G% years ago =t9er indications for re"eat vaccination; ne"9rotic syndrome5 c9ronic renal disease5 imm'nocom"romised states

Administer 9e"atitis 8 vaccination "er CDC recommendations (C)


ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$0.

2I& (RE2ENTION AND MANA!EMENT OF DIABETES COM(LICATIONS

Ca"diovas -la" Disease .C2D/ in Individ-als 8it' Diabetes


C,D is t9e maKor ca'se of mor!idity5 mortality for t9ose 4it9 dia!etes Common conditions coe7isting 4it9 ty"e $ dia!etes (e.g.5 9y"ertension5 dysli"idemia) are clear risB factors for C,D Dia!etes itself confers inde"endent risB 8enefits o!served 49en individ'al cardiovasc'lar risB factors are controlled to "revent-slo4 C,D in "eo"le 4it9 dia!etes
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S$0.

Re o%%endations) 9$,e"tension3Blood ("ess-"e Cont"ol


Screening and diagnosis &eas're !lood "ress're at every ro'tine dia!etes visit (C) If "atients 9ave systolic !lood "ress're >13. mmDg or diastolic !lood "ress're >0. mmDg (C)
Confirm !lood "ress're on a se"arate day Re"eat systolic !lood "ress're >13. mmDg or diastolic !lood "ress're >0. mmDg confirms a diagnosis of 9y"ertension

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S$0-S$+.

Re o%%endations) 9$,e"tension3Blood ("ess-"e Cont"ol


Goals A goal systolic !lood "ress're H13. mmDg is a""ro"riate for most "atients 4it9 dia!etes (C) 8ased on "atient c9aracteristics and res"onse to t9era"y5 9ig9er or lo4er systolic !lood "ress're targets may !e a""ro"riate (8) #atients 4it9 dia!etes s9o'ld !e treated to a diastolic !lood "ress're H0. mmDg (8)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S$+.

Re o%%endations) 9$,e"tension3Blood ("ess-"e Cont"ol


reatment (1) #atients 4it9 a systolic !lood "ress're 13.E13+ mmDg or a diastolic !lood "ress're 0.E0+ mmDg (E)
&ay !e given lifestyle t9era"y alone for a ma7im'm of 3 mont9s If targets are not ac9ieved5 "atients s9o'ld !e treated 4it9 t9e addition of "9armacological agents

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S$+.

Re o%%endations) 9$,e"tension3Blood ("ess-"e Cont"ol


reatment ($) #atients 4it9 more severe 9y"ertension (systolic !lood "ress're >14. mmDg or diastolic !lood "ress're >+. mmDg) at diagnosis or follo4-'" (A)
S9o'ld receive "9armacologic t9era"y in addition to lifestyle t9era"y

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S$+.

Re o%%endations) 9$,e"tension3Blood ("ess-"e Cont"ol


reatment (3) 2ifestyle t9era"y for 9y"ertension (8)
Ceig9t loss if over4eig9t DASD-style dietary "attern incl'ding red'cing sodi'm5 increasing "otassi'm intaBe &oderation of alco9ol intaBe Increased "9ysical activity

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S$/.

Re o%%endations) 9$,e"tension3Blood ("ess-"e Cont"ol


reatment (4) #9armacologic t9era"y for "atients 4it9 dia!etes and 9y"ertension
A regimen t9at incl'des eit9er an ACE in9i!itor or angiotensin II rece"tor !locBer If one class is not tolerated5 t9e ot9er s9o'ld !e s'!stit'ted

&'lti"le dr'g t9era"y (t4o or more agents at ma7imal doses) is generally re3'ired to ac9ieve !lood "ress're targets (8)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S$+.

Re o%%endations) 9$,e"tension3Blood ("ess-"e Cont"ol


reatment (%) If ACE in9i!itors5 AR8s5 or di'retics are 'sed5 Bidney f'nction5 ser'm "otassi'm levels s9o'ld !e monitored (E) In "regnant "atients 4it9 dia!etes and c9ronic 9y"ertension5 !lood "ress're target goals of 11.E1$+-*%E/+ mmDg are s'ggested in interest of long-term maternal 9ealt9 and minimi6ing im"aired fetal gro4t9: ACE in9i!itors5 AR8s5 contraindicated d'ring "regnancy (E)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S$+.

Re o%%endations) D$sli,ide%ia3Li,id Mana#e%ent


Screening In most ad'lt "atients5 meas're fasting li"id "rofile at least ann'ally (E) In ad'lts 4it9 lo4-risB li"id val'es (2D2 c9olesterol H1.. mg-d25 DD2 c9olesterol G%. mg-d25 and triglycerides H1%. mg-d2)5 li"id assessments may !e re"eated every $ years (E)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S$+.

Re o%%endations) D$sli,ide%ia3Li,id Mana#e%ent


reatment recommendations and goals (1) o im"rove li"id "rofile in "atients 4it9 dia!etes5 recommend lifestyle modification (A)5 foc'sing on
Red'ction of sat'rated fat5 trans fat5 c9olesterol intaBe Increased n-3 fatty acids5 visco's fi!er5 "lant stanols-sterols Ceig9t loss (if indicated) Increased "9ysical activity

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3..

Re o%%endations) D$sli,ide%ia3Li,id Mana#e%ent


reatment recommendations and goals ($) Statin t9era"y s9o'ld !e added to lifestyle t9era"y5 regardless of !aseline li"id levels
4it9 overt C,D (A) 4it9o't C,D G4. years of age 49o 9ave one or more ot9er C,D risB factors (A)

@or "atients at lo4er risB (e.g.5 4it9o't overt C,D5 H4. years of age) (E)
Consider statin t9era"y in addition to lifestyle t9era"y if 2D2 c9olesterol remains G1.. mg-d2 In t9ose 4it9 m'lti"le C,D risB factors
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3.-31.

Re o%%endations) D$sli,ide%ia3Li,id Mana#e%ent


reatment recommendations and goals (3) In individ'als 4it9o't overt C,D
#rimary goal is an 2D2 c9olesterol H1.. mg-d2 ($.* mmol-2) (A)

In individ'als 4it9 overt C,D


2o4er 2D2 c9olesterol goal of H/. mg-d2 (1.0 mmol-2)5 'sing a 9ig9 dose of a statin5 is an o"tion (8)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S31.

Re o%%endations) D$sli,ide%ia3Li,id Mana#e%ent


reatment recommendations and goals (4) If targets not reac9ed on ma7imal tolerated statin t9era"y
Alternative t9era"e'tic goal; red'ce 2D2 c9olesterol L3.E4.? from !aseline (A)

riglyceride levels H1%. mg-d2 (1./ mmol-2)5 DD2 c9olesterol G4. mg-d2 (1.. mmol-2) in men and G%. mg-d2 (1.3 mmol-2) in 4omen5 are desira!le
Do4ever5 2D2 c9olesterolEtargeted statin t9era"y remains t9e "referred strategy (C)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S31.

Re o%%endations) D$sli,ide%ia3Li,id Mana#e%ent


reatment recommendations and goals (%) If targets are not reac9ed on ma7imally tolerated doses of statins (E)
Com!ination t9era"y 'sing statins and ot9er li"id lo4ering agents may !e considered to ac9ieve li"id targets Das not !een eval'ated in o'tcome st'dies for eit9er C,D o'tcomes or safety

Statin t9era"y is contraindicated in "regnancy (8)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S31.

Re o%%endations) !l$ e%i * Blood ("ess-"e* Li,id Cont"ol in Ad-lts


A1C 8lood "ress're 2i"ids 2D2 c9olesterol H/..?A H13.-0. mmDgM

H1.. mg-d2 (H$.* mmol-2)R

A&ore or less stringent glycemic goals may !e a""ro"riate for individ'al "atients. Goals s9o'ld !e individ'ali6ed !ased on; d'ration of dia!etes5 age-life e7"ectancy5 comor!id conditions5 Bno4n C,D or advanced microvasc'lar com"lications5 9y"oglycemia 'na4areness5 and individ'al "atient considerations. M8ased on "atient c9aracteristics and res"onse to t9era"y5 9ig9er or lo4er systolic !lood "ress're targets may !e a""ro"riate. RIn individ'als 4it9 overt C,D5 a lo4er 2D2 c9olesterol goal of H/. mg-d2 (1.0 mmol-2)5 'sing a 9ig9 dose of statin5 is an o"tion. ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3$. a!le 11.

Re o%%endations) Anti,latelet A#ents .1/


Consider as"irin t9era"y (/%E1*$ mg-day) (C)
As a "rimary "revention strategy in t9ose 4it9 ty"e 1 or ty"e $ dia!etes at increased cardiovasc'lar risB (1.-year risB G1.?) Incl'des most men G%. years of age or 4omen G*. years of age 49o 9ave at least one additional maKor risB factor
@amily 9istory of C,D Dy"ertension SmoBing Dysli"idemia Al!'min'ria
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3$.

Re o%%endations) Anti,latelet A#ents .2/


As"irin s9o'ld not !e recommended for C,D "revention for ad'lts 4it9 dia!etes at lo4 C,D risB5 since "otential adverse effects from !leeding liBely offset "otential !enefits (C)
1.-year C,D risB H%?; men H%. and 4omen H*. years of age 4it9 no maKor additional C,D risB factors

In "atients in t9ese age gro'"s 4it9 m'lti"le ot9er risB factors (1.-year risB %E1.?)5 clinical K'dgment is re3'ired (E)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3$.

Re o%%endations) Anti,latelet A#ents .0/


Fse as"irin t9era"y (/%E1*$ mg-day)
Secondary "revention strategy in t9ose 4it9 dia!etes 4it9 a 9istory of C,D (A)

@or "atients 4it9 C,D and doc'mented as"irin allergy


Clo"idogrel (/% mg-day) s9o'ld !e 'sed (8)

Com!ination t9era"y 4it9 ASA (/%E1*$ mg-day) and clo"idogrel (/% mg-day)
Reasona!le for '" to a year after an ac'te coronary syndrome (8)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3$.

Re o%%endations) S%o<in# Cessation


Advise all "atients not to smoBe (A) Incl'de smoBing cessation co'nseling and ot9er forms of treatment as a ro'tine com"onent of dia!etes care (8)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S33.

Re o%%endations) Co"ona"$ 9ea"t Disease S "eenin#


In asym"tomatic "atients5 ro'tine screening for CAD is not recommended5 as it does not im"rove o'tcomes as long as C,D risB factors are treated (A)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3$.

Re o%%endations) Co"ona"$ 9ea"t Disease T"eat%ent .1/


o red'ce risB of cardiovasc'lar events in "atients 4it9 Bno4n C,D5 'se
ACE in9i!itorA (C) As"irinA (A) Statin t9era"yA (A)

In "atients 4it9 a "rior &I


8eta-!locBers s9o'ld !e contin'ed for at least $ years after t9e event (8)

AIf not contraindicated. ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S33.

Re o%%endations) Co"ona"$ 9ea"t Disease T"eat%ent .2/


2onger-term 'se of !eta-!locBers in t9e a!sence of 9y"ertension
Reasona!le if 4ell tolerated5 !'t data are lacBing (E)

Avoid SD treatment
In "atients 4it9 sym"tomatic 9eart fail're (C)

&etformin 'se in "atients 4it9 sta!le CD@


Indicated if renal f'nction is normal S9o'ld !e avoided in 'nsta!le or 9os"itali6ed "atients 4it9 CD@ (C)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S33.

Re o%%endations) Ne,'"o,at'$
o red'ce risB or slo4 t9e "rogression of ne"9ro"at9y
="timi6e gl'cose control (A) ="timi6e !lood "ress're control (A)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S34.

Re o%%endations) Ne,'"o,at'$ S "eenin#


Assess 'rine al!'min e7cretion ann'ally (8)
In ty"e 1 dia!etic "atients 4it9 dia!etes d'ration of >% years In all ty"e $ dia!etic "atients at diagnosis

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


In all ad'lts 4it9 dia!etes regardless of degree of 'rine al!'min e7cretion Ser'm creatinine s9o'ld !e 'sed to estimate G@R and stage level of c9ronic Bidney disease5 if "resent
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S34.

Re o%%endations) Ne,'"o,at'$ T"eat%ent .1/


Non"regnant "atient 4it9 micro- or macroal!'min'ria
Fse eit9er ACE in9i!itors or AR8s (A) If one class is not tolerated5 t9e ot9er s9o'ld !e s'!stit'ted (E)

Red'ction of "rotein intaBe may im"rove meas'res of renal f'nction ('rine al!'min e7cretion rate5 G@R) (8)
o ..0E1.. g 7 Bg !ody 4tE1 7 dayE1 in t9ose 4it9 dia!etes5 earlier stages of CJD o ..0 g 7 Bg !ody 4tE1 7 dayE1 in later stages of CJD
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S34.

Re o%%endations) Ne,'"o,at'$ T"eat%ent .2/


C9en ACE in9i!itors5 AR8s5 or di'retics are 'sed5 monitor ser'm creatinine and "otassi'm levels for t9e develo"ment of increased creatinine and 9y"erBalemia (E) Contin'ed monitoring of 'rine al!'min e7cretion to assess !ot9 res"onse to t9era"y and "rogression of disease is reasona!le (E) C9en estimated G@R is H*. m2 7 min-1./3 m$5 eval'ate and manage "otential com"lications of CJD (E)
ADA. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S34.

Re o%%endations) Ne,'"o,at'$ T"eat%ent .0/


Consider referral to a "9ysician e7"erienced in care of Bidney disease (8)
Fncertainty a!o't etiology of Bidney disease Diffic'lt management iss'es Advanced Bidney disease

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S34.

Definitions of Abno"%alities in Alb-%in E? "etion


S"ot collection (Tg-mg creatinine) H3. 3.-$++ >3..

Category Normal &icroal!'min'ria &acroal!'min'ria (clinical)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S34. a!le 1$.

Sta#es of C'"oni @idne$ Disease


G@R (m2-min "er 1./3 m$ !ody s'rface area) >+. *.E0+ 3.E%+ 1%E$+ H1% or dialysis

Stage 1 $ 3 4 %

Descri"tion Jidney damageA 4it9 normal or increased G@R Jidney damageA 4it9 mildly decreased G@R &oderately decreased G@R Severely decreased G@R Jidney fail're

?@3 4 glomerular "iltration rate >idne+ damage de"ined as abnormalities on )athologic. urine. blood. or imaging tests' ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3%. a!le 13.

Mana#e%ent of C@D in Diabetes .1/


G@R (m2-min1./3 m$) All "atients 4%-*. Recommended Nearly meas'rement of creatinine5 'rinary al!'min e7cretion5 "otassi'm Referral to ne"9rology if "ossi!ility for nondia!etic Bidney disease e7ists Consider dose adK'stment of medications &onitor eG@R every * mont9s &onitor electrolytes5 !icar!onate5 9emoglo!in5 calci'm5 "9os"9or's5 "arat9yroid 9ormone at least yearly Ass're vitamin D s'fficiency Consider !one density testing Referral for dietary co'nselling
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3%. a!le 14: Ada"ted from 9tt";--444.Bidney.org-"rofessionals-JD=UI-g'idelineVdia!etes-.

Mana#e%ent of C@D in Diabetes .2/


G@R (ml-min1./3 m$) 3.-44 Recommended &onitor eG@R every 3 mont9s &onitor electrolytes5 !icar!onate5 calci'm5 "9os"9or's5 "arat9yroid 9ormone5 9emoglo!in5 al!'min5 4eig9t every 3E* mont9s Consider need for dose adK'stment of medications H3. Referral to ne"9rologists

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3%. a!le 14: Ada"ted from 9tt";--444.Bidney.org-"rofessionals-JD=UI-g'idelineVdia!etes-.

Re o%%endations) Retino,at'$
o red'ce risB or slo4 "rogression of retino"at9y
="timi6e glycemic control (A) ="timi6e !lood "ress're control (A)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3%.

Re o%%endations) Retino,at'$ S "eenin# .1/


Initial dilated and com"re9ensive eye e7amination !y an o"9t9almologist or o"tometrist
Ad'lts and c9ildren aged 1. years or older 4it9 ty"e 1 dia!etes
Cit9in % years after dia!etes onset (8)

#atients 4it9 ty"e $ dia!etes


S9ortly after diagnosis of dia!etes (8)

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Re o%%endations) Retino,at'$ S "eenin# .2/


S'!se3'ent e7aminations for ty"e 1 and ty"e $ dia!etic "atients
S9o'ld !e re"eated ann'ally !y an o"9t9almologist or o"tometrist

2ess fre3'ent e7ams (every $E3 years)


&ay !e considered follo4ing one or more normal eye e7ams

&ore fre3'ent e7aminations re3'ired if retino"at9y is "rogressing (8)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3%-S3*.

Re o%%endations) Retino,at'$ S "eenin# .0/


Dig9-3'ality f'nd's "9otogra"9s
Can detect most clinically significant dia!etic retino"at9y (E)

Inter"retation of t9e images


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

C9ile retinal "9otogra"9y may serve as a screening tool for retino"at9y5 it is not a s'!stit'te for a com"re9ensive eye e7am
#erform com"re9ensive eye e7am at least initially and at intervals t9ereafter as recommended !y an eye care "rofessional (E)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3*.

Re o%%endations) Retino,at'$ S "eenin# .4/


Comen 4it9 "ree7isting dia!etes 49o are "lanning "regnancy or 49o 9ave !ecome "regnant (8)
Com"re9ensive eye e7amination Co'nseled on risB of develo"ment and-or "rogression of dia!etic retino"at9y

Eye e7amination s9o'ld occ'r in t9e first trimester (8)


Close follo4-'" t9ro'g9o't "regnancy @or 1 year "ost"art'm

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Re o%%endations) Retino,at'$ T"eat%ent .1/


#rom"tly refer "atients 4it9 any level of mac'lar edema5 severe N#DR5 or any #DR
o an o"9t9almologist Bno4ledgea!le and e7"erienced in management5 treatment of dia!etic retino"at9y (A)

2aser "9otocoag'lation t9era"y is indicated (A)


o red'ce risB of vision loss in "atients 4it9
Dig9-risB #DR Clinically significant mac'lar edema Some cases of severe N#DR

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3*.

Re o%%endations) Retino,at'$ T"eat%ent .2/


#resence of retino"at9y
Not a contraindication to as"irin t9era"y for cardio"rotection5 as t9is t9era"y does not increase t9e risB of retinal 9emorr9age (A)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3*.

Re o%%endations) Ne-"o,at'$ S "eenin#* T"eat%ent .1/


All "atients s9o'ld !e screened for distal symmetric "olyne'ro"at9y (D#N) (8)
At diagnosis of ty"e $ dia!etes 4it9 % years after diagnosis of ty"e 1 dia!etes At least ann'ally t9ereafter 'sing sim"le clinical tests

Electro"9ysiological testing rarely needed


E7ce"t in sit'ations 49ere clinical feat'res are aty"ical (E)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3*.

Re o%%endations) Ne-"o,at'$ S "eenin#* T"eat%ent .2/


Screening for signs and sym"toms of cardiovasc'lar a'tonomic ne'ro"at9y
S9o'ld !e instit'ted at diagnosis of ty"e $ dia!etes and % years after t9e diagnosis of ty"e 1 dia!etes S"ecial testing rarely needed: may not affect management or o'tcomes (E)

&edications for relief of s"ecific sym"toms related to D#N5 a'tonomic ne'ro"at9y are recommended
Im"rove 3'ality of life of t9e "atient (E)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3*.

Re o%%endations) Foot Ca"e .1/


@or all "atients 4it9 dia!etes5 "erform an ann'al com"re9ensive foot e7amination to identify risB factors "redictive of 'lcers and am"'tations
Ins"ection Assessment of foot "'lses est for loss of "rotective sensation; 1.-g monofilament "l's testing any one of
,i!ration 'sing 1$0-D6 t'ning forB #in"ricB sensation AnBle refle7es ,i!ration "erce"tion t9res9old (8)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3/.

Re o%%endations) Foot Ca"e .2/


1,,e" ,anel o "erform t9e 1.-g monofilament test5 "lace t9e device "er"endic'lar to t9e sBin5 4it9 "ress're a""lied 'ntil t9e monofilament !'cBles Dold in "lace for 1 second and t9en release Lo8e" ,anel 9e monofilament test s9o'ld !e "erformed at t9e 9ig9lig9ted sites 49ile t9e "atientIs eyes are closed
8o'lton AW&5 et al. Diabetes Care. $..0:31;1*/+-1*0%.

Re o%%endations) Foot Ca"e .0/


#rovide general foot self-care ed'cation (8) Fse m'ltidisci"linary a""roac9
Individ'als 4it9 foot 'lcers5 9ig9-risB feet: es"ecially "rior 'lcer or am"'tation (8)

Refer "atients to foot care s"ecialists for ongoing "reventive care5 life-long s'rveillance (C)
SmoBers 2oss of "rotective sensation or str'ct'ral a!normalities Distory of "rior lo4er-e7tremity com"lications
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3/.

Re o%%endations) Foot Ca"e .4/


Initial screening for "eri"9eral arterial disease (#AD)
Incl'de a 9istory for cla'dication5 assessment of "edal "'lses Consider o!taining an anBle-!rac9ial inde7 (A8I): many "atients 4it9 #AD are asym"tomatic (C)

Refer "atients 4it9 significant cla'dication or a "ositive A8I for f'rt9er vasc'lar assessment
Consider e7ercise5 medications5 s'rgical o"tions (C)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3/.

2II& ASSESSMENT OF COMMON COMORBID CONDITIONS

Re o%%endations) Assess%ent of Co%%on Co%o"bid Conditions


@or "atients 4it9 risB factors5 signs or sym"toms5 consider assessment and treatment for common dia!etes-associated conditions (8) Common comor!idities for 49ic9 increased risB is associated 4it9 dia!etes
Dearing im"airment =!str'ctive slee" a"nea @atty liver disease 2o4 testosterone in men #eriodontal disease Certain cancers @ract'res Cognitive im"airment

ADA. ,II. Assessment of Common Comor!id Conditions. Diabetes Care. $.1$:3%(s'""l 1);S30: a!le 1%.

2III& DIABETES CARE IN S(ECIFIC (O(1LATIONS

Re o%%endations) (ediat"i !l$ e%i Cont"ol .T$,e 1 Diabetes/


Consider age 49en setting glycemic goals in c9ildren and adolescents 4it9 ty"e 1 dia!etes (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4..

Re o%%endations) (ediat"i Ne,'"o,at'$ .T$,e 1 Diabetes/


Ann'al screening for microal!'min'ria5 4it9 a random s"ot 'rine sam"le for al!'min-to-creatinine (ACR) ratio
Consider once c9ild is 1. years of age and 9as 9ad dia!etes for % years (E)

Confirmed5 "ersistently elevated ACR on t4o additional 'rine s"ecimens from different days
reat 4it9 an ACE in9i!itor5 titrated to normali6ation of al!'min e7cretion5 if "ossi!le (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4..

Re o%%endations) (ediat"i 9$,e"tension .T$,e 1 Diabetes/ .1/


reat 9ig9-normal !lood "ress're (systolic or diastolic !lood "ress're consistently a!ove t9e +.t9 "ercentile for age5 se75 and 9eig9t) 4it9
Dietary intervention E7ercise aimed at 4eig9t control and increased "9ysical activity5 if a""ro"riate

If target !lood "ress're is not reac9ed 4it9 3E* mont9s of lifestyle intervention
Consider "9armacologic treatment (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4..

Re o%%endations) (ediat"i 9$,e"tension .T$,e 1 Diabetes/ .2/


#9armacologic treatment of 9y"ertension
Systolic or diastolic !lood "ress're consistently a!ove t9e +%t9 "ercentile for age5 se75 and 9eig9t Or Consistently G13.-0. mmDg5 if +%? e7ceeds t9at val'e

Initiate treatment as soon as diagnosis is confirmed (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4..

Re o%%endations) (ediat"i 9$,e"tension .T$,e 1 Diabetes/ .0/


ACE in9i!itors
Consider for initial treatment of 9y"ertension5 follo4ing a""ro"riate re"rod'ctive co'nseling d'e to "otential teratogenic effects (E)

Goal of treatment
8lood "ress're consistently H13.-0. mmDg or !elo4 t9e +.t9 "ercentile for age5 se75 and 9eig9t5 49ic9ever is lo4er (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4..

Re o%%endations) (ediat"i D$sli,ide%ia .T$,e 1 Diabetes/ .1/


Screening (1) If family 9istory of 9y"erc9olesterolemia (total c9olesterol G$4. mg-d2) or a cardiovasc'lar event !efore age %% years5 or if family 9istory is 'nBno4n
#erform fasting li"id "rofile on c9ildren G$ years of age soon after diagnosis (after gl'cose control 9as !een esta!lis9ed)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4.-S41.

Re o%%endations) (ediat"i D$sli,ide%ia .T$,e 1 Diabetes/ .2/


Screening ($) If family 9istory is not of concern
Consider first li"id screening at "'!erty (>1. years)

All c9ildren diagnosed 4it9 dia!etes at or after "'!erty


#erform fasting li"id "rofile soon after diagnosis (after gl'cose control 9as !een esta!lis9ed) (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.

Re o%%endations) (ediat"i D$sli,ide%ia .T$,e 1 Diabetes/ .0/


Screening (3) @or !ot9 age-gro'"s5 if li"ids are a!normal
Ann'al monitoring is recommended

If 2D2 c9olesterol val'es are 4it9in acce"ted risB levels (H1.. mg-d2 X$.* mmol-2Y)
Re"eat li"id "rofile every % years (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.

Re o%%endations) (ediat"i D$sli,ide%ia .T$,e 1 Diabetes/ .4/


reatment Initial t9era"y; o"timi6e gl'cose control5 &N 'sing Ste" II ADA diet aimed at decreasing dietary sat'rated fat (E) G age 1. years5 statin reasona!le in t9ose (after &N and lifestyle c9anges) 4it9
2D2 c9olesterol G1*. mg-d2 (4.1 mmol-2) or 2D2 c9olesterol G13. mg-d2 (3.4 mmol-2) and one or more C,D risB factors (E)

Goal; 2D2 c9olesterol H1.. mg-d2 ($.* mmol-2) (E)


&N Zmedical n'trition t9era"y ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.

Re o%%endations) (ediat"i Retino,at'$ .T$,e 1 Diabetes/


@irst o"9t9almologic e7amination
=!tain once c9ild is 1. years of age: 9as 9ad dia!etes for 3E% years (E)

After initial e7amination


Ann'al ro'tine follo4-'" generally recommended 2ess fre3'ent e7aminations may !e acce"ta!le on advice of an eye care "rofessional (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.

Re o%%endations) (ediat"i Celia Disease .T$,e 1 Diabetes/ .1/


C9ildren 4it9 ty"e 1 dia!etes
Screen for celiac disease !y meas'ring tiss'e transgl'taminase or antiendomysial anti!odies5 4it9 doc'mentation of normal total ser'm IgA levels5 soon after t9e diagnosis of dia!etes (E)

Re"eat testing in c9ildren 4it9


Gro4t9 fail're @ail're to gain 4eig9t5 4eig9t loss Diarr9ea5 flat'lence5 a!dominal "ain5 or signs of mala!sor"tion @re3'ent 'ne7"lained 9y"oglycemia or deterioration in glycemic control (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.

Re o%%endations) (ediat"i Celia Disease .T$,e 1 Diabetes/ .2/


C9ildren 4it9 "ositive anti!odies
Refer to a gastroenterologist for eval'ation 4it9 endosco"y and !io"sy (E)

C9ildren 4it9 !io"sy-confirmed celiac disease


#lace on a gl'ten-free diet Cons'lt 4it9 a dietitian e7"erienced in managing !ot9 dia!etes and celiac disease (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.

Re o%%endations) (ediat"i 9$,ot'$"oidis% .T$,e 1 Diabetes/


C9ildren 4it9 ty"e 1 dia!etes
Screen for t9yroid "ero7idase5 t9yroglo!'lin anti!odies at diagnosis (E)

9yroid-stim'lating 9ormone ( SD) concentrations


&eas're after meta!olic control esta!lis9ed
If normal5 rec9ecB every 1-$ years: or If "atient develo"s sym"toms of t9yroid dysf'nction5 t9yromegaly5 or an a!normal gro4t9 rate

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.

Re o%%endations) T"ansition f"o% (ediat"i to Ad-lt Ca"e


As teens transition into emerging ad'lt9ood5 9ealt9 care "roviders and families m'st recogni6e t9eir many v'lnera!ilities (8) and "re"are t9e develo"ing teen5 !eginning in early to mid adolescence and at least 1 year "rior to t9e transition (E) 8ot9 "ediatricians and ad'lt 9ealt9 care "roviders s9o'ld assist in "roviding s'""ort and linBs to reso'rces for t9e teen and emerging ad'lt (8)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4$.

Re o%%endations) ("e on e,tion Ca"e .1/


A1C levels s9o'ld !e as close to normal as "ossi!le (/?) in an individ'al "atient !efore conce"tion is attem"ted (8) Starting at "'!erty5 incor"orate "reconce"tion co'nseling in ro'tine dia!etes clinic visit for all 4omen of c9ild!earing "otential (C) Comen 4it9 dia!etes contem"lating "regnancy s9o'ld !e eval'ated and5 if indicated5 treated for dia!etic retino"at9y5 ne"9ro"at9y5 C,D (8)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4$.

Re o%%endations) ("e on e,tion Ca"e .2/


&edications s9o'ld !e eval'ated "rior to conce"tion5 since dr'gs commonly 'sed to treat dia!etes and its com"lications may !e contraindicated or not recommended in "regnancy5 incl'ding statins5 ACE in9i!itors5 AR8s5 and most nonins'lin t9era"ies (E) Since many "regnancies are 'n"lanned5 consider "otential risBs-!enefits of medications contraindicated in "regnancy in all 4omen of c9ild!earing "otential: co'nsel accordingly (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4$.

Re o%%endations) Olde" Ad-lts .1/


@'nctional5 cognitively intact older ad'lts 4it9 significant life e7"ectancies s9o'ld receive dia!etes care 'sing goals develo"ed for yo'nger ad'lts (E) Glycemic goals for t9ose not meeting t9e a!ove criteria may !e rela7ed 'sing individ'al criteria5 !'t 9y"erglycemia leading to sym"toms or risB of ac'te 9y"erglycemic com"lications s9o'ld !e avoided in all "atients (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S43.

Re o%%endations) Olde" Ad-lts .2/


reat ot9er cardiovasc'lar risB factors 4it9 consideration of t9e time frame of !enefit and t9e individ'al "atient reatment of 9y"ertension is indicated in virt'ally all older ad'lts: li"id5 as"irin t9era"y may !enefit t9ose 4it9 life e7"ectancy e3'al to time frame of "rimary-secondary "revention trials (E) Individ'ali6e screening for dia!etes com"lications 4it9 attention to t9ose leading to f'nctional im"airment (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S43.

Re o%%endations) C$sti Fib"osis= Related Diabetes .CFRD/


Ann'al screening for C@RD 4it9 =G s9o'ld !egin !y age 1. years in all "atients 4it9 cystic fi!rosis 49o do not 9ave C@RD (8)
Fse of A1C as a screening test for C@RD is not recommended (8)

D'ring a "eriod of sta!le 9ealt95 diagnosis of C@RD can !e made in "atients 4it9 cystic fi!rosis according to 's'al diagnostic criteria (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S44.

Re o%%endations) C$sti Fib"osis= Related Diabetes .CFRD/


#atients 4it9 C@RD s9o'ld !e treated 4it9 ins'lin to attain individ'ali6ed glycemic goals (A) Ann'al monitoring for com"lications of dia!etes is recommended5 !eginning % years after t9e diagnosis of C@RD (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S44.

IA& DIABETES CARE IN S(ECIFIC SETTIN!S

Re o%%endations) Diabetes Ca"e in t'e 9os,ital .1/


All "atients 4it9 dia!etes admitted to t9e 9os"ital s9o'ld 9ave t9eir dia!etes clearly identified in t9e medical record (E) All "atients 4it9 dia!etes s9o'ld 9ave an order for !lood gl'cose monitoring5 4it9 res'lts availa!le to all mem!ers of t9e 9ealt9 care team (E)

ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S44.

Re o%%endations) Diabetes Ca"e in t'e 9os,ital .2/


Goals for !lood gl'cose levels
Critically ill "atients; 14.-10. mg-d2 (/.0E1. mmol-2) (A) &ore stringent goals5 s'c9 as 11.-14. mg-d2 (*.1E/.0 mmol-2) may !e a""ro"riate for selected "atients5 if ac9ieva!le 4it9o't significant 9y"oglycemia (C) Critically ill "atients re3'ire an I, ins'lin "rotocol t9at 9as demonstrated efficacy and safety in ac9ieving t9e desired gl'cose range 4it9o't increasing risB for severe 9y"oglycemia (E)
ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S44.

Re o%%endations) Diabetes Ca"e in t'e 9os,ital .0/


Goals for !lood gl'cose levels
Noncritically ill "atients; No clear evidence for s"ecific !lood gl'cose goals If treated 4it9 ins'lin5 "remeal !lood gl'cose targets (if safely ac9ieved)
Generally H14. mg-d2 (/.0 mmol-2) 4it9 random !lood gl'cose H10. mg-d2 (1... mmol-2)

&ore stringent targets may !e a""ro"riate in sta!le "atients 4it9 "revio's tig9t glycemic control 2ess stringent targets may !e a""ro"riate in t9ose 4it9 severe comor!idities (E)
ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S44.

Re o%%endations) Diabetes Ca"e in t'e 9os,ital .4/


Sc9ed'led s'!c'taneo's ins'lin 4it9 !asal5 n'tritional5 and correction com"onents is t9e "referred met9od for ac9ieving and maintaining gl'cose control in noncritically ill "atients

ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S44.

Re o%%endations) Diabetes Ca"e in t'e 9os,ital .5/


Initiate gl'cose monitoring in any "atient not Bno4n to !e dia!etic 49o receives t9era"y associated 4it9 9ig9-risB for 9y"erglycemia
Dig9-dose gl'cocorticoid t9era"y5 initiation of enteral or "arenteral n'trition5 or ot9er medications s'c9 as octreotide or imm'nos'""ressive medications (8)

If 9y"erglycemia is doc'mented and "ersistent5 consider treating s'c9 "atients to t9e same glycemic goals as "atients 4it9 Bno4n dia!etes (E)
ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S44.

Re o%%endations) Diabetes Ca"e in t'e 9os,ital .6/


A 9y"oglycemia management "rotocol s9o'ld !e ado"ted and im"lemented !y eac9 9os"ital or 9os"ital system
Esta!lis9 a "lan for treating 9y"oglycemia for eac9 "atient: doc'ment e"isodes of 9y"oglycemia in medical record and tracB (E)

=!tain A1C for all "atients if res'lts 4it9in "revio's $E3 mont9s 'navaila!le (E) #atients 4it9 9y"erglycemia 4it9o't a diagnosis of dia!etes; doc'ment "lans for follo4-'" testing and care at disc9arge (E)
ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S44.

Diabetes Ca"e in t'e 9os,ital) NICE=S1!AR St-d$ .1/


2argest randomi6ed controlled trial to date ested effect of tig9t glycemic control (target 01E1.0 mg-d2) on o'tcomes among *51.4 critically ill "artici"ants &aKority (G+%?) re3'ired mec9anical ventilation

ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S4%.

Diabetes Ca"e in t'e 9os,ital) NICE=S1!AR St-d$ .2/


In !ot9 s'rgical-medical "atients5 +.-day mortality significantly 9ig9er in intensively treated vs conventional gro'" (target 144E10. mg-d2)
/0 more deat9s ($/.%? vs $4.+?: PZ...$) /* more deat9s from cardiovasc'lar ca'ses (41.*? vs 3%.0?: PZ...$) Severe 9y"oglycemia more common (*.0? vs ..%?: PH....1)

ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S4%.

A& STRATE!IES FOR IM(RO2IN! DIABETES CARE

Re o%%endations) St"ate#ies fo" I%,"ovin# Diabetes Ca"e .1/


Care s9o'ld !e aligned 4it9 com"onents of t9e C9ronic Care &odel to ens're "rod'ctive interactions !et4een a "re"ared "roactive "ractice team and an informed activated "atient (A) C9en feasi!le5 care systems s9o'ld s'""ort team-!ased care5 comm'nity involvement5 "atient registries5 and em!edded decision s'""ort tools to meet "atient needs (8)

ADA. 1. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1$:3%(s'""l 1);S40.

Re o%%endations) St"ate#ies fo" I%,"ovin# Diabetes Ca"e .2/


reatment decisions s9o'ld !e timely and !ased on evidence-!ased g'idelines t9at are tailored to individ'al "atient "references5 "rognoses5 and comor!idities (8) A "atient-centered comm'nication style s9o'ld !e em"loyed t9at incor"orates "atient "references5 assesses literacy and n'meracy5 and addresses c'lt'ral !arriers to care (8)

ADA. 1. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1$:3%(s'""l 1);S40.

ObBe tive 1) O,ti%i>e ("ovide" and Tea% Be'avio"


Care team s9o'ld "rioriti6e timely5 a""ro"riate intensification of lifestyle and-or "9armace'tical t9era"y
#atients 49o 9ave not ac9ieved !eneficial levels of !lood "ress're5 li"id5 or gl'cose control

Strategies incl'de
E7"licit goal setting 4it9 "atients Identifying and addressing !arriers to care Integrating evidence-!ased g'idelines Incor"orating care management teams
ADA. 1. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1$:3%(s'""l 1);S4+.

ObBe tive 2) S-,,o"t (atient Be'avio" C'an#e


Im"lement a systematic a""roac9 to s'""ort "atient !e9avior c9ange efforts
a) Dealt9y lifestyle; "9ysical activity5 9ealt9y eating5 non'se of to!acco5 4eig9t management5 effective co"ing !) Disease self-management; medication taBing and management5 self-monitoring of gl'cose and !lood "ress're 49en clinically a""ro"riate c) #revention of dia!etes com"lications; self-monitoring of foot 9ealt95 active "artici"ation in screening for eye5 foot5 and renal com"lications5 and imm'ni6ations
ADA. 1. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1$:3%(s'""l 1);S4+.

ObBe tive 0) C'an#e t'e S$ste% of Ca"e


9e most s'ccessf'l "ractices 9ave an instit'tional "riority for "roviding 9ig9 3'ality of care
8asing care on evidence-!ased g'idelines E7"anding t9e role of teams and staff Redesigning t9e "rocesses of care Im"lementing electronic 9ealt9 record tools Activating and ed'cating "atients Identifying and-or develo"ing comm'nity reso'rces and "'!lic "olicy t9at s'""orts 9ealt9y lifestyles Alterations in reim!'rsement
ADA. 1. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1$:3%(s'""l 1);S4+.