ada standards of medical care 2013 final 21 dec 2012

8/9/2019 ADA Standards of Medical Care 2013 FINAL 21 Dec 2012

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STANDARDS OF MEDICAL CARESTANDARDS OF MEDICAL CAREIN DIABETES—2013IN DIABETES—2013


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Table of ContentsTable of ContentsSectionSection Slide No.Slide No.

ADA Evidence Grading System of Clinical Recommendations

3

I. Classification and Diagnosis 4-11

II. esting for Dia!etes in Asym"tomatic #atients 1$-1%

III. Detection and Diagnosis of

Gestational Dia!etes &ellit's (GD&) 1*-1+

I,. #reventionDelay of y"e $ Dia!etes $-$$

,. Dia!etes Care $3-*4

,I. #revention and &anagement of

Dia!etes Com"lications

*%-1/

,II. Assessment of Common Comor!id Conditions 1+-11

,III. Dia!etes Care in S"ecific #o"'lations 111-131

I0. Dia!etes Care in S"ecific Settings 13$-14

0. Strategies for Im"roving Dia!etes Care 141-14*


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ADA Evien!e "#ain$ S%ste& fo#ADA Evien!e "#ain$ S%ste& fo#Clini!al Re!o&&enationsClini!al Re!o&&enations

evel ofevel ofEvidenceEvidence Descri"tionDescri"tion

A Clear or s'""ortive evidence from ade2'ately

"oered ell-cond'cted generali5a!le

randomi5ed controlled trials

Com"elling none6"erimental evidence

7 S'""ortive evidence from ell-cond'cted co8ort

st'dies or case-control st'dy

C S'""ortive evidence from "oorly controlled or

'ncontrolled st'diesConflicting evidence it8 t8e eig8t of evidence

s'""orting t8e recommendation

E E6"ert consens's or clinical e6"erience

ADA. Diabetes Care $1393*(s'""l 1):S1$9 a!le 1.


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I' CLASSIFICATION ANDDIA"NOSIS


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Classifi!ation of DiabetesClassifi!ation of Diabetes

• y"e 1 dia!etes – ;-cell destr'ction

• y"e $ dia!etes

– #rogressive ins'lin secretory defect

•


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C#ite#ia fo# t(e Dia$nosis of DiabetesC#ite#ia fo# t(e Dia$nosis of Diabetes

A1C =*.%>

OR

?asting "lasma gl'cose (?#G)

=1$* mgd (@. mmol)OR

$-8 "lasma gl'cose =$ mgd

(11.1 mmol) d'ring an


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A1C =*.%>

8e test s8o'ld !e "erformed in a

la!oratory 'sing a met8od t8at isNGS# certified and standardi5edto t8e DCC assay

In t8e a!sence of 'ne2'ivocal 8y"erglycemia res'lt s8o'ld !e confirmed !y re"eat testing.

ADA. I. Classification and Diagnosis. Diabetes Care $1393*(s'""l 1):S139 a!le $.


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?asting "lasma gl'cose (?#G)

=1$* mgd (@. mmol)

?asting is defined as no caloric intaBefor at least / 8

In t8e a!sence of 'ne2'ivocal 8y"erglycemia res'lt s8o'ld !e confirmed !y re"eat testing.



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$-8 "lasma gl'cose =$ mgd(11.1 mmol) d'ring an


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In a "atient it8 classic sym"toms of8y"erglycemia or 8y"erglycemic crisis

a random "lasma gl'cose =$ mgd

(11.1 mmol)



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)#eiabetes* IF"+ I"T+ In!#ease A1C)#eiabetes* IF"+ I"T+ In!#ease A1C

Categories of increased risB for dia!etes

("redia!etes)

?#G 11$% mgd (%.**.+ mmol): I?G

OR

$-8 "lasma gl'cose in t8e @%-g

?or all t8ree tests risB is contin'o's e6tending !elo t8e loer limit of a range and !ecomingdis"ro"ortionately greater at 8ig8er ends of t8e range.

ADA. I. Classification and Diagnosis. Diabetes Care $1393*(s'""l 1):S139 a!le 3.


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II' TESTIN" FOR DIABETES INII' TESTIN" FOR DIABETES INAS,M)TOMATIC )ATIENTSAS,M)TOMATIC )ATIENTS


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Re!o&&enations* Testin$ fo#Re!o&&enations* Testin$ fo#Diabetes in As%&-to&ati! )atientsDiabetes in As%&-to&ati! )atients

• Consider testing overeig8to!ese ad'lts(7&I =$% Bgm$) and 8o 8ave one or moreadditional risB factors

– In t8ose it8o't risB factors !egin testing at age4% years (7)

• If tests are normal – Re"eat testing at least at 3-year intervals (E)

• Fse A1C ?#G or $-8 @%-g


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C#ite#ia fo# Testin$ fo# Diabetes inC#ite#ia fo# Testin$ fo# Diabetes inAs%&-to&ati! A.lt Inivi.als /1As%&-to&ati! A.lt Inivi.als /1

•#8ysical inactivity

•?irst-degree relative it8

dia!etes

•ig8-risB raceet8nicity (e.g.African American atinoNative American Asian

American #acific Islander)

•omen 8o delivered a !a!y

eig8ing + l! or erediagnosed it8 GD&

•y"ertension (=14+

mmg or on t8era"y for8y"ertension)

• D c8olesterol levelH3% mgd (.+ mmol)andor a triglyceride level$% mgd ($./$ mmol)

• omen it8 "olycystic ovarysyndrome (#C IG or I?G on"revio's testing

•


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2' In t8e a!sence of criteria (risB factors on"revio's slide) testing for dia!etes s8o'ld !egin

at age 4% years

3' If res'lts are normal testing s8o'ld !e re"eatedat least at 3-year intervals it8 consideration of

more fre2'ent testing de"ending on initialres'lts (e.g. t8ose it8 "redia!etes s8o'ld !e

tested yearly) and risB stat's

ADA. esting for Dia!etes in Asym"tomatic #atients. Diabetes Care $1393*(s'""l 1):S149 a!le 4.

C#ite#ia fo# Testin$ fo# Diabetes inC#ite#ia fo# Testin$ fo# Diabetes inAs%&-to&ati! A.lt Inivi.als /2As%&-to&ati! A.lt Inivi.als /2


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III' DETECTION ANDIII' DETECTION ANDDIA"NOSIS OFDIA"NOSIS OF"ESTATIONAL DIABETES"ESTATIONAL DIABETESMELLITS /"DMMELLITS /"DM


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Re!o&&enations*Re!o&&enations*Dete!tion an Dia$nosis of "DM /1Dete!tion an Dia$nosis of "DM /1

• Screen for 'ndiagnosed ty"e $ dia!etesat t8e first "renatal visit in t8ose it8risB factors 'sing standard diagnosticcriteria (7)

• In "regnant omen not "revio'slyBnon to 8ave dia!etes screen for GD&at $4$/ eeBs gestation 'sing a@%-g


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Re!o&&enations*Re!o&&enations*Dete!tion an Dia$nosis of "DM /2Dete!tion an Dia$nosis of "DM /2

• Screen omen it8 GD& for "ersistent dia!etesat *1$ eeBs "ost"art'm 'sing


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S!#eenin$ fo# an Dia$nosis of "DMS!#eenin$ fo# an Dia$nosis of "DM

•#erform a @%-g


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I' )REENTIONDELA, OFI' )REENTIONDELA, OFT,)E 2 DIABETEST,)E 2 DIABETES


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Re!o&&enations*Re!o&&enations*)#eventionDela% of T%-e 2 Diabetes)#eventionDela% of T%-e 2 Diabetes

• Refer "atients it8 IG (A) I?G (E) or A1C%.@*.4> (E) to ongoing s'""ort "rogram – argeting eig8t loss of @> of !ody eig8t

– At least 1% mineeB moderate "8ysical activity

• ?ollo-'" co'nseling im"ortant for s'ccess (7)

• 7ased on cost-effectiveness of dia!etes"revention t8ird-"arty "ayers s8o'ld covers'c8 "rograms (E)

ADA. I,. #reventionDelay of y"e $ Dia!etes. Diabetes Care $1393*(s'""l 1):S1*.


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Re!o&&enations*Re!o&&enations*)#eventionDela% of T%-e 2 Diabetes)#eventionDela% of T%-e 2 Diabetes

•Consider metformin for "revention of ty"e $dia!etes if IG (A) I?G (E) or A1C %.@*.4> (E) – Es"ecially for t8ose it8 7&I 3% Bgm$

age H* years and omen it8 "rior GD& (A)

• In t8ose it8 "redia!etes monitor for

develo"ment of dia!etes ann'ally (E)

• Screen for and treat modifia!le risB factors forC,D (7)

ADA. I,. #reventionDelay of y"e $ Dia!etes. Diabetes Care $1393*(s'""l 1):S1*.


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' DIABETES CARE


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• A com"lete medical eval'ation s8o'ld !e "erformed to

Classify t8e dia!etes

Detect "resence of dia!etes com"lications

Revie "revio's treatment risB factor control in "atients it8esta!lis8ed dia!etes

Assist in form'lating a management "lan

#rovide a !asis for contin'ing care• #erform la!oratory tests necessary to eval'ate eac8 "atients

medical condition

Diabetes Ca#e* Initial Eval.ationDiabetes Ca#e* Initial Eval.ation

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S1*.

C f ( C ( i


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Co&-onents of t(e Co&-#e(ensiveCo&-onents of t(e Co&-#e(ensiveDiabetes Eval.ation /1Diabetes Eval.ation /1

&edical 8istory (1)• Age and c8aracteristics of onset of dia!etes

(e.g. DJA asym"tomatic la!oratory finding)

• Eating "atterns "8ysical activity 8a!its

n'tritional stat's and eig8t 8istory9 grot8and develo"ment in c8ildren and adolescents

•Dia!etes ed'cation 8istory

• Revie of "revio's treatment regimens and

res"onse to t8era"y (A1C records)

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S1@9 a!le @.

f ( ( iC f ( C ( i


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&edical 8istory ($)• C'rrent treatment of dia!etes incl'ding

medications medication ad8erence and !arrierst8ereto meal "lan "8ysical activity "atterns

and readiness for !e8avior c8ange

• Res'lts of gl'cose monitoring and "atients'se of data

• DJA fre2'ency severity and ca'se

• y"oglycemic e"isodes y"oglycemia aareness

Any severe 8y"oglycemia: fre2'ency and ca'se

C f ( C ( iC t f t( C ( i


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&edical 8istory (3)• istory of dia!etes-related com"lications

&icrovasc'lar: retino"at8y ne"8ro"at8y ne'ro"at8y

• Sensory ne'ro"at8y incl'ding 8istory of foot lesions

• A'tonomic ne'ro"at8y incl'ding se6'al dysf'nction andgastro"aresis

&acrovasc'lar: CD cere!rovasc'lar disease #AD


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#8ysical e6amination (1)•eig8t eig8t 7&I

• 7lood "ress're determination incl'ding

ort8ostatic meas'rements 8en indicated

•?'ndosco"ic e6amination

•8yroid "al"ation

• SBin e6amination (for acant8osis nigricans andins'lin inKection sites)

See a""ro"riate referrals for t8ese categories.

C t f t( C ( iC t f t( C ( i


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#8ysical e6amination ($)• Com"re8ensive foot e6amination

Ins"ection

#al"ation of dorsalis "edis and "osterior ti!ial "'lses

#resencea!sence of "atellar and Ac8illes refle6es Determination of "ro"rioce"tion vi!ration and

monofilament sensation



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a!oratory eval'ation• A1C if res'lts not availa!le it8in "ast

$3 mont8s

• If not "erformedavaila!le it8in "ast year

?asting li"id "rofile incl'ding total D and Dc8olesterol and triglycerides

iver f'nction tests

est for 'rine al!'min e6cretion it8 s"ot 'rine

al!'min-to-creatinine ratio

Ser'm creatinine and calc'lated G?R

8yroid-stim'lating 8ormone in ty"e 1 dia!etesdysli"idemia or omen over age % years





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Referrals

•Eye care "rofessional for ann'al dilated eye e6am

•?amily "lanning for omen of re"rod'ctive age

•Registered dietitian for &N

•Dia!etes self-management ed'cation

• Dentist for com"re8ensive "eriodontal

e6amination

• &ental 8ealt8 "rofessional if needed




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ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S1@.

Diabetes Ca#e* Mana$e&entDiabetes Ca#e* Mana$e&ent

• #eo"le it8 dia!etes s8o'ld receive medical care from a

team t8at may incl'de – #8ysicians n'rse "ractitioners "8ysicians assistants n'rses

dietitians "8armacists mental 8ealt8 "rofessionals

– In t8is colla!orative and integrated team a""roac8 essential t8atindivid'als it8 dia!etes ass'me an active role in t8eir care

• &anagement "lan s8o'ld recogni5e dia!etes self-management ed'cation (DS&E) and on-going dia!etess'""ort


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ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S1@.

Diabetes Ca#e* "l%!e&i! Cont#olDiabetes Ca#e* "l%!e&i! Cont#ol

• o "rimary tec8ni2'es availa!le for 8ealt8"roviders and "atients to assess effectivenessof management "lan on glycemic control

– #atient self-monitoring of !lood gl'cose (S&7G)or interstitial gl'cose

– A1C

R tiRe!o&&enations*


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Re!o&&enations*Re!o&&enations*"l.!ose Monito#in$ /1"l.!ose Monito#in$ /1

• #atients on m'lti"le-dose ins'lin (&DI) orins'lin "'m" t8era"y s8o'ld do S&7G (7)

– At least "rior to meals and snacBs

–


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• 8en "rescri!ed as "art of a !roader ed'cational

conte6t S&7G res'lts may !e 8el"f'l to g'idetreatment decisions andor "atient self-managementfor "atients 'sing less fre2'ent ins'lin inKections ornonins'lin t8era"ies (E)

• 8en "rescri!ing S&7G ens're t8at "atientsreceive ongoing instr'ction and reg'lar eval'ation ofS&7G tec8ni2'e and S&7G res'lts as ell as t8eira!ility to 'se S&7G data to adK'st t8era"y (E)

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S1*.

Re!o&&enations*Re!o&&enations*


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• Contin'o's gl'cose monitoring (CG&) it8intensive ins'lin regimens 'sef'l tool to loerA1C in selected ad'lts (age =$% years) it8 ty"e1 dia!etes (A)

• Evidence for A1C-loering less strong inc8ildren teens and yo'nger ad'lts9 8oeverCG& may !e 8el"f'l9 s'ccess correlates it8ad8erence to device 'se (C)

• CG& may !e a s'""lemental tool to S&7G int8ose it8 8y"oglycemia 'naareness andorfre2'ent 8y"oglycemic e"isodes (E)

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S1@-S1/.


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Re!o&&enations* A1CRe!o&&enations* A1C

• #erform A1C test at least tice yearly in"atients meeting treatment goals (and8ave sta!le glycemic control) (E)

• #erform A1C test 2'arterly in "atients

8ose t8era"y 8as c8anged or 8o arenot meeting glycemic goals (E)

• Fse of "oint-of-care (#


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

&ean "lasma gl'cose

A1C (>) mgd mmol

* 1$* @.

@ 1%4 /.*

/ 1/3 1.$+ $1$ 11./

1 $4 13.4

11 $*+ 14.+

1$ $+/ 1*.%

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S1+9 a!le /.

8ese estimates are !ased on ADAG data of L$@ gl'cose meas'rements over 3 mont8s "er A1Cmeas'rement in %@ ad'lts it8 ty"e 1 ty"e $ and no dia!etes. 8e correlation !eteen A1C andaverage gl'cose as .+$. A calc'lator for converting A1C res'lts into estimated average gl'cose (eAG)in eit8er mgd or mmol is availa!le at 8tt":"rofessional.dia!etes.orgeAG.



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• oering A1C to !elo or aro'nd @> 8as !eens8on to red'ce microvasc'lar com"licationsand if im"lemented soon after t8e diagnosis ofdia!etes is associated it8 long-term red'ctionin macrovasc'lar disease (7)

• 8erefore a reasona!le A1C goal for manynon"regnant ad'lts is H@> (7)

Re!o&&enations*Re!o&&enations*"l%!e&i! "oals in A.lts /1"l%!e&i! "oals in A.lts /1

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S1+.



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• #roviders mig8t reasona!ly s'ggest more stringent

A1C goals (s'c8 as H*.%>) for selected individ'al"atients if t8is can !e ac8ieved it8o't significant8y"oglycemia or ot8er adverse effects of treatment (C)

• A""ro"riate "atients mig8t incl'de t8ose it8 s8ort

d'ration of dia!etes long life e6"ectancy and nosignificant C,D (C)





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• ess stringent A1C goals (s'c8 as H/>)

may !e a""ro"riate for "atients it8 (7)

istory of severe 8y"oglycemia limited lifee6"ectancy advanced microvasc'lar or

macrovasc'lar com"lications e6tensivecomor!id conditions

8ose it8 longstanding dia!etes in 8om t8egeneral goal is diffic'lt to attain des"ite dia!etes

self-management ed'cation a""ro"riate gl'cosemonitoring and effective doses of m'lti"legl'cose loering agents incl'ding ins'lin

Intensive "l%!e&i! Cont#ol anIntensive "l%!e&i! Cont#ol an


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Intensive "l%!e&i! Cont#ol anIntensive "l%!e&i! Cont#ol anCa#iovas!.la# O.t!o&es* ACCORDCa#iovas!.la# O.t!o&es* ACCORD

Gerstein C et al for t8e Action to Control Cardiovasc'lar RisB in Dia!etes St'dy Gro'".N Engl J Med $/93%/:$%4%-$%%+.

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

*rimar+ ,utcome# -on"atal MI. non"atal stroke. 01 death

34%'% (%'6&78'%9!



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Intensive "l%!e&i! Cont#ol anIntensive "l%!e&i! Cont#ol anCa#iovas!.la# O.t!o&es* ADANCECa#iovas!.la# O.t!o&es* ADANCE

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

*rimar+ ,utcome# Microvascular )lus macrovascular

(non"atal MI. non"atal stroke. 01 death!

#atel A et al. for t8e AD,ANCE Colla!orative Gro'". N Engl J Med $/93%/:$%*-$%@$.

34%'% (%'&27%'&!



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Intensive "l%!e&i! Cont#ol anIntensive "l%!e&i! Cont#ol anCa#iovas!.la# O.t!o&es* ADTCa#iovas!.la# O.t!o&es* ADT

D'cBort8 et al. for t8e ,AD Investigators. N Engl J Med $+93*:1$+-13+.

*rimar+ ,utcome# -on"atal MI. non"atal stroke. 01 death.

hos)itali:ation "or heart "ailure. revasculari:ation34%'&& (%'6978'%5!

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

"l%!e&i! Re!o&&enations fo#"l%!e&i! Re!o&&enations fo#


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"l%!e&i! Re!o&&enations fo#"l%!e&i! Re!o&&enations fo#Non-#e$nant A.lts 8it( Diabetes /1Non-#e$nant A.lts 8it( Diabetes /1

A1C H@.>

#re"randial ca"illary

"lasma gl'cose

@13 mgd

(3.+@.$ mmol)

#eaB "ost"randialca"illary "lasma gl'coseM

H1/ mgd (H1. mmol)

Individ'ali5e goals !ased on t8ese val'es.;#ost"randial gl'cose meas'rements s8o'ld !e made 1$ 8 after t8e !eginning of t8e meal generally"eaB levels in "atients it8 dia!etes.

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S$19 a!le +.



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• Goals s8o'ld !e individ'ali5ed !ased on

D'ration of dia!etes

Agelife e6"ectancy

Comor!id conditions

Jnon C,D or advanced microvasc'larcom"lications

y"oglycemia 'naareness

Individ'al "atient considerations





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• &ore or less stringent glycemic goals may!e a""ro"riate for individ'al "atients

• #ost"randial gl'cose may !e targeted ifA1C goals are not met des"ite reac8ing

"re"randial gl'cose goals



Re!o&&enations* Ins.lin T(e#a-%Re!o&&enations* Ins.lin T(e#a-%


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Re!o&&enations* Ins.lin T(e#a-%Re!o&&enations* Ins.lin T(e#a-%fo# T%-e 1 Diabetes /1fo# T%-e 1 Diabetes /1

• &ost "eo"le it8 ty"e 1 dia!etes

– S8o'ld !e treated it8 &DI inKections (34inKections "er day of !asal and "randial ins'lin)or contin'o's s'!c'taneo's ins'lin inf'sion(CSII) (A)

– S8o'ld !e ed'cated in 8o to matc8 "randialins'lin dose to car!o8ydrate intaBe "remeal!lood gl'cose and antici"ated activity (E)

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S$1.

Re!o&&enations* Ins.lin T(e#a-%Re!o&&enations* Ins.lin T(e#a-%


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Re!o&&enations* Ins.lin T(e#a-%Re!o&&enations* Ins.lin T(e#a-%fo# T%-e 1 Diabetes /2fo# T%-e 1 Diabetes /2

• &ost "eo"le it8 ty"e 1 dia!etes s8o'ld'se ins'lin analogs to red'ce8y"oglycemia risB (A)

• Consider screening t8ose it8 ty"e 1

dia!etes for ot8er a'toimm'ne diseases(t8yroid vitamin 71$ deficiency celiac) asa""ro"riate (7)


Re!o&&enations* T(e#a-%Re!o&&enations* T(e#a-%


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• &etformin if not contraindicated andif tolerated is t8e "referred initial"8armacological agent for ty"e $ dia!etes(A)

• In nely diagnosed ty"e $ dia!etic"atients it8 marBedly sym"tomaticandor elevated !lood gl'cose levels orA1C consider ins'lin t8era"y it8 or

it8o't additional agents from t8eo'tset (E)

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S$$.

Re!o&&enations* T(e#a-%Re!o&&enations* T(e#a-%fo# T%-e 2 Diabetes /1fo# T%-e 2 Diabetes /1



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Re!o&&enations*Re!o&&enations*T(e#a-% fo# T%-e 2 Diabetes /2T(e#a-% fo# T%-e 2 Diabetes /2

• If nonins'lin monot8era"y at ma6imaltolerated dose does not ac8ieve ormaintain t8e A1C target over 3* mont8sadd a second oral agent a G#-1 rece"tor

agonist or ins'lin (A)




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Re!o&&enations*Re!o&&enations*T(e#a-% fo# T%-e 2 Diabetes /3T(e#a-% fo# T%-e 2 Diabetes /3

• A "atient-centered a""roac8 s8o'ld !e'sed to g'ide c8oice of "8armacologicalagents9 considerations incl'de efficacycost "otential side effects effects on

eig8t comor!idities 8y"oglycemia risBand "atient "references (E)

• D'e to t8e "rogressive nat're of ty"e $dia!etes ins'lin t8era"y is event'ally

indicated for many "atients it8 ty"e $dia!etes (7)




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Re!o&&enations*Re!o&&enations*Mei!al N.t#ition T(e#a-% /MNTMei!al N.t#ition T(e#a-% /MNT


• Individ'als 8o 8ave "redia!etes ordia!etes s8o'ld receive individ'ali5ed &Nas needed to ac8ieve treatment goals"refera!ly "rovided !y a registered

dietitian familiar it8 t8e com"onents ofdia!etes &N (A)

• 7eca'se &N can res'lt in cost-savingsand im"roved o'tcomes (7) &N s8o'ld

!e ade2'ately covered !y ins'rance andot8er "ayers (E)

Loo9 A:EAD /A!tion fo# :ealt( inLoo9 A:EAD /A!tion fo# :ealt( in


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Loo9 A:EAD /A!tion fo# :ealt( inLoo9 A:EAD /A!tion fo# :ealt( inDiabetes* T#ial :alte Ea#l%Diabetes* T#ial :alte Ea#l%

1 $. ooB AEAD Researc8 Gro'". Diabetes Care. $@93:13@4-13/3 and Arch Intern Med .$191@:1%**1%@%9 8tt":.ni8.govnes8ealt8oct$1$niddB-1+.8tm.

• Intensive lifestyle intervention res'lted in1

– Average /.*> eig8t loss

– Significant red'ction of A1C

– Red'ction in several C,D risB factors

• 7enefits s'stained at 4 years$• oever trial 8alted after 11 years of

follo-'" !eca'se t8ere as no significantdifference in "rimary cardiovasc'lar

o'tcome !eteen eig8t loss standardcare gro'"


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Re!o&&enations* DiabetesRe!o&&enations* Diabetes


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Re!o&&enations* DiabetesRe!o&&enations* DiabetesSelf;Mana$e&ent E.!ation+ S.--o#tSelf;Mana$e&ent E.!ation+ S.--o#t

• DS&E and DS&S "rograms are a""ro"riateven'es for "eo"le it8 "redia!etes to receiveed'cation and s'""ort to develo" andmaintain !e8aviors t8at can "revent or delayt8e onset of dia!etes (C)

• 7eca'se DS&E can res'lt in cost-savings andim"roved o'tcomes (7) DS&E s8o'ld !ereim!'rsed !y t8ird-"arty "ayers (E)


R ti )( i l A ti itRe!o&&enations* )(%si!al A!tivit%


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Re!o&&enations* )(%si!al A!tivit%Re!o&&enations* )(%si!al A!tivit%

• Advise "eo"le it8 dia!etes to "erform atleast 1% mineeB of moderate-intensityaero!ic "8ysical activity (%@> ofma6im'm 8eart rate) s"read over at least

3 days "er eeB it8 no more t8an$ consec'tive days it8o't e6ercise (A)

• In a!sence of contraindications ad'ltsit8 ty"e $ dia!etes s8o'ld !e enco'raged

to "erform resistance training at leasttice "er eeB (A)




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Re!o&&enations*Re!o&&enations*)s%!(oso!ial Assess&ent an Ca#e)s%!(oso!ial Assess&ent an Ca#e

•


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Re!o&&enations* :%-o$l%!e&ia /1Re!o&&enations* :%-o$l%!e&ia /1

• Individ'als at risB for 8y"oglycemia s8o'ld!e asBed a!o't sym"tomatic andasym"tomatic 8y"oglycemia at eac8enco'nter (C)

• Gl'cose (1%$ g) "referred treatment forconscio's individ'al it8 8y"oglycemia (E)

• Gl'cagon s8o'ld !e "rescri!ed for allindivid'als at significant risB of severe

8y"oglycemia and caregiversfamilymem!ers instr'cted in administration (E)

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S$*.



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• y"oglycemia 'naareness or one or more

e"isodes of severe 8y"oglycemia s8o'ldtrigger re-eval'ation of t8e treatmentregimen (E)

• Ins'lin-treated "atients it8 8y"oglycemia'naareness or an e"isode of severe8y"oglycemia

– Advised to raise glycemic targets to strictly avoidf'rt8er 8y"oglycemia for at least several eeBsto "artially reverse 8y"oglycemia 'naarenessand to red'ce risB of f't're e"isodes (A)

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S$*.



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•


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Re!o&&enations* Ba#iat#i! S.#$e#%Re!o&&enations* Ba#iat#i! S.#$e#%

• Consider !ariatric s'rgery for ad'lts it8 7&I

=3% Bgm$ and ty"e $ dia!etes (7)

• After s'rgery life-long lifestyle s'""ort andmedical monitoring is necessary (7)

• Ins'fficient evidence to recommend s'rgery in"atients it8 7&I H3% Bgm$ o'tside of aresearc8 "rotocol (E)

• ell-designed randomi5ed controlled trialscom"aring o"timal medicallifestyle t8era"yneeded to determine long-term !enefits cost-effectiveness risBs (E)

ADA. ,. Dia!etes Care. Diabetes Care $1393*(s'""l 1):S$@.

Re!o&&enations* I&&.ni


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I' )REENTION ANDMANA"EMENT OFDIABETES COM)LICATIONS

Ca#iovas!.la# Disease /CD inCa#iovas!.la# Disease /CD in


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• C,D is t8e maKor ca'se of mor!idity mortality for t8ose it8

dia!etes• Common conditions coe6isting it8 ty"e $ dia!etes (e.g.

8y"ertension dysli"idemia) are clear risB factors for C,D

• Dia!etes itself confers inde"endent risB

• 7enefits o!served 8en individ'al cardiovasc'lar risB factors

are controlled to "reventslo C,D in "eo"le it8 dia!etes

/ / Inivi.als 8it( DiabetesInivi.als 8it( Diabetes

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S$/-$+.



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:%-e#tensionBloo )#ess.#e Cont#ol:%-e#tensionBloo )#ess.#e Cont#ol

Screening and diagnosis

• 7lood "ress're s8o'ld !e meas'red atevery ro'tine visit

• #atients fo'nd to 8ave elevated !lood

"ress're s8o'ld 8ave !lood "ress'reconfirmed on a se"arate day (7)

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S$/-S$+.

Re!o&&enations*Re!o&&enations*i l l


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Goals

• #eo"le it8 dia!etes and 8y"ertension s8o'ld !e treated to asystolic !lood "ress're goal of H14 mmg (7)

• oer systolic targets s'c8 as H13 mmg may !ea""ro"riate for certain individ'als s'c8 as yo'nger "atientsif it can !e ac8ieved it8o't 'nd'e treatment !'rden (C)

• #atients it8 dia!etes s8o'ld !e treated to a diastolic !lood"ress're H/ mmg (7)

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S$+.

Re!o&&enations*Re!o&&enations*i l C l


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reatment (1)

• #atients it8 a !lood "ress're (7#) 1$/ mmgs8o'ld !e advised on lifestyle c8anges to red'ce 7# (7)

• #atients it8 confirmed 7# =14/ mmg s8o'ld inaddition to lifestyle t8era"y 8ave "rom"t initiation and

timely s'!se2'ent titration of "8armacological t8era"yto ac8ieve 7# goals (7)


Re!o&&enations*Re!o&&enations*i l l: i Bl ) C l


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reatment ($)

• ifestyle t8era"y for elevated 7# (7)

– eig8t loss if overeig8t

– DAS-style dietary "attern incl'ding red'cing sodi'mincreasing "otassi'm intaBe

– &oderation of alco8ol intaBe – Increased "8ysical activity


Re!o&&enations*Re!o&&enations*i l C l: t i Bl ) C t l


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reatment (3)

• #8armacological t8era"y for "atients it8 dia!etes and8y"ertension (C)

– A regimen t8at incl'des eit8er an ACE in8i!itor or angiotensin IIrece"tor !locBer9 if one class is not tolerated s'!stit'te t8e ot8er

• &'lti"le dr'g t8era"y (to or more agents at ma6imal doses)generally re2'ired to ac8ieve 7# targets (7)

• Administer one or more anti8y"ertensive medications at!edtime (A)


Re!o&&enations*Re!o&&enations*: i Bl ) C l: t i Bl ) C t l


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reatment (4)

• If ACE in8i!itors AR7s or di'retics are 'sed Bidneyf'nction ser'm "otassi'm levels s8o'ld !e monitored (E)

• In "regnant "atients it8 dia!etes and c8ronic8y"ertension !lood "ress're target goals of 111$+*%@+ mmg are s'ggested in interest of long-term maternal

8ealt8 and minimi5ing im"aired fetal grot89 ACEin8i!itors AR7s contraindicated d'ring "regnancy (E)


Re!o&&enations*Re!o&&enations*D li i i Li i M t /1D li i i Li i M t /1


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D%sli-ie&iaLi-i Mana$e&ent /1D%sli-ie&iaLi-i Mana$e&ent /1

Screening

• In most ad'lt "atients meas're fasting li"id"rofile at least ann'ally (7)

• In ad'lts it8 lo-risB li"id val'es(D c8olesterol H1 mgd D c8olesterol

% mgd and triglycerides H1% mgd) li"idassessments may !e re"eated every $ years (E)

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S31.



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reatment recommendations and goals (1)

• o im"rove li"id "rofile in "atients it8 dia!etesrecommend lifestyle modification (A) foc'sing on

– Red'ction of sat'rated fat trans fat c8olesterol intaBe

– Increased n-3 fatty acids visco's fi!er"lant stanolssterols

– eig8t loss (if indicated)

– Increased "8ysical activity




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reatment recommendations and goals ($)

• Statin t8era"y s8o'ld !e added to lifestyle t8era"y regardless of!aseline li"id levels

– it8 overt C,D (A)

– it8o't C,D 4 years of age 8o 8ave one or more ot8er C,D risB factors (A)

• ?or "atients at loer risB (e.g. it8o't overt C,D H4 years of age)(C)

– Consider statin t8era"y in addition to lifestyle t8era"y if D c8olesterol remains1 mgd

– In t8ose it8 m'lti"le C,D risB factors




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• In individ'als it8o't overt C,D – #rimary goal is an D c8olesterol

H1 mgd ($.* mmol) (7)

• In individ'als it8 overt C,D

–oer D c8olesterol goal of H@ mgd(1./ mmol) 'sing a 8ig8 dose of a statinis an o"tion (7)


Re!o&&enations*Re!o&&enations*D li i i Li i M t /5D sli-ie&iaLi-i Mana$e&ent /5


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• If targets not reac8ed on ma6imal tolerated statin t8era"y – Alternative t8era"e'tic goal: red'ce D c8olesterol L34> from !aseline (7)

• riglyceride levels H1% mgd(1.@ mmol) D c8olesterol 4 mgd (1. mmol) in men and% mgd(1.3 mmol) in omen are desira!le (C)

– oever D c8olesteroltargeted statin t8era"y remains t8e "referred strategy(A)


Re!o&&enations*Re!o&&enations*D li i i Li i M t /6D%sli-ie&iaLi-i Mana$e&ent /6


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reatment recommendations and goals (%)

• Com!ination t8era"y 8as !een s8on not to"rovide additional cardiovasc'lar !enefit a!ovestatin t8era"y alone and is not generallyrecommended (A)

• Statin t8era"y is contraindicated in "regnancy (7)


Re!o&&enations* "l%!e&i!+ BlooRe!o&&enations* "l%!e&i!+ Bloo) e e Li i Co t ol i A lt)#ess.#e Li-i Cont#ol in A.lts


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)#ess.#e+ Li-i Cont#ol in A.lts)#ess.#e+ Li-i Cont#ol in A.lts

A1C H@.>

7lood "ress're H14/ mmgM

i"ids: D

c8olesterol

H1 mgd (H$.* mmol)

Statin t8era"y for t8ose it88istory of &I or age 4O or

ot8er risB factors

&ore or less stringent glycemic goals may !e a""ro"riate for individ'al "atients. Goals s8o'ld !eindivid'ali5ed !ased on: d'ration of dia!etes agelife e6"ectancy comor!id conditions Bnon C,D oradvanced microvasc'lar com"lications 8y"oglycemia 'naareness and individ'al "atientconsiderations.

M7ased on "atient c8aracteristics and res"onse to t8era"y 8ig8er or loer systolic !lood "ress're targetsmay !e a""ro"riate.

In individ'als it8 overt C,D a loer D c8olesterol goal of H@ mgd (1./ mmol) 'sing a 8ig8dose of statin is an o"tion.

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S339 a!le 1.

Re!o&&enations*Re!o&&enations*Anti-latelet A$ents /1Anti-latelet A$ents /1


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Anti-latelet A$ents /1Anti-latelet A$ents /1

• Consider as"irin t8era"y (@%1*$ mgday) (C)

– As a "rimary "revention strategy in t8ose it8 ty"e 1 or ty"e $dia!etes at increased cardiovasc'lar risB (1-year risB 1>)

– Incl'des most men % years of age or omen * years of age8o 8ave at least one additional maKor risB factor

• ?amily 8istory of C,D

• y"ertension

• SmoBing• Dysli"idemia

• Al!'min'ria

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S3$-S33.



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• As"irin s8o'ld not !e recommended for C,D "revention for

ad'lts it8 dia!etes at lo C,D risB since "otential adverseeffects from !leeding liBely offset "otential !enefits (C)

• 1-year C,D risB H%>: men H% and omen H* years of ageit8 no maKor additional C,D risB factors

• In "atients in t8ese age gro'"s it8 m'lti"le ot8er risB

factors (1-year risB%1>) clinical K'dgment is re2'ired (E)




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• Fse as"irin t8era"y (@%1*$ mgday)

– Secondary "revention strategy in t8ose it8 dia!etes it8 a8istory of C,D (A)

• ?or "atients it8 C,D and doc'mented as"irin allergy

– Clo"idogrel (@% mgday) s8o'ld !e 'sed (7)

• Com!ination t8era"y it8 as"irin (@%1*$ mgday) and

clo"idogrel (@% mgday) – Reasona!le for '" to a year after an ac'te coronary syndrome (7)

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S33-S34.

Re!o&&enations*Re!o&&enations*S&o9in$ CessationS&o9in$ Cessation


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S&o9in$ CessationS&o9in$ Cessation

• Advise all "atients not to smoBe or 'se

to!acco "rod'cts (A)

• Incl'de smoBing cessation co'nseling andot8er forms of treatment as a ro'tine

com"onent of dia!etes care (7)


Re!o&&enations*Re!o&&enations*Co#ona#% :ea#t Disease S!#eenin$Co#ona#% :ea#t Disease S!#eenin$


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Co#ona#% :ea#t Disease S!#eenin$Co#ona#% :ea#t Disease S!#eenin$

• In asym"tomatic "atients ro'tine

screening for CAD is not recommended asit does not im"rove o'tcomes as long asC,D risB factors are treated (A)


Re!o&&enations*Re!o&&enations*Co#ona#% :ea#t Disease T#eat&ent /1Co#ona#% :ea#t Disease T#eat&ent /1


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Co#ona#% :ea#t Disease T#eat&ent /1Co#ona#% :ea#t Disease T#eat&ent /1

• o red'ce risB of cardiovasc'lar events in "atients it8

Bnon C,D consider – ACE in8i!itor (C)

– As"irin (A)

– Statin t8era"y (A)

• In "atients it8 a "rior &I

– ;-!locBers s8o'ld !e contin'ed for at least$ years after t8e event (7)


If not contraindicated.

Re!o&&enations*Re!o&&enations*Co#ona#% :ea#t Disease T#eat&ent /2Co#ona#% :ea#t Disease T#eat&ent /2


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Co#ona#% :ea#t Disease T#eat&ent /2Co#ona#% :ea#t Disease T#eat&ent /2

• Avoid t8ia5olidinedione treatment in

"atients it8 sym"tomatic 8eart fail're (C)

• &etformin 'se in "atients it8 sta!le C?

– Indicated if renal f'nction is normal (C)

– S8o'ld !e avoided in 'nsta!le or 8os"itali5ed"atients it8 C? (C)


Re!o&&enations* Ne-(#o-at(%Re!o&&enations* Ne-(#o-at(%


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- - %- - %

• o red'ce t8e risB or slo t8e "rogression

of ne"8ro"at8y –


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Re!o&&enations*Re!o&&enations*Ne-(#o-at(% T#eat&ent /1Ne-(#o-at(% T#eat&ent /1


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Ne-(#o-at(% T#eat&ent /1Ne-(#o-at(% T#eat&ent /1

• Non"regnant "atient it8 modestly elevated (3-$++ mgday) (C)

or 8ig8er levels (=3 mgday) (A) of 'rinary al!'min e6cretion – Fse eit8er ACE in8i!itors or AR7s

• Red'ction of "rotein intaBe may im"rove meas'res of renalf'nction ('rine al!'min e6cretion rate G?R) (7)

– o ./1. gBg !ody t "er day in t8oseit8 dia!etes earlier stages of CJD

– o ./ gBg !ody t "er day in later stagesof CJD

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S34-S3%.



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• 8en ACE in8i!itors AR7s or di'retics are 'sed monitor

ser'm creatinine and "otassi'm levels for t8e develo"ment ofincreased creatinine or c8anges in "otassi'm (E)

• Reasona!le to contin'e monitoring 'rine al!'min e6cretion toassess !ot8 res"onse to t8era"y and disease "rogression (E)

• 8en estimated G?R is H* mmin

1.@3 m$

eval'ate and manage "otential com"lications of CJD(E)

ADA. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S3%.



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• Consider referral to a "8ysician

e6"erienced in care of Bidney disease (7) – Fncertainty a!o't etiology of Bidney disease

– Diffic'lt management iss'es

– Advanced Bidney disease

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S3%.

Definitions of Abno#&alities inDefinitions of Abno#&alities inAlb.&in E=!#etionAlb.&in E=!#etion


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Alb.&in E=!#etionAlb.&in E=!#etion

Category

S"ot collection(Pgmg

creatinine)

Normal H3Increased 'rinary

al!'min e6cretion =3

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S3%9 a!le 11.

istorically ratios !eteen 3 and $++ 8ave !een called microal!'min'ria and t8ose 3 or greater8ave !een called macroal!'min'ria (or clinical al!'min'ria).

Sta$es of C(#oni! >ine% DiseaseSta$es of C(#oni! >ine% Disease


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$ %

Stage Descri"tion

G?R (mmin

"er 1.@3 m$ !ody s'rface

area)

1 Jidney damage it8 normal or

increased G?R

=+

$ Jidney damage it8 mildly

decreased G?R

*/+

3 &oderately decreased G?R 3%+

4 Severely decreased G?R 1%$+

% Jidney fail're H1% or dialysis


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G?R RecommendedAll "atients Qearly meas'rement of creatinine 'rinary

al!'min e6cretion "otassi'm

4%-* Referral to ne"8rology if "ossi!ility for

nondia!etic Bidney disease e6ists

Consider dose adK'stment of medications

&onitor eG?R every * mont8s

&onitor electrolytes !icar!onate 8emoglo!in

calci'm "8os"8or's "arat8yroid 8ormone at

least yearlyAss're vitamin D s'fficiency

Consider !one density testing

Referral for dietary co'nselling

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S3@9 a!le 139 Ada"ted from 8tt":.Bidney.org"rofessionalsJD


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ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S3@9 a!le 139 Ada"ted from 8tt":.Bidney.org"rofessionalsJD


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• o red'ce t8e risB or slo t8e "rogression

of retino"at8y –


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Retino-at(% S!#eenin$ /1Retino-at(% S!#eenin$ /1

• Initial dilated and com"re8ensive eye

e6amination !y an o"8t8almologist or o"tometrist – Ad'lts and c8ildren aged 1 years or older

it8 ty"e 1 dia!etes• it8in % years after dia!etes onset (7)

– #atients it8 ty"e $ dia!etes• S8ortly after diagnosis of dia!etes (7)

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S3%.

Re!o&&enations*Re!o&&enations*Retino-at(% S!#eenin$ /2Retino-at(% S!#eenin$ /2


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• S'!se2'ent e6aminations for ty"e 1 and ty"e $ dia!etic

"atients (7) – S8o'ld !e re"eated ann'ally !y an o"8t8almologist or

o"tometrist

• ess fre2'ent e6ams (every $3 years) (7)

– &ay !e considered folloing one or more normal eye e6ams

• &ore fre2'ent e6aminations re2'ired if retino"at8y is"rogressing (7)

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S3%-S3*.



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• ig8-2'ality f'nd's "8otogra"8s

– Can detect most clinically significantdia!etic retino"at8y (E)

• Inter"retation of t8e images

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

• 8ile retinal "8otogra"8y may serve as a screening tool forretino"at8y it is not a s'!stit'te for a com"re8ensive eye e6am

– #erform com"re8ensive eye e6am at least initially and at intervalst8ereafter as recommended !y an eye care "rofessional (E)

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S3*.



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• omen it8 "ree6isting dia!etes 8o are "lanning

"regnancy or 8o 8ave !ecome "regnant (7) – Com"re8ensive eye e6amination

– Co'nseled on risB of develo"ment andor "rogression ofdia!etic retino"at8y

• Eye e6amination s8o'ld occ'r in t8e first trimester (7)

– Close follo-'" t8ro'g8o't "regnancy

– ?or 1 year "ost"art'm


Re!o&&enations*Re!o&&enations*Retino-at(% T#eat&ent /1Retino-at(% T#eat&ent /1


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Retino-at(% T#eat&ent /1Retino-at(% T#eat&ent /1

• #rom"tly refer "atients it8 any level of mac'lar edema

severe N#DR or any #DR – o an o"8t8almologist Bnoledgea!le and e6"erienced in

management treatment of dia!etic retino"at8y (A)

• aser "8otocoag'lation t8era"y is indicated (A)

– o red'ce risB of vision loss in "atients it8•

ig8-risB #DR• Clinically significant mac'lar edema

• Some cases of severe N#DR


Re!o&&enations*Re!o&&enations*Retino-at(% T#eat&ent /2Retino-at(% T#eat&ent /2


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Retino-at(% T#eat&ent /2Retino-at(% T#eat&ent /2

• Anti-vasc'lar endot8elial grot8 factor (,EG?)

t8era"y is indicated for dia!etic mac'laredema (A)

• #resence of retino"at8y

– Not a contraindication to as"irin t8era"y for

cardio"rotection as t8is t8era"y does not increaset8e risB of retinal 8emorr8age (A)


Re!o&&enations*Re!o&&enations*Ne.#o-at(% S!#eenin$+ T#eat&ent /1Ne.#o-at(% S!#eenin$+ T#eat&ent /1


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Ne.#o-at(% S!#eenin$+ T#eat&ent /1Ne.#o-at(% S!#eenin$+ T#eat&ent /1

• All "atients s8o'ld !e screened for distal symmetric

"olyne'ro"at8y (D#N) (7) – At diagnosis of ty"e $ dia!etes and % years after diagnosis

of ty"e 1 dia!etes

– At least ann'ally t8ereafter 'sing sim"le clinical tests

• Electro"8ysiological testing rarely needed

– E6ce"t in sit'ations 8ere clinical feat'res are aty"ical (E)

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S3@.


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Re!o&&enations* Foot Ca#e /1Re!o&&enations* Foot Ca#e /1


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• ?or all "atients it8 dia!etes "erform an ann'al com"re8ensive foote6amination to identify risB factors "redictive of 'lcers andam"'tations (7)

– 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$/-5 t'ning forB

• #in"ricB sensation

• AnBle refle6es• ,i!ration "erce"tion t8res8old

ADA. ,I. #revention &anagement of Com"lications. Diabetes Care $1393*(s'""l 1):S3/.



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--e# -anel

•o "erform t8e 1-gmonofilament test "lacet8e device "er"endic'lar tot8e sBin it8 "ress'rea""lied 'ntil t8e

monofilament !'cBles•old in "lace for 1 secondand t8en release

Lo8e# -anel

•8e monofilament tests8o'ld !e "erformed at t8e8ig8lig8ted sites 8ile t8e"atients eyes are closed

7o'lton AT& et al. Diabetes Care. $/931:1*@+-1*/%.



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• #rovide general foot self-care ed'cation (7)

• Fse m'ltidisci"linary a""roac8 – Individ'als it8 foot 'lcers 8ig8-risB feet9 es"ecially "rior 'lcer or

am"'tation (7)

• Refer "atients to foot care s"ecialists for ongoing "reventive carelife-long s'rveillance (C)

– SmoBers

– oss of "rotective sensation or str'ct'ral a!normalities

– istory of "rior loer-e6tremity com"lications




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• Initial screening for "eri"8eral arterial disease (#AD) (C)

– Incl'de a 8istory for cla'dication assessment of "edal "'lses – Consider o!taining an anBle-!rac8ial inde6 (A7I)9 many

"atients it8 #AD are asym"tomatic

• Refer "atients it8 significant cla'dication or a "ositiveA7I for f'rt8er vasc'lar assessment (C)

– Consider e6ercise medications s'rgical o"tions



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II' ASSESSMENT OF COMMONCOMORBID CONDITIONS

Re!o&&enations* Assess&ent ofRe!o&&enations* Assess&ent ofCo&&on Co&o#bi ConitionsCo&&on Co&o#bi Conitions


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• ?or "atients it8 risB factors signs or

sym"toms consider assessment andtreatment for common dia!etes-associatedconditions (7)

• Common comor!idities for 8ic8 increasedrisB is associated it8 dia!etes

ADA. ,II. Assessment of Common Comor!id Conditions. Diabetes Care. $1393*(s'""l 1):S3+9 a!le 14.

earing im"airment Certain cancers

?atty liver disease Cognitive im"airmento testosterone in men De"ression

#eriodontal disease


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Re!o&&enations* )eiat#i!Re!o&&enations* )eiat#i!"l%!e&i! Cont#ol /T%-e 1 Diabetes"l%!e&i! Cont#ol /T%-e 1 Diabetes


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% / %-

• As is t8e case for all c8ildren c8ildren it8

dia!etes or "redia!etes s8o'ld !eenco'raged to engage in at least *min'tes of "8ysical activity eac8 day (7)

• Consider age 8en setting glycemic goalsin c8ildren and adolescents it8 ty"e 1dia!etes (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $1393*(s'""l 1):S4-S41.

Re!o&&enations* )eiat#i!Re!o&&enations* )eiat#i!Ne-(#o-at(% /T%-e 1 DiabetesNe-(#o-at(% /T%-e 1 Diabetes


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- - % / %-

• Ann'al screening for microal!'min'ria

it8 a random s"ot 'rine sam"le foral!'min-to-creatinine (ACR) ratio (7)

– Consider once c8ild is 1 years of age and8as 8ad dia!etes for % years

• Confirmed elevated ACR on to additional'rine s"ecimens from different days

– reat it8 an ACE in8i!itor titrated to

normali5ation of al!'min e6cretion (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $1393*(s'""l 1):S41.

Re!o&&enations* )eiat#i!Re!o&&enations* )eiat#i!:%-e#tension /T%-e 1 Diabetes /1:%-e#tension /T%-e 1 Diabetes /1


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• &eas're !lood "ress're (7#) at eac8 ro'tine

visit9 confirm 8ig8-normal 7# or 8y"ertensionon a se"arate day (7)

• reat 8ig8-normal 7# (systolic or diastolicconsistently a!ove +t8 "ercentile for age se6

and 8eig8t) it8 – Dietary intervention9 e6ercise aimed at eig8t

control and increased "8ysical activity

• If target 7# is not reac8ed it8 3* mont8s of

lifestyle intervention consider "8armacologictreatment (E)




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• #8armacologic treatment of 8y"ertension

– Systolic or diastolic !lood "ress're consistentlya!ove t8e +%t8 "ercentile for age se6 and8eig8t

Or

– Consistently 13/ mmg if +%> e6ceedst8at val'e

• Initiate treatment as soon as diagnosisis confirmed (E)




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• ACE in8i!itors

– Consider for initial treatment of 8y"ertensionfolloing a""ro"riate re"rod'ctive co'nselingd'e to "otential teratogenic effects (E)

• Goal of treatment

– 7lood "ress're consistently H13/ mmg or!elo t8e +t8 "ercentile for age se6 and8eig8t 8ic8ever is loer (E)


Re!o&&enations* )eiat#i!Re!o&&enations* )eiat#i!D%sli-ie&ia /T%-e 1 Diabetes /1D%sli-ie&ia /T%-e 1 Diabetes /1


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Screening (1)

• If family 8istory of 8y"erc8olesterolemia or acardiovasc'lar event !efore age %% years or iffamily 8istory is 'nBnon

– #erform fasting li"id "rofile on c8ildren

$ years of age soon after diagnosis (after gl'cosecontrol 8as !een esta!lis8ed)




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Screening ($)

• If family 8istory is not of concern – Consider first li"id screening at "'!erty

(=1 years) (E)

• All c8ildren diagnosed it8 dia!etes at or after "'!erty

– #erform fasting li"id "rofile soon after diagnosis (after

gl'cose control 8as !een esta!lis8ed) (E)




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Screening (3)

• ?or !ot8 age-gro'"s if li"ids are a!normal – Ann'al monitoring is reasona!le

• If D c8olesterol val'es are it8in acce"ted risBlevels (H1 mgd

U$.* mmolV) – Re"eat li"id "rofile every % years (E)




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reatment

• Initial t8era"y: o"timi5e gl'cose control &N 'sing Ste" $ AA dietaimed at decreasing dietary sat'rated fat (E)

• age 1 years statin reasona!le in t8ose (after &N and lifestylec8anges) it8

– D c8olesterol 1* mgd (4.1 mmol) or

– D c8olesterol 13 mgd (3.4 mmol) and one or more C,D risB factors (E)

• Goal: D c8olesterol H1 mgd($.* mmol) (E)


&NWmedical n'trition t8era"y

Re!o&&enations* )eiat#i!Re!o&&enations* )eiat#i!Retino-at(% /T%-e 1 DiabetesRetino-at(% /T%-e 1 Diabetes


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• ?irst o"8t8almologic e6amination

–

• After initial e6amination

– Ann'al ro'tine follo-'" generally recommended

– ess fre2'ent e6aminations may !e acce"ta!le onadvice of an eye care "rofessional (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $1393*(s'""l 1):S4$.

Re!o&&enations* )eiat#i!Re!o&&enations* )eiat#i!Celia! Disease /T%-e 1 Diabetes /1Celia! Disease /T%-e 1 Diabetes /1


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• C8ildren it8 ty"e 1 dia!etes

– Screen for celiac disease !y meas'ring tiss'e transgl'taminase or

antiendomysial anti!odies it8 doc'mentation of normal total ser'm IgAlevels soon after t8e diagnosis of dia!etes (E)

• Re"eat testing in c8ildren it8

– Grot8 fail're

– ?ail're to gain eig8t eig8t loss

– Diarr8ea flat'lence a!dominal "ain or signs of mala!sor"tion

– ?re2'ent 'ne6"lained 8y"oglycemia or deterioration in glycemic control (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $1393*(s'""l 1):S4$.


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Re!o&&enations* )eiat#i!Re!o&&enations* )eiat#i!:%-ot(%#oiis& /T%-e 1 Diabetes:%-ot(%#oiis& /T%-e 1 Diabetes


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• C8ildren it8 ty"e 1 dia!etes

– Screen for t8yroid "ero6idase t8yroglo!'lin anti!odiessoon after diagnosis (E)

• 8yroid-stim'lating 8ormone (S) concentrations

– &eas're after meta!olic control esta!lis8ed• If normal rec8ecB every 1$ years9 or

• If "atient develo"s sym"toms of t8yroid dysf'nctiont8yromegaly or an a!normal grot8 rate (E)


Re!o&&enations* T#ansition f#o&Re!o&&enations* T#ansition f#o&)eiat#i! to A.lt Ca#e)eiat#i! to A.lt Ca#e


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• As teens transition into emerging ad'lt8ood 8ealt8 care

"roviders and families m'st recogni5e t8eir manyv'lnera!ilities (7) and "re"are t8e develo"ing teen!eginning in early to mid adolescence and at least 1 year"rior to t8e transition (E)

• 7ot8 "ediatricians and ad'lt 8ealt8 care "roviders s8o'ld

assist in "roviding s'""ort and linBs to reso'rces for t8eteen and emerging ad'lt (7)


Re!o&&enations*Re!o&&enations*)#e!on!e-tion Ca#e /1)#e!on!e-tion Ca#e /1


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• A1C levels s8o'ld !e as close to normal as "ossi!le (@>)

in an individ'al "atient !efore conce"tion is attem"ted (7)• Starting at "'!erty incor"orate "reconce"tion co'nseling

in ro'tine dia!etes clinic visit for all omen ofc8ild!earing "otential (C)

• omen it8 dia!etes contem"lating "regnancy s8o'ld !e

eval'ated and if indicated treated for dia!eticretino"at8y ne"8ro"at8y ne'ro"at8y C,D (7)


Re!o&&enations*Re!o&&enations*)#e!on!e-tion Ca#e /2)#e!on!e-tion Ca#e /2


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• &edications s8o'ld !e eval'ated "rior to conce"tion sincedr'gs commonly 'sed to treat dia!etes and its com"licationsmay !e contraindicated or not recommended in "regnancyincl'ding statins ACE in8i!itors AR7s and most nonins'lint8era"ies (E)

• Since many "regnancies are 'n"lanned consider "otentialrisBs!enefits of medications contraindicated in "regnancy inall omen of c8ild!earing "otential9 co'nsel accordingly (E)


Re!o&&enations* Ole# A.lts /1Re!o&&enations* Ole# A.lts /1


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• ?'nctional cognitively intact older ad'lts it8

significant life e6"ectancies s8o'ld receive dia!etescare 'sing goals develo"ed for yo'nger ad'lts (E)

• Glycemic goals for t8ose not meeting t8e a!ove criteriamay !e rela6ed 'sing individ'al criteria !'t8y"erglycemia leading to sym"toms or risB of ac'te

8y"erglycemic com"lications s8o'ld !e avoided in all"atients (E)


Re!o&&enations* Ole# A.lts /2Re!o&&enations* Ole# A.lts /2


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• reat ot8er cardiovasc'lar risB factors it8 consideration

of t8e time frame of !enefit and t8e individ'al "atient (E)• reatment of 8y"ertension is indicated in virt'ally all olderad'lts9 li"id as"irin t8era"y may !enefit t8ose it8 lifee6"ectancy e2'al to time frame of "rimarysecondary"revention trials (E)

• Individ'ali5e screening for dia!etes com"lications it8attention to t8ose leading to f'nctional im"airment (E)


Re!o&&enations* C%sti! Fib#osis;Re!o&&enations* C%sti! Fib#osis;Relate Diabetes /CFRD /1Relate Diabetes /CFRD /1


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• Ann'al screening for C?RD it8


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• #atients it8 C?RD s8o'ld !e treated it8

ins'lin to attain individ'ali5ed glycemicgoals (A)

• Ann'al monitoring for com"lications of

dia!etes is recommended !eginning %years after t8e diagnosis of C?RD (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $1393*(s'""l 1):S4%.


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I?' DIABETES CARE IN

S)ECIFIC SETTIN"S

Re!o&&enations*Re!o&&enations*Diabetes Ca#e in t(e :os-ital /1Diabetes Ca#e in t(e :os-ital /1


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• All "atients it8 dia!etes admitted to t8e

8os"ital s8o'ld 8ave t8eir dia!etes clearlyidentified in t8e medical record (E)

• All "atients it8 dia!etes s8o'ld 8ave an orderfor !lood gl'cose monitoring it8 res'lts

availa!le to all mem!ers of t8e 8ealt8 care team(E)

ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $1393*(s'""l 1):S4%.



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• Goals for !lood gl'cose levels

– Critically ill "atients: Initiate ins'lin t8era"y for treatment of "ersistent8y"erglycemia starting at a t8res8old of no greater t8an 14-1/mgd (@./1 mmol) (A)

– &ore stringent goals s'c8 as 11-14 mgd (*.1@./ mmol) may!e a""ro"riate for selected "atients if ac8ieva!le it8o't significant8y"oglycemia (C)

– Critically ill "atients re2'ire an I, ins'lin "rotocol it8 demonstrated

efficacy safety in ac8ieving desired gl'cose range it8o't increasingrisB for severe 8y"oglycemia (E)

ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $1393*(s'""l 1):S4%.



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• Goals for !lood gl'cose levels – Noncritically ill "atients: No clear evidence for s"ecific !lood gl'cose

goals

– If treated it8 ins'lin "remeal !lood gl'cose targets (if safely ac8ieved)• Generally H14 mgd (@./ mmol) it8 random !lood gl'cose H1/ mgd (1.

mmol)

– &ore stringent targets may !e a""ro"riate in sta!le "atients it8"revio's tig8t glycemic control

– ess stringent targets may !e a""ro"riate in t8ose it8 severecomor!idities (E)

ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $1393*(s'""l 1):S4*.



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• Sc8ed'led s'!c'taneo's ins'lin it8 !asal

n'tritional and correction com"onents ist8e "referred met8od for ac8ieving andmaintaining gl'cose control in non-criticallyill "atients (C)




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• Initiate gl'cose monitoring in any "atient not Bnon to !edia!etic 8o receives t8era"y associated it8 8ig8-risB for8y"erglycemia – ig8-dose gl'cocorticoid t8era"y initiation of enteral or "arenteral

n'trition or ot8er medications s'c8 as octreotide orimm'nos'""ressive medications (7)

• If 8y"erglycemia is doc'mented and "ersistent consider

treating s'c8 "atients to t8e same glycemic goals as "atientsit8 Bnon dia!etes (E)




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• A 8y"oglycemia management "rotocol s8o'ld !e ado"tedand im"lemented !y eac8 8os"ital or 8os"ital system (E)

•

– it8 dia!etes risB factors 8o e68i!it 8y"erglycemia

• #atients it8 8y"erglycemia it8o't a diagnosis of

dia!etes: doc'ment "lans for follo-'" testing and careat disc8arge (E)



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Diabetes Ca#e in t(e :os-ital*Diabetes Ca#e in t(e :os-ital*NICE;S"AR St.% /2NICE;S"AR St.% /2


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• In !ot8 s'rgicalmedical "atients +-day mortalitysignificantly 8ig8er in intensively treated vs conventionalgro'" (target 1441/ mgd)

– Severe 8y"oglycemia more common(*./> vs .%>9 P H.1)

– ?indings strongly s'ggest may not !e necessary to target !loodgl'cose levels

H14 mgd9 8ig8ly stringent target of H11 mgd may !e dangero's



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?' STRATE"IES FOR

IM)ROIN"DIABETES CARE

Re!o&&enations* St#ate$ies fo#Re!o&&enations* St#ate$ies fo#I&-#ovin$ Diabetes Ca#e /1I&-#ovin$ Diabetes Ca#e /1


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ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $1393*(s'""l 1):S4+-S%.

• Care s8o'ld !e aligned it8 com"onents of t8e C8ronic

Care &odel to ens're "rod'ctive interactions !eteen a"re"ared "roactive "ractice team and an informedactivated "atient (A)

• 8en feasi!le care systems s8o'ld s'""ort team-!ased care comm'nity involvement "atient registries

and em!edded decision s'""ort tools to meet "atientneeds (7)

Re!o&&enations* St#ate$ies fo#Re!o&&enations* St#ate$ies fo#I&-#ovin$ Diabetes Ca#e /2I&-#ovin$ Diabetes Ca#e /2


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ADA. 0. Strategies for Im"roving Dia!etes Care.Diabetes Care

. $1393*(s'""l 1):S%.

• reatment decisions s8o'ld !e timely

and !ased on evidence-!ased g'idelines t8at aretailored to individ'al "atient "references "rognosesand comor!idities (7)

• A "atient-centered comm'nication style s8o'ld !eem"loyed t8at incor"orates "atient "references

assesses literacy and n'meracy and addresses c'lt'ral!arriers to care (7)

Ob@e!tive 1*Ob@e!tive 1*O-ti&i


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ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $1393*(s'""l 1):S%.

• Care team s8o'ld "rioriti5e timely a""ro"riate intensificationof lifestyle andor "8armace'tical t8era"y

– #atients 8o 8ave not ac8ieved !eneficial levels of !lood "ress'reli"id or gl'cose control

• Strategies incl'de – E6"licit goal setting it8 "atients

– Identifying and addressing !arriers to care

– Integrating evidence-!ased g'idelines – Incor"orating care management teams

Ob@e!tive 2*Ob@e!tive 2*S.--o#t )atient Be(avio# C(an$eS.--o#t )atient Be(avio# C(an$e


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• Im"lement a systematic a""roac8 to s'""ort "atient !e8aviorc8ange efforts

– a) ealt8y lifestyle: "8ysical activity 8ealt8y eating non'se of to!accoeig8t management effective co"ing

– !) Disease self-management: medication taBing and management self-monitoring of gl'cose and !lood "ress're 8en clinically a""ro"riate

– c) #revention of dia!etes com"lications:self-monitoring of foot 8ealt8 active "artici"ation in screening for eye

foot and renal com"lications and imm'ni5ations

ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $1393*(s'""l 1):S%.

Ob@e!tive 3*Ob@e!tive 3*C(an$e t(e S%ste& of Ca#eC(an$e t(e S%ste& of Ca#e


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• 8e most s'ccessf'l "ractices 8ave an instit'tional "riority for"roviding 8ig8 2'ality of care

– 7asing care on evidence-!ased g'idelines

– E6"anding t8e role of teams and staff

– Redesigning t8e "rocesses of care

– Im"lementing electronic 8ealt8 record tools

– Activating and ed'cating "atients

– Identifying andor develo"ing comm'nity reso'rces and "'!lic "olicy t8at

s'""orts 8ealt8y lifestyles

– Alterations in reim!'rsement

ada standards of medical care 2013 final 21 dec 2012

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