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  • 1. E X E C U T I V E S U M M A R YExecutive Summary: Standards of MedicalCare in Diabetes—2010Current criteria for the diagnosis of Detection and diagnosis of medical nutrition therapy (MNT)diabetes gestational diabetes mellitus alone, SMBG may be useful as a guide to● A1C 6.5%: The test should be per- ● Screen for gestational diabetes mellitus the success of therapy. (E) formed in a laboratory using a method (GDM) using risk-factor analysis and, if ● To achieve postprandial glucose tar- that is National Glycohemoglobin Stan- appropriate, the OGTT. (C) gets, postprandial SMBG may be appro- dardization Program (NGSP) certified ● Women with GDM should be screened priate. (E) and standardized to the Diabetes Control for diabetes 6 –12 weeks postpartum ● When prescribing SMBG, ensure that and Complications Trial (DCCT) assay. and should be followed up with subse- patients receive initial instruction in,● FPG 126 mg/dl (7.0 mmol/l): Fasting is quent screening for the development of and routine follow-up evaluation of, defined as no caloric intake for at least diabetes or pre-diabetes. (E) SMBG technique and their ability to use 8 h. data to adjust therapy. (E)● 2-h plasma glucose Prevention of type 2 diabetes ● Continuous glucose monitoring (CGM) 200 mg/dl (11.1 ● Patients with IGT (A), IFG (E), or an in conjunction with intensive insulin mmol/l) during an oral glucose tolerance test (OGTT): The test should be per- A1C of 5.7– 6.4% (E) should be re- regimens can be a useful tool to lower formed as described by the World Health ferred to an effective ongoing support A1C in selected adults (age 25 years) Organization using a glucose load con- program for weight loss of 5–10% of with type 1 diabetes. (A) body weight and increase in physical ● Although the evidence for A1C- taining the equivalent of 75 g anhydrous activity to at least 150 min/week of lowering is less strong in children, glucose dissolved in water.● In a patient with classic symptoms of moderate activity such as walking. teens, and younger adults, CGM may ● Follow-up counseling appears to be im- be helpful in these groups. Success cor- hyperglycemia or hyperglycemic crisis: portant for success. (B) relates with adherence to ongoing use a random plasma glucose 200 mg/dl ● Based on potential cost savings of dia- of the device. (C) (11.1 mmol/l). betes prevention, such counseling ● CGM may be a supplemental tool to should be covered by third-party pay- SMBG in those with hypoglycemia un-Testing for diabetes in asymptomatic ors. (E) awareness and/or frequent hypoglyce-patients ● In addition to lifestyle counseling, met- mic episodes. (E)● Testing to detect type 2 diabetes and formin may be considered in those who assess risk for future diabetes in asymp- are at very high risk for developing di- A1C tomatic people should be considered in abetes (combined IFG and IGT plus ● Perform the A1C test at least two times adults of any age who are overweight or other risk factors such as A1C 6%, a year in patients who are meeting treat- obese (BMI 25 kg/m2) and who have hypertension, low HDL cholesterol, el- ment goals (and who have stable glyce- one or more additional risk factors for evated triglycerides, or family history of mic control). (E) diabetes in a first-degree relative) and ● Perform the A1C test quarterly in pa- diabetes (see Table 4 of Standards of Medical Care in Diabetes—2010). In who are obese and under 60 years of tients whose therapy has changed or those without these risk factors, testing age. (E) who are not meeting glycemic goals. (E) ● Monitoring for the development of di- ● Use of point-of-care testing for A1C al- should begin at age 45 years. (B)● If tests are normal, repeat testing should abetes in those with pre-diabetes lows for timely decisions on therapy should be performed every year. (E) changes, when needed. (E) be carried out at least at 3-year intervals. (E) Glucose monitoring Glycemic goals in adults● To test for diabetes or to assess risk of ● Self-monitoring of blood glucose ● Lowering A1C to below or around 7% future diabetes, A1C, FPG , or 2-h 75-g (SMBG) should be carried out three or has been shown to reduce microvascu- OGTT are appropriate. (B) more times daily for patients using mul- lar and neuropathic complications of● In those identified with increased risk tiple insulin injections or insulin pump type 1 and type 2 diabetes. Therefore, for future diabetes, identify and, if ap- therapy. (A) for microvascular disease prevention, propriate, treat other cardiovascular ● For patients using less frequent insulin the A1C goal for nonpregnant adults in disease (CVD) risk factors. (B) injections, noninsulin therapies, or general is 7%. (A) ● In type 1 and type 2 diabetes, random- ized controlled trials of intensive versus● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● standard glycemic control have not shown a significant reduction in CVDDOI: 10.2337/dc10-S004© 2010 by the American Diabetes Association. Readers may use this article as long as the work is properly outcomes during the randomized por- cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons. tion of the trials. Long-term follow-up org/licenses/by-nc-nd/3.0/ for details. of the DCCT and UK Prospective Dia-S4 DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
  • 2. Executive Summary betes Study (UKPDS) cohorts suggests dividuals who have or are at risk for Other nutrition recommendations that treatment to A1C targets below or diabetes. (A) ● Sugar alcohols and nonnutritive sweet- around 7% in the years soon after the ● For weight loss, either low-carbohy- eners are safe when consumed within diagnosis of diabetes is associated with drate or low-fat calorie-restricted diets the acceptable daily intake levels estab- long-term reduction in risk of macro- may be effective in the short-term (up lished by the Food and Drug Adminis- vascular disease. Until more evidence to 1 year). (A) tration (FDA). (A) becomes available, the general goal of ● For patients on low-carbohydrate diets, ● If adults with diabetes choose to use 7% appears reasonable for many monitor lipid profiles, renal function, alcohol, daily intake should be limited adults for macrovascular risk reduc- and protein intake (in those with ne- to a moderate amount (one drink per tion. (B) phropathy) and adjust hypoglycemic day or less for adult women and two● Subgroup analyses of clinical trials such drinks per day or less for adult men). therapy as needed. (E) as the DCCT and UKPDS and evidence ● Physical activity and behavior modifi- (E) for reduced proteinuria in the AD- ● Routine supplementation with antioxi- cation are important components of VANCE trial suggest a small but incre- weight loss programs and are most dants, such as vitamins E and C and mental benefit in microvascular helpful in maintenance of weight loss. carotene, is not advised because of lack outcomes with A1C values closer to (B) of evidence of efficacy and concern re- normal. Therefore, for selected individ- lated to long-term safety. (A) ual patients, providers might reason- ● Benefit from chromium supplementa- ably suggest even lower A1C goals than Primary prevention of diabetes tion in people with diabetes or obesity the general goal of 7%, if this can be ● Among individuals at high risk for de- has not been conclusively demon- achieved without significant hypogly- veloping type 2 diabetes, structured strated and, therefore, cannot be rec- cemia or other adverse effects of treat- programs emphasizing lifestyle ommended. (C) ment. Such patients might include changes including moderate weight ● Individualized meal planning should those with short duration of diabetes, loss (7% body weight) and regular include optimization of food choices long life expectancy, and no significant physical activity (150 min/week), with to meet recommended dietary allow- CVD. (B) dietary strategies including reduced ances (RDAs)/dietary reference intakes● Conversely, less stringent A1C goals calories and reduced intake of dietary (DRIs) for all micronutrients. (E) than the general goal of 7% may be fat, can reduce the risk for developing appropriate for patients with a history diabetes and are therefore recom- Bariatric surgery of severe hypoglycemia, limited life ex- ● Bariatric surgery should be considered mended. (A) pectancy, advanced microvascular or ● Individuals at high risk for type 2 dia- for adults with BMI 35 kg/m2 and macrovascular complications, or exten- betes should be encouraged to achieve type 2 diabetes, especially if the diabe- sive comorbid conditions and those the U.S. Department of Agriculture tes or associated comorbidities are dif- with longstanding diabetes in whom (USDA) recommendation for dietary fi- ficult to control with lifestyle and the general goal is difficult to attain de- ber (14 g fiber/1,000 kcal) and foods pharmacologic therapy. (B) spite diabetes self-management educa- ● Patients with type 2 diabetes who have containing whole grains (one-half of tion, appropriate glucose monitoring, grain intake). (B) undergone bariatric surgery need life- and effective doses of multiple glucose- long lifestyle support and medical lowering agents including insulin. (C) monitoring. (E) Dietary fat intake in diabetes ● Although small trials have shown gly- management cemic benefit of bariatric surgery in pa-Medical nutrition therapy ● Saturated fat intake should be 7% of tients with type 2 diabetes and BMI ofGeneral recommendations● Individuals who have pre-diabetes or total calories. (A) 30 –35 kg/m2, there is currently insuf- ● Reducing intake of trans fat lowers LDL ficient evidence to generally recom- diabetes should receive individualized cholesterol and increases HDL choles- mend surgery in patients with BMI 35 medical nutrition therapy (MNT) as terol (A); therefore, intake of trans fat kg/m2 outside of a research protocol. needed to achieve treatment goals, pref- should be minimized. (E) (E) erably provided by a registered dietitian ● The long-term benefits, cost-effective- familiar with the components of diabe- ness, and risks of bariatric surgery in tes MNT. (A) Carbohydrate intake in diabetes● Because MNT can result in cost-savings individuals with type 2 diabetes should management be studied in well-designed random- and improved outcomes (B), MNT ● Monitoring carbohydrate, whether by ized controlled trials with optimal should be covered by insurance and carbohydrate counting, exchanges, or medical and lifestyle therapy as the other payors. (E) experience-based estimation, remains a comparator. (E) key strategy in achieving glycemic con-Energy balance, overweight, and trol. (A) Diabetes self-management educationobesity ● For individuals with diabetes, the use of ● People with diabetes should receive di-● In overweight and obese insulin- the glycemic index and glycemic load abetes self-management education resistant individuals, modest weight may provide a modest additional bene- (DSME) according to national stan- loss has been shown to reduce insulin fit for glycemic control over that ob- dards when their diabetes is diagnosed resistance. Thus, weight loss is recom- served when total carbohydrate is and as needed thereafter. (B) mended for all overweight or obese in- considered alone. (B) ● Effective self-management and DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010 S5
  • 3. Executive Summary of life are the key outcomes of DSME awareness or one or more episodes of style dietary pattern including reducing and should be measured and moni- severe hypoglycemia should be advised sodium and increasing potassium intake, tored as part of care. (C) to raise their glycemic targets to strictly moderation of alcohol intake, and in-● DSME should address psychosocial is- avoid further hypoglycemia for at least creased physical activity. (B) sues, since emotional well-being is several weeks, to partially reverse hypo- ● Pharmacologic therapy for patients with associated with positive diabetes out- glycemia unawareness and reduce risk diabetes and hypertension should be comes. (C) of future episodes. (B) with a regimen that includes either an● Because DSME can result in cost- ACE inhibitor or an angiotensin receptor savings and improved outcomes (B), Immunization blocker (ARB). If one class is not toler- DSME should be reimbursed by third- ● Annually provide an influenza vaccine ated, the other should be substituted. If party payors. (E) to all diabetic patients 6 months of age. needed to achieve blood pressure targets, (C) a thiazide diuretic should be added toPhysical activity ● Administer pneumococcal polysaccha- those with an estimated glomerular filtra-● People with diabetes should be advised ride vaccine to all diabetic patients 2 tion rate (GFR) (see below) 30 ml/min to perform at least 150 min/week of years of age. A one-time revaccination is per 1.73 m2 and a loop diuretic for those moderate-intensity aerobic physical ac- recommended for individuals 64 with an estimated GFR 30 ml/min per tivity (50 –70% of maximum heart years of age previously immunized 1.73 m2. (C) rate). (A) when they were 65 years of age if the ● Multiple drug therapy (two or more● In the absence of contraindications, vaccine was administered 5 years agents at maximal doses) is generally people with type 2 diabetes should be ago. Other indications for repeat vacci- required to achieve blood pressure tar- encouraged to perform resistance train- nation include nephrotic syndrome, gets. (B) ing three times per week. (A) chronic renal disease, and other immu- ● If ACE inhibitors, ARBs, or diuretics are nocompromised states, such as after used, kidney function and serum potas-Psychosocial assessment and care transplantation. (C) sium levels should be closely moni-● Assessment of psychological and social tored. (E) situation should be included as an on- Hypertension/blood pressure control ● In pregnant patients with diabetes and going part of the medical management Screening and diagnosis chronic hypertension, blood pressure of diabetes. (E) ● Blood pressure should be measured at target goals of 110 –129/65–79 mmHg● Psychosocial screening and follow-up every routine diabetes visit. Patients are suggested in the interest of long- should include, but is not limited to, found to have systolic blood pressure term maternal health and minimizing attitudes about the illness, expectations 130 mmHg or diastolic blood pres- impaired fetal growth. ACE inhibitors for medical management and out- sure 80 mmHg should have blood and ARBs are contraindicated during comes, affect/mood, general and diabe- pressure confirmed on a separate day. pregnancy. (E) tes-related quality of life, resources Repeat systolic blood pressure 130 (financial, social, and emotional), and mmHg or diastolic blood pressure 80 Dyslipidemia/lipid management psychiatric history. (E) mmHg confirms a diagnosis of hyperten- Screening● Screen for psychosocial problems such sion. (C) ● In most adult patients, measure fasting as depression and diabetes-related dis- lipid profile at least annually. In adults tress, anxiety, eating disorders, and Goals with low-risk lipid values (LDL choles- cognitive impairment when self- ● Patients with diabetes should be treated terol 100 mg/dl, HDL cholesterol management is poor. (C) to a systolic blood pressure 130 50 mg/dl, and triglycerides 150 mmHg. (C) mg/dl), lipid assessments may be re-Hypoglycemia ● Patients with diabetes should be treated peated every 2 years. (E)● Glucose (15–20 g) is the preferred to a diastolic blood pressure 80 treatment for the conscious individual mmHg. (B) with hypoglycemia, although any form Treatment recommendations and of carbohydrate that contains glucose Treatment goals may be used. If SMBG 15 min after ● Patients with a systolic blood pressure ● Lifestyle modification focusing on the treatment shows continued hypoglyce- of 130 –139 mmHg or a diastolic blood reduction of saturated fat, trans fat, and mia, the treatment should be repeated. pressure of 80 – 89 mmHg may be given cholesterol intake; increase of n-3 fatty Once SMBG glucose returns to normal, lifestyle therapy alone for a maximum acids, viscous fiber, and plant stanols/ the individual should consume a meal of 3 months, and then if targets are not sterols; weight loss (if indicated); and or snack to prevent recurrence of hypo- achieved, be treated with addition of increased physical activity should be glycemia. (E) pharmacological agents. (E) recommended to improve the lipid● Glucagon should be prescribed for all ● Patients with more severe hypertension profile in patients with diabetes. (A) individuals at significant risk of severe (systolic blood pressure 140 or dia- ● Statin therapy should be added to life- hypoglycemia, and caregivers or family stolic blood pressure 90 mmHg) at style therapy, regardless of baseline members of these individuals in- diagnosis or follow-up should receive lipid levels, for diabetic patients: structed in its administration. Gluca- pharmacologic therapy in addition to ● with overt CVD. (A) gon administration is not limited to lifestyle therapy. (A) ● without CVD who are over the age of health care professionals. (E) ● Lifestyle therapy for hypertension con- 40 years and have one or more other● Individuals with hypoglycemia un- sists of: weight loss if overweight, DASH- CVD risk factors. (A)S6 DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
  • 4. Executive Summary● For lower risk patients than the above ● Combination therapy with ASA (75– Treatment (e.g., without overt CVD and under the 162 mg/day) and clopidogrel (75 mg/ ● In the treatment of the nonpregnant pa- age of 40 years), statin therapy should day) is reasonable for up to a year after tient with micro- or macroalbuminuria, be considered in addition to lifestyle an acute coronary syndrome. (B) either ACE inhibitors or ARBs should therapy if LDL cholesterol remains be used. (A) above 100 mg/dl or in those with mul- Smoking cessation ● While there are no adequate head-to- tiple CVD risk factors. (E) ● Advise all patients not to smoke. (A) head comparisons of ACE inhibitors● In individuals without overt CVD, the ● Include smoking cessation counseling and ARBs, there is clinical trial support primary goal is an LDL cholesterol and other forms of treatment as a rou- for each of the following statements: 100 mg/dl (2.6 mmol/l). (A) tine component of diabetes care. (B) ● In patients with type 1 diabetes with● In individuals with overt CVD, a lower hypertension and any degree of albu- LDL cholesterol goal of 70 mg/dl (1.8 Coronary heart disease minuria, ACE inhibitors have been mmol/l), using a high dose of a statin, is Screening shown to delay the progression of ne- an option. (B) ● In asymptomatic patients, evaluate risk phropathy. (A)● If drug-treated patients do not reach the factors to stratify patients by 10-year ● In patients with type 2 diabetes, hy- above targets on maximal tolerated sta- risk, and treat risk factors accordingly. pertension, and microalbuminuria, tin therapy, a reduction in LDL choles- (B) both ACE inhibitors and ARBs have terol of 30 – 40% from baseline is an been shown to delay the progression alternative therapeutic goal. (A) Treatment to macroalbuminuria. (A)● Triglycerides levels 150 mg/dl (1.7 ● In patients with known CVD, ACE in- ● In patients with type 2 diabetes, hy- mmol/l) and HDL cholesterol 40 hibitor (C) and aspirin and statin ther- pertension, macroalbuminuria, and mg/dl (1.0 mmol/l) in men and 50 apy (A) (if not contraindicated) should renal insufficiency (serum creatinine mg/dl (1.3 mmol/l) in women are desir- be used to reduce the risk of cardiovas- 1.5 mg/dl), ARBs have been shown able. However, LDL cholesterol– cular events. to delay the progression of nephrop- targeted statin therapy remains the ● In patients with a prior myocardial in- athy. (A) preferred strategy. (C) farction, B-blockers should be contin- ● If one class is not tolerated, the other● If targets are not reached on maximally ued for at least 2 years after the event. should be substituted. (E) Reduction of tolerated doses of statins, combination (B) protein intake to 0.8 –1.0 g kg body therapy using statins and other lipid- ● Longer term use of B-blockers in the wt–1 day–1 in individuals with diabetes lowering agents may be considered to absence of hypertension is reasonable if and the earlier stages of CKD and to achieve lipid targets but has not been well tolerated, but data are lacking. (E) 0.8 g kg body wt–1 day–1 in the later evaluated in outcome studies for either ● Avoid TZD treatment in patients with stages of CKD may improve measures CVD outcomes or safety. (E) symptomatic heart failure. (C) of renal function (urine albumin excre-● Statin therapy is contraindicated in ● Metformin may be used in patients with tion rate, GFR) and is recommended. pregnancy. (E) stable congestive heart failure (CHF) if (B) renal function is normal. It should be ● When ACE inhibitors, ARBs, or diuret-Antiplatelet agents avoided in unstable or hospitalized pa- ics are used, monitor serum creatinine● Consider aspirin therapy (75–162 mg/ tients with CHF. (C) and potassium levels for the develop- day) as a primary prevention strategy in ment of acute kidney disease and hy- those with type 1 or type 2 diabetes at Nephropathy screening and perkalemia. (E) increased cardiovascular risk (10-year treatment ● Continued monitoring of urine albu- risk 10%). This includes most men General recommendations min excretion to assess both response 50 years of age or women 60 years ● To reduce the risk or slow the progres- to therapy and progression of disease is of age who have at least one additional sion of nephropathy, optimize glucose recommended. (E) major risk factor (family history of control. (A) ● Consider referral to a physician ex- CVD, hypertension, smoking, dyslipi- ● To reduce the risk or slow the progres- perienced in the care of kidney dis- demia, or albuminuria). (C) sion of nephropathy, optimize blood ease when there is uncertainty about● There is not sufficient evidence to rec- pressure control. (A) the etiology of kidney disease (active ommend aspirin for primary preven- urine sediment, absence of retinopathy, tion in lower risk individuals, such as Screening rapid decline in GFR), difficult manage- men 50 years of age or women 60 ● Perform an annual test to assess urine ment issues, or advanced kidney dis- years of age without other major risk albumin excretion in type 1 diabetic pa- ease. (B) factors. In patients in these age-groups tients with diabetes duration of 5 with multiple other risk factors, clinical years and in all type 2 diabetic patients judgment is required. (C) starting at diagnosis. (E) Retinopathy screening and treatment● Use aspirin therapy (75–162 mg/day) ● Measure serum creatinine at least annu- General recommendations as a secondary prevention strategy in ally in all adults with diabetes regard- ● To reduce the risk or slow the progres- those with diabetes with a history of less of the degree of urine albumin sion of retinopathy, optimize glycemic CVD. (A) excretion. The serum creatinine should control. (A)● For patients with CVD and docu- be used to estimate GFR and stage the ● To reduce the risk or slow the progres- mented aspirin allergy, clopidogrel (75 level of chronic kidney disease (CKD), sion of retinopathy, optimize blood mg/day) should be used. (B) if present. (E) pressure control. (A) DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010 S7
  • 5. Executive SummaryScreening not increase the risk of retinal hemor- ● Consider age when setting glycemic● Adults and children aged 10 years or rhage. (A) goals in children and adolescents with older with type 1 diabetes should have type 1 diabetes, with less stringent goals an initial dilated and comprehensive Neuropathy screening and treatment for younger children. (E) eye examination by an ophthalmologist ● All patients should be screened for dis- or optometrist within 5 years after the tal symmetric polyneuropathy (DPN) at Nephropathy onset of diabetes. (B) diagnosis and at least annually thereaf- ● Annual screening for microalbumin-● Patients with type 2 diabetes should ter, using simple clinical tests. (B) uria, with a random spot urine sample have an initial dilated and comprehen- ● Electrophysiological testing is rarely for microalbumin-to-creatinine ratio, sive eye examination by an ophthalmol- needed, except in situations where the should be initiated once the child is 10 ogist or optometrist shortly after the clinical features are atypical. (E) years of age and has had diabetes for 5 diagnosis of diabetes. (B) ● Screening for signs and symptoms of years. (E)● Subsequent examinations for type 1 cardiovascular autonomic neuropathy ● Confirmed, persistently elevated mi- and type 2 diabetic patients should should be instituted at diagnosis of type croalbumin levels on two additional be repeated annually by an ophthal- 2 diabetes and 5 years after the diagno- urine specimens should be treated with mologist or optometrist. Less-frequent sis of type 1 diabetes. Special testing is an ACE inhibitor, titrated to normaliza- exams (every 2–3 years) may be consid- rarely needed and may not affect man- tion of microalbumin excretion if pos- ered following one or more normal eye agement or outcomes. (E) sible. (E) exams. Examinations will be required ● Medications for the relief of specific more frequently if retinopathy is pro- symptoms related to DPN and auto- Hypertension gressing. (B) nomic neuropathy are recommended, ● Treatment of high-normal blood pres-● High-quality fundus photographs can as they improve the quality of life of the sure (systolic or diastolic blood pres- detect most clinically significant dia- patient. (E) sure consistently above the 90th betic retinopathy. Interpretation of the percentile for age, sex, and height) images should be performed by a Foot care should include dietary intervention trained eye care provider. While retinal ● For all patients with diabetes, perform and exercise, aimed at weight control photography may serve as a screening an annual comprehensive foot exami- and increased physical activity, if ap- tool for retinopathy, it is not a substi- nation to identify risk factors predictive propriate. If target blood pressure is not tute for a comprehensive eye exam, of ulcers and amputations. The foot ex- reached with 3– 6 months of lifestyle which should be performed at least ini- amination should include inspection, intervention, pharmacologic treatment tially and at intervals thereafter as rec- assessment of foot pulses, and testing should be initiated. (E) ommended by an eye care professional. for loss of protective sensation (10-g ● Pharmacologic treatment of hyperten- (E) monofilament plus testing any one of: sion (systolic or diastolic blood pres-● Women with preexisting diabetes who vibration using 128-Hz tuning fork, sure consistently above the 95th are planning pregnancy or who have pinprick sensation, ankle reflexes, or percentile for age, sex, and height or become pregnant should have a com- vibration perception threshold). (B) consistently greater than 130/80 prehensive eye examination and be ● Provide general foot self-care education mmHg, if 95% exceeds that value) counseled on the risk of development to all patients with diabetes. (B) should be initiated as soon as the diag- and/or progression of diabetic retinop- ● A multidisciplinary approach is recom- nosis is confirmed. (E) athy. Eye examination should occur in mended for individuals with foot ulcers ● ACE inhibitors should be considered the first trimester with close follow-up and high-risk feet, especially those with for the initial treatment of hyperten- throughout pregnancy and for 1 year a history of prior ulcer or amputation. sion. (E) postpartum. (B) (B) ● The goal of treatment is a blood pres- ● Refer patients who smoke, have loss of sure consistently 130/80 or below the protective sensation and structural ab- 90th percentile for age, sex, and height,Treatment normalities, or have history of prior whichever is lower. (E)● Promptly refer patients with any level of lower-extremity complications to foot macular edema, severe nonproliferative care specialists for ongoing preventive Dyslipidemia diabetic retinopathy (NPDR), or any care and life-long surveillance. (C) Screening proliferative diabetic retinopathy ● Initial screening for peripheral artery ● If there is a family history of hypercho- (PDR) to an ophthalmologist who is disease (PAD) should include a history lesterolemia (total cholesterol 240 knowledgeable and experienced in the for claudication and an assessment of mg/dl) or a cardiovascular event before management and treatment of diabetic the pedal pulses. Consider obtaining an age 55 years, or if family history is un- retinopathy. (A) ankle-brachial index (ABI), as many pa- known, then a fasting lipid profile● Laser photocoagulation therapy is indi- tients with PAD are asymptomatic. (C) should be performed on children 2 cated to reduce the risk of vision loss in ● Refer patients with significant claudica- years of age soon after diagnosis (after patients with high-risk PDR, clinically tion or a positive ABI for further vascu- glucose control has been established). significant macular edema, and in some lar assessment and consider exercise, If family history is not of concern, then cases of severe NPDR. (A) medications, and surgical options. (C) the first lipid screening should be per-● The presence of retinopathy is not a formed at puberty ( 10 years). All chil- contraindication to aspirin therapy for Children and adolescents dren diagnosed with diabetes at or after cardioprotection, as this therapy does Glycemic control puberty should have a fasting lipid pro-S8 DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
  • 6. Executive Summary file performed soon after diagnosis Hypothyroidism ● Screening for diabetes complications (after glucose control has been estab- ● Children with type 1 diabetes should be should be individualized in older lished). (E) screened for thyroid peroxidase and adults, but particular attention should● For both age-groups, if lipids are abnor- be paid to complications that would thyroglobulin antibodies at diagnosis. mal, annual monitoring is recom- (E) lead to functional impairment. (E) mended. If LDL cholesterol values are ● TSH concentrations should be mea- within the accepted risk levels ( 100 sured after metabolic control has Diabetes care in the hospital mg/dl [2.6 mmol/l]), a lipid profile been established. If normal, they ● All patients with diabetes admitted to should be repeated every 5 years. (E) should be rechecked every 1–2 years, the hospital should have their diabetes or if the patient develops symptoms clearly identified in the medical record.Treatment of thyroid dysfunction, thyromegaly, (E)● Initial therapy should consist of optimi- or an abnormal growth rate. Free T4 ● All patients with diabetes should have zation of glucose control and MNT should be measured if TSH is abnor- an order for blood glucose monitoring, using a Step II American Heart Associ- mal. (E) with results available to all members of ation diet aimed at a decrease in the the health care team. (E) amount of saturated fat in the diet. (E) Preconception care ● Goals for blood glucose levels:● After the age of 10 years, the addition of ● A1C levels should be as close to normal ● Critically ill patients: Insulin ther- a statin is recommended in patients as possible ( 7%) in an individual pa- apy should be initiated for treat- who, after MNT and lifestyle changes, tient before conception is attempted. ment of persistent hyperglycemia have LDL cholesterol 160 mg/dl (4.1 (B) starting at a threshold of no greater mmol/l) or LDL cholesterol 130 ● Starting at puberty, preconception than 180 mg/dl (10 mmol/l). Once mg/dl (3.4 mmol/l) and one or more counseling should be incorporated in insulin therapy is started, a glucose CVD risk factors. (E) the routine diabetes clinic visit for all range of 140 –180 mg/dl (7.8 to 10● The goal of therapy is an LDL choles- women of child-bearing potential. (C) mmol/l) is recommended for the terol value 100 mg/dl (2.6 mmol/l). ● Women with diabetes who are contem- majority of critically ill patients. (A) (E) plating pregnancy should be evaluated These patients require an intrave- and, if indicated, treated for diabetic nous insulin protocol that has dem-Retinopathy retinopathy, nephropathy, neuropathy, onstrated efficacy and safety in and CVD. (E) achieving the desired glucose range● The first ophthalmologic examination ● Medications used by such women without increasing risk for severe should be obtained once the child is 10 should be evaluated prior to concep- hypoglycemia. (E) years of age and has had diabetes for tion, since drugs commonly used to ● Non– critically ill patients: There is 3–5 years. (E) treat diabetes and its complications no clear evidence for specific blood● After the initial examination, annual may be contraindicated or not recom- glucose goals. If treated with insu- routine follow-up is generally recom- mended in pregnancy, including st- lin, the premeal blood glucose tar- mended. Less frequent examinations atins, ACE inhibitors, ARBs, and most get should generally be 140 mg/dl may be acceptable on the advice of an noninsulin therapies. (E) (7.8 mmol/l) with random blood eye care professional. (E) glucose 180 mg/dl (10.0 mmol/l), Older adults provided these targets can be safelyCeliac disease ● Older adults who are functional, cogni- achieved. More stringent targets● Children with type 1 diabetes should tively intact, and have significant life may be appropriate in stable pa- be screened for celiac disease by mea- expectancy should receive diabetes care tients with previous tight glycemic suring tissue transglutaminase or using goals developed for younger control. Less stringent targets may anti-endomysial antibodies, with adults. (E) be appropriate in those with severe documentation of normal serum IgA ● Glycemic goals for older adults not comorbidites. (E) levels, soon after the diagnosis of di- meeting the above criteria may be re- ● Scheduled subcutaneous insulin with abetes. (E) laxed using individual criteria, but hy- basal, nutritional, and correction.● Testing should be repeated if growth perglycemia leading to symptoms or Components is the preferred method failure, failure to gain weight, weight risk of acute hyperglycemic complica- for achieving and maintaining glucose loss, or gastroenterologic symptoms oc- tions should be avoided in all patients. control in noncritically ill patients. (C) cur. (E) (E) Using correction dose or “supplemen-● Consideration should be given to peri- ● Other cardiovascular risk factors tal” insulin to correct premeal hyper- odic re-screening of asymptomatic in- should be treated in older adults with glycemia in addition to scheduled dividuals. (E) consideration of the time frame of ben- prandial and basal insulin is recom-● Children with positive antibodies efit and the individual patient. Treat- mended. (E) should be referred to a gastroenterolo- ment of hypertension is indicated in ● Glucose monitoring should be initiated gist for evaluation. (E) virtually all older adults, and lipid and in any patient not known to be diabetic● Children with confirmed celiac disease aspirin therapy may benefit those with who receives therapy associated with should have consultation with a dieti- life expectancy at least equal to the time high risk for hyperglycemia, including tian and placed on a gluten-free diet. frame of primary or secondary preven- high-dose glucocorticoid therapy, initi- (E) tion trials. (E) ation of enteral or parenteral nutrition, DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010 S9
  • 7. Executive Summary or other medications such as octreotide ● A plan for treating hypoglycemia previous 2–3 months is not available. or immunosuppressive medications. should be established for each patient. (E) (B) If hyperglycemia is documented Episodes of hypoglycemia in the hospi- ● Patients with hyperglycemia in the hos- and persistent, treatment is necessary. tal should be tracked. (E) pital who do not have a diagnosis of Such patients should be treated to the ● All patients with diabetes admitted to diabetes should have appropriate plans same glycemic goals as patients with the hospital should have an A1C ob- for follow-up testing and care docu- known diabetes. (E) tained if the result of testing in the mented at discharge. (E)S10 DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010