Standares de diabetes 2012
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  • 1. E X E C U T I V E S U M M A R YExecutive Summary: Standards ofMedical Care in Diabetesd2012Current criteria for the c In those identified with increased risk those with IGT (A), IFG (E), or an A1C ofdiagnosis of diabetes for future diabetes, identify and, if ap- 5.7–6.4% (E), especially for those withc A1C $6.5%. The test should be per- propriate, treat other cardiovascular dis- BMI .35 kg/m2, those aged ,60 years, formed in a laboratory using a method ease (CVD) risk factors. (B) and those with prior GDM. (A) that is National Glycohemoglobin Stan- c At least annual monitoring for the de- dardization Program (NGSP)-certified Detection and diagnosis of velopment of diabetes in those with and standardized to the Diabetes Con- gestational diabetes prediabetes is suggested. (E) trol and Complications Trial (DCCT) mellitus (GDM) assay; or c Screen for undiagnosed type 2 diabetes Glucose monitoringc fasting plasma glucose (FPG) $126 at the first prenatal visit in those with c Self-monitoring of blood glucose (SMBG) mg/dL (7.0 mmol/l). Fasting is de- risk factors, using standard diagnostic should be carried out three or more fined as no caloric intake for at least criteria. (B) times daily for patients using multiple 8 h; or c In pregnant women not previously insulin injections or insulin pump ther-c 2-h plasma glucose $200 mg/dL (11.1 known to have diabetes, screen for apy. (B) mmol/l) during an oral glucose toler- GDM at 24-28 weeks gestation, using a c For patients using less frequent insulin ance test (OGTT). The test should be 75-g 2-h OGTT and the diagnostic injections, noninsulin therapies, or med- performed as described by the World cutpoints in Table 6 of the “Standards ical nutrition therapy (MNT) alone, Health Organization, using a glucose of Medical Care in Diabetesd2012”. SMBG may be useful as a guide to man- load containing the equivalent of 75 g (B) agement. (E) anhydrous glucose dissolved in wa- c Screen women with GDM for persistent c To achieve postprandial glucose tar- ter; or diabetes at 6–12 weeks postpartum, gets, postprandial SMBG may be ap-c in a patient with classic symptoms of using a test other than A1C. (E) propriate. (E) hyperglycemia or hyperglycemic crisis, c Women with a history of GDM should c When prescribing SMBG, ensure that a random plasma glucose $200 mg/dL have lifelong screening for the devel- patients receive initial instruction in, (11.1 mmol/l); opment of diabetes or prediabetes at and routine follow-up evaluation of,c in the absence of unequivocal hypergly- least every 3 years. (B) SMBG technique and their ability to cemia, the result should be confirmed by c Women with a history of GDM found use data to adjust therapy. (E) repeat testing. to have prediabetes should receive c Continuous glucose monitoring (CGM) lifestyle interventions or metformin to in conjunction with intensive insulin prevent diabetes. (A) regimens can be a useful tool to lowerTesting for diabetes in A1C in selected adults (age $25 years)asymptomatic patients Prevention/delay of type 2 with type 1 diabetes. (A)c Testing to detect type 2 diabetes and to diabetes c Although the evidence for A1C-lowering assess risk for future diabetes in asymp- c Patients with IGT (A), IFG (E), or an is less strong in children, teens, and tomatic people should be considered in A1C of 5.7–6.4% (E) should be re- younger adults, CGM may be helpful in adults of any age who are overweight or ferred to an effective ongoing sup- these groups. Success correlates with obese (BMI $25 kg/m2) and who have port program targeting weight loss of adherence to ongoing use of the de- one or more additional risk factors for 7% of body weight and increasing vice. (C) diabetes (see Table 4 of the “Standards physical activity to at least 150 min c CGM may be a supplemental tool to of Medical Care in Diabetesd2012”). In per week of moderate activity such as SMBG in those with hypoglycemia un- those without these risk factors, testing walking. awareness and/or frequent hypoglyce- should begin at age 45 years. (B) c Follow-up counseling appears to be mic episodes. (E)c If tests are normal, repeat testing at important for success. (B) least at 3-year intervals is reasonable. c Based on the cost-effectiveness of dia- A1C (E) betes prevention, such programs should c Perform the A1C test at least two timesc To test for diabetes or to assess risk of be covered by third-party payers. (B) a year in patients who are meeting treat- future diabetes, A1C, FPG, or 2-h 75-g c Metformin therapy for prevention of ment goals (and who have stable glyce- OGTT are appropriate. (B) type 2 diabetes may be considered in mic control). (E) c Perform the A1C test quarterly in pa-c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c tients whose therapy has changed or who are not meeting glycemic goals. (E)DOI: 10.2337/dc12-s004 c Use of point-of-care testing for A1C© 2012 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/ provides the opportunity for more timely licenses/by-nc-nd/3.0/ for details. treatment changes. (E)S4 DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 care.diabetesjournals.org
  • 2. Executive SummaryGlycemic goals in adults Recommendations for energy moderate amount (one drink per day orc Lowering A1C to below or around 7% balance, overweight, and obesity less for adult women and two drinks per has been shown to reduce microvascular c Weight loss is recommended for all day or less for adult men) and should complications of diabetes, and if im- overweight or obese individuals who take extra precautions to prevent hypo- plemented soon after the diagnosis of have or are at risk for diabetes. (A) glycemia. (E) diabetes is associated with long-term c For weight loss, either low-carbohydrate, c Routine supplementation with anti- reduction in macrovascular disease. low-fat calorie-restricted, or Mediterra- oxidants, such as vitamins E and C and Therefore, a reasonable A1C goal for nean diets may be effective in the short carotene, is not advised because of lack many nonpregnant adults is ,7%. (B) term (up to 2 years). (A) of evidence of efficacy and concern re-c Providers might reasonably suggest more c For patients on low-carbohydrate di- lated to long-term safety. (A) stringent A1C goals (such as ,6.5%) for ets, monitor lipid profiles, renal func- c It is recommended that individualized selected individual patients, if this can tion, and protein intake (in those with meal planning include optimization of be achieved without significant hypo- nephropathy) and adjust hypoglyce- food choices to meet recommended glycemia or other adverse effects of mic therapy as needed. (E) daily allowance (RDA)/dietary reference treatment. Appropriate patients might c Physical activity and behavior modi- intake (DRI) for all micronutrients. (E) include those with short duration of fication are important components of diabetes, long life expectancy, and no weight loss programs and are most help- Diabetes self-management significant CVD. (C) ful in maintenance of weight loss. (B) education (DSME)c Less stringent A1C goals (such as c People with diabetes should receive ,8%) may be appropriate for patients Recommendations for primary DSME according to national standards with a history of severe hypoglycemia, prevention of diabetes and diabetes self-management support limited life expectancy, advanced micro- c Among individuals at high risk for de- at the time their diabetes is diagnosed vascular or macrovascular complications, veloping type 2 diabetes, structured pro- and as needed thereafter. (B) and extensive comorbid conditions and grams that emphasize lifestyle changes c Effective self-management and quality for those with longstanding diabetes that include moderate weight loss (7% of life are the key outcomes of DSME in whom the general goal is difficult to body weight) and regular physical ac- and should be measured and moni- attain despite diabetes self-management tivity (150 min/week), with dietary tored as part of care. (C) education, appropriate glucose moni- strategies that include reduced calories c DSME should address psychosocial is- toring, and effective doses of multiple and reduced intake of dietary fat, can sues, since emotional wellbeing is associ- glucose-lowering agents including in- reduce the risk for developing diabetes ated with positive diabetes outcomes. (C) sulin. (B) and are therefore recommended. (A) c Because DSME can result in cost-savings c Individuals at risk for type 2 diabetes and improved outcomes (B), DSMETherapy for type 2 diabetes should be encouraged to achieve the U.S. should be adequately reimbursed byc At the time of type 2 diabetes diagnosis, Department of Agriculture (USDA) rec- third-party payers. (E) initiate metformin therapy along with ommendation for dietary fiber (14 g fiber/ lifestyle interventions, unless metformin 1,000 kcal) and foods containing whole Physical activity is contraindicated. (A) grains (one-half of grain intake). (B) c People with diabetes should be advisedc In newly diagnosed type 2 diabetic c Individuals at risk for type 2 diabetes to perform at least 150 min/week of patients with markedly symptomatic should be encouraged to limit their moderate-intensity aerobic physical ac- and/or elevated blood glucose levels or intake of sugar-sweetened beverages. (B) tivity (50–70% of maximum heart rate), A1C, consider insulin therapy, with or spread over at least 3 days per week with without additional agents, from the out- Recommendations for management no more than 2 consecutive days with- set. (E) of diabetes out exercise. (A)c If noninsulin monotherapy at maxi- Macronutrients in diabetes management c In the absence of contraindications, mal tolerated dose does not achieve c The mix of carbohydrate, protein, and people with type 2 diabetes should be or maintain the A1C target over 3–6 fat may be adjusted to meet the meta- encouraged to perform resistance train- months, add a second oral agent, a GLP-1 bolic goals and individual preferences ing at least twice per week. (A) receptor agonist, or insulin. (E) of the person with diabetes. (C) c Monitoring carbohydrate intake, whether Psychosocial assessmentMedical nutrition therapy by carbohydrate counting, choices, or and care(MNT) experience-based estimation, remains a c It is reasonable to include assessmentGeneral Recommendations key strategy in achieving glycemic con- of the patient’s psychological and so-c Individuals who have prediabetes or trol. (B) cial situation as an ongoing part of the diabetes should receive individualized c Saturated fat intake should be ,7% of medical management of diabetes. (E) MNT as needed to achieve treatment total calories. (B) c Psychosocial screening and follow-up goals, preferably provided by a regis- c Reducing intake of trans fat lowers LDL may include, but is not limited to, atti- tered dietitian familiar with the com- cholesterol and increases HDL choles- tudes about the illness, expectations for ponents of diabetes MNT. (A) terol (A); therefore intake of trans fat medical management and outcomes,c Because MNT can result in cost-savings should be minimized. (E) affect/mood, general and diabetes-related and improved outcomes (B), MNT should Other nutrition recommendations. quality of life, resources (financial, so- be adequately covered by insurance c If adults with diabetes choose to use cial, and emotional), and psychiatric and other payers. (E) alcohol, they should limit intake to a history. (E)care.diabetesjournals.org DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 S5
  • 3. Executive Summaryc Consider screening for psychosocial prob- c Administer pneumococcal polysaccharide c Patients with diabetes and hypertension lems such as depression and diabetes- vaccine to all diabetic patients $2 years should be treated with a pharmacologic related distress, anxiety, eating disorders, of age. A one-time revaccination is rec- therapy regimen that includes either an and cognitive impairment when self- ommended for individuals .64 years of ACE inhibitor or an ARB). If one class is management is poor. (C) age previously immunized when they not tolerated, the other should be were ,65 years of age if the vaccine substituted. (C)Hypoglycemia was administered .5 years ago. Other c Multiple drug therapy (two or morec Glucose (15–20 g) is the preferred treat- indications for repeat vaccination in- agents at maximal doses) is generally ment for the conscious individual with clude nephrotic syndrome, chronic renal required to achieve blood pressure tar- hypoglycemia, although any form of car- disease, and other immunocompro- gets. (B) bohydrate that contains glucose may be mised states, such as after transplan- c Administer one or more antihyperten- used. If SMBG 15 min after treatment tation. (C) sive medications at bedtime. (A) shows continued hypoglycemia, the treat- c Administer hepatitis B vaccination to c If ACE inhibitors, ARBs, or diuretics are ment should be repeated. Once SMBG adults with diabetes as per Centers for used, kidney function and serum potas- glucose returns to normal, the individual Disease Control and Prevention (CDC) sium levels should be monitored. (E) should consume a meal or snack to pre- recommendations. (C) c In pregnant patients with diabetes and vent recurrence of hypoglycemia. (E) chronic hypertension, blood pressure tar-c Glucagon should be prescribed for all Hypertension/blood get goals of 110–129/65–79 mmHg are individuals at significant risk of severe pressure control suggested in the interest of long-term hypoglycemia, and caregivers or family Screening and diagnosis maternal health and minimizing impaired members of these individuals should be c Blood pressure should be measured at fetal growth. ACE inhibitors and ARBs instructed in its administration. Gluca- every routine diabetes visit. Patients found are contraindicated during pregnancy. (E) gon administration is not limited to to have systolic blood pressure $130 health care professionals. (E) mmHg or diastolic blood pressure $80 Dyslipidemia/lipidc Individuals with hypoglycemia un- mmHg should have blood pressure management awareness or one or more episodes of confirmed on a separate day. Repeat Screening severe hypoglycemia should be advised systolic blood pressure $130 mmHg or c In most adult patients, measure fasting to raise their glycemic targets to strictly diastolic blood pressure $80 mmHg lipid profile at least annually. In adults avoid further hypoglycemia for at least confirms a diagnosis of hypertension. (C) with low-risk lipid values (LDL choles- several weeks, to partially reverse hy- terol ,100 mg/dL, HDL cholesterol .50 poglycemia unawareness and reduce Goals mg/dL, and triglycerides ,150 mg/dL), risk of future episodes. (B) c A goal systolic blood pressure ,130 lipid assessments may be repeated every mmHg is appropriate for most patients 2 years. (E)Bariatric surgery with diabetes. (C)c Bariatric surgery may be considered for c Based on patient characteristics and Treatment recommendations adults with BMI .35 kg/m2 and type 2 response to therapy, higher or lower and goals diabetes, especially if the diabetes or systolic blood pressure targets may be c Lifestyle modification focusing on the associated comorbidities are difficult to appropriate. (B) reduction of saturated fat, trans fat, and control with lifestyle and pharmaco- c Patients with diabetes should be trea- cholesterol intake; increase of n-3 fatty logic therapy. (B) ted to a diastolic blood pressure ,80 acids, viscous fiber and plant stanols/c Patients with type 2 diabetes who have mmHg. (B) sterols; weight loss (if indicated); and undergone bariatric surgery need life- increased physical activity should be long lifestyle support and medical mon- Treatment recommended to improve the lipid itoring. (B) c Patients with a systolic blood pressure profile in patients with diabetes. (A)c Although small trials have shown glyce- of 130–139 mmHg or a diastolic blood c Statin therapy should be added to life- mic benefit of bariatric surgery in patients pressure of 80–89 mmHg may be given style therapy, regardless of baseline lipid with type 2 diabetes and BMI of 30– lifestyle therapy alone for a maximum levels, for diabetic patients: 35 kg/m2, there is currently insufficient of 3 months and then, if targets are not c with overt CVD. (A) evidence to generally recommend sur- achieved, may be treated with the ad- c without CVD who are over the age of gery in patients with BMI ,35 kg/m2 dition of pharmacological agents. (E) 40 years and have one or more other outside of a research protocol. (E) c Patients with more severe hypertension CVD risk factors. (A)c The long-term benefits, cost-effectiveness, (systolic blood pressure $140 or di- and risks of bariatric surgery in indi- astolic blood pressure $90 mmHg) at c For lower-risk patients than the above viduals with type 2 diabetes should be diagnosis or follow-up should receive (e.g., without overt CVD and under the studied in well-designed controlled trials pharmacologic therapy in addition to age of 40 years), statin therapy should with optimal medical and lifestyle ther- lifestyle therapy. (A) be considered in addition to lifestyle apy as the comparator. (E) c Lifestyle therapy for hypertension con- therapy if LDL cholesterol remains .100 sists of weight loss, if overweight; DASH- mg/dL or in those with multiple CVDImmunization style dietary pattern, including reducing risk factors. (E)c Annually provide an influenza vaccine sodium and increasing potassium in- c In individuals without overt CVD, the to all diabetic patients $6 months of take; moderation of alcohol intake; and primary goal is LDL cholesterol ,100 age. (C) increased physical activity. (B) mg/dL (2.6 mmol/l). (A)S6 DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 care.diabetesjournals.org
  • 4. Executive Summaryc In individuals with overt CVD, a lower c Include smoking cessation counsel- either ACE inhibitors or ARBs should be LDL cholesterol goal of ,70 mg/dL ing and other forms of treatment as used. (A) (1.8 mmol/l), using a high dose of a a routine component of diabetes care. c If one class is not tolerated, the other statin, is an option. (B) (B) should be substituted. (E)c If drug-treated patients do not reach c Reduction of protein intake to 0.8–1.0 the above targets on maximal tolerated Coronary heart disease (CHD) g z kg body wt21 z day21 in individuals statin therapy, a reduction in LDL cho- screening and treatment with diabetes and the earlier stages of lesterol of ;30–40% from baseline is an Screening CKD and to 0.8 g z kg body wt21 z day21 alternative therapeutic goal. (A) c In asymptomatic patients, routine screen- in the later stages of CKD may improvec Triglycerides levels ,150 mg/dL (1.7 ing for coronary artery disease (CAD) is measures of renal function (UAE rate, mmol/l) and HDL cholesterol .40 mg/ not recommended, as it does not im- GFR) and is recommended. (B) dL (1.0 mmol/l) in men and .50 mg/dL prove outcomes as long as CVD risk c When ACE inhibitors, ARBs, or diuretics (1.3 mmol/l) in women, are desirable. factors are treated. (A) are used, monitor serum creatinine However, LDL cholesterol–targeted statin and potassium levels for the develop- therapy remains the preferred strategy. (C) Treatment ment of increased creatinine and hy-c If targets are not reached on maximally c In patients with known CVD, consider perkalemia. (E) tolerated doses of statins, combination ACE inhibitor therapy (C) and use as- c Continued monitoring of UAE to assess therapy using statins and other lipid- pirin and statin therapy (A) (if not both response to therapy and pro- lowering agents may be considered to contraindicated) to reduce the risk of gression of disease is reasonable. (E) achieve lipid targets but has not been cardiovascular events. In patients with a c When estimated GFR (eGFR) is ,60 evaluated in outcome studies for either prior myocardial infarction, b-blockers ml z min/1.73 m2, evaluate and manage CVD outcomes or safety. (E) should be continued for at least 2 years potential complications of CKD. (E)c Statin therapy is contraindicated in after the event. (B) c Consider referral to a physician ex- pregnancy. (B) c Longer-term use of b-blockers in the perienced in the care of kidney dis- absence of hypertension is reasonable if ease for uncertainty about the etiologyAntiplatelet agents well tolerated, but data are lacking. (E) of kidney disease, difficult manage-c Consider aspirin therapy (75–162 mg/ c Avoid TZD treatment in patients with ment issues, or advanced kidney dis- day) as a primary prevention strategy in symptomatic heart failure. (C) ease. (B) those with type 1 or type 2 diabetes at c Metformin may be used in patients with increased cardiovascular risk (10-year stable congestive heart failure (CHF) if risk .10%). This includes most men renal function is normal. It should be Retinopathy screening and .50 years of age or women .60 years avoided in unstable or hospitalized pa- treatment of age who have at least one additional tients with CHF. (C) General recommendations major risk factor (family history of c To reduce the risk or slow the pro- CVD, hypertension, smoking, dyslipi- Nephropathy screening gression of retinopathy, optimize gly- demia, or albuminuria). (C) and treatment cemic control. (A)c Aspirin should not be recommended c To reduce the risk or slow the progres- General recommendations for CVD prevention for adults with c To reduce the risk or slow the progres- sion of retinopathy, optimize blood pres- diabetes at low CVD risk (10-year CVD sion of nephropathy, optimize glucose sure control. (A) risk ,5%, such as in men ,50 years control. (A) and women ,60 years of age with no c To reduce the risk or slow the progres- Screening major additional CVD risk factors), sion of nephropathy, optimize blood c Adults and children aged 10 years or since the potential adverse effects from pressure control. (A) older with type 1 diabetes should have bleeding likely offset the potential an initial dilated and comprehensive benefits. (C) eye examination by an ophthalmologistc In patients in these age-groups with Screening or optometrist within 5 years after the c Perform an annual test to assess urine multiple other risk factors (e.g., 10-year onset of diabetes. (B) risk 5–10%), clinical judgment is re- albumin excretion (UAE) in type 1 di- c Patients with type 2 diabetes should quired. (E) abetic patients with diabetes duration have an initial dilated and comprehen-c Use aspirin therapy (75–162 mg/day) as a of $5 years and in all type 2 diabetic sive eye examination by an ophthalmol- secondary prevention strategy in those patients starting at diagnosis. (B) ogist or optometrist shortly after the c Measure serum creatinine at least annu- with diabetes with a history of CVD. (A) diagnosis of diabetes. (B)c For patients with CVD and documented ally in all adults with diabetes regardless c Subsequent examinations for type 1 aspirin allergy, clopidogrel (75 mg/day) of the degree of UAE. The serum creati- and type 2 diabetic patients should be should be used. (B) nine should be used to estimate glo- repeated annually by an ophthalmolo-c Combination therapy with ASA (75– merular filtration rate (GFR) and stage gist or optometrist. Less-frequent exams 162 mg/day) and clopidogrel (75 mg/ the level of chronic kidney disease (every 2–3 years) may be considered day) is reasonable for up to a year after (CKD), if present. (E) following one or more normal eye exams. an acute coronary syndrome. (B) Examinations will be required more fre- Treatment quently if retinopathy is progressing. (B)Smoking cessation c In the treatment of the nonpregnant pa- c High-quality fundus photographs can de-c Advise all patients not to smoke. (A) tient with micro- or macroalbuminuria, tect most clinically significant diabeticcare.diabetesjournals.org DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 S7
  • 5. Executive Summary retinopathy. Interpretation of the im- Foot care years of age and has had diabetes for 5 ages should be performed by a trained eye c For all patients with diabetes, perform years. (B) care provider. While retinal photogra- an annual comprehensive foot exami- c Treatment with an ACE inhibitor, titrated phy may serve as a screening tool for nation to identify risk factors predictive to normalization of albumin excretion, retinopathy, it is not a substitute for a of ulcers and amputations. The foot should be considered when elevated comprehensive eye exam, which should examination should include inspec- ACR is subsequently confirmed on be performed at least initially and at in- tion, assessment of foot pulses, and two additional specimens from differ- tervals thereafter as recommended by testing for loss of protective sensation ent days. (E) an eye care professional. (E) (10-g monofilament plus testing anyc Women with preexisting diabetes who one of the following: vibration using Hypertension are planning pregnancy or who have 128-Hz tuning fork, pinprick sensa- c Initial treatment of high-normal blood become pregnant should have a com- tion, ankle reflexes, or vibration per- pressure (systolic or diastolic blood prehensive eye examination and should ception threshold). (B) pressure consistently above the 90th per- be counseled on the risk of development c Provide general foot self-care education centile for age, sex, and height) includes and/or progression of diabetic retinopa- to all patients with diabetes. (B) dietary intervention and exercise, aimed thy. Eye examination should occur in c A multidisciplinary approach is rec- at weight control and increased phys- the first trimester with close follow-up ommended for individuals with foot ical activity, if appropriate. If target throughout pregnancy and for 1 year ulcers and high-risk feet, especially blood pressure is not reached with 3–6 postpartum. (B) those with a history of prior ulcer or months of lifestyle intervention, phar- amputation. (B) macologic treatment should be consid- c Refer patients who smoke, have loss of ered. (E)Treatmentc Promptly refer patients with any level protective sensation and structural ab- c Pharmacologic treatment of hyper- normalities, or have history of prior tension (systolic or diastolic blood of macular edema, severe nonproli- lower-extremity complications to foot pressure consistently above the 95th ferative diabetic retinopathy (NPDR), care specialists for ongoing preventive percentile for age, sex, and height or or any PDR to an ophthalmologist who is knowledgeable and experienced care and life-long surveillance. (C) consistently .130/80 mmHg, if 95% c Initial screening for peripheral arterial exceeds that value) should be consid- in the management and treatment of disease (PAD) should include a history ered as soon as the diagnosis is con- diabetic retinopathy. (A)c Laser photocoagulation therapy is in- for claudication and an assessment of firmed. (E) the pedal pulses. Consider obtaining c ACE inhibitors should be considered dicated to reduce the risk of vision loss an ankle-brachial index (ABI), as many for the initial treatment of hyperten- in patients with high-risk PDR, clini- cally significant macular edema, and patients with PAD are asymptomatic. (C) sion, following appropriate reproduc- c Refer patients with significant claudi- tive counseling due to the potential some cases of severe NPDR. (A) cation or a positive ABI for further vas- teratogenic effects. (E)c The presence of retinopathy is not a contraindication to aspirin therapy for cular assessment and consider exercise, c The goal of treatment is a blood pres- cardioprotection, as this therapy does medications, and surgical options. (C) sure consistently ,130/80 or below the not increase the risk of retinal hemor- 90th percentile for age, sex, and height, rhage. (A) Assessment of common whichever is lower. (E) comorbid conditionsNeuropathy screening and Dyslipidemia c For patients with risk factors, signs ortreatement Screeningc All patients should be screened for symptoms, consider assessment and treat- c If there is a family history of hyper- ment for common diabetes-associated distal symmetric polyneuropathy (DPN) cholesterolemia or a cardiovascular conditions (see Table 15 of the “Stand- starting at diagnosis of type 2 diabetes event before age 55 years, or if family ards of Medical Care in Diabetesd and 5 years after the diagnosis of type 1 history is unknown, then consider 2012”). (B) diabetes and at least annually thereafter, obtaining a fasting lipid profile on using simple clinical tests. (B) children .2 years of age soon afterc Electrophysiological testing is rarely Children and adolescents diagnosis (after glucose control has needed, except in situations where the Glycemic control been established). If family history is clinical features are atypical. (E) c Consider age when setting glycemic goals not of concern, then consider the firstc Screening for signs and symptoms of in children and adolescents with type 1 lipid screening at puberty ($10 years). cardiovascular autonomic neuropathy diabetes. (E) For children diagnosed with diabetes should be instituted at diagnosis of type at or after puberty, consider obtaining 2 diabetes and 5 years after the diagnosis Screening and management a fasting lipid profile soon after dia- of type 1 diabetes. Special testing is of chronic complications in gnosis (after glucose control has been rarely needed and may not affect man- children and adolescents established). (E) agement or outcomes. (E) with type 1 diabetes c For both age-groups, if lipids are abnor-c Medications for the relief of specific Nephropathy mal, annual monitoring is reasonable. If symptoms related to painful DPN and c Annual screening for microalbuminuria, LDL cholesterol values are within the autonomic neuropathy are recom- with a random spot urine sample for accepted risk levels (,100 mg/dL [2.6 mended, as they improve the quality of albumin-to-creatinine ratio (ACR), should mmol/l]), a lipid profile repeated every life of the patient. (E) be considered once the child is 10 5 years is reasonable. (E)S8 DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 care.diabetesjournals.org
  • 6. Executive SummaryTreatment if the patient develops symptoms of may benefit those with life expectancy atc Initial therapy may consist of optimi- thyroid dysfunction, thyromegaly, or least equal to the time frame of primary or zation of glucose control and MNT an abnormal growth rate. (E) secondary prevention trials. (E) using a Step 2 American Heart Associ- c Screening for diabetes complications ation Diet aimed at a decrease in the Transition from pediatric to adult care should be individualized in older adults, amount of saturated fat in the diet. (E) c As teens transition into emerging adult- but particular attention should be paid toc After the age of 10 years, the addition hood, health care providers and families complications that would lead to func- of a statin in patients who, after MNT must recognize their many vulnerabi- tional impairment. (E) and lifestyle changes, have LDL cho- lities (B) and prepare the developing lesterol .160 mg/dL (4.1 mmol/l), or teen, beginning in early to mid adoles- Cystic fibrosis–related LDL cholesterol . 30 mg/dL (3.4 cence and at least one year prior to the diabetes (CFRD) mmol/l) and one or more CVD risk transition. (E) c Annual screening for CFRD with OGTT factors, is reasonable. (E) c Both pediatricians and adult health care should begin by age 10 years in all pa-c The goal of therapy is an LDL choles- providers should assist in providing sup- tients with CF who do not have CFRD terol value ,100 mg/dL (2.6 mmol/l). (E) port and links to resources for the teen (B). Use of A1C as a screening test for and emerging adult. (B) CFRD is not recommended. (B)Retinopathy c During a period of stable health thec The first ophthalmologic examination Preconception care diagnosis of CFRD can be made in CF should be obtained once the child is c A1C levels should be as close to normal as patients according to usual diagnostic $10 years of age and has had diabetes possible (,7%) in an individual patient criteria. (E) for 3–5 years. (B) before conception is attempted. (B) c Patients with CFRD should be treatedc After the initial examination, annual c Starting at puberty, preconception coun- with insulin to attain individualized gly- routine follow-up is generally recom- seling should be incorporated in the cemic goals. (A) mended. Less-frequent examinations routine diabetes clinic visit for all women c Annual monitoring for complications may be acceptable on the advice of an of childbearing potential. (C) of diabetes is recommended, beginning eye care professional. (E) c Women with diabetes who are contem- 5 years after the diagnosis of CFRD. (E) plating pregnancy should be evaluatedCeliac disease and, if indicated, treated for diabeticc Consider screening children with type 1 retinopathy, nephropathy, neuropathy, Diabetes care in the hospital c All patients with diabetes admitted to the diabetes for celiac disease by measur- and CVD. (B) ing tissue transglutaminase or antiendo- c Medications used by such women should hospital should have their diabetes clearly mysial antibodies, with documentation be evaluated prior to conception, since identified in the medical record. (E) c All patients with diabetes should have of normal total serum IgA levels, soon drugs commonly used to treat diabetes after the diagnosis of diabetes. (E) and its complications may be contra- an order for blood glucose monitoring,c Testing should be considered in chil- indicated or not recommended in preg- with results available to all members dren with growth failure, failure to gain nancy, including statins, ACE inhibitors, of the health care team. (E) c Goals for blood glucose levels: weight, weight loss, diarrhea, flatulence, ARBs, and most noninsulin therapies. (E) abdominal pain, or signs of malabsorp- c Since many pregnancies are unplanned, ○ Critically ill patients: Insulin ther- tion, or in children with frequent un- consider the potential risks and benefits apy should be initiated for treatment explained hypoglycemia or deterioration of medications that are contraindicated of persistent hyperglycemia starting in glycemic control. (E) in pregnancy in all women of childbear- at a threshold of no greater than 180c Consider referral to a gastroenterolo- ing potential, and counsel women using mg/dL (10 mmol/L). Once insulin gist for evaluation with endoscopy and such medications accordingly. (E) therapy is started, a glucose range of biopsy for confirmation of celiac disease 140–180 mg/dL (7.8 to 10 mmol/L) is in asymptomatic children with positive Older adults recommended for the majority of antibodies. (E) c Older adults who are functional, cog- critically ill patients. (A)c Children with biopsy-confirmed celiac nitively intact, and have significant life ○ More stringent goals, such as 110– disease should be placed on a gluten- expectancy should receive diabetes care 140 mg/dL (6.1–7.8 mmol/l) may be free diet and have consultation with a using goals developed for younger appropriate for selected patients, as dietitian experienced in managing both adults. (E) long as this can be achieved without diabetes and celiac disease. (B) c Glycemic goals for older adults not significant hypoglycemia. (C) meeting the above criteria may be re- ○ Critically ill patients require an in-Hypothyroidism laxed using individual criteria, but hy- travenous insulin protocol that hasc Consider screening children with type 1 perglycemia leading to symptoms or risk demonstrated efficacy and safety in diabetes for thyroid disease using thyroid of acute hyperglycemic complications achieving the desired glucose range peroxidase and thyroglobulin antibodies should be avoided in all patients. (E) without increasing risk for severe soon after diagnosis. (E) c Other cardiovascular risk factors should hypoglycemia. (E)c Measuring TSH concentrations soon be treated in older adults with consid- ○ Non–critically ill patients: There is after diagnosis of type 1 diabetes, after eration of the time frame of benefit and no clear evidence for specific blood metabolic control has been established, the individual patient. Treatment of hy- glucose goals. If treated with in- is reasonable. If normal, consider re- pertension is indicated in virtually all sulin, premeal blood glucose targets checking every 1–2 years, especially older adults, and lipid and aspirin therapy generally ,140 mg/dL (7.8 mmol/l)care.diabetesjournals.org DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 S9
  • 7. Executive Summary with random blood glucose ,180 octreotide or immunosuppressive medi- Strategies for improving care mg/dL (10.0 mmol/l) are reasonable, cations. (B) If hyperglycemia is docu- c Care should be aligned with compo- provided these targets can be safely mented and persistent, consider treating nents of the Chronic Care Model to achieved. More stringent targets such patients to the same glycemic goals ensure productive interactions be- may be appropriate in stable pa- as patients with known diabetes. (E) tween a prepared proactive practice tients with previous tight glycemic c A hypoglycemia management protocol team and an informed activated pa- control. Less stringent targets may be should be adopted and implemented tient. (A) appropriate in those with severe co- by each hospital or hospital system. A c When feasible, care systems should morbidites. (E) plan for preventing and treating hy- support team-based care, community poglycemia should be established for involvement, patient registries, andc Scheduled subcutaneous insulin with each patient. Episodes of hypoglycemia embedded decision support tools to basal, nutritional, and correction com- in the hospital should be documented meet patient needs. (B) ponents is the preferred method for in the medial record and tracked. (E) c Treatment decisions should be timely achieving and maintaining glucose con- c Consider obtaining an A1C on patients and based on evidence-based guidelines trol in noncritically ill patients. with diabetes admitted to the hospital that are tailored to individual patientc Glucose monitoring should be initi- if the result of testing in the previous preferences, prognoses, and comorbid- ated in any patient not known to be 2–3 months is not available. (E) ities. (B) diabetic who receives therapy associ- c Patients with hyperglycemia in the c A patient centered communication style ated with high-risk for hyperglycemia, hospital who do not have a prior di- should be employed that incorporates including high-dose glucocorticoid agnosis of diabetes should have ap- patient preferences, assesses literacy and therapy, initiation of enteral or parenteral propriate plans for follow-up testing numeracy, and addresses cultural bar- nutrition, or other medications such as and care documented at discharge. (E) riers to care. (B)S10 DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 care.diabetesjournals.org