AMERICAN DIABETES ASSOCIATION NEWCLINICAL PRACTICE RECOMMENDATIONS2012http://crisbertcualteros.page.tl
CURRENT CRITERIA FOR THE DIAGNOSIS OFDIABETES HbA1C ≥6.5% (FPG) ≥126 mg/dL (7.0 mmol/l) 2-h plasma glucose ≥200 mg/dL (11.1 mmol/l)/ 2-h 75-g OGTT random plasma glucose ≥200 mg/dL (11.1 mmol/l)
TESTING FOR DIABETES IN ASYMPTOMATICPATIENTS adults who are overweight/obese (BMI ≥25 kg/m2) have one or more additional risk factors for diabetes those without these risk factors, testing should begin at age 45 years. If normal, repeat at least at 3-year intervals increased risk for future DM, identify /treat other (CVD) risk factors
DETECTION AND DIAGNOSIS OF (GDM) Screen for undiagnosed T2DM at the 1st PNC in those with risk factors not known to have DM, screen at 24-28 wks AOG (75-g 2-h OGTT) Screen for persistent GDM at 6–12 wks postpartum, using a test other than A1C Hx of GDM – test every 3 years Hx of GDM found prediabetic – lifestyle interventions OR Metformin
PREVENTION/DELAY OF TYPE 2 DM IGT, IFG, or A1C 5.7–6.4%:1. wt loss 7% body wt2. increase physical activity atleast 150 min/week of moderate activity (ex. Walking) Metformin tx: for prevention of T2DM in those w/ IGT, IFG, A1C 5.7-6.4%, BMI>35, <60 yo & prior GDM Annual monitoring for prediabetes
GLUCOSE MONITORING Self-monitoring of blood glucose (SMBG) should be 3 or more times daily for pt w/ multiple insulin injections or insulin pump therapy To achieve postprandial glucose targets, postprandial SMBG may be appropriate
HBA1C at least 2x a year in patients who are meeting treatment goals (and who have stable glycemic control) quarterly in patients whose therapy has changed or who are not meeting glycemic goals
GLYCEMIC GOALS IN ADULTS Lower A1C to <7% to reduce microvascular complications reasonable A1C goal for nonpregnant adults is <7% More stringent A1C goals (<6.5%) if achieved w/o significant hypoglycemia or other adverse effects Less stringent A1C goals (<8%) for pt w/ hx of severe hypoglycemia, limited life expectancy, advanced micro/macrovascular complications, extensive comorbid conditions and longstanding DM in whom the goal is difficult to attain
THERAPY FOR TYPE 2 DM initiate Metformin with lifestyle interventions, unless contraindicated markedly symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents If noninsulin monotherapy at maximal tolerated dose does not achieve/maintain the A1C target over 3–6 months, add a second oral agent, a GLP-1 receptor agonist, or insulin.
RECOMMENDATIONS FOR ENERGY BALANCE,OVERWEIGHT, AND OBESITY Wt loss is for all overweight/obese For wt loss: low-carbohydrate, low-fat calorie- restricted, or Mediterranean diets may be effective in the short term (up to 2 years) For pt on low-carbohydrate diets: monitor lipid profiles, renal function, and protein intake
PRIMARY PREVENTION OF DIABETES1. moderate weight loss (7% body weight)2. regular physical activity (150 min/week)3. dietary strategies that include reduced calories and reduced intake of dietary fat4. dietary fiber (14 g fiber/1,000 kcal) & foods containing whole grains (one-half of grain intake)5. limit their intake of sugar-sweetened beverages.
OTHER NUTRITION RECOMMENDATIONSAlcohol: one drink per day or less for adult women two drinks per day or less for adult men should take extra precautions to prevent hypoglycemiaNot advised: routine supplementation:antioxidants(vitamins E and C and carotene)
PHYSICAL ACTIVITY at least 150 min/week, moderate-intensity aerobic physical activity(50–70% of max heart rate), spread over at least 3 days/wk with no >2 consecutive days w/o exercise In the absence of contraindications, people with type 2 DM: encouraged to perform resistance training at least twice/week
HYPOGLYCEMIA Glucose (15–20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used If SMBG 15 min after treatment shows continued hypoglycemia, repeat treatment Once glucose returns to normal, pt should consume a meal or snack to prevent recurrence of hypoglycemia
HYPOGLYCEMIA Glucagon should be prescribed for all individuals at risk of severe hypoglycemia, & caregivers instructed for administration. Individuals with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks
IMMUNIZATION Annually: influenza vaccine to all DM pts ≥6 months of age Pneumococcal vaccine to all DM pts ≥2 yo. A one- time revaccination is recommended for individuals >64 yo previously immunized when they were <65 yo if the vaccine was administered >5 years ago. Administer hep B vaccination to adults with DM as per (CDC) recommendations
HPN/BP CONTROL SCREENING ANDDIAGNOSIS Goal systolic BP <130 mmHg is appropriate for most patients with diabetes Pts with DM should be treated to a DBP<80 mmHg
HPN TX either an ACE inhibitor or an ARB Administer one or more antihypertensive medications at bedtime If ACE inhibitors (Ramipril), ARBs(Losartan), or diuretics(HCTZ) are used, kidney function and serum potassium levels should be monitored.
LIPID MANAGEMENT SCREENINGlow-risk lipid values:1. LDL cholesterol <100 mg/dL2. HDL cholesterol >50 mg/dL3. triglycerides <150 mg/dL) lipid assessments may be repeated every 2 years
TREATMENT RECOMMENDATIONS AND GOALS Lifestyle modification: reduction of saturated fat, trans fat, and cholesterol intake increase of n-3 fatty acids, viscous fiber and plant stanols/sterols weight loss increased physical activity
Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels for diabetic patients: w/ overt CVD w/o CVD who are > 40 years and have one or more other CVD risk factors Lower-risk pts: statin should be considered in addition to lifestyle therapy if LDL cholesterol remains >100 mg/dL or in those with multiple CVD risk factors
w/o overt CVD, the primary goal is LDL cholesterol <100 mg/dL w/ overt CVD, a lower LDL cholesterol goal of <70 mg/dL, using a high dose of a statin If pts do not reach the targets on maximal tolerated statin therapy, a reduction in LDL cholesterol of ∼30–40% from baseline is an alternative therapeutic goal
TG <150 mg/dL & HDL >40 mg/dL in men HDL>50 mg/dL in women are desirable. LDL cholesterol–targeted statin therapy remains the preferred strategy If targets are not reached on maximally tolerated doses of statins, combination therapy W/ statins and other lipid-lowering agents may be considered
ANTIPLATELET AGENTS Aspirin 75–162 mg/day: primary prevention for DM at high cardiovascular risk: men >50 or women >60 w/ atleast 1 additional major risk factor (family w/ CVD, HPN, smoking, dyslipidemia, albuminuria) Aspirin not be recommended for CVD prevention for DM at low CVD risk Aspirin: 2ndary prevention in DM with Hx of CVD Aspirin allergy: Clopidogrel (75 mg/day) Combination: ASA & clopidogrel for 1 year after an acute coronary syndrome
CORONARY HEART DISEASE SCREENING ANDTREATMENT w/ CVD: ACE inhibitor, aspirin and statin therapy (if not contraindicated) to reduce the risk of cardiovascular event prior myocardial infarction: β-blockers should be continued for at least 2 years after the event. Avoid TZD in symptomatic heart failure Metformin may be used in stable (CHF) if renal function is normal.
NEPHROPATHY SCREENING AND TREATMENT To slow the progression of nephropathy, optimize glucose control & blood pressure control Screening:1. Annual urine albumin excretion2. Annual serum creatinine regardless of degree of UAE Treatment: nonpregnant w/ micro/macroalbuminuria - either ACE inh or ARBs Continued monitoring of UAE to assess both response to therapy and progression of disease
RETINOPATHY SCREENING AND TREATMENT To slow the progression of retinopathy, optimize glycemic & BP controlScreening: Adults & children aged 10 yo or older with type 1 DM should have an initial dilated and comprehensive eye examination within 5 years after the onset of diabetes
T2DM pts should have initial dilated and comprehensive eye examination shortly after the diagnosis Subsequent examinations for type 1 and type 2 DM patients should be repeated annually Every 2–3 years: may be considered following one or more normal eye exams.
Tx: Promptly refer pts w/ any level of macular edema, severe nonproliferative diabetic retinopathy (NPDR), or any PDR to an ophthalmologist Laser photocoagulation therapy is indicated to reduce the risk of vision loss in high-risk PDR, clinically significant macular edema, and some cases of severe NPDR
NEUROPATHY SCREENING AND TREATMENT should be screened for distal symmetric polyneuropathy (DPN) starting at diagnosis & 5 years after the diagnosis & annually thereafter Meds for the relief of specific symptoms related to painful DPN & autonomic neuropathy are recommended
FOOT CARE For all DM: annual comprehensive foot examination to identify risk factors predictive of ulcers & amputations The foot examination include: inspection, assessment of foot pulses, and testing for loss of protective sensation (10-g monofilament plus testing any one of the following: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold)
Refer pts who smoke, loss of protective sensation & structural abnormalities, or w/ history of prior lower- extremity complications to foot care specialists for preventive care and life-long surveillance Initial screening for peripheral arterial disease (PAD) include: history for claudication and an assessment of the pedal pulses. Consider obtaining an ankle-brachial index (ABI), as many patients with PAD are asymptomatic