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American Diabetes Association clinical practice recommendations 2012
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American Diabetes Association clinical practice recommendations 2012


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American Diabetes Association clinical practice recommendations 2012

American Diabetes Association clinical practice recommendations 2012

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  • 2. 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)
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. 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.
  • 10. 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
  • 11. 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.
  • 12. 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)
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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.
  • 19. 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
  • 20. 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
  • 21.  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
  • 22.  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
  • 23.  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
  • 24. 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
  • 25. 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.
  • 26. 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
  • 27. 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
  • 28.  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.
  • 29. 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
  • 30. 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
  • 31. 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)
  • 32.  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
  • 33.