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ADA GUIDELINE.pptx

Diabetes guidelines

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Standards of Care
in Diabetes—2023
Intended to provide clinicians, patients,
researchers, payers, and other
interested individuals with the
components of diabetes care, general
treatment goals, and tools to evaluate
the quality of care.
The Standards.
| 3
Introduction:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S1-S4
| 4
Table of Contents.
1. Improving Care and Promoting Health in
Populations
2. Classification and Diagnosis of Diabetes
3. Prevention or Delay of T2D and Associated
Comorbidities
4. Comprehensive Medical Evaluation and
Assessment of Comorbidities
5. Facilitating Positive Health Behaviors and Well-
being to Improve Health Outcomes
6. Glycemic Targets
7. Diabetes Technology
8. Obesity and Weight Management for the
Prevention and Treatment of Type 2 Diabetes
9. Pharmacologic Approaches to Glycemic
Treatment
10. CVD and Risk Management
11. CKD and Risk Management
12. Retinopathy, Neuropathy, and Foot Care
13. Older Adults
14. Children and Adolescents
15. Management of Diabetes in Pregnancy
16. Diabetes Care in the Hospital
17. Diabetes and Advocacy
Section 2.
Classification and
Diagnosis of
Diabetes
| 6
Classification
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Diabetes can be classified into the following general categories:
1. Type 1 diabetes (due to autoimmune ß-cell destruction, usually leading to absolute
insulin deficiency, including latent autoimmune diabetes of adulthood)
2. Type 2 diabetes (due to a non-autoimmune progressive loss of adequate ß-cell
insulin secretion frequently on the background of insulin resistance and metabolic
syndrome)
3. Specific types of diabetes due to other causes, e.g., monogenic diabetes
syndromes (such as neonatal diabetes and maturity-onset diabetes of the young),
diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and
drug- or chemical-induced diabetes (such as with glucocorticoid use, in the
treatment of HIV/AIDS, or after organ transplantation)
4. Gestational diabetes mellitus (diabetes diagnosed in the second or third trimester
of pregnancy that was not clearly overt diabetes prior to gestation)

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ADA GUIDELINE.pptx

  • 1. Standards of Care in Diabetes—2023
  • 2. Intended to provide clinicians, patients, researchers, payers, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. The Standards.
  • 3. | 3 Introduction: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S1-S4
  • 4. | 4 Table of Contents. 1. Improving Care and Promoting Health in Populations 2. Classification and Diagnosis of Diabetes 3. Prevention or Delay of T2D and Associated Comorbidities 4. Comprehensive Medical Evaluation and Assessment of Comorbidities 5. Facilitating Positive Health Behaviors and Well- being to Improve Health Outcomes 6. Glycemic Targets 7. Diabetes Technology 8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes 9. Pharmacologic Approaches to Glycemic Treatment 10. CVD and Risk Management 11. CKD and Risk Management 12. Retinopathy, Neuropathy, and Foot Care 13. Older Adults 14. Children and Adolescents 15. Management of Diabetes in Pregnancy 16. Diabetes Care in the Hospital 17. Diabetes and Advocacy
  • 6. | 6 Classification CLASSIFICATION AND DIAGNOSIS OF DIABETES Diabetes can be classified into the following general categories: 1. Type 1 diabetes (due to autoimmune ß-cell destruction, usually leading to absolute insulin deficiency, including latent autoimmune diabetes of adulthood) 2. Type 2 diabetes (due to a non-autoimmune progressive loss of adequate ß-cell insulin secretion frequently on the background of insulin resistance and metabolic syndrome) 3. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young), diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (such as with glucocorticoid use, in the treatment of HIV/AIDS, or after organ transplantation) 4. Gestational diabetes mellitus (diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation)
  • 7. | 7 CLASSIFICATION AND DIAGNOSIS OF DIABETES Hold for table 2.1 Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40
  • 8. | 8  No mention of hybride forms of diabetes ADA vs WHO classification of DM Latent autoimmune diabetes of adult Ketosis prone diabetes
  • 9. | 9 CLASSIFICATION AND DIAGNOSIS OF DIABETES Table 2.2 Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40
  • 10. | 10 Classic symptoms of hyperglycemia  Polyuria  Polydipsia  Weight loss Polyphagia no longer considered a classic symptom
  • 11. | 11 Screening for type 2 DM Screening of high risk population Screening of subject with pre – diabetes Screening of women with GDM Universal screening of population
  • 12. | 12 CLASSIFICATION AND DIAGNOSIS OF DIABETES Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40
  • 13. | 13 CLASSIFICATION AND DIAGNOSIS OF DIABETES Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40
  • 14. | 14  HBA1C maintained < 6.5 % for 3 months without use of OHA and INSULIN Remission of DM
  • 15. | 15  2.1b Point-of-care A1C testing for diabetes screening and diagnosis should be restricted to U.S. Food and Drug Administration–approved devices at laboratories proficient in performing testing of moderate complexity or higher by trained personnel. B UPDATE 2023
  • 16. Section 3. Prevention or Delay of Type 2 Diabetes and Associated Comorbidities
  • 17. Prevention of DM Life style changes • 150 min / week • 7 % weight loss Metformin • Age 25 to 59 years with • BMI > 35 • FBS > 110 • HBAIC >6 • Previous GDM Pioglitazone • Lower the risk of stroke , MI and progression to DM
  • 18.  3.1 Monitor for the development of type 2 diabetes in those with prediabetes at least annually; modified based on individual risk/benefit assessment. E  3.9 Statin therapy may increase the risk of type 2 diabetes in people at high risk of developing type 2 diabetes. In such individuals, glucose status should be monitored regularly and diabetes prevention approaches reinforced. It is not recommended that statins be discontinued. B  3.10 In people with a history of stroke and evidence of insulin resistance and prediabetes, pioglitazone may be considered to lower the risk of stroke or myocardial infarction. However, this benefit needs to be balanced with the increased risk of weight gain, edema, and fracture. A Lower doses may mitigate the risk of adverse effects. C UPDATE 2023
  • 20. Comordities in DM Systemic HTN DLP NAFLD CAD Cognitive impairment Fractures Hearing loss Peridontal disease Hypogonadism / pcod
  • 21. | 21 Immunizations COMPREHENSIVE MEDICAL EVALUATION AND ASSESSMENT OF COMORBIDITIES
  • 22. | 22 Immunizations COMPREHENSIVE MEDICAL EVALUATION AND ASSESSMENT OF COMORBIDITIES
  • 23. | 23 Immunizations COMPREHENSIVE MEDICAL EVALUATION AND ASSESSMENT OF COMORBIDITIES
  • 25.  Should engage in 150 min or more of moderate – to vigorous intensity activity weekly , spread over atleast 3 days / week  No more than 2 consecutive days without activity  Resistance training in 2 -3 sessions / week on non consecutive days  Flexibility training and balance training are recommended 2-3 times / week for older adult with DM EXERCISE PLAN
  • 26. | 26 FACILITATING POSITIVE HEALTH BEHAVIORS AND WELL-BEING TO IMPROVE HEALTH OUTCOMES Medical Nutrition Therapy Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S68-S96
  • 27. | 27 FACILITATING POSITIVE HEALTH BEHAVIORS AND WELL-BEING TO IMPROVE HEALTH OUTCOMES Medical Nutrition Therapy (continued) Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S68-S96
  • 28. | 28 FACILITATING POSITIVE HEALTH BEHAVIORS AND WELL-BEING TO IMPROVE HEALTH OUTCOMES Medical Nutrition Therapy (continued) Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S68-S96
  • 29. | 29  Time restricted eating and intermittent fasting  Time restricted eating is generally easier to follow compared with alternative day fasting or the 5:2 plan  No significant difference in weight loss when compared with contious calorie restriction Update 2023
  • 31. Glycemic targets FBS • 80 – 130 mg/dl PPBS • < 180 mg/dl HBA1C • < 7% • < 7.5 % type 1 DM with hypoglycemia • < 8 % Elderly , frail individual
  • 32. TIME IN RANGE Target blood glucose range in DM Non pregnant : 70 – 180 mg/dl Pregnant : 63 – 140 mg/dl
  • 33. Section 8. Obesity and Weight Management for the Treatment of Type 2 Diabetes
  • 34. Obesity management 5 % weight loss improves glycemia > 10 % weight loss has disease modifying effects and impact on long term CV mortality 500 – 750 kcal deficit required for significant weight loss
  • 35. | 35 OBESITY MANAGEMENT FOR THE TREATMENT OF TYPE 2 DIABETES Obesity Management for the Treatment of Type 2 Diabetes: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S128-S139
  • 38. Insulin as default HBA1C > 10 % / RBS > 300 mg/dl Features of catabolism ( significant weight loss ) Ongoing ketosis Pregnancy HBA1C > 9 % with 3 or more OHA Severe organ involvement Perioperative patients
  • 39. | 39 PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT Pharmacologic Approaches to Glycemic Management: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S140-S157
  • 40. | 40 Tirzepatide GIP/GLP -1 CO AGONIST Glycemic weight cvs
  • 42. | 42 CARDIOVASCULAR DISEASE AND RISK MANAGEMENT Cardiovascular Disease and Risk Management: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S158-S190
  • 43. Hypertension management •BP target < 130/80 mmhg if 10 year ASCVD > 15 % •OTHERS < 140/9O mmhg 2022 •Target < 130/80 mmhg 2023
  • 44. | 44 CARDIOVASCULAR DISEASE AND RISK MANAGEMENT Recommendations for the Treatment of Confirmed Hypertension in People with Diabetes (1 of 2) Cardiovascular Disease and Risk Management: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S158-S190
  • 45. | 45 CARDIOVASCULAR DISEASE AND RISK MANAGEMENT Recommendations for the Treatment of Confirmed Hypertension in People with Diabetes (2 of 2) Cardiovascular Disease and Risk Management: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S158-S190
  • 46. | 46 Lipid management – statins for primary prevention Age CV risk factors 40 - 75 nil Moderate intensity statin LDL < 100 mg/dl 40 -75 1 or more High intensity statin LDL < 70 Reduce LDL 50% from base line 20- 39 + Reasonable to initiate statin > 75 Nil Reasonable to initiate moderate intensity statin > 75 + Continue statin therapy
  • 47. | 47  For people of all age with diabetes and ASCVD , high intensity statin therapy should be added to lifestyle therapy  Target LDL < 55mg / dl ( add ezetimibe / PCSK9 inhibitors if target not achieved  ASCVD or other CV risk factors on a statin with controlled LDL cholesterol but elevated triglycerides ( 135 – 499) the addition of icosapent ethyl can be considered to reduce CV risk Lipid management – statins for secondary prevention
  • 48. | 48 CARDIOVASCULAR DISEASE AND RISK MANAGEMENT Cardiovascular Disease and Risk Management: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S158-S190
  • 49. | 49 Reduce cardiovascular risk Controll of hypertension Lipid goal achievement Aspirin use Avoidance of smoking Anti hyperglycemic with CV risk reduction Primary prevention
  • 50. | 50 Reduce cardiovascular risk ASPIRIN HIGH INTENSITY STATINS BETA BLOCKERS Avoidance of smoking ACEI/ARBs GLP 1RA/ SGLT 2i SECONDARY prevention
  • 51. | 51 Aspirin in DM Secondary prevention • HTN • DLP • SMOKING • FAMILY H/O CAD • ALBUMINURIA Primary prevention DM > 50 YR with one or more hish risk
  • 52. Section 11. Chronic Kidney Disease and Risk Management
  • 53.  ACEI/ARB recommended in moderately increased albuminuria ( 30 -299 mg/g cr) strongly recommened in severly increased albuminuria ( >300 mg/g cr ) and or e GFR < 60  SGLT2i In all patients with DKD , recommended to reduce CKD progression and CV events in patient with an e GFR > 20 Ml/min/1.73m2 and urinary albumin > 200mg/g cr CKD and risk management
  • 54.  FINERENONE used if e GFR > 25 Ml /min/1,73m2 and k+ < 5 mEq/L 10 mg / 20 mg once weekly weekly e GFR , K + monitoring CKD and risk management
  • 56.  12.20 Gabapentinoids, serotoninnorepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers are recommended as initial pharmacologic treatments for neuropathic pain in diabetes. A Refer to neurologist or pain specialist when pain control is not achieved within the scope of practice of the treating physician. E  SNRI – duloxetine , venlafaxine , all selective SNRI  TCA – amitriptyline  Capsaicin – FDA approved for pain as 8% patch Neuropathy
  • 57.  Sodium channel blockers – lamotrigine , lacosamide , oxcarbamazepine , and valproic acid  Carbamazepine not approved Neuropathy
  • 58. | 58  Fatty infiltration of > 5 %  Hepatic steatosis associated with inflammation and hepatocyte injury with or without fibrosis – NASH  ASSESSMENT FIB 4 SCORE – age , SGOT, SGPT, platelet count Fibroelastography NAFLD
  • 59. | 59
  • 60. | 60

Editor's Notes

  1. IRIS TRIAL DATA