แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013
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แนวทางการดูแลผู้ป่วยเบาหวาน 2556 ADA Guideline 2013

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แนวทางการดูแลผู้ป่วยเบาหวาน 2556
ADA Guideline 2013

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  • The American Diabetes Association recommends the following for dyslipidemia and lipid management. Measure fasting lipids at least annually in adults with diabetes. Adults with low-risk lipid values (LDL-C <100 mg/dL, HDL-C >50 mg/dL, triglycerides <150 mg/dL) can be measured every 2 years. Treatment should include lifestyle modification, focusing on Reduced intake of saturated fat, trans fat, cholesterol Increased intake of omega-3 fatty acids, viscous fiber, plant stenols/sterols Weight loss (if indicated) Increased physical activity Statin therapy and lifestyle changes should be used in those with Overt cardiovascular disease (CVD) No CVD who are aged >40 years and have ≥1 CVD risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria) Consider statins in lower-risk patients (no overt CVD, aged <40 years) if LDL-C >100 mg/dL or in presence of multiple CVD risk factors Statins are contraindicated in pregnancy Goals No overt CVD: LDL-C <100 mg/dL (2.6 mmol/L) Overt CVD: <70 mg/dL (1.8 mmol/L) (using high-dose statin therapy) Alternative goal for those not reaching above targets on maximal statin therapy: 30–40% LDL-C reduction from baseline American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • The American Diabetes Association recommends the following for dyslipidemia and lipid management. Measure fasting lipids at least annually in adults with diabetes. Adults with low-risk lipid values (LDL-C <100 mg/dL, HDL-C >50 mg/dL, triglycerides <150 mg/dL) can be measured every 2 years. Treatment should include lifestyle modification, focusing on Reduced intake of saturated fat, trans fat, cholesterol Increased intake of omega-3 fatty acids, viscous fiber, plant stenols/sterols Weight loss (if indicated) Increased physical activity Statin therapy and lifestyle changes should be used in those with Overt cardiovascular disease (CVD) No CVD who are aged >40 years and have ≥1 CVD risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria) Consider statins in lower-risk patients (no overt CVD, aged <40 years) if LDL-C >100 mg/dL or in presence of multiple CVD risk factors Statins are contraindicated in pregnancy Goals No overt CVD: LDL-C <100 mg/dL (2.6 mmol/L) Overt CVD: <70 mg/dL (1.8 mmol/L) (using high-dose statin therapy) Alternative goal for those not reaching above targets on maximal statin therapy: 30–40% LDL-C reduction from baseline American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • The American Diabetes Association recommends the following criteria for diagnosis of diabetes: A1C ≥6.5%* † OR Fasting plasma glucose ‡ ≥126 mg/dL (7.0 mmol/L) † OR 2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test; 75-g glucose load should be used † OR Random plasma glucose concentration ≥200 mg/dL (11.1 mmol/L) in persons with symptoms of hyperglycemia or hyperglycemic crisis *Test should be performed in a lab using a NGSP-certified method and standardized to the Diabetes Control and Complications Trial (DCCT) assay; † In the absence of unequivocal hyperglycemia results should be confirmed using repeat testing; ‡ Fasting defined as no caloric intake for ≥8 hours. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • The American Diabetes Association cites the following as categories of increased risk for development of diabetes (prediabetes): Fasting plasma glucose 100 mg/dl (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) (impaired fasting glucose [IFG]) 2-hour plasma glucose on 75-g oral glucose tolerance test 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L) (impaired glucose tolerance [IGT]) A1C 5.7%–6.4% For each of the tests listed above, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at higher ends of the range. Both IFG and IGT should be viewed as risk factors for both diabetes and cardiovascular disease. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Testing should be considered in all adults who are overweight (body mass index [BMI] ≥25 kg/m 2 ) and have ≥1 of the following risk factors (note that at-risk BMI may be lower in some ethnic groups): physical inactivity first-degree relative with diabetes member of a high-risk race or ethnic group (African American, Latino, Native American, Asian American, and Pacific Islander) women who delivered a baby weighing >9 lb or were diagnosed with gestational diabetes mellitus HDL-C <35 mg/dL and/or triglycerides >250 mg/dL hypertension (≥140/90 mm Hg or on therapy) A1C ≥5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing other clinical conditions associated with insulin resistance (eg, severe obesity, acanthosis nigricans, women with polycystic ovary syndrome) history of cardiovascular disease In the absence of the above criteria, testing should begin no later than age 45 because age is a major risk factor for diabetes. If results are normal, testing should be repeated in ≥3-year intervals or more frequently depending on initial results and risk status. A1C, FPG, and 75-g 2-h OGTT are all appropriate tests for diabetes or prediabetes. In those identified with prediabetes, other cardiovascular disease risk factors should be identified and treated if appropriate. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Consider testing children (persons aged ≤18 years) who are overweight (BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% ideal for height) and have ≥2 of any of the following risk factors Family history of type 2 diabetes in first- or second-degree relative Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight) Maternal history of diabetes or gestational diabetes mellitus during child’s gestation Begin testing at age 10 years or onset of puberty (if puberty occurs at a younger age) and test every 3 years. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Refer patients with impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or A1C 5.7%–6.4% to ongoing support program targeting weight loss (7% of body weight) and increased physical activity (≥150 min/week moderate activity). Consider metformin therapy for diabetes prevention among those with IGT, IFG, or A1C 5.7%–6.4% Especially with body mass index >35 kg/m 2 , persons aged <60 years, and women with prior gestational diabetes mellitus Annually monitor individuals with prediabetes for diabetes development. Screening for and treatment of modifiable cardiovascular disease risk factors (obesity, hypertension, and dyslipidemia) is suggested. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Self-monitoring of blood glucose (SMBG) should be used among patients receiving multiple-dose insulin or insulin pump therapy At least prior to meals and snacks Occasionally postprandially At bedtime Prior to exercise When they suspect low blood glucose After treating low blood glucose until they are normoglycemic Prior to critical tasks (such as driving) Results from SMBG may be useful for guiding treatment decisions and/or patient self-management for those using less frequent insulin injections or noninsulin therapies. Ensure that patients receive ongoing instruction and regular evaluation of SMBG technique and results, and have the ability to use SMBG data to adjust therapy American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • In selected adults (aged ≥25 years) with type 1 diabetes, continuous glucose monitoring (CGM), along with intensive insulin treatment regimens, can be useful for A1C lowering May be useful among children, teens, and younger adults, although evidence for A1C lowering is less strong in these populations Success is related to adherence to ongoing use of the device CGM may be a useful supplement to SMBG among patients with hypoglycemia unawareness and/or frequent hypoglycemic episodes American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • A1C test should be performed At least 2 times/year in patients who are meeting treatment goals and have stable glycemic control Quarterly in patients whose therapy has changed or who are not meeting glycemic goals Use of point-of-care testing for A1C allows for more timely treatment changes. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • The table on the slide shows the correlation of A1C with average glucose based on data from the A1C-Derived Average Glucose (ADAG) trial. ADAG utilized frequent self-monitoring of blood glucose and continuous glucose monitoring Subjects (N=507) enrolled in ADAG had type 1, type 2, and no diabetes; 83% were Caucasian Study results showed a 0.92 correlation between A1C and average glucose The strength of this correlation justifies reporting of both A1C and estimated average glucose when an A1C test is ordered. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. Nathan DM, Kuenen J, Borg R, et al. Translating the A1C assay into estimated average glucose values. Diabetes Care. 2008;31(8):1473-1478. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • ADA glycemic recommendations for many nonpregnant adults with diabetes: A1C <7.0% Preprandial capillary plasma glucose 70–130 mg/dL (3.9–7.2 mmol/L) Peak postprandial capillary plasma glucose <180 mg/dL (<10.0 mmol/L; postprandial glucose measurements should be made 1–2 h after beginning of meal). Individualize goals based on Age/life expectancy Comorbid conditions Diabetes duration Hypoglycemia status Individual patient considerations (more or less stringent goals may be appropriate) Known CVD/advanced microvascular complications American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Metformin is preferred initial therapy (if tolerated and not contraindicated). Consider insulin therapy with or without other agents at outset in newly diagnosed patients with markedly symptomatic and/or elevated blood glucose levels or A1C. Add second oral agent, GLP-1 receptor agonist, or insulin if noninsulin monotherapy at maximal tolerated dose does not achieve or maintain A1C target over 3–6 months. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Choice of pharmacologic therapy should be based on a patient-centered approach Consider Efficacy Cost Potential side effects Effects on weight Comorbidities Hypoglycemia risk Patient preferences Insulin therapy is eventually needed for many patients due to the progressive nature of type 2 diabetes. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Medical nutrition therapy is recommended for patients with diabetes or prediabetes as needed to reach target goals. Should preferably be provided by a registered dietician familiar with diabetes medical nutrition therapy Weight loss is recommended for all overweight or obese individuals with or at risk for diabetes. Low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short term (up to 2 years) for weight loss in patients with diabetes. For patients with low-carbohydrate diets, it is recommended that lipid profiles, renal function, and protein intake (in those with nephropathy) be monitored, and hypoglycemic therapies should be adjusted as needed. Physical activity and behavior modification are important components of weight loss programs and can aid in weight maintenance. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Individuals at high risk for type 2 diabetes: Begin a structured program emphasizing lifestyle changes, including moderate weight loss (7% body weight) and regular physical activity (150 min/week) with dietary strategies, including reduced calories and reduced intake of dietary fat Achieve the U.S. Department of Agriculture recommendation for dietary fiber (14 g/1,000 kcal) and foods containing whole grains (one-half of grain intake). Limit intake of sugar-sweetened beverages. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Adjust mix of carbohydrates, protein, and fat to meet metabolic goals and preferences of person with diabetes. Monitor carbohydrate consumption to achieve glycemic control Saturated fat should be <7% of total calories Minimize trans fat intake If adults with diabetes choose to use alcohol, daily intake should be limited to one drink per day or less for women and two or less for men. There is insufficient evidence on the efficacy of antioxidants, such as vitamins E and C and carotene, and concern regarding long-term safety; as such, supplementation with antioxidants is not recommended. Meal planning should be individualized and include optimization of food choices to meet recommended daily allowance (RDA)/dietary reference intake (DRI) for all micronutrients. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Provide diabetes self-management education (DSME) and diabetes self-management support (DSMS) to persons with diabetes at diagnosis and as needed thereafter. Effectiveness of self-management and quality of life should be measured and monitored as part of overall care. DSME and DSMS programs should Address psychosocial issues Provide education and support to persons with prediabetes to encourage behaviors that may prevent or delay diabetes onset American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Exercise programs should include the following: ≥ 150 min/week moderate-intensity aerobic activity (50%–70% maximum heart rate), spread over ≥3 days/week with no more than 2 consecutive days without exercise Resistance training ≥2 times/week (in the absence of contraindications) Patients should be evaluated for contraindications (eg, uncontrolled hypertension, severe autonomic or peripheral neuropathy, history of foot lesions, unstable proliferative retinopathy) that would prohibit certain types of exercise before recommending an exercise program. Age and previous level of physical activity should also be considered. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • It is reasonable to include psychological and social assessments of patient as part of diabetes management. Psychosocial screening and follow-up may include: Attitudes about diabetes Expectations for medical management and outcomes Affect/mood Quality of life Financial, social, emotional resources Psychiatric history In the presence of poor self-management, screen for depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Patients at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter. Glucose (15–20 g) is preferred treatment for hypoglycemia, although any form of glucose-containing carbohydrate can be used Repeat treatment if hypoglycemia continues (per self-monitoring of blood glucose [SMBG]) 15 minutes after initial treatment SMBG normal levels: patient should consume a meal or snack to prevent hypoglycemia recurrence Prescribe glucagon for all persons at significant risk of severe hypoglycemia. Glycemia targets should be raised among un-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia. Raise targets for several weeks to partially reverse hypoglycemia unawareness and reduce recurrence In cases of low or declining cognition, continually assess cognitive function with increased vigilance for hypoglycemia. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • The American Diabetes Association recommends the following for blood pressure screening and goals. Blood pressure (BP) screening Measure blood pressure (BP) at all routine visits. Elevated BP should be confirmed at a separate visit. BP goals <140 mm Hg systolic for those with diabetes and hypertension; lower targets (such as <130 mm Hg) may be appropriate in certain patients if target can be achieved without treatment burden <80 mm Hg diastolic for persons with diabetes American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • The American Diabetes Association recommends the following for blood pressure (BP) treatment. BP ≥120/80 mm Hg: advise on lifestyle changes to reduce BP, including weight loss (if overweight), Dietary Approaches to Stop Hypertension (DASH)-style diet (including reducing sodium and increasing potassium intake), moderation of alcohol intake, and increased physical activity BP ≥140/80 mm Hg: Lifestyle changes to reduce BP Initiation and titration of pharmacologic therapy to achieve BP goals For those with diabetes and hypertension, use either an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). If one class is not well tolerated, the other class should be used. ≥ 2 agents at maximal doses usually required to achieve BP targets Administer ≥1 agent at bedtime Monitor serum creatinine/estimated glomerular filtration rate and serum potassium if using ACE inhibitor, ARB, or diuretic Pregnant women with diabetes and hypertension 110–129/65–79 mm Hg target goal ACE inhibitor, ARBs contraindicated American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • The American Diabetes Association recommends the following with regard to antiplatelet therapies. Aspirin for primary prevention 75–162 mg/day recommended as primary prevention in patients with types 1 and 2 diabetes at increased cardiovascular disease (CVD) risk (10-year risk >10%) Aspirin not recommended in lower-risk individuals (10-year risk <5%) since potential adverse effects from bleeding likely offset potential benefits Use clinical judgment for treating patients in these age groups with multiple other risk factors (10-year risk 5%–10%) Aspirin for secondary prevention 75–162 mg/day recommended as a secondary prevention strategy in those with diabetes with history of CVD Clopidogrel 75 mg/day recommended for patients with CVD and documented aspirin allergy Combination therapy with aspirin (75–162 mg/day) and clopidogrel (75 mg/day) is reasonable for ≤1 year after acute coronary syndrome American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • The American Diabetes Association recommends an A1C goal of <7% for most adults with diabetes. A more or less stringent A1C goal may be appropriate for individual patients; goals should be individualized based on diabetes duration, age/life expectancy, comorbid conditions, known cardiovascular disease or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations. The recommended blood pressure goal for most adults with diabetes is <140/<80 mm Hg. Based on individual patient characteristics and response to therapy, higher or lower blood pressure targets may be appropriate. The recommended LDL-C level goal for most adults with diabetes is <100 mg/dL (<2.6 mmol/L). In patients with diabetes and overt cardiovascular disease, an LDL-C goal of <70 mg/dL (<1.8 mmol/L), using a high dose of a statin, is an option. Statin therapy is recommended for those with history of myocardial infarction or aged >40 years with other risk factors. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • With regard to smoking cessation, the American Diabetes Association recommends that all patients with diabetes should be advised not to smoke or use tobacco products. Patients should be counseled on smoking prevention and cessation as a routine. The level of nicotine dependence should be assessed, and pharmacologic therapy should be offered as appropriate. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Guidelines from the American Diabetes Association with regard to coronary heart disease screening and treatment cite that routine screening for coronary artery disease (CAD) is not recommended in asymptomatic patients: as long as cardiovascular disease (CVD) risk factors are treated, CAD screening in these patients does not improve outcomes. Consider angiotensin-converting enzyme (ACE) inhibitor therapy and use aspirin and statin to reduce CV event risk in those with overt CVD. Continue use of beta-blockers for ≥2 years in those with prior myocardial infarction Avoid thiazolidinediones in those with symptomatic heart failure. Metformin may be used in patients with stable heart failure in presence of normal renal function. Avoid metformin in unstable or hospitalized heart failure patients American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Glucose and blood pressure control should be optimized to reduce risk or slow progression of nephropathy. Measure urine albumin excretion annually in type 1 patients with ≥5-year diabetes duration, and in all type 2 patients starting at diagnosis. Measure serum creatinine annually in all patients, regardless of degree of urine albumin excretion. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) recommended for nonpregnant patients with modest elevations (30-299 mg/day; microalbuminuria) or higher levels (≥300 mg/day; macroalbuminuria or clinical albuminuria) of urinary albumin excretion (<30 mg/day, normal). Limit protein intake to 0.8–1.0 g/kg body weight/day in patients with diabetes and early stages of chronic kidney disease (CKD) and to 0.8 g/kg body weight/day in advanced CKD. Monitor serum creatinine and potassium levels in all patients receiving angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or diuretics Monitor urine albumin excretion continually to assess therapeutic response and disease progression If estimated glomerular filtration rate (eGFR) is <60 mL/min/1.73 m2: evaluate and manage potential chronic kidney disease complications Consider specialist referral for: uncertainty about etiology of kidney disease, difficult management issues, advanced kidney disease. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Glycemic and blood pressure control should be optimized to reduce risk or slow progression of diabetic retinopathy. An initial dilated and comprehensive eye exam should be performed by an ophthalmologist or optometrist. Adults and children ≥10 years with type 1 diabetes: within 5 years after diabetes onset Patients with type 2 diabetes: shortly after diagnosis Repeat eye exam annually for all patients, less frequently (every 2–3 years) following ≥1 normal exam More frequent exams may be needed in presence of progressing retinopathy Fundus photographs may be used to screen for retinopathy; fundus photographs should not be used as a substitute for a comprehensive eye exam. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Pregnant women with preexisting diabetes should have an eye exam and retinopathy counseling in the first trimester with close follow-up throughout pregnancy and 1 year postpartum. In cases of macular edema, severe nonproliferative diabetic retinopathy (NPDR), any proliferative diabetic retinopathy (PDR): refer to an ophthalmologist specializing in retinopathy. Laser photocoagulation therapy is indicated to reduce risk of vision loss for high-risk PDR, clinically significant macular edema, and some cases of severe NPDR. Anti-vascular endothelial growth factor (VEGF) therapy is indicated for diabetic macular edema. Presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • An annual foot exam is recommended for all patients with diabetes to identify high-risk conditions and risk factors predictive of ulcers and amputations. Foot self-care education should be provided to all patients. A multidisciplinary approach is recommended for patients with foot ulcers and high-risk feet, in particular, those with previous ulcer or amputation. Refer patients with the following to a foot care specialist: loss of protective sensation and structural abnormalities, history of prior lower-extremity complications. Include history for claudication and assessment of pedal pulses in initial peripheral arterial disease screenings; also consider obtaining ankle-brachial index (ABI). Refer positive ABI or significant claudication for further vascular assessment and consider exercise, medications, and surgical options. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Encourage children/adolescents with diabetes or prediabetes to engage in ≥60 minutes of physical activity/day. Consider age when setting glycemic goals for children/adolescents with type 1 diabetes. Screen for and manage complications, which may include Nephropathy Hypertension Dyslipidemia Retinopathy Celiac disease Hypothyroidism Provide support and links to resources as individuals transition from pediatric to adult care. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • With regard to preconception care, the American Diabetes Association recommends that A1C levels be maintained as close to normal as possible (<7.0%) before attempting conception. Preconception counseling should be provided starting at puberty for all women of childbearing potential. Evaluate and treat (if necessary) diabetic retinopathy, nephropathy, neuropathy, and cardiovascular disease in women contemplating pregnancy. Evaluate and consider the risk/benefit profile of medications being used for treatment of diabetes and associated conditions prior to conception. Statins, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and most noninsulin therapies are contraindicated/not recommended in pregnancy. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Diabetes treatment goals for younger adults are appropriate for older adults who are functional and cognitively intact, and expected to live long enough to reap benefits. Relax glycemic goals if they are not being met using individual criteria, but avoid hyperglycemic complications. Treat cardiovascular risk factors considering time frame of benefit and individual patient characteristics. Hypertension treatment is indicated in many older adults; lipid and aspirin therapy may benefit those with life expectancy equal to time frame of primary or secondary prevention trials. Individualize screening for complications, paying particular attention to complications that may lead to functional impairment. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • The American Diabetes Association recommends that annual screening for cystic fibrosis-related diabetes (CFRD) using an oral glucose tolerance test (OGTT) should begin by age 10 in those with cystic fibrosis who do not have CFRD. A1C is not recommended as screening test. CFRD diagnosis can be made using usual glucose criteria during a period of stable health. Treat patients with insulin to achieve individualized glycemic goals. Annual monitoring for diabetes complications is recommended starting 5 years post-CFRD diagnosis. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Diabetes should be clearly identified in the patient’s medical record. Blood glucose monitoring should be ordered for all patients with results made available to healthcare team. Goals for blood glucose levels in critically ill patients Initiate insulin for treatment of persistent hyperglycemia starting at threshold of ≤180 mg/dL (10.0 mmol/L); once insulin is started, 140–180 mg/dL (7.8–10.0 mmol/L) is the recommended range for most patients More stringent goals (such as 110–140 mg/dL [6.1–7.8 mmol/L]) may be appropriate for certain patients IV insulin protocol with demonstrated efficacy and safety in achieving glucose targets with no increased hypoglycemia risk Goals for blood glucose in non–critically ill patients No clear evidence for specific goals; insulin-treated: premeal target <140 mg/dL (7.8 mmol/L) with random blood glucose <180 mg/dL (10.0 mmol/L) More or less stringent targets may be appropriate for certain patients American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • The preferred method for achieving/maintaining glucose control in non–critically ill patients is scheduled subcutaneous insulin with basal, nutritional, and correction components. Monitor glucose in nondiabetic patients receiving therapy associated with high risk for hyperglycemia, and consider treating these patients to the same goals as patients with known diabetes. Establish hypoglycemia management protocol and create a plan for each patient for treating and preventing hypoglycemia; track all hypoglycemic episodes. Consider obtaining A1C for Patients with diabetes if no previous test results from last 2–3 months available Patients with risk factors for undiagnosed diabetes who exhibit hyperglycemia Patients with hyperglycemia with no prior diabetes should have plans for follow-up testing and care documented at discharge. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Consider referring relatives of individuals with type 1 diabetes for antibody testing for risk assessment in clinical research setting. Such testing, in addition to diabetes education and follow-up in an observational clinical study, may allow for earlier identification of onset and lessen the likelihood of presentation with ketoacidosis at diagnosis. Widespread testing of asymptomatic low-risk persons is not recommended, as this type of testing would identify few individuals who are at risk. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
  • Most patients with type 1 diabetes: Treat with multiple-dose insulin injections (3-4 injections/day of basal and prandial insulin) or continuous subcutaneous insulin infusion Educate how to match prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated activity Use insulin analogs to reduce risk of hypoglycemia Consider screening for autoimmune diseases such as thyroid dysfunction, vitamin B12 deficiency, and celiac disease as appropriate. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care . 2013;36(suppl 1):S11-S66. January 2013 Click here to return to NDEI.org. This slide was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.
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