3. Process
• ADA’s Professional Practice Committee (PPC)
conducts annual review & revision.
• Searched Medline for human studies related to each
subsection and published since January 1, 2015.
• Recommendations revised per new evidence, for
clarity, or to better match text to strength of
evidence.
Professional.diabetes.org/SOC
4. Clinical Practice Recommendations Evidence Grading System
American Diabetes Association Standards of Medical Care in Diabetes.
Introduction. Diabetes Care 2016; 39 (Suppl. 1): S1-S2
5. • Higher level recommendations defined as A or B evidence grades
• Lower level recommendations defined as C or E evidence grades
Trends in the Number and Proportion of Higher and Lower
Level Recommendations
Grant R W , and Kirkman M S Dia Care 2015;38:6-8
6. Care Delivery Systems
• 33-49% of patients still do not meet targets for A1C,
blood pressure, or lipids.
• 14% meet targets for all A1C, BP, lipids, and nonsmoking
status.
• Progress in CVD control is slowing.
• Substantial system-level improvements are needed.
• Delivery system is fragmented, lacks clinical information
capabilities, duplicates services & is poorly designed.
American Diabetes Association Standards of Medical Care in Diabetes.
Strategies for improving diabetes care. Diabetes Care 2016; 39 (Suppl. 1): S6-S12
7. Change the Care System
Successful practices prioritize providing a high quality
of care. Changes that have been shown to increase
quality of care include:
1. Basing care on evidence-based guidelines
2. Expanding the role of teams to implement more intensive
disease management strategies
3. Redesigning the care process
4. Implementing electronic health record tools
5. Activating and educating patients
American Diabetes Association Standards of Medical Care in Diabetes.
Strategies for improving diabetes care. Diabetes Care 2016; 39 (Suppl. 1): S6-S12
8. Change the Care System (2)
Successful practices prioritize providing a high quality of
care. Changes that have been shown to increase quality of
care include:
6. Removing financial barriers and reducing patient out-of-pocket
costs
7. Identifying community resources and public policy that supports
healthy lifestyles
8. Coordinated primary care, e.g., through Patient-Centered
Medical Home
9. Changes to reimbursement structure
American Diabetes Association Standards of Medical Care in Diabetes.
Strategies for improving diabetes care. Diabetes Care 2016; 39 (Suppl. 1): S6-S12
9. 1. Type 1 diabetes
– β-cell destruction
2. Type 2 diabetes
– Progressive insulin secretory defect
3. Gestational Diabetes Mellitus (GDM)
4. Other specific types of diabetes
– Monogenic diabetes syndromes
– Diseases of the exocrine pancreas, e.g., cystic fibrosis
– Drug- or chemical-induced diabetes
Classification of Diabetes
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
10. Fasting plasma glucose (FPG)
≥126 mg/dL (7.0 mmol/L)
OR
2-h plasma glucose ≥200 mg/dL
(11.1 mmol/L) during an OGTT
OR
A1C ≥6.5%
OR
Random plasma glucose
≥200 mg/dL (11.1 mmol/L)
Criteria for the Diagnosis of Diabetes
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
11. A1C ≥6.5% *
• Performed in a laboratory using a method that is
NGSP certified and standardized to the DCCT assay -
www.ngsp.org
• POC testing not recommended
• Greater convenience, preanalytical stability, and less
day-to-day perturbations than FPG and OGTT
• Consider cost, age, race/ethnicity, anemia, etc.
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
12. FPG 100–125 mg/dL
(5.6–6.9 mmol/L): IFG
OR
2-h plasma glucose 140–199 mg/dL (7.8–11.0
mmol/L): IGT
OR
A1C 5.7–6.4%
Prediabetes*
* For all three tests, risk is continuous, extending below the lower limit of a
range and becoming disproportionately greater at higher ends of the range.
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
13. • Consider testing in asymptomatic adults of any
age with BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian
Americans who have 1 or more add’l dm risk
factors. B
• For all patients, testing should begin at age 45
years. B
• If tests are normal, repeat testing carried out at a
minimum of 3-year intervals is reasonable. C
Recommendations: Screening for T2DM
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
14. Recommendations: Monogenic Diabetes Syndromes
All children diagnosed with diabetes in the first 6
months of life should have genetic testing. B
• Consider Maturity-Onset Diabetes of the Young (MODY) in
patients who have mild stable fasting hyperglycemia and
multiple family members with diabetes not characteristic of
T1DM or T2DM. E
• Consider referring individuals with diabetes that is not typical
of T1DM or T2DM and occurs in successive
generations to a specialist for further evaluation. E
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
15. Criteria for Testing for T2DM in Children & Adolescents
• Overweight plus any 2 :
– Family history of type 2 diabetes in 1st or 2nd degree relative
– Race/ethnicity
– Signs of insulin resistance or conditions associated with
insulin resistance
– Maternal history of diabetes or GDM
• Age of initiation 10 years or at onset of puberty
• Frequency: every 3 years
• Screen with A1C
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
16. • Women with GDM history should have lifelong
screening for development of diabetes or
prediabetes at least every 3 years. B
• Women with GDM history found to have
prediabetes should receive lifestyle interventions
or metformin to prevent diabetes. A
Recommendations: Detection and Diagnosis of GDM
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
17. Basis for Initial Care
• Diabetes Self-Management Education (DSME)
• Diabetes Self-Management Support (DSMS)
• Medical Nutrition Therapy (MNT)
• Physical activity education
• Smoking cessation counseling
• Guidance on routine immunizations
• Psychosocial care
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care
and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
18. Recommendations: Diabetes Self-Management Education & Support
• All people with diabetes should participate in DSME and
DSMS both at diagnosis and as needed thereafter. B
• Effective self-management, improved clinical outcomes,
health status, and quality-of-life are key outcomes of
DSME and DSMS and should be measured and
monitored as part of care. C
• DSME/S should be patient-centered, respectful, and
responsive to individual patient preferences, needs, and
values that should guide clinical decisions. A
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care
and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
19. Recommendations: Nutrition
Effectiveness of Nutrition Therapy:
● An individualized MNT program is recommended for all
people with type 1 and type 2 diabetes. A
● For people with T1DM or those with T2DM who are on a
flexible insulin program, education on carb counting or
estimation. A
● For patients on a fixed insulin program, having a
consistent pattern of carbohydrate intake with respect to
time and amount can result in improved glycemic control
and a reduced risk of hypoglycemia. B
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care
and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
20. Recommendations: Physical Activity
• Children with diabetes/prediabetes: at least 60 min/day
physical activity B
• Adults with diabetes: at least 150 min/wk of moderate-
intensity aerobic activity over at least 3 days/week with no
more than 2 consecutive days without exercise A
• All individuals, including those with diabetes, should reduce
sedentary time, particularly by breaking up extended amounts
of time (>90 min) spent sitting. B
• Adults with type 2 diabetes should perform resistance training
at least twice weekly A
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care
and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
21. Recommendations: Smoking Cessation
• Advise all patients not to use cigarettes, other
tobacco products, or e-cigarettes. A
• Include smoking cessation counseling and other
forms of treatment as a routine component of
diabetes care. B
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care
and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
22. Recommendations: Psychosocial Care
• Routinely screen for depression, diabetes-related
distress, anxiety, eating disorders & cognitive
impairment. B
• Adults aged ≥65 years with DM should be
considered for evaluation of cognitive function,
depression screening and treatment. B
• Patients with diabetes and depression should
receive a collaborative care approach for depression
mgmt. A
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care
and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
23. Diabetes Care: Glycemic Control
• Two primary techniques available for health
providers and patients to assess effectiveness of
management plan on glycemic control
1. Patient self-monitoring of blood glucose (SMBG)
2. A1C
• CGM or interstitial glucose may be a useful
adjunct to SMBG in selected patients.
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
24. Recommendations: Glucose Monitoring
• Patients on multiple-dose insulin (MDI) or insulin
pump therapy should do SMBG B
– Prior to meals and snacks
– 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
– Possibly also post-prandially
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
25. Recommendations: A1C Testing
• Perform the A1C test at least 2x annually in
patients that meet treatment goals (and have
stable glycemic control). E
• Perform the A1C test quarterly in patients whose
therapy has changed or who are not meeting
glycemic goals. E
• Use of point-of-care (POC) testing for A1C
provides the opportunity for more timely treatment
changes. E
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
26. Recommendations: Glycemic Goals in Adults
• Lowering A1C to <7% has been shown to reduce
microvascular complications and, if implemented soon
after the diagnosis of diabetes, is associated with long-
term reduction in macrovascular disease. B
• Consider more stringent goals (e.g. <6.5%) for select
patients if achievable without significant hypos or other
adverse effects. C
• Consider less stringent goals (e.g. <8%) for patients with
a hx of severe hypoglycemia, limited life expectancy, or
other conditions that make <7% difficult to attain. B
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
27. Recommendations: Pharmacological Therapy For T1DM
• Most people with T1DM should be treated with
multiple dose insulin (MDI) injections
(3-4 injections /day of basal & prandial insulin) or
continuous subcutaneous insulin infusion (CSII). A
• Individuals who have been successfully using
CSII should have continued access after they turn
65 years old. E
American Diabetes Association Standards of Medical Care in Diabetes.
Approaches to glycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S59
28. Recommendations: Pharmacological Therapy For T1DM (2)
• Consider educating individuals with T1DM on
matching prandial insulin dose to carbohydrate
intake, premeal blood glucose, and anticipated
activity. E
• Most individuals with T1DM should use insulin
analogs to reduce hypoglycemia risk. A
American Diabetes Association Standards of Medical Care in Diabetes.
Approaches to glycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S59
29. Antihyperglycemic Therapy in T2DM
American Diabetes Association Standards of Medical Care in Diabetes. Approaches to Glycemic
Treatment. Diabetes Care 2016; 39 (Suppl. 1): SX
30. Approach to the Management of Hyperglycemia
low high
newly diagnosed long-standing
long short
absent severe
Few/mild
absent severe
Few/mild
highly motivated, adherent, excellent
self-care capabilities
readily available limited
less motivated, nonadherent, poor
self-care capabilities
A1C
7%
more
stringent
less
stringent
Patient/Disease Features
Risks associated with hypoglycemia
& other drug adverse effects
Disease Duration
Life expectancy
Important comorbidities
Established vascular complications
Patient attitude & expected
treatment efforts
Resources & support system
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
31. Cardiovascular Disease
• CVD is the leading cause of morbidity & mortality for those
with diabetes.
• Largest contributor to direct/indirect costs
• Common conditions coexisting with T2DM (e.g., hypertension,
dyslipidemia) are clear risk factors for ASCVD.
• Diabetes itself confers independent risk
• Control individual cardiovascular risk factors to prevent/slow
CVD in people with diabetes.
• Systematically assess all patients with diabetes for
cardiovascular risk factors.
American Diabetes Association Standards of Medical Care in Diabetes.
Cardiovascular disease and risk management. Diabetes Care 2016; 39 (Suppl. 1): S60-S71
32. Recommendations: Hypertension/ Blood Pressure Control
Systolic Targets:
• People with diabetes and hypertension should be
treated to a systolic blood pressure goal of <140
mmHg. A
• Lower systolic targets, such as <130 mmHg, may
be appropriate for certain individuals, such as
younger patients, if it can be achieved without
undue treatment burden. C
American Diabetes Association Standards of Medical Care in Diabetes.
Cardiovascular disease and risk management. Diabetes Care 2016; 39 (Suppl. 1): S60-S71
33. Recommendations: Hypertension/ Blood Pressure Control (2)
Diastolic Targets:
• Patients with diabetes should be treated to a
diastolic blood pressure <90 mmHg. A
• Lower diastolic targets, such as <80 mmHg, may
be appropriate for certain individuals, such as
younger patients, if it can be achieved without
undue treatment burden. B
American Diabetes Association Standards of Medical Care in Diabetes.
Cardiovascular disease and risk management. Diabetes Care 2016; 39 (Suppl. 1): S60-S71
34. Age Risk Factors Statin Intensity*
<40 years
None None
ASCVD risk factor(s)** Moderate or high
ASCVD High
40–75 years
None Moderate
ASCVD risk factors High
ACS & LDL >50 who can’t tolerate high dose statin Moderate + ezetimibe
>75 years
None Moderate
ASCVD risk factors Moderate or high
ASCVD High
ACS & LDL >50 who can’t tolerate high dose statin Moderate + ezetimibe
Recommendations for Statin Treatment in People with Diabetes
* In addition to lifestyle therapy. ** ASCVD risk factors include LDL cholesterol ≥100 mg/dL (2.6 mmol/L),
high blood pressure, smoking, overweight and obesity, and family history of premature ASCVD.
American Diabetes Association Standards of Medical Care in Diabetes.
Cardiovascular disease and risk management. Diabetes Care 2016; 39 (Suppl. 1): S60-S71
35. Recommendations: Antiplatelet Agents
Consider aspirin therapy (75–162 mg/day) C
• As a primary prevention strategy in those with T1DM or
T2DM at increased cardiovascular risk
(10-year risk >10%)
• Includes most men or women with diabetes age ≥50 years
who have at least one additional major risk factor, including:
– Family history of premature ASCVD
– Hypertension
– Smoking
– Dyslipidemia
– Albuminuria
American Diabetes Association Standards of Medical Care in Diabetes.
Cardiovascular disease and risk management. Diabetes Care 2016; 39 (Suppl. 1): S60-S71
36. Recommendations: Coronary Heart Disease
Screening
• In asymptomatic patients, routine screening for CAD
isn’t recommended & doesn’t improve outcomes
provided ASCVD risk factors are treated. A
• Consider investigations for CAD with:
– Atypical cardiac symptoms (e.g. unexplained dyspnea, chest discomfort)
– Signs or symptoms of associated vascular disease incl. carotid bruits,
transient ischemic attack, stroke, claudication or PAD
– EKG abnormalities (e.g. Q waves) E
American Diabetes Association Standards of Medical Care in Diabetes.
Cardiovascular disease and risk management. Diabetes Care 2016; 39 (Suppl. 1): S60-S71
37. Recommendations: Diabetic Kidney Disease
Treatment
• Optimize glucose control to reduce risk or slow
progression of diabetic kidney disease. A
• Optimize blood pressure control
(<140/90 mmHg) to reduce risk or slow
progression of diabetic kidney disease. A
American Diabetes Association Standards of Medical Care in Diabetes.
Microvascular complications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
38. Management of CKD in Diabetes
GFR Recommended
All
patient
s
Yearly measurement of creatinine, urinary albumin
excretion, potassium
45-60 Referral to a nephrologist if possibility for nondiabetic
kidney disease exists
Consider dose adjustment of medications
Monitor eGFR every 6 months
Monitor electrolytes, bicarbonate, hemoglobin, calcium,
phosphorus, parathyroid hormone at least yearly
Assure vitamin D sufficiency
Consider bone density testing
Referral for dietary counselling
American Diabetes Association Standards of Medical Care in Diabetes.
Microvascular complications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
39. Management of CKD in Diabetes (2)
GFR Recommended
30-44 Monitor eGFR every 3 months
Monitor electrolytes, bicarbonate, calcium,
phosphorus, parathyroid hormone,
hemoglobin, albumin
weight every 3–6 months
Consider need for dose adjustment of
medications
<30 Referral to a nephrologist
American Diabetes Association Standards of Medical Care in Diabetes.
Microvascular complications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
40. Recommendations: Diabetic Retinopathy
• To reduce the risk or slow the progression of
retinopathy
– Optimize glycemic control A
– Optimize blood pressure control A
American Diabetes Association Standards of Medical Care in Diabetes.
Microvascular complications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
41. Recommendations: Diabetic Retinopathy (2)
Screening:
• Initial dilated and comprehensive eye
examination by an ophthalmologist or optometrist:
– Adults with type 1 diabetes, within 5 years of diabetes
onset. B
– Patients with type 2 diabetes at the time of diabetes
diagnosis. B
American Diabetes Association Standards of Medical Care in Diabetes.
Microvascular complications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
42. Recommendations: Diabetic Retinopathy (3)
Treatment:
• Promptly refer patients with macular edema,
severe NPDR, or any PDR to an ophthalmologist
knowledgeable & experienced in management,
treatment of diabetic retinopathy. A
• Laser photocoagulation therapy is indicated to
reduce the risk of vision loss in patients with
high-risk PDR and, in some cases, severe NPDR. A
American Diabetes Association Standards of Medical Care in Diabetes.
Microvascular complications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
43. Screening:
• Assess all patients for DPN at dx for T2DM, 5 years after
dx for T1DM, and at least annually thereafter. B
• Assessment should include history & 10g monofilament
testing, and at least one of the following: pinprick,
temperature, and vibration sensation. B
• Autonomic neuropathy symptoms should be assessed in
patients with microvascular & neuropathic complications. E
Recommendations: Neuropathy
American Diabetes Association Standards of Medical Care in Diabetes.
Microvascular complications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
44. Treatment:
• Optimize glucose control to prevent or delay the
development of neuropathy in patients with T1DM
A & to slow progression in patients with T2DM. B
• Assess & treat patients to reduce pain related to
DPN B and symptoms of autonomic neuropathy
and to improve quality of life. E
Recommendations: Neuropathy (2)
American Diabetes Association Standards of Medical Care in Diabetes.
Microvascular complications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
45. • Perform a comprehensive foot evaluation
annually to identify risk factors for ulcers &
amputations. B
• History should contain prior hx of ulceration,
amputation, Charcot foot, angioplasty or
vascular surgery, cigarette smoking, retinopathy
& renal disease; and should assess current
symptoms of neuropathy and vascular disease.
B
Recommendations: Foot Care
American Diabetes Association Standards of Medical Care in Diabetes.
Microvascular complications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
46. • Functional, cognitively intact older adults
(≥65 years of age) with significant life expectancy
should receive diabetes care using goals
developed for younger adults. E
• Determine targets & therapeutic approaches by
assessment of medical, functional, mental, and
social geriatric domains for diabetes
management. E
Recommendations: Older Adults
American Diabetes Association Standards of Medical Care in Diabetes.
Older adults. Diabetes Care 2016; 39 (Suppl. 1): S81-S85
47. Trends in age-standardized rates of diabetes-related
complications among U.S. adults with diabetes, 1990-2010
-67.8%
-52.9%
-51.4%
-28.3%
-64.4%
0
20
40
60
80
100
120
140
1990 1995 2000 2005 2010
Cases/10,000
persons Acute MI
Stroke
Amputation
ESRD
Death from Hyperglycemic Crisis
American Diabetes Association Standards of Medical Care in Diabetes.
Older adults. Diabetes Care 2016; 39 (Suppl. 1): S81-S85
Editor's Notes
Trend from 2005 to 2014 in number and proportion of recommendations (Recs) made each year in the ADA Standards of Care that were based on higher-level evidence vs. lower-level evidence.
Reference:
Grant RW, Kirkman MS. Trends in the Evidence Level for the ADA Standards of Medical Care in Diabetes from 2004 – 2014. Diabetes Care. 2015 Jan;
Here are the diagnostic cutpoints for prediabetes across the three tests. Note that risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range.
[SLIDE]
Type 2 diabetes, previously referred to as “non-insulin-dependent diabetes” or “adult-onset diabetes,” accounts for 90–95% of all diabetes. This form encompasses individuals who have insulin resistance and usually relative (rather than absolute) insulin deficiency. At least initially, and often throughout their lifetime, patients with type 2 diabetes may not need insulin treatment to survive.
These recommendations look just like the screening recommendations for prediabetes, so we won’t spend more time on them.
[SLIDE]
Diabetes Self-Management Education, Diabetes Self-Management Support, Medical Nutrition Therapy, counseling on smoking cessation, education on physical activity, guidance on routine immunizations, and psychosocial care are the cornerstone of diabetes management.
Patients should be referred for such services if not readily available in the clinical care setting.
[SLIDE]
Here are the recommendations on diabetes self management education and support.
In accordance with the National Standards for Diabetes Self-Management Education and Support, the Association recommends that all people with diabetes should participate in DSME, to facilitate knowledge, skill, and ability necessary for diabetes self-care, and DSMS, to assist with implementing and sustaining skills and behaviors needed for on-going self-management, both at diagnosis and as needed thereafter. [CLICK]
Effective self-management, improved clinical outcomes, health status, and quality-of-life are key outcomes of DSME and DSMS and should be measured and monitored as part of care. [CLICK]
DSME and DSMS should be patient-centered, respectful, and responsive to individual patient preferences, needs, and values that should guide clinical decisions
[SLIDE]
Routinely screen for psychosocial problems such as depression, diabetes-related distress, anxiety, eating disorders, and cognitive impairment. [CLICK]
Older adults (aged ≥65 years) with diabetes should be considered for evaluation of cognitive function, depression screening and treatment. [CLICK]
And finally,
Patients with comorbid diabetes and depression should receive a stepwise collaborative care approach for the management of depression.
[SLIDE]
In addition to an initial evaluation and management, diabetes care requires an assessment of glycemic control
Two primary techniques available for health providers and patients to assess the effectiveness of the management plan on glycemic control are summarized on this slide
Patient self-monitoring of blood glucose (SMBG)
A1C
Continuous Glucose Monitoring or interstitial glucose may be a useful adjunct to SMBD in some patients.
Recommendations for glucose monitoring, A1C testing, correlation of A1C with average glucose, glycemic goals in adults, intensive glycemic control and cardiovascular outcomes, and recommended glycemic goals for many nonpregnant adults with diabetes as well as glycemic goals in pregnant women are summarized in the following slides.
[SLIDE]
Recommendations for glucose monitoring are summarized on three slides
Patients on multiple-dose insulin (MDI) or insulin pump therapy should do SMBG 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, and prior to critical tasks such as driving This may mean testing 6-10 times per day, though individual needs vary. But at least in studies of children with type 1 diabetes, increased daily frequency of SMBG was significantly associated with lower A1C.
SMBG frequency and timing should be dictated by the patient’s specific needs and goals
SMBG is especially important for patients treated with insulin to monitor for and prevent asymptomatic hypoglycemia and hyperglycemia
[SLIDE]
A1C reflects average glycemia over several months and has strong predictive value for diabetes complications. Thus, A1C testing should be performed routinely in all patients with diabetes—at initial assessment and as part of continuing care. Measurement about every 3 months determines whether patients’ glycemic targets have been reached and maintained, though the frequency of A1C testing should depend on the clinical situation, the treatment regimen, and the clinician’s judgment.
For your patients meeting treatment goals and with stable control, check the A1C at least twice a year, and for your patients whose therapy has changed or who aren’t meeting glycemic goals, test quarterly. You may also have patients who are unstable or highly intensively managed, such as pregnant women with type 1, whom you may wish to test more frequently than every 3 months.
Point of care A1C testing can help accommodate more timely decisions, for example on when to change therapy.
The A1C test is subject to certain limitations: conditions that affect erythrocyte turnover (e.g., hemolysis, blood loss) and hemoglobin variants must be considered, particularly when the A1C result does not correlate with the patient’s clinical situation;2 in addition, A1C does not provide a measure of glycemic variability or hypoglycemia
For patients prone to glycemic variability (especially type 1 diabetic patients, or type 2 diabetic patients with severe insulin deficiency), glycemic control is best judged by the combination of result of self-monitoring of blood glucose (SMBG) testing and A1C
The A1C may also confirm the accuracy of a patient’s meter (or the patient’s reported SMBG results) and the adequacy of the SMBG testing schedule
[SLIDE]
We’ll discuss glycemic goals in children and adolescents and in pregnant women in the sections specific to care of those populations. These slides are specific to nonpregnant adults.
Hyperglycemia defines diabetes, and glycemic control is fundamental to diabetes management; recommendations for glycemic goals in adults1 are reviewed on three slides. The concerning mortality findings in the ACCORD trial, discussed which we’ll get to shortly, and the relatively intense efforts required to achieve near-euglycemia should also be considered when setting glycemic targets.
Glycemic control achieved using A1C targets of <7% has been shown to reduce microvascular complications of diabetes and, in type 1 diabetes, mortality. If implemented soon after the diagnosis of diabetes this target is associated with long-term reduction in macrovascular disease.
Providers might suggest more stringent A1C goals (such as <6.5%) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease.
Less stringent A1C goals (such as <8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin.
[SLIDE]
Starting off with type 1 diabetes, there are plenty of other resources out there on initiating and managing insulin therapy, so we won’t go into that here.
Most of your patients with type 1 diabetes should be treated with multiple dose injections or insulin pump therapy. There are minimal differences between the two as far as hypoglycemia is concerned. Whichever one a patient chooses, intensive management and active patient or family participation should be strongly encouraged. [CLICK]
Individuals who have been successfully using an insulin pump should have continued access after they turn 65.
[SLIDE]
Consider educating your patients with type 1 diabetes on matching prandial insulin doses to carbohydrate intake, premeal blood glucose, and anticipated activity. [CLICK]
And finally, most individuals with type 1 should use insulin analogs to reduce the risk of hypoglycemia.
[SLIDE]
This slide summarizes the general recommendations for antihyperglycemic therapy in type 2 diabetes, as outlined in the ADA-European Association for the Study of Diabetes (EASD) position statement
Definitions: DPP-4-i,DPP-4 inhibitor; Fx’s, bone fractures; GI, gastrointestinal; GLP-1-RA, GLP-1 receptor agonist; HF, heart failure; SU, sulfonylurea; TZD, thiazolidinedione
This 2015 position statement is less prescriptive than prior algorithms and discusses advantages/disadvantages of the available medication classes and considerations for use
A patient-centered approach is stressed, including patient preferences, cost and potential side effects of each class, effects on body weight, and hypoglycemia risk
Metformin is reaffirmed as the preferred initial agent, barring contraindication or intolerance, either in addition to lifestyle counseling and support for weight loss and exercise, or when lifestyle efforts alone have not achieved or maintained glycemic goals
The progressive nature of type 2 diabetes and its therapies should be regularly and objectively explained to patients
Equipping patients with an algorithm for self-titration of insulin doses based on SMBG results improves glycemic control in type 2 diabetic patients initiating insulin3
This slide, “Approach to Management of Hyperglycemia,” depicts the elements of decision making used to determine appropriate efforts to achieve glycemic targets1 (Adapted with permission from Inzucchi et al.)
You may have seen this before, but in case not we’ll walk through it briefly. Going down the left side you see a series of patient or disease characteristics with a corresponding A1C impact scale on the right. The small end of the triangle aligns with a more stringent A1C and the fatter end aligns with less stringent A1C. So taking the first one, the red triangle, risks associated with hypoglycemia and other drug adverse effects…. Clearly the risks are lower with a more stringent A1C and higher with a less stringent A1C.
These are grouped into two categories, the [CLICK] top set consists of factors that are usually not modifiable and [CLICK] the bottom set may be potentially modifiable.
Where possible, such decisions should be made in conjunction with the patient, reflecting his or her preferences, needs, and values
This “scale” is not designed to be applied rigidly but to be used as a broad construct to help guide clinical decisions
Those with long duration of diabetes, known history of severe hypoglycemia, advanced atherosclerosis, and advanced age/frailty may benefit from less aggressive targets
Providers should be vigilant in preventing severe hypoglycemia in patients with advanced disease and should not aggressively attempt to achieve near-normal A1C levels in patients in whom such targets cannot be safely and reasonably achieved
Severe or frequent hypoglycemia is an absolute indication for the modification of treatment regimens, including setting higher glycemic goals
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Cardiovascular disease is the major cause of morbidity and mortality for individuals with diabetes, and the largest contributor to the direct and indirect costs of diabetes [CLICK]
The common conditions coexisting with type 2 diabetes, such as hypertension and dyslipidemia, are clear risk factors for atherosclerotic cardiovascular disease, and diabetes itself confers independent risk [CLICK]
Common conditions coexisting with type 2 diabetes are clear risk factors for ASCVD. [CLICK]
Diabetes confers independent risk for ASCVD [CLICK]
Numerous studies have shown the efficacy of controlling individual cardiovascular risk factors in preventing of slowing CVD in people with diabetes. Large benefits are seen when multiple risk factors are addressed globally. [CLICK]
Finally, the Association recommends systematic assessment at least annually of all people with diabetes for cardiovascular risk factors, including dyslipidemia, hypertension, smoking, family history of premature coronary disease, and the presence of albuminuria. Abnormal risk factors should be treated.
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People with diabetes and hypertension should be treated to a systolic blood pressure goal of <140 mmHg. There is strong evidence that systolic BP greater than 140 is harmful, and suggests clinicians should promptly initiate and titrate therapy in an ongoing fashion to achieve and maintain SBP <140 mmHg in most patients; We’ll talk about your older adult patients shortly;
Lower systolic targets, such as <130 mmHg, may be appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden.
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Similarly, strong evidence from randomized clinical trials supports diastolic blood pressure targets less than 90.
Lower diastolic targets, such as <80 mmHg, may be appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden.
These targets are in harmonization with a recent publication by the Eighth Joint National Committee that recommended, for individuals over 18 years of age with diabetes, a DBP threshold of <90 mmHg and SBP <140 mmHg.
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Here is a summary of recommendations for statin treatment in people with diabetes. All of these recommendations are in addition to lifestyle therapy, as indicated by the asterisk by Recommended Statin Intensity.
For your patients less than 40 years old without ASCVD risk factors, no statins are recommended. If they do have risk factors-- which, as indicated by the double asterisk there, include LDL ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, overweight or obesity, and family history of premature ASCVD–moderate or high dose statin therapy is recommended. For patients with overt ASCVD, a high dose is recommended.
For your patients aged 40-75 with no risk factors, moderate dose statin therapy is recommended in addition to lifestyle. For patients in this age group with ASCVD risk factors, a high dose is recommended, and for your patients with acute coronary syndrome and LDL over 50 who can’t tolerate high dose statin therapy, a moderate dose plus ezetimibe is recommended (along with lifestyle intervention).
And finally, for your patients over 75 years old with no risk factors, a moderate dose is recommended. With ASCVD risk factors, a moderate or high dose, and with overt ASCVD, a high dose along with that lifestyle therapy. And again for your patients in this age group with acute coronary syndrome and LDL over 50 who can’t tolerate high dose statin therapy, moderate dose plus ezetimibe is recommended.
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*In addition to lifestyle therapy.
**ASCVD risk factors include LDL cholesterol ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, overweight and obesity, and family history of premature ASCVD.
Aspirin has been shown to be effective in reducing cardiovascular morbidity and mortality in high-risk patients with previous MI or stroke (secondary prevention). Its net benefit in primary prevention among patients with no previous cardiovascular events is more controversial, both for patients with and without diabetes.
Multiple recent well-conducted studies and meta-analyses reported a risk of heart disease and stroke that is equivalent if not higher in women compared to men with diabetes, including among non-elderly adults. Thus, the recommendations for using aspirin as primary prevention are now revised to include both men and women aged 50 years or older with diabetes and one or more major risk factors, to reflect these more recent findings.
Recommendations for the use of antiplatelet agents are summarized in three slides.
Consider aspirin therapy as a primary prevention strategy in those with type 1 and type 2 diabetes who are at increased cardiovascular risk. This includes most men or women with diabetes aged 50 years and up who have at least one additional major risk factor (such as family history of premature ASCVD, hypertension, smoking, dyslipidemia, or albuminuria) and are not at increased risk of bleeding.
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Recommendations for screening for coronary heart disease are summarized on this slide:
The screening of asymptomatic patients with high ASCVD risk is not recommended, in part because these high-risk patients should already be receiving intensive medical therapy, an approach that provides similar benefit as invasive revascularization. There is also some evidence that silent MI may reverse over time, adding to the controversy concerning aggressive screening strategies
But do consider investigations for coronary artery disease in the presence of any of the following:
Atypical cardiac symptoms (e.g. unexplained dyspnea, chest discomfort)
Signs or symptoms of associated vascular disease including carotid bruits, transient ischemic attack, stroke, claudication or peripheral arterial disease
EKG abnormalities (e.g. Q waves)
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Treatment
Optimize glucose control to reduce the risk or slow the progression of diabetic kidney disease.
Optimize blood pressure control to reduce the risk or slow the progression of diabetic kidney disease.
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Complications of kidney disease correlate with level of kidney function
When the eGFR is <60, screening for complications of CKD is indicated, as summarized on this slide
Early vaccination against HBV is indicated in patients likely to progress to end-stage renal disease
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Consultation with a nephrologist when stage 4 CKD develops has been found to reduce cost, improve quality of care, and keep people off dialysis longer
However, nonrenal specialists should not delay educating their patients about the progressive nature of diabetic kidney disease; the renal preservation benefits of aggressive treatment of blood pressure, blood glucose, and hyperlipidemia, and the potential need for renal transplant
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Diabetic retinopathy is a highly specific vascular complication of both type 1 and type 2 diabetes, with prevalence strongly related to duration of diabetes. It’s the most frequent cause of new cases of blindness among adults aged 20–74 years
Glaucoma, cataracts, and other disorders of the eye occur earlier and more frequently in people with diabetes
In addition to duration of diabetes, other factors that increase the risk of, or are associated with, retinopathy include chronic hyperglycemia2, the presence of nephropathy3, and hypertension4
The first line of defense against diabetic retinopathy, to reduce the risk or slow its progression, is to optimize glycemic control and blood pressure.
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As far as screening for diabetic retinopathy, your patients with diabetes should have a dilated and comprehensive eye exam by an ophthalmologist or optometrist.
Because retinopathy is estimated to take at least 5 years to develop after the onset of hyperglycemia, patients with type 1 diabetes should have an initial dilated and comprehensive eye examination within 5 years after the diagnosis of diabetes
Patients with type 2 diabetes who may have had years of undiagnosed diabetes and have a significant risk of prevalent diabetic retinopathy at the time of diagnosis should have an initial dilated and comprehensive eye examination at the time of diagnosis.
Results of eye examinations should be documented and transmitted to the referring health care professional
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Promptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy (NPDR) (a precursor of proliferative diabetic retinopathy), or any proliferative diabetic retinopathy (PDR) to an ophthalmologist who is knowledgeable and experienced in the management and treatment of diabetic retinopathy.
Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with high-risk PDR and, in some cases, severe NPDR.
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Near-normal glycemic control, implemented early in the course of diabetes, has been shown to effectively delay or prevent the development of DPN and cardiovascular autonomic diabetes in patients with type 1 diabetes.
While the evidence for the benefit of near-normal glycemic control is not as strong for type 2 diabetes, some studies have demonstrated a modest slowing of progression without reversal of neuronal loss.
Recommendations for treatment of neuropathy in patients with diabetes include:
Optimize glucose control to prevent or delay the development of neuropathy in patients with type 1 diabetes and to slow the progression of neuropathy in patients with type 2 diabetes. [CLICK]
Assess and treat patients to reduce pain related to DPN and symptoms of autonomic neuropathy and to improve quality of life.
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For all patients with diabetes, perform a comprehensive foot evaluation each year to identify risk factors for ulcers and amputations. [CLICK]
The history should obtain a prior history of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy and renal disease, and assess current symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication).
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Older adults who are functional and cognitively intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults.
Consider the assessment of medical, functional, mental, and social geriatric domains for diabetes management in older adults to provide a framework to determine targets and therapeutic approaches.
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