Ada 2015 summary pdf

2016 American Diabetes Association (ADA) Diabetes Guidelines Summary Recommendations from NDEI

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This content was created by Ashfield Healthcare Communications and was not associated with funding via an educational grant or a promotional/commercial interest. The National Diabetes Education Initiative® (NDEI®) is sponsored by Ashfield Healthcare Communications, Lyndhurst, NJ. Copyright © 2016 Ashfield Healthcare Communications. All rights reserved.

2016 American Diabetes Association (ADA) Diabetes Guidelines

Summary Recommendations from NDEI

Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including level of evidence rating.

1. Diabetes Diagnosis Criteria for Diabetes Diagnosis: 4 options

FPG ≥126 mg/dL (7.0 mmol/L)* Fasting is defined as no caloric intake for ≥8 hours

2-hr PG ≥200 mg/dL (11.1 mmol/L) during OGTT (75-g)* Using a glucose load containing the equivalent of 75g anhydrous glucose dissolved in water

A1C ≥6.5% (48 mmol/mol)* Performed in a lab using NGSP-certified method and standardized to DCCT assay

Random PG ≥200 mg/dL (11.1 mmol/L) In individuals with symptoms of hyperglycemia or hyperglycemic crisis

*In the absence of unequivocal hyperglycemia results should be confirmed using repeat testing• No clear clinical diagnosis? Immediately repeat the same test using a new blood sample. • Same test with same or similar results? Diagnosis confirmed. • Different tests above diagnostic threshold? Diagnosis confirmed. • Discordant results from two separate tests? Repeat the test with a result above diagnostic cut-point.


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Testing for Type 2 Diabetes and Prediabetes in Asymptomatic Adults Type 2 diabetes screening should be performed in adults of any age who are overweight or obese, and who have one or more diabetes risk factor (See Diabetes Risk Factors) • Testing should begin at age 45 • If test is normal? Repeat it at least every 3 years (See Diabetes Risk Factors): Screening for prediabetes can be done using A1C, FPG, or 2-hr PG after 75-g OGTT criteria • CVD risk factors should be identified and treated • Testing may be considered in children and adolescents who are overweight or obese and have two or more risk

factors for diabetes (See Diabetes Risk Factors)

Type 2 Diabetes Risk Factors

• Physical inactivity • First-degree relative with diabetes • High-risk race/ethnicity • Women who delivered a baby >9 lb or were diagnosed with GDM • HDL-C <35 mg/dL ± TG >250 mg/dL • Hypertension (≥140/90 mm Hg or on therapy) • A1C ≥5.7%, IGT, or IFG on previous testing • Conditions associated with insulin resistance: severe obesity, acanthosis

nigricans, PCOS • History of CVD


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Categories of Increased Risk for Diabetes (Prediabetes)

FPG 2-hr PG A1C 100-125 mg/dL

(5.6-6.9 mmol/L) Impaired fasting glucose (IFG)

140-199 mg/dL (7.8-11.0 mmol/L)

Impaired glucose tolerance (IGT)

5.7-6.4% (39-46 mmol/mol)

For all tests, risk is continuous, extending below lower limit of range and becoming disproportionately greater at higher ends of range

Screening Children for Type 2 Diabetes and Prediabetes Consider screening for type 2 diabetes and prediabetes for all children who are overweight* and have two or more of the following risk factors: • Family history of type 2 diabetes in a first- or second-degree relative • Native American, African American, Latino, Asian American, or Pacific Islander descent • Signs of insulin resistance or conditions associated with insulin resistance† • Maternal history of diabetes or GDM during the child’s gestation Test every 3 years using A1C beginning at age 10 or onset of puberty *BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% ideal weight †Acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, or small-for-gestational-age birth weight Children defined as age <18 years


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Screening for Gestational Diabetes Mellitus (GDM) Pregnant women with risk factors Test for undiagnosed type 2 at first prenatal visit using stansard

diagnostic criteria

Pregnant women without known prior diabetes Test for GDM at 24-28 weeks Women with GDM Screen for persistent diabetes 6-12 wks postpartum using OGTT

and standard diagnostic criteria Women with a history of GDM Lifelong screening for diabetes or prediabetes every ≥3 yrs Women with a history of GDM and prediabetes Lifestyle interventions or metformin for diabetes prevention • Women with diabetes in the first trimester have type 2 diabetes • GDM is diagnosed in the second or third trimester and not clearly associated with type 1 or type 2 diabetes Screening is recommended at 24-48 weeks in women who were not previously diagnosed with overt diabetes One-step diagnosis strategy Two-step diagnosis strategy • Perform 75-g OGTT with plasma glucose

measurement • Test in the morning after the patient has fasted for ≥8 hours

• Repeat test at 1 and 2 hours after initial measurement

Step 1:

• Perform a 50-g nonfasting GLT with plasma measurement at 1 hour

• If PG measured 1 hour after the load is ≥140 mg/dL (7.8 mmol/L), proceed to 100-g OGTT

Diagnosis is confirmed when PG levels meet or exceed:

• Fasting 92 mg/dL (5.1 mmol/L) • 1 hr: 180 mg/dL (10.0 mmol/L) • 2 hr: 153 mg/dL (8.5 mmol/L)

Step 2: • Perform 100-g OGTT while patient is fasting Diagnosis is confirmed when two or more PG levels meet or exceed:

• Fasting: 95 mg/dL or 105 mg/dL (5.3/5.8) • 1 hr: 180 mg/dL or 190 mg/dL (10.0/10.6) • 2 hr: 155 mg/dL or 165 mg/dL (8.6/9.2) • 3 hr: 140 mg/dL or 145 mg/dL (7.8/8.0)


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Screening for Type 1 Diabetes There are two manifestations of type 1 diabetes: • Immune-mediated diabetes, previously called “insulin-dependent diabetes” or “juvenile-onset diabetes”, is due to

cellular-mediated autoimmune destruction of beta-cells • Idiopathic type 1 diabetes largely has no known cause with no evidence of beta-cell autoimmunity Blood glucose is preferred over A1C to diagnose acute onset of type 1 diabetes with symptoms of hyperglycemia Inform relatives of individuals with type 1 diabetes of the opportunity to be tested • Testing should occur only in the setting of a clinical research study BMI=body mass index; FPG=fasting plasma glucose; GDM=gestational diabetes mellitus; HDL-C=high-density lipoprotein cholesterol; OGTT=oral glucose tolerance test; PG=plasma glucose; TG=triglycerides

Download the full 2016 ADA diabetes guidelines slide set http://ndei.org/dsl/mainpage.aspx


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2. Glycemic Targets Blood Glucose Targets for Non-Pregnant Adults With Diabetes A1C <7.0% (53 mmol/L) Preprandial capillary PG 80-130 mg/Dl (4.4-7.2 mmol/L) Peak postprandial capillary PG <180 mg/dL* (10.0 mmol/L)

More or less stringent targets may be appropriate for individual patients if achieved without significant hypoglycemia or adverse events

More stringent (<6.5%) • Short diabetes duration • Long life expectancy • Type 2 diabetes treated with lifestyle or metformin

only • No significant CVD/vascular complications

Less stringent (<8.0%) • Severe hypoglycemia history • Limited life expectancy • Advanced microvascular or macrovascular complications • Extensive comorbidities • Long-term diabetes in whom general A1C targets are difficult

to attain Targets may be individualized based on: • Age/life expectancy • Comorbid conditions • Diabetes duration • Hypoglycemia status • Individual patient considerations Lowering A1C below or around 7.0% has been shown to reduce: • Microvascular complications


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• Macrovascular disease (if implemented soon after diagnosis) • Mortality (individuals with type 1 diabetes only) *Postprandial glucose measurements should be made 1-2 hours after the beginning of the meal Management of Hypoglycemia Ask at-risk patients about symptomatic and asymptomatic hypoglycemia at each encounter Glucose (15-20 g) is the preferred treatment of hypoglycemia for conscious patients • 15 minutes after treatment, repeat if SMBG shows continued hypoglycemia • When SMBG is normal, the patient should consume a meal or snack to prevent hypoglycemia recurrence Glucagon may be prescribed for all individuals who are at risk for severe hypoglycemia If an individual has hypoglycemia unawareness or an episode of severe hypoglycemia: • Re-evaluate the treatment regimen • In patients treated with insulin, raise glycemic targets for several weeks to partially reverse hypoglycemia unawareness

and reduce the recurrence of hypoglycemia For individuals with low or declining cognition, continually assess cognitive function with increased vigilance for hypoglycemia PG=plasma glucose; SMBG=self-monitoring of blood glucose



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3. Type 2 Diabetes Prevention Strategies for Preventing or Delaying Type 2 Diabetes Individuals with prediabetes: IGT, IFG, or A1C 5.7-6.4%

Refer these individuals to a behavioral counseling program targeting intensive diet and physical activity to achieve: • 7% of body weight loss • Increased physical activity, targeting at least 150 minutes per week

(moderate activity Consider metformin* therapy for type 2 diabetes prevention in individuals with prediabetes, especially in the presence of: • BMI >35 kg/m2 • Age <60 years • Women who have had gestational diabetes Monitoring at least once per year is recommended for all individuals with prediabetes Screen for and treat modifiable CVD risk factors: • Obesity • Hypertension • Dyslipidemia Diabetes self-management education (DSME) and diabetes self-management support (DSMS) are appropriate for all individuals with prediabetes for type 2 diabetes prevention or delay *Metformin is not FDA approved in the United States for type 2 diabetes prevention BMI=body mass index; CVD=cardiovascular disease; IFG=impaired fasting glucose; IGT=impaired glucose tolerance


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4. Pharmacologic Therapy for Type 2 Diabetes Management Pharmacologic Therapy Recommendations Lifestyle changes should be the first-line therapy for most individuals with type 2 diabetes When lifestyle changes alone have not achieved or maintained glycemic goals

• Add metformin • Preferred initial pharmacologic therapy if

tolerated and not contraindicated* For newly diagnosed individuals who are markedly symptomatic and/or have elevated glucose levels or A1C

• Consider insulin therapy with or without other agents

If noninsulin monotherapy (OAD) at maximal tolerated dose(s) does not achieve or maintain A1C target over 3 months

• Add: • A second oral agent or • A GLP-1 receptor agonist or • Basal insulin

Due to the progressive nature of type 2 diabetes, insulin is eventually needed Insulin therapy should not be delayed


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Choice of Pharmacologic Therapy The choice of pharmacologic therapy should be based on a patient-centered approach with consideration of the following:• Efficacy • Cost • Potential side effects • Effects on weight • Comorbidities • Hypoglycemia risk • Patient preferences *Metformin is contraindicated in individuals with: • Renal disease or renal dysfunction (e.g., as suggested by serum creatinine levels ≥1.5 mg/dL (males), ≥1.4 mg/dL

(females) or abnormal creatinine clearance) which may also result from conditions such as cardiovascular collapse (shock), acute myocardial infarction, and septicemia

• Known hypersensitivity to Metformin hydrochloride • Acute or chronic metabolic acidosis, including diabetic ketoacidosis, with or without coma. Diabetic ketoacidosis should

be treated with insulin OAD=oral antidiabetic drugs Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug Administration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States.



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5. Pharmacologic Therapy for Type 1 Diabetes Pharmacologic Therapy for Type 1 Diabetes Management Insulin therapy is the mainstay for individuals with type 1 diabetes • Treat with multiple-dose insulin injections* or continuous subcutaneous insulin infusion (CSII) • Match prandial insulin to carbohydrate intake, premeal glucose, and anticipate physical activity • Use insulin analogs to reduce the risk of hypoglycemia • Consider using sensor-augmented low glucose suspend threshold pump in patients with frequent nocturnal

hypoglycemia and/or hypoglycemia unawareness Non-insulin agents • Pramlinitide (amylin analog) • Delays gastric emptying • Blunts pancreatic secretion of glucagon • Enhances satiety • Induces weight loss • Lowers insulin dose • Use only in adults

Investigational agents† • Metformin + insulin • May reduce insulin requirements and improve

metabolic control in obese/overweight with poor glycemic control

• Incretins • GLP-1 receptor agonists • DPP-4 inhibitors • SGLT2 inhibitors

*3-4 injections/day of basal and prandial insulin) †Not FDA approved for the treatment of type 1 diabetes in the United States Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug Administration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States.


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6. Insulin & Glucose Monitoring

Self-monitoring of blood glucose (SMBG) Encourage individuals receiving multiple dose insulin or insulin pump therapy to perform SMBG: • Prior to meals and snacks • Occasionally after meals (postprandially) • At bedtime • Prior to exercise • When low blood glucose is suspected • After treating low blood glucose until normoglycemia is achieved • Prior to critical tasks, such as driving SMBG results may be useful for guiding treatment and/or self-management for individuals using less frequent insulin injections or noninsulin therapies • It is important to provide ongoing instruction and regular evaluation of SMBG technique, results, and the patient’s ability

to use the data to adjust therapy Continuous Glucose Monitoring (CGM) CGM is useful for A1C lowering in select adults (aged ≥25 yrs) with type 1 diabetes who require intensive insulin: • The technique may be useful among children, teens, and younger adults* • Success is related with adherence to ongoing use CGM may be a useful supplement to SMBG among individuals with hypoglycemia unawareness and/or frequent hypoglycemic episodes *Evidence for A1C lowering is less strong in these populations


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7. Lifestyle Changes

Medical Nutrition Therapy (MNT) The ADA acknowledges that there is no one-size-fits-all eating pattern for individuals with type 2 diabetes. MNT is recommended for all individuals with type 1 and type 2 diabetes as part of an overall treatment plan, preferably provided by a registered dietitian skilled in diabetes MNT Goals of MNT: • A healthful eating pattern to improve overall health, specifically: • Achievement and maintenance of weight goals • Attainment of individualized glycemic, blood pressure, and lipid goals • Type 2 diabetes prevention or delay

• Attain individualized glycemic, blood pressure, and lipid goals • Achieve and maintain body weight goals • Delay or prevent diabetes complications

Physical Activity Adults with diabetes Exercise programs should include: • ≥150 min/wk moderate-intensity aerobic activity (50%-70% max heart rate), spread over ≥3 days/wk with no more than 2 consecutive days without exercise

• Resistance training ≥2 times/wk (in absence of contraindications)* • Reduce sedentary time = break up >90 minutes spent sitting Evaluate patients for contraindications prohibiting certain types of exercise before recommending exercise program†


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Consider age and previous level of physical activity Children with diabetes or prediabetes • ≥60 min physical activity/day *Adults with type 2 diabetes †Eg, uncontrolled hypertension, severe autonomic or peripheral neuropathy, history of foot lesions, unstable proliferative retinopathy

Physical Activity in Individuals With Hypoglycemia • If an individual is taking insulin and/or insulin secretagogues, physical activity can cause hypoglycemia if medication

dose or carb consumption is not altered • Added carbohydrate should be ingested when pre-exercise glucose is <100 mg/dL (5.6 mmol/L)

Physical Activity in Individuals With Diabetes Complications Retinopathy • Proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy

• Vigorous aerobic or resistance exercise may be contraindicated Autonomic neuropathy • Can increase the risk for exercise-induced injury

• All individuals with autonomic neuropathy should undergo cardiac investigation before beginning more-intense-than-usual physical activity

Peripheral neuropathy • Decreased pain sensation and a higher pain threshold in the extremities cause increased risk of skin breakdown and infection

• All individuals with neuropathy should wear proper footwear and examine feet daily for lesions

• Individuals with foot injury or open sores are restricted to non–weight-bearing activity Albuminuria and nephropathy

• Physical activity can acutely increase urinary protein excretion • There is no evidence that vigorous-intensity exercise increases the progression of diabetic

kidney disease • No restrictions are necessary for individuals with diabetic kidney disease


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8. Management of Obesity in Individuals With Type 2 Diabetes Obesity Management • Management of obesity has been shown to delay the progression from prediabetes to type 2 diabetes • It may also be beneficial for treating type 2 diabetes • Modest and sustained weight loss has been shown to improve glycemic control and reduce the need for glucose-

lowering medications General Recommendations Calculate BMI at each patient encounter to determine the presence of overweight or obesity Advise patients that higher BMI increases the risk for CVD and mortality Assess the patient’s readiness to achieve weight loss • With the patient, determine weight loss goals and the treatment strategy

Lifestyle Changes for Obesity Management Diet, physical activity, and behavior therapy designed to achieve 5% weight loss are recommended for overweight and obese individuals with type 2 diabetes who are motivated to lose weight • High-intensity interventions (eg, 16 or more sessions within 6 months • Focus on diet, physical activity, and behavioral strategies to achieve a 500-750 kcal/day deficit Recommendations for individuals who achieve short-term weight loss: • Prescribe a long-term (more than 1 year) comprehensive weight management program • Make contact with the patient at least monthly, with ongoing monitoring of body weight thereafter • Prescribe a reduced-calorie diet


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• Encourage high levels of physical activity (200-300 mins/wk) To achieve short-term weight loss, recommend: • Short-term (3-month) high-intensity lifestyle interventions that use low-calorie diets (fewer than

800 kcal/day) • Long-term comprehensive weight management counseling to maintain weight loss

Pharmacologic Therapy for Obesity Management Glucose-lowering medications may affect weight in individuals with type 2 diabetes who are overweight or obese • Consider the effects of antihyperglycemic medications on weight before prescribing • Minimize where possible the medications for comorbid conditions that are associated with weight gain Among selected individuals with type 2 diabetes and BMI ≥27 kg/m2: • Weight loss medications may be effective as adjuncts to diet, physical activity, and behavioral counseling • The potential benefits of these medications must be balanced against potential risks If an individual who was prescribed weight loss medications does not lose >5% body weight after 3 months, or experiences safety or tolerability issues: • Discontinue the medication • Use an alternative medication or treatment approach

Bariatric Surgery in Type 2 Diabetes Bariatric surgery may be considered for adults with type 2 diabetes whose BMI is >35 kg/m2 • In particular in individuals in whom their diabetes or associated comorbidities are difficult to control with lifestyle and

pharmacologic therapy • Lifelong support and monitoring are necessary There is insufficient evidence to recommend bariatric surgery for individuals with BMI ≤35 kg/m2 outside of a research protocol Advantages of bariatric surgery • Achieves near or complete normalization of glycemia

2 years after surgery*1 • Younger age, shorter diabetes duration, lower A1C,

higher insulin levels, and non-use of insulin are associated with higher post-surgery remission rates

Disadvantages of bariatric surgery • Costly • Outcomes are variable based on the procedure and experience

of the surgeon • Long term: • Dumping syndrome


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• Vitamin and mineral deficiencies • Osteoporosis • Severe hypoglycemia from insulin hypersecretion • Increased risk for substance abuse

*Among 72% of subjects compared with 16% control subjects treated with lifestyle and pharmacologic therapy

BMI=body mass index Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug Administration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States.



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9. Cardiovascular Disease (CVD) and Diabetes Blood Pressure (Hypertension) Management & Treatment Targets Screening • Measure BP at every patient visit

• Confirm elevated BP at a separate visit Treatment targets

Systolic (SBP) targets • <140 mm Hg • Lower target (<130) may be appropriate in certain individuals* Diastolic (DBP) targets • <90 mm Hg • Lower target (<80) may be appropriate in certain individuals*

*Younger individuals, people with albuminuria, and/or individuals with hypertension and one or more additional ASCVD risk factor • Only if the lower target can be achieved without undue treatment burden



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Treatment of High Blood Pressure Individuals with BP >120/80 mm Hg • Lifestyle changes (See below) Individuals with confirmed office BP >140/90 mm Hg

• Prompt initiation and timely subsequent titration of pharmacologic therapy (see below)in addition to lifestyle changes

Older adults • Treating to <130/70 mm Hg is not recommended • SBP <130 has not been shown to improve CV outcomes • DBP <70 has been associated with increased mortality

Pregnant individuals • Targets of 110-129/65-79 are recommended to optimize long-term maternal health and minimize impaired fetal growth

Pharmacologic Therapy for High Blood Pressure • Regimen to include ACEI or ARB—but never in combination • If either ACEI or ARB is not tolerated, substitute one for the other • If using ACEI, ARB, or diuretic, monitor serum creatinine/eGFR and serum potassium levels Lifestyle Changes for High Blood Pressure • Weight loss • DASH-style dietary pattern, including: • Reduced sodium intake (<2,300 mg/day) • Increased potassium intake • Increased fruit/vegetable intake (8-10 servings/day)

• Moderate alcohol intake • Increased physical activity


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Lipid Management Adults not taking a statin • Obtain a lipid profile

• At diabetes diagnosis, initial medical evaluation, and every 5 years thereafter

• At initiation of statin therapy and periodically thereafter Lifestyle changes • Weight loss (if indicated)

• Reduced intake of saturated fat, trans fat, and cholesterol • Increased intake of omega-3 fatty acids, viscous fiber, and plant

stanols/sterols • Increased physical activity

Intensify lifestyle changes and optimize glycemic control among individuals with

• TG ≥150 mg/dL • HDL-C <40 mg/dL (men), <50 mg/dL (women

Individuals with fasting TG ≥500mg/dL • Evaluate for secondary causes of hypertriglyceridemia • Consider medical therapy to reduce pancreatitis risk

Statin Therapy for Lipid Management Individuals with diabetes and ASCVD* • High-intensity statin therapy + lifestyle changes Age <40 with diabetes and ASCVD risk factors • Moderate- or high-intensity statin + lifestyle Age 40-75 years with diabetes but without ASCVD risk factors

• Moderate-intensity statin + lifestyle

Age 40-75 with diabetes and ASCVD risk factors • High-intensity statin + lifestyle Age >75 with diabetes but without ASCVD risk factors†

• Moderate- or high-intensity statin + lifestyle

Age >75 with diabetes and ASCVD risk factors • Moderate- or high-intensity statin + lifestyle The intensity of statin therapy may require adjustment based on an individual’s response


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ASCVD Risk Factors

• LDL-C ≥100 mg/dL (2.6 mmol/L) • High blood pressure • Smoking • Overweight or obesity • Family history of premature ASCVD

*Regardless of age †Routinely evaluate risk-benefit profile of statin therapy, with down-titration as needed Combination Therapy for Lipid Management Statin + ezetimibe • Adding ezetimibe to moderate-intensity statin therapy has been shown to provide

incremental CV benefit compared with moderate statin therapy along • This combination is a consideration for individuals: • With recent ACS and LDL-C ≥50 mg/dL • Who cannot tolerate a high-intensity statin

Statin + fibrate • This combination has not been shown to improve ASCVD outcomes • As such, it is not recommended • Statin + fenofibrate may be considered for men with

TG ≥204 mg/dL and HDL-C ≤34 mg/dL Statin + niacin • This combination has not been shown to provide additional CV benefit above statin therapy

alone • It may increase the risk for stroke • This combination is not recommended

Statin + PCSK9 inhibitor • 36%-59% reductions have been shown with PCSK9 inhibitors on top of maximal tolerated statin therapy

• Combination statin + PCSK9 may be considered as adjunctive therapy for individuals with diabetes who are at high ASCVD risk or who are intolerant to a high-intensity statin


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Statins & Incident Diabetes • Increased risk of incident diabetes with statin use has been reported1,2 • May be limited to individuals with diabetes risk factors

• Analysis of initial study3: cardiovascular event rate reduction with statins outweighed risk of incident diabetes • Even for individuals at highest diabetes risk

• Meta-analysis of 13 randomized statin trials:2 • Odds ratio of 1.09 for new diabetes diagnosis • Treatment of 255 patients with statins for 4 yrs resulted

in 1 additional diabetes case • Simultaneously prevented 5.4 vascular events

Antiplatelet Therapy Recommendations Aspirin for primary prevention

• 75-162 mg/day for individuals with type 1 or type 2 diabetes who are at increased ASCVD risk (10-yr risk >10%)* and not at increased bleeding risk

• Aspirin is not recommended for ASCVD prevention in adults with diabetes who are at low ASCVD risk (10-yr risk <5%)† • The potential for bleeding in these individuals likely offsets potential benefits of aspirin

• Clinical judgement is required for individuals with diabetes and multiple other risk factors (10-yr risk 5%-10%)

Aspirin for secondary prevention

• 75-162 mg/day for individuals with diabetes and a history of ASCVD

• For individuals with ASCVD and a documented aspirin allergy, clopidogrel 75 mg/day should be used • Dual antiplatelet therapy is reasonable for up to 1 year after ACS *Includes most men or women with diabetes aged ≥50 yrs with ≥1 add’l major risk factor: family history of premature ASCVD, hypertension, smoking, dyslipidemia, or albuminuria


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Coronary Heart Disease (CHD) Screening and Treatment Screening

Routine coronary artery disease (CAD) screening in asymptomatic individuals is not recommended • It does not improve outcomes as long as ASCVD risk factors are treated Consider investigating for CAD in the presence of: • Atypical cardiac symptoms • Signs or symptoms of associated vascular disease, including carotid bruits, TIA, stroke, claudiation, or

PAD • Electrocardiogram abnormalities

Treatment

In individuals with known ASCVD • Use aspirin and statin therapy if not contraindicated • Consider therapy with an ACEI to reduce the risk of CV events In individuals with symptomatic heart failure: • Do not use TZDs, as these agents are associated with heart failure In individuals with type 2 diabetes and stable heart failure: • Metformin may be used if renal function is normal • Metformin therapy should be avoided in unstable or hospitalized patients with heart failure

Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug Administration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States.



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10. Microvascular Complications and Foot Care Diabetic Kidney Disease (Nephropathy) Screening and Treatment Screening Annually measure urinary albumin and eGFR in:

• Patients with type 1 diabetes with ≥5-year duration • Patients with type 2 diabetes starting at diagnosis • All patients with hypertension

Treatment

For individuals with nondialysis-dependent diabetic kidney disease: • Dietary protein intake should be 0.8 g/kg of body weight/day For individuals on dialysis: • Higher levels of protein intake should be considered ACEI or ARB is recommended for treating nonpregnant individuals with diabetes and modestly elevated urinary albumin excretion (30-299 mg/d) • This is strongly recommended for individuals with urinary albumin excretion ≥300 mg/d and/or

eGFR <60 mL/min/1.73m2 Periodically monitor serum creatinine and potassium levels when ACEIs, ARBs, or diuretics are used for treatment Monitor urinary albumin-to-creatinine ratio in individuals with albuminuria treated with an ACEI or ARB ACEI or ARB treatment is not recommended for primary prevention of diabetic kidney disease in individuals with diabetes who have normal blood pressure, urinary albumin-to-creatinine ratio, and eGFR

If eGFR is <60 mL/min/1.73m2


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Management

• Evaluate and manage potential complications of chronic kidney disease If eGFR is <30 mL/min/1.73m2 • Refer for evaluation of renal replacement treatment Refer to a physician experienced in the care of kidney disease for uncertainty regarding cause of kidney disease, difficult management issues, or rapidly progressing disease eGFR 45-60 mL/min/1.73m2

• Refer to a nephrologist if the possibility exists for nondiabetic kidney disease

• Consider the need for dose adjustment of medications • Monitor eGFR, electrolytes, bicarbonate, calcium, phosphorous,

parathyroid hormone, hemoglobin, albumin, and weight every 6 months • Assure vitamin D sufficiency • Consider bone density testing • Refer for dietary counseling

eGFR 30-44 mL/min/1.73m2

• Monitor eGFR every 3 months • Monitor eGFR, electrolytes, bicarbonate, calcium, phosphorous,

parathyroid hormone, hemoglobin, albumin, and weight every 3 months • Consider the need for dose adjustment of medications

eGFR 30-44 mL/min/1.73m2

• Refer to a nephrologist

Retinopathy Screening and Treatment Screening Optimize glucose, BP, and lipid control to reduce the risk or slow the progression of retinopathy Adults with type 1 diabetes Initial dilated and comprehensive eye exam within 5 years of diabetes onset Adults with type 2 diabetes Initial dilated and comprehensive eye exam at the time of diabetes

diagnosis No evidence of retinopathy for one or more annual eye exam

Consider exams every 2 years

Any evidence of retinopathy present Subsequent dilated retinal exam for type 1 or type 2 repeated at least


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annually Retinopathy progressive or sight threatening

More frequent dilated retinal exams are recommended

Eye exams should occur prior to pregnancy or in the first trimester

Thereafter, monitor every trimester and for 1 year postpartum as indicated by degree of retinopathy

Treatment • Refer individuals with macular edema, severe NPDR, or any PDR to an ophthalmologist • Laser photocoagulation therapy indicated to reduce the risk of vision loss in high-risk PDR and severe NPDR • Intravitreal injections of antivascular endothelial growth factor are indicated for center-involved diabetic macular edema • The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection Neuropathy Screening and Treatment Screening

Screen all patients for diabetic peripheral neuropathy • Type 2 diabetes: at diagnosis • Type 1 diabetes: 5 yrs after diagnosis and at least annually thereafter Assessment should include careful history, 10-g monofilament testing, and one or more of the following: • Pinprick • Temperature • Vibration sensation Symptoms of autonomic neuropathy should be assessed in individuals with microvascular and neuropathic complications

Treatment

Optimize glucose control to: • Type 1: prevent or delay neuropathy onset • Type 2: slow neuropathy progression Assess and treat patients to reduce pain related to DPN and symptoms of autonomic neuropathy


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Foot Care Recommendations All individuals with diabetes • Annual foot exam to identify risk factors predictive of ulcers and

amputations • Assessment of foot deformities, skin inspection, neurological exam, vascular

assessment (pulses) • Provide foot self-care education

All individuals with insensate feet, foot deformities, or history of foot ulcers

• Examine feet at every patient visit

Patients with foot ulcers, high-risk feet (previous ulcer or amputation), or peripheral artery disease

• Use a multidisciplinary approach

Symptoms of claudication or decreased or absent pedal pulses

• Refer for ankle-brachial index and further vascular assessment

Patients who smoke or have a history of prior lower-extremity complications, loss of sensation, structural abnormalities, or peripheral artery disease

• Refer to foot care specialist for ongoing preventive care

ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; eGFR=estimated glomerular filtration rate; NPDR=nonproliferative diabetic retinopathy; PDR=proliferative diabetic retinopathy



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11. Diabetes in Pregnancy (Gestational Diabetes—GDM)

Screening for Gestational Diabetes Mellitus (GDM) Pregnant women with risk factors Test for undiagnosed type 2 at first prenatal visit using stansard

diagnostic criteria

Pregnant women without known prior diabetes Test for GDM at 24-28 weeks Women with GDM Screen for persistent diabetes 6-12 wks postpartum using OGTT

and standard diagnostic criteria Women with a history of GDM Lifelong screening for diabetes or prediabetes every ≥3 yrs Women with a history of GDM and prediabetes Lifestyle interventions or metformin for diabetes prevention • Women with diabetes in the first trimester have type 2 diabetes • GDM is diagnosed in the second or third trimester and not clearly associated with type 1 or type 2 diabetes Screening is recommended at 24-48 weeks in women who were not previously diagnosed with overt diabetes One-step diagnosis strategy Two-step diagnosis strategy • Perform 75-g OGTT with plasma glucose

measurement • Test in the morning after the patient has fasted for ≥8 hours

• Repeat test at 1 and 2 hours after initial measurement

Step 1:

• Perform a 50-g nonfasting GLT with plasma measurement at 1 hour

• If PG measured 1 hour after the load is ≥140 mg/dL (7.8 mmol/L), proceed to 100-g OGTT

Diagnosis is confirmed when PG levels meet or Step 2:


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exceed:

• Fasting 92 mg/dL (5.1 mmol/L) • 1 hr: 180 mg/dL (10.0 mmol/L) • 2 hr: 153 mg/dL (8.5 mmol/L)

• Perform 100-g OGTT while patient is fasting Diagnosis is confirmed when two or more PG levels meet or exceed:

• Fasting: 95 mg/dL or 105 mg/dL (5.3/5.8) • 1 hr: 180 mg/dL or 190 mg/dL (10.0/10.6) • 2 hr: 155 mg/dL or 165 mg/dL (8.6/9.2) • 3 hr: 140 mg/dL or 145 mg/dL (7.8/8.0)

Glycemic Targets in Pregnancy Pregestational diabetes Gestational diabetes mellitus (GDM)

Fasting ≤90 mg/dL (5.0 mmol/L)

≤95 mg/dL (5.3 mmol/L)

1-hr postprandial ≤130-140 mg/dL (7.2-7.8 mmol/L)

≤140 mg/dL (7.8 mmol/L)

2-hr postprandial ≤120 mg/dL (6.7 mmol/L)

≤120 mg/dL (6.7 mmol/L)

A1C 6.0-6.5% (42-48 mmol/L) recommended <6.0% may be optimal as pregnancy progresses

Achieve without hypoglycemia

Recommendations for Pregestational Diabetes Pregestational type 1 and type 2 diabetes confer greater maternal and fetal risk than GDM • Spontaneous abortion • Fetal anomalies • Preeclampsia • Intrauterine fetal demise • Macrosomia • Neonatal hypoglycemia • Neonatal hyperbilirubinemia


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Diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life Maintain A1C levels as close to normal as is safely possible • Ideally, A1C <6.5% (48 mmol/L) without hypoglycemia Discuss family planning • Prescribe effective contraception until woman is prepared to become pregnant Women with preexisting type 1 or type 2 diabetes • Counsel on the risk of development and/or progression of diabetic retinopathy • Perform eye exams before pregnancy or in first trimester; monitor every trimester and for 1 year postpartum

Management of Pregestational Diabetes Insulin is the preferred medication for pregestational type 1 and type 2 diabetes not adequately controlled with diet, exercise, and metformin Insulin* management during pregnancy is complex • Requires frequent titration to match changing requirements • Referral to specialized center recommended Women with type 1 diabetes are at high risk for hypoglycemia • Hypoglycemia education important before and during pregnancy to prevent hypoglycemia Women with type 1 diabetes are at risk for ketoacidosis • At lower blood glucose levels than in the nonpregnant state • Provide education on prevention and treatment of diabetic ketoacidosis Women with type 2 diabetes are at risk for obesity • Recommended weight gain during pregnancy: 15-25 lb overweight, 10-20 lb obese • Glycemic control easier to achieve than in type 1 but can require higher insulin doses Targets: • Fasting ≤90 mg/dL (5.0 mmol/L) • 1-hr postprandial ≤130-140 mg/dL (7.2-7.8 mmol/L) • 2-hr postprandial ≤120 mg/dL (6.7 mmol/L *Most insulins are category B; glargine, glulisine, and degludec are category C


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Recommendations for Gestational Diabetes Mellitus (GDM) GDM increases the risk of macrosomia, birth complications, and maternal diabetes after pregnancy • Risks increase with progressive hyperglycemia • Risk may be reduced with diet, physical activity, and lifestyle counseling Lifestyle management • Medical nutrition, physical activity, weight management Pharmacologic therapy • Insulin* is first line • Requires frequent titration to match changing requirements • Referral to specialized center recommended

• Sulfonylureas: • May be inferior to insulin and metformin due to increased risk of neonatal hypoglycemia and macrosomia • No long-term safety data

• Metformin • May be preferable to insulin for maternal health if can control hyperglycemia • May increase risk of prematurity • Lower hypoglycemia & weight gain • Long-term outcomes in offspring not known

*Most insulins are category B; glargine, glulisine, and degludec are category C

Recommendations for Postpartum Follow-Up in Women With GDM An oral glucose tolerance test (OGTT) is recommended at the 6- to 12-week postpartum visit GDM is associated with increased maternal risk for type 2 diabetes • Test women with GDM every 1-3 years if her 6- to 12-wk OGTT is normal • The frequency of screening is based on the presence of risk factors: family history,

pre-pregnancy BMI, or need for insulin or OAD medications during pregnancy • Ongoing screening may be done with any glycemic test (A1C, fasting plasma glucose, OGTT) using nonpregnancy cut

points Metformin and intensive lifestyle changes prevent or delay progression to type 2 diabetes


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Managing Hypertension During Pregnancy Target BP for pregnancy complicated by diabetes • SBP: 110-129 mm Hg

• DBP: 65-79 mm Hg Antihypertensive medications Safe medications • Methyldopa • Labetalol • Diltiazem • Clonidine • Prazosin

Unsafe medications (contraindicated) • ACEIs • ARBs

ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; BMI=body mass index; DBP=diastolic blood pressure; OAD=oral antidiabetic drug; SBP=systolic blood pressure Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug Administration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States.



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12. In-Patient Glycemia

Diabetes Care in the Hospital Insulin is preferred method for glycemic control in the hospital setting • Exclusive use of SSI is strongly discouraged Recommendations for diabetes care of patients in the ICU (critical care): • Intravenous insulin shown to be the best method for achieving glycemic targets • Administer using validated written or computerized protocols that allow for predefined adjustments in infusion rate

based on glycemic fluctuations and insulin dose Recommendations for diabetes care of patients in noncritical care settings: • Scheduled subcutaneous insulin injections that align with meals and bedtime* • Insulin regimen with basal, nutritional, and correction components (basal-bolus) for individuals with good nutritional

intake • Basal plus correction insulin regimen for individuals with poor oral intake or who are NPO The safety and efficacy of noninsulin therapies are being studied *Or every 4-6 hrs if no meals or if continuous enteral/parenteral therapy being used

Glycemic Targets for Critically Ill Individuals Insulin is the preferred method for achieving glycemic control for diabetes care in the hospital Recommendations for critically ill individuals with persistent hyperglycemia: • Initiate insulin starting at ≤180 mg/dL (10.0 mmol/L) • Once insulin is started, a target glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) is recommended for most patients More stringent targets may be appropriate for certain patients providing a lower target does not confer increased


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hypoglycemia risk • 110-140 mg/dL (6.1-7.8 mmol/L) A hypoglycemia management protocol should be established for each patient: • A plan for prevention and treatment of hypoglycemia should be developed • All episodes of hypoglycemia should be documented and tracked • The treatment plan should be reviewed and changed when glucose is <70 mg/dL (3.9 mmol/L)

Glycemic Targets for Noncritically Ill Individuals • Glucose target of 140-180 mg/dL (7.8-10.0 mmol/L) is recommended for most • A lower target (<140 mg/dL) may be appropriate for individuals with a prior history of successful tight glycemic control

and who are clinically stable • Higher ranges may be appropriate for individuals who are terminally ill, have severe comorbidities, or are in in-patient

care settings where frequent glucose monitoring is not feasible

Recommendations for Perioperative Care Target glucose range for perioperative period: • 80-180 mg/dL (4.4-10.0 mmol/L) Perioperative risk assessment for individuals at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure On the morning of the procedure, withhold OADs and give half of the NPH dose or full doses of long-acting analog or pump basal insulin Monitor blood glucose every 4-6 hours while NPO and dose with short-acting insulin as needed

NPH=neutral protamine hagedorn; NPO=nothing by mouth; OADs=oral antidiabetes drugs; SSI=sliding scale insulin

Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug Administration (FDA) unless otherwise

noted. Consult individual prescribing information for approved uses outside of the United States.



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Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including level of evidence rating. 13. Diabetes Care for Older Adults General Recommendations for Diabetes Care of Older Adults Individuals aged ≥65 with diabetes are a high-priority population for depression screening and treatment Avoid hypoglycemia • Screen for and manage by adjusting glycemic targets and pharmacologic interventions Functional and cognitively intact older adults with long life expectancy • Provide diabetes care with goals similar to those for younger adults Glycemic goals may be relaxed based in selected individuals • But avoid hyperglycemia leading to symptoms or risk of acute hyperglycemic complications Individualize screening for diabetes complications • Pay close attention to complications leading to functional impairment Treat other CV risk factors • Hypertension treatment indicated for all • Lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the timeframe of primary

and secondary prevention trials


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Pharmacologic Therapy Considerations for Older Adults Cost May be a significant factor due to polypharmacy Metformin • First-line agent for older adults

• Contraindicated in patients with renal insufficiency or significant heart failure TZDs • Use cautiously in individuals with, or at risk for, heart failure

• Associated with fractures Sulfonylureas Insulin secretagogues Insulin*

• Can cause hypoglycemia • Use with caution • Glyburide contraindicated in older adults

GLP-1 receptor agonists* DPP-4 inhibitors

• Few side effects • Cost may be a barrier

SGLT2 inhibitors • Oral administration may be convenient • Limited long-term experience despite initial safety and efficacy

*Injectable agent—requires that patients or caregivers have good visual and motor skills, cognitive ability

Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug Administration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States.



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Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including level of evidence rating. 14. Diabetes Care for Children and Adolescents Screening Children for Type 2 Diabetes and Prediabetes Consider screening for type 2 diabetes and prediabetes for all children who are overweight* and have two or more of the following risk factors: • Family history of type 2 diabetes in a first- or second-degree relative • Native American, African American, Latino, Asian American, or Pacific Islander descent • Signs of insulin resistance or conditions associated with insulin resistance† • Maternal history of diabetes or GDM during the child’s gestation Test every 3 years using A1C beginning at age 10 or onset of puberty *BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% ideal weight †Acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, or small-for-gestational-age birth weight Children defined as age <18 years Glycemic Targets for Children and Adolescents With Type 1 Diabetes

Consider a risk-benefit assessment, including hypoglycemia risk, when individualizing glycemic targets for children and adolescents with type 1 diabetes

A1C target <7.5% (58 mmol/L) A lower A1C target (<7.0%) is reasonable if it can be achieved without excessive hypoglycemia

Plasma glucose before meals 90-130 mg/dL


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(preprandial) (5.0-7.2 mmol/L) Plasma glucose at bedtime and overnight 90-150 mg/dL

(5.0-8.3 mmol/L) Glucose goals should be modified in children with frequent hypoglycemiaor hypoglycemia unawareness If the child is taking basal-bolus therapy, measure postprandial glucose when there is a discrepancy between preprandial glucose values and A1C levels, and to assess preprandial insulin doses Managing Microvascular Complications in Children and Adolescents With Type 1 Diabetes Nephropathy Screening • Annual albuminuria screen with a random spot urine sample for ACR with 5-yr diabetes diabetes

duration • Measure eGFR at initial evaluation and then based on age, diabetes duration, and treatment

Treatment/Follow-Up

• ACEI* titrated to normalization of albumin excretion if elevated ACR (>30 mg/g) confirmed with 2 of 3 urine samples • Obtain samples over 6-month interval after efforts to improve glycemic control and normalize

BP Retinopathy Screening • Initial dilated and comprehensive eye exam at age ≥10 yrs or post-puberty onset (whichever

occurs first) in children with diabetes duration of 3-5 years Neuropathy Screening • Consider annual comprehensive foot exam at age ≥10 yrs or post-puberty onset (whichever

occurs first) in children with diabetes duration of 3-5 years *ACEIs are not approved by the U.S. Food and Drug Administration (FDA) for treatment of nephropathy. Not all ACEIs are indicated for use in children/adolescents by the FDA. Refer to full prescribing information for indications and uses in pediatric populations.


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Managing High Blood Pressure in Children and Adolescents With Type 1 Diabetes Screening • Measure BP at every visit

• Confirm elevated BP at separate visit • High-normal BP* or hypertension†: confirm BP on 3 separate days

Treatment High-normal BP* • Lifestyle changes (diet & physical activity) aimed at weight

control • If target BP is not achieved within

3-6 months, initiate pharmacologic therapy

Initial pharmacologic

therapy: ACEI or ARB‡ Hypertension†

• Initiate lifestyle changes and pharmacologic therapy BP target: Consistently <90th percentile for age, gender, and height

*SBP or DBP consistently ≥90th percentile for age, , and height †SBP or DBP consistently ≥95th percentile for age, gender, and height ‡Provide counseling regarding potential teratogenic effects Not all ACEIs and ARBs are indicated for use in children/adolescents by the U.S. Food and Drug Administration (FDA). Refer to full prescribing information for indications and uses in pediatric populations. Managing Dyslipidemia in Children and Adolescents With Type 1 Diabetes Screening Obtain a fasting lipid profile in children aged ≥10 years soon after diagnosis* Abnormal lipids?

• Annual monitoring LDL-C <100 mg/dL? • Repeat lipid panel every 3-5 years

Treatment Initial therapy • Optimize glucose control and medical nutrition therapy (MNT)† • Starting at age 10, a statin§ can be initiated in individuals with: • LDL-C >160 mg/dL or >130 mg/dL (4.1 mmol/L or 3.4 mmol/L) • ≥1 CVD risk factor despite lifestyle and MNT

LDL-C target: LDL-C <100 mg/dL (<2.6 mmol/L) *When glucose levels are well controlled †Using Step 2 AHA diet to decrease saturated fat intake ‡Statins are approved by the U.S. Food and Drug Administration for treatment of heterozygous familial


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hypercholesterolemia in children and adolescents. Not all statins are FDA approved for use under the age of 10 yrs; statins should generally not be used in children with type 1 diabetes before age 10. Refer to full prescribing information for indications and uses in pediatric populations. For postpubertal girls, pregnancy prevention is important as statins are contraindicated in pregnancy. Screening for Autoimmunities in Children and Adolescents With Type 1 Diabetes Hypothyroidism Soon after type 1 diabetes diagnosis Consider screening for

• Antithyroid peroxidase antibodies • Antithyroglobulin antibodies

Measure TSH soon after diagnosis and after glucose control has been established • Reassess every 1-2 yrs if normal

Celiac disease Screen soon after type 1 diabetes diagnosis by measuring tissue transglutaminase or deamidated gliadin antibodies, with documentation of normal total serum IgA levels Candidates for testing • Family history of celiac disease

• Failure to grow or gain weight • Weight loss • Diarrhea or flatulence • Abdominal pain • Signs of malabsorption • Repeated hypoglycemia of unknown cause or decline in glycemic control

Biopsy confirms diagnosis Place child on gluten-free diet and refer to dietitian


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Recommendations for Monogenic Diabetes Syndromes in Children and Adolescents Neonatal diabetes • Monogenic form of diabetes with onset

in the first 6 months of life

Maturity-onset diabetes of the young • Inherited autosomal dominant pattern • Impaired insulin secretion with minimal or no defects in insulin action

A diagnosis of monogenic diabetes should be considered in children with: • Diabetes diagnosed within first 6 months of life • Strong family history of diabetes but without typical features • Mild fasting hyperglycemia*, especially if young and non-obese • Diabetes with negative diabetes-associated antibodies without typical type 2 diabetes clinical features Recommendations: • Genetic testing for all children diagnosed in first 6 months of life • Consider MODY with mild stable fasting hyperglycemia, multiple family members with diabetes not characteristic of

type 1 or 2 • Consider referring individuals with diabetes not characteristic of type 1 or type 2

and occurring in successive generations to a specialist *100-150 mg/dL (5.5-8.5 mmol/L) ACEI=angiotensin-converting enzyme inhibitor; ACR=albumin-to-creatinine ratio; ARB=angiotensin-receptor blockerBP=blood pressure; eGFR=estimated glomerular filtration rate; MNT=medical nutrition therapy; TSH=thyroid-stimulating hormone Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug Administration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States.



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Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including level of evidence rating. 15. Psychosocial Assessment and Care Psychological and Social Assessments Include psychological & social assessments as part of diabetes management Psychosocial screening and follow-up may include: • Attitudes about diabetes • Expectations for medical management and outcomes • Mood • Quality of life • Financial, social, emotional resources • Psychiatric history Screen for and treat depression in older adults (≥65 yrs) with diabetes Routinely screen for depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment Stepwise collaborative care approach to manage depression for patients with comorbidities Refer patients who exhibit these symptoms/behaviors to a mental health professional: • Disregard for medical regimen • Depression • Self-harm potential • Stress • Debilitating anxiety • Eating disorder • Cognitive function signaling impaired judgment


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Recommendations for Individuals With Cognitive Dysfunction Intensive glucose control is not recommended for the improvement of poor cognitive function Tailor glycemic therapy to avoid significant hypoglycemia in individuals with: • Poor cognitive function • Severe hypoglycemia In individuals with diabetes who are at high CV risk: • CV benefits of statin therapy outweigh the risk of cognitive dysfunction Second-generation antipsychotic medication prescribed: • Monitor changes in weight, glycemic control, cholesterol levels • Reassess treatment regimen if significant changes



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Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including level of evidence rating. 16. Immunization & Vaccinations Immunization Recommendations Provide routine vaccinations for children and adults with diabetes according to age-related recommendations Influenza vaccine Annually in all patients with diabetes aged ≥6 mos Pneumococcal polysaccharide vaccine 23 (PPSV23)

• All patients with diabetes aged ≥2 yrs • Routinely in patients with diabetes aged ≥65 yrs

Pneumococcal conjugate vaccine 13 (PCV13)

• Routinely in patients with diabetes aged ≥65 yrs

Hepatitis B vaccine • All adults with diabetes



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Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including level of evidence rating. 17. Recommendations for Individuals With HIV Recommendations for Individuals With HIV Individuals with HIV who are taking ART are a higher risk for developing prediabetes and diabetes Screen for diabetes and prediabetes with a fasting glucose level: • Prior to starting ART • 3 months after starting or changing ART Initial screen normal? • Check fasting glucose each year Prediabetes identified? • Measure glucose levels every 3-6 months for diabetes progression • Weight loss via diet and physical activity may reduce progression Diabetes diagnosed? • Preventive health measures to reduce the risk of microvascular and macrovascular complications ART=antiretroviral therapy; HIV=human immunodeficiency virus


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Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including level of evidence rating. 18. Cystic-Fibrosis Related Diabetes Recommendations for Individuals With Cystic Fibrosis Screening • Annually using OGTT

• Begin by age 10 in patients with cystic fibrosis who do not have CFRD • A1C not recommended as screening test

Diagnosis • Use usual glucose criteria during period of stable health Treatment CFRD:

• Insulin to achieve individualized glycemic targets

• CF & IGT (no diabetes): Consider prandial insulin to maintain weight

Annual monitoring for diabetes complications

Start 5 years after CFRD diagnosis

CF=cystic fibrosis; CFRD=cystic fibrosis-related diabetes; IGT=impaired glucose tolerance; OGTT=oral glucose tolerance test


Health & Medicine

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