ADA Standards of Medical Care 2012 FINAL (1).pptx

7/24/2019 ADA Standards of Medical Care 2012 FINAL (1).pptx

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STANDARDS OF MEDICAL CAREIN DIABETES2012


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Table of ContentsSection Slide No.

ADA Evidence Grading System ofClinical Recommendations

3

I. Classification and Diagnosis 4-11

II. esting for Dia!etes in Asym"tomatic #atients 1$-1%

III. Detection and Diagnosis of

Gestational Dia!etes &ellit's (GD&) 1*-1+

I,. #reventionDelay of y"e $ Dia!etes $-$1

,. Dia!etes Care $$-*/

,I. #revention and &anagement of

Dia!etes Com"lications

*0-11$

,II. Assessment of Common Comor!id Conditions 113-114

,III. Dia!etes Care in S"ecific #o"'lations 11%-13%

I. Dia!etes Care in S"ecific Settings 13*-144

. Strategies for Im"roving Dia!etes Care 14%-1%


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ADA Evidene !"adin# S$ste% fo"Clinial Reo%%endations

2evel ofEvidence Descri"tion

A Clear or s'""ortive evidence from ade'ately

"oered ell-cond'cted5 generali6a!le5

randomi6ed controlled trials

Com"elling none7"erimental evidence

8 S'""ortive evidence from ell-cond'cted co9ort

st'dies or case-control st'dy

C S'""ortive evidence from "oorly controlled or

'ncontrolled st'diesConflicting evidence it9 t9e eig9t of evidence

s'""orting t9e recommendation

E E7"ert consens's or clinical e7"erience

ADA. Diabetes Care$1$:3%(s'""l 1);S1$. a!le 1.


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I& CLASSIFICATION ANDDIA!NOSIS


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Classifiation of Diabetes

y"e 1 dia!etes


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C"ite"ia fo" t'e Dia#nosis of Diabetes

A1C >*.%?

OR

@asting "lasma gl'cose (@#G)

>1$* mgd2 (/. mmol2)OR

$-9 "lasma gl'cose >$ mgd2

(11.1 mmol2) d'ring an =GOR

A random "lasma gl'cose >$ mgd2(11.1 mmol2)

ADA. I. Classification and Diagnosis. Diabetes Care $1$:3%(s'""l 1);S1$. a!le $.


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A1C >*.%?

9e test s9o'ld !e "erformed in a

la!oratory 'sing a met9od t9at isNGS# certified and standardi6ed

to t9e DCC assay

In t9e a!sence of 'ne'ivocal 9y"erglycemia5 res'lt s9o'ld !e confirmed !y re"eat testing.



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@asting "lasma gl'cose (@#G)>1$* mgd2 (/. mmol2)

@asting is defined as no caloric intaBefor at least 0 9




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$-9 "lasma gl'cose >$ mgd2(11.1 mmol2) d'ring an =G

9e test s9o'ld !e "erformed asdescri!ed !y t9e =5 'sing a

gl'cose load containing t9e e'ivalent

of /% g an9ydro's gl'cose

dissolved in ater


ADA. I. Classification and Diagnosis. Diabetes Care$1$:3%(s'""l 1);S1$. a!le $.


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In a "atient it9 classic sym"toms of

9y"erglycemia or 9y"erglycemic crisis5a random "lasma gl'cose >$ mgd2

(11.1 mmol2)



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("ediabetes) IF!* I!T* In"eased A1C

Categories of increased risB for dia!etes("redia!etes)

@#G 11$% mgd2 (%.**.+ mmol2); I@G

OR

$-9 "lasma gl'cose in t9e /%-g =G

141++ mgd2 (/.011. mmol2); IG

ORA1C %./*.4?

@or all t9ree tests5 risB is contin'o's5 e7tending !elo t9e loer limit of a range and !ecomingdis"ro"ortionately greater at 9ig9er ends of t9e range.

ADA. I. Classification and Diagnosis. Diabetes Care $1$:3%(s'""l 1);S13. a!le 3.


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II& TESTIN! FOR DIABETES INAS+M(TOMATIC (ATIENTS


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Reo%%endations) Testin# fo"Diabetes in As$%,to%ati (atients

Consider testing overeig9to!ese ad'lts (8&I >$%Bgm$) it9 one or more additional risB factors

In t9ose it9o't risB factors5 !egin testing at age 4%years (8)

If tests are normal Re"eat testing at least at 3-year intervals (E)

Fse A1C5 @#G5 or $-9 /%-g =G (8)

In t9ose it9 increased risB for f't're dia!etes

Identify and5 if a""ro"riate5 treat ot9er C,D risB factors(8)

ADA. II. esting in Asym"tomatic #atients. Diabetes Care $1$:3%(s'""l 1);S13.


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C"ite"ia fo" Testin# fo" Diabetes inAs$%,to%ati Ad-lt Individ-als .1/

#9ysical inactivity

@irst-degree relative it9

dia!etes

ig9-risB raceet9nicity (e.g.5African American5 2atino5

Native American5 AsianAmerican5 #acific Islander)

omen 9o delivered a !a!y

eig9ing + l! or erediagnosed it9 GD&

y"ertension (>14+

mmg or on t9era"y for

9y"ertension)

D2 c9olesterol levelH3% mgd2 (.+ mmol2)andor a triglyceride level$% mgd2 ($.0$ mmol2)

omen it9 "olycystic ovariansyndrome (#C=S)

A1C >%./?5 IG5 or I@G on"revio's testing

=t9er clinical conditions

associated it9 ins'linresistance (e.g.5 severeo!esity5 acant9osis nigricans)

istory of C,D

At-risB 8&I may !e loer in some et9nic gro'"s.

1.Testing should be considered in all adults who are overweight(BMI 25 kg/m2! and who have one or more additional risk "actors#

ADA. esting in Asym"tomatic #atients. Diabetes Care $1$:3%(s'""l 1);S14. a!le 4.


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2& In t9e a!sence of criteria (risB factors on"revio's slide)5 testing for dia!etes s9o'ld !eginat age 4% years

&If res'lts are normal5 testing s9o'ld !e re"eatedat least at 3-year intervals5 it9 consideration of

more fre'ent testing de"ending on initialres'lts (e.g.5 t9ose it9 "redia!etes s9o'ld !e

tested yearly)5 and risB stat's

ADA. esting in Asym"tomatic #atients. Diabetes Care $1$:3%(s'""l 1);S14. a!le 4.

C"ite"ia fo" Testin# fo" Diabetes inAs$%,to%ati Ad-lt Individ-als .2/


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III& DETECTION ANDDIA!NOSIS OF!ESTATIONAL DIABETES

MELLITS .!DM/


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Reo%%endations)Detetion and Dia#nosis of !DM .1/

Screen for 'ndiagnosed ty"e $ dia!etesat t9e first "renatal visit in t9ose it9risB factors5 'sing standard diagnosticcriteria (8)

In "regnant omen not "revio'slyBnon to 9ave dia!etes5 screen for GD&at $4$0 eeBs gestation5 'sing a/%-g =G and s"ecific diagnosticc't "oints (8)

ADA. III. Detection and Diagnosis of GD&. Diabetes Care $1$:3%(s'""l 1);S1%.


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Reo%%endations)Detetion and Dia#nosis of !DM .2/

Screen omen it9 GD& for "ersistentdia!etes at *1$ eeBs "ost"art'm5'sing a test ot9er t9an A1C (E)

omen it9 a 9istory of GD& s9o'ld

9ave lifelong screening for t9edevelo"ment of dia!etes or "redia!etesat least every 3 years (8)

omen it9 a 9istory of GD& fo'nd to9ave "redia!etes s9o'ld receive lifestyleinterventions or metformin to "reventdia!etes (A)

ADA. III. Detection and Diagnosis of GD&. Diabetes Care $1$:3%(s'""l 1);S1%.


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S"eenin# fo" and Dia#nosis of !DM

#erform a /%-g =G5 it9 "lasma gl'cosemeas'rement fasting and at 1 and $ 95 at

$4$0 eeBs gestation in omen not"revio'sly diagnosed it9 overt dia!etes

#erform =G in t9e morning after anovernig9t fast of at least 0 9

GD& diagnosis; 9en any of t9e folloing

"lasma gl'cose val'es are e7ceeded @asting >+$ mgd2 (%.1 mmol2)

1 9 >10 mgd2 (1. mmol2)

$ 9 >1%3 mgd2 (0.% mmol2)

ADA. III. Detection and Diagnosis of GD&. Diabetes Care $1$:3%(s'""l 1);S1%. a!le *.


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I& (REENTION3DELA+ OFT+(E 2 DIABETES


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Reo%%endations)("evention3Dela$ of T$,e 2 Diabetes

Refer "atients it9 IG (A)5 I@G (E)5 or A1C%./*.4? (E) to ongoing s'""ort "rogram argeting eig9t loss of /? of !ody eig9t

At least 1% mineeB moderate "9ysical activity

@ollo-'" co'nseling im"ortant for s'ccess (8)

8ased on cost-effectiveness of dia!etes "revention5t9ird-"arty "ayers s9o'ld cover s'c9 "rograms (E)

Consider metformin for "revention of ty"e $dia!etes if IG (A)5 I@G (E)5 or A1C %./*.4? (E) Es"ecially for t9ose it9 8&I 3% Bgm$5

age H* years5 and omen it9 "rior GD& (A)

In t9ose it9 "redia!etes5 monitor for develo"mentof dia!etes ann'ally (E)

ADA. I,. #reventionDelay of y"e $ Dia!etes. Diabetes Care $1$:3%(s'""l 1);S1*.


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& DIABETES CARE


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A com"lete medical eval'ation s9o'ld !e"erformed to

Classify t9e dia!etes

Detect "resence of dia!etes com"lications

Revie "revio's treatment5 glycemic control in"atients it9 esta!lis9ed dia!etes

Assist in form'lating a management "lan

#rovide a !asis for contin'ing care

#erform la!oratory tests necessary toeval'ate eac9 "atients medical condition

Diabetes Ca"e) Initial Eval-ation

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S1*.

f ' ' i


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Co%,onents of t'e Co%,"e'ensiveDiabetes Eval-ation .1/

&edical 9istory (1) Age and c9aracteristics of onset of dia!etes

(e.g.5 DJA5 asym"tomatic la!oratory finding)

Eating "atterns5 "9ysical activity 9a!its5

n'tritional stat's5 and eig9t 9istory: grot9and develo"ment in c9ildren and adolescents

Dia!etes ed'cation 9istory

Revie of "revio's treatment regimens and

res"onse to t9era"y (A1C records)

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S1/. a!le /.

C f ' C ' i


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&edical 9istory ($) C'rrent treatment of dia!etes5 incl'ding

medications and medication ad9erence5meal "lan5 "9ysical activity "atterns5 and

readiness for !e9avior c9ange

Res'lts of gl'cose monitoring and "atients

'se of data

DJA fre'ency5 severity5 and ca'se

y"oglycemic e"isodes y"oglycemia aareness

Any severe 9y"oglycemia; fre'ency and ca'se

C f ' C ' i


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Co%,onents of t'e Co%,"e'ensiveDiabetes Eval-ation ./


&edical 9istory (3) istory of dia!etes-related com"lications

&icrovasc'lar; retino"at9y5 ne"9ro"at9y5 ne'ro"at9y

Sensory ne'ro"at9y5 incl'ding 9istory of foot lesions

A'tonomic ne'ro"at9y5 incl'ding se7'al dysf'nctionand gastro"aresis

&acrovasc'lar; CD5 cere!rovasc'lar disease5 #AD

=t9er; "syc9osocial "ro!lems5 dental disease

See a""ro"riate referrals for t9ese categories.

C t f t' C ' i


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#9ysical e7amination (1)eig9t5 eig9t5 8&I

8lood "ress're determination5 incl'ding ort9ostaticmeas'rements 9en indicated

@'ndosco"ic e7amination

9yroid "al"ation

SBin e7amination (for acant9osis nigricans and

ins'lin inKection sites)

See a""ro"riate referrals for t9ese categories.

C t f t' C ' i


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#9ysical e7amination ($) Com"re9ensive foot e7amination

Ins"ection

#al"ation of dorsalis "edis and "osterior ti!ial "'lses

#resencea!sence of "atellar and Ac9illes refle7es Determination of "ro"rioce"tion5 vi!ration5 and

monofilament sensation

C t f t' C ' i


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2a!oratory eval'ation A1C5 if res'lts not availa!le it9in "ast

$3 mont9s

If not "erformedavaila!le it9in "ast year

@asting li"id "rofile5 incl'ding total5 2D25 and D2c9olesterol and triglycerides

2iver f'nction tests

est for 'rine al!'min e7cretion it9 s"ot 'rine

al!'min-to-creatinine ratioSer'm creatinine and calc'lated G@R

9yroid-stim'lating 9ormone in ty"e 1 dia!etes5

dysli"idemia5 or omen over age % years



C t f t' C ' i


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Referrals

Eye care "rofessional for ann'al dilated eye e7am

@amily "lanning for omen of re"rod'ctive age

Registered dietitian for &N

Dia!etes self-management ed'cation

Dentist for com"re9ensive "eriodontal

e7amination

&ental 9ealt9 "rofessional5 if needed




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Diabetes Ca"e) Mana#e%ent

#eo"le it9 dia!etes s9o'ld receivemedical care from a "9ysician-coordinatedteam #9ysicians5 n'rse "ractitioners5 "9ysicians

assistants5 n'rses5 dietitians5 "9armacists5mental 9ealt9 "rofessionals

In t9is colla!orative and integrated teama""roac95 essential t9at individ'als it9dia!etes ass'me an active role in t9eir care

&anagement "lan s9o'ld recogni6edia!etes self-management ed'cation(DS&E) and on-going dia!etes s'""ort


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Diabetes Ca"e) !l$e%i Cont"ol

o "rimary tec9ni'es availa!le for9ealt9 "roviders and "atients to assesseffectiveness of management "lan onglycemic control

#atient self-monitoring of !lood gl'cose(S&8G)5 or interstitial gl'cose

A1C

Reo%%endations)


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Reo%%endations)!l-ose Monito"in# .1/

Self-monitoring of !lood gl'cose (S&8G)s9o'ld !e carried o't t9ree or more timesdaily for "atients 'sing m'lti"le ins'lininKections or ins'lin "'m" t9era"y (8)

@or "atients 'sing less fre'ent ins'lininKections5 nonins'lin t9era"ies5 or medicaln'trition t9era"y (&N) alone5 S&8G may!e 'sef'l as a g'ide to management (E)


Reo%%endations)


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Reo%%endations)!l-ose Monito"in# .2/

o ac9ieve "ost"randial gl'cose targets5"ost"randial S&8G may !e a""ro"riate (E)

9en "rescri!ing S&8G5 ens're "atientsreceive initial instr'ction in5 and ro'tine

follo-'" eval'ation of5 S&8G tec9ni'eand t9eir a!ility to 'se data to adK'stt9era"y (E)


Reo%%endations)


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Reo%%endations)!l-ose Monito"in# ./

Contin'o's gl'cose monitoring (CG&) it9intensive ins'lin regimens 'sef'l tool toloer A1C in selected ad'lts (age >$%years) it9 ty"e 1 dia!etes (A)

Evidence for A1C-loering less strong inc9ildren5 teens5 and yo'nger ad'lts:9oever5 CG& may !e 9el"f'l: s'ccesscorrelates it9 ad9erence to device 'se (C)

CG& may !e a s'""lemental tool to S&8Gin t9ose it9 9y"oglycemia 'naarenessandor fre'ent 9y"oglycemic e"isodes (E)

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S1*-S1/.


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Reo%%endations) A1C

#erform A1C test at least tice yearly in"atients meeting treatment goals (and9ave sta!le glycemic control) (E)

#erform A1C test 'arterly in "atients

9ose t9era"y 9as c9anged or 9o arenot meeting glycemic goals (E)

Fse of "oint-of-care (#=C) testing for A1C"rovides t9e o""ort'nity for more timelytreatment c9anges (E)

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S10.

Co""elation of A1C 8it'


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Co""elation of A1C 8it'Ave"a#e !l-ose .A!/

&ean "lasma gl'cose

A1C (?) mgd2 mmol2

* 1$* /.

/ 1%4 0.*

0 103 1.$+ $1$ 11.0

1 $4 13.4

11 $*+ 14.+

1$ $+0 1*.%

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S10. a!le 0.

9ese estimates are !ased on ADAG data of L$5/ gl'cose meas'rements over 3 mont9s "er A1Cmeas'rement in %/ ad'lts it9 ty"e 15 ty"e $5 and no dia!etes. 9e correlation !eteen A1C andaverage gl'cose as .+$. A calc'lator for converting A1C res'lts into estimated average gl'cose (eAG)5in eit9er mgd2 or mmol25 is availa!le at 9tt";"rofessional.dia!etes.orgGl'coseCalc'lator.as"7.

Reo%%endations)


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2oering A1C to !elo or aro'nd /? 9as!een s9on to red'ce microvasc'larcom"lications and5 if im"lemented soonafter t9e diagnosis of dia!etes5 is

associated it9 long-term red'ction inmacrovasc'lar disease

9erefore5 a reasona!le A1C goal for manynon"regnant ad'lts is H/? (8)

Reo%%endations)!l$e%i !oals in Ad-lts .1/

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S10-1+.

Reo%%endations)


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#roviders mig9t reasona!ly s'ggest morestringent A1C goals (s'c9 as H*.%?) forselected individ'al "atients5 if t9is can !eac9ieved it9o't significant 9y"oglycemia

or ot9er adverse effects of treatment A""ro"riate "atients mig9t incl'de t9oseit9 s9ort d'ration of dia!etes5 long lifee7"ectancy5 and no significant C,D (C)

Reo%%endations)!l$e%i !oals in Ad-lts .2/

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S1+.

Reo%%endations)


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Reo%%endations)!l$e%i !oals in Ad-lts ./

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S1+.

2ess stringent A1C goals (s'c9 as H0?)may !e a""ro"riate for "atients it9 (8)

istory of severe 9y"oglycemia5 limited lifee7"ectancy5 advanced microvasc'lar or

macrovasc'lar com"lications5 e7tensivecomor!id conditions

9ose it9 longstanding dia!etes in 9om t9e

general goal is diffic'lt to attain des"ite dia!etesself-management ed'cation5 a""ro"riate gl'cosemonitoring5 and effective doses of m'lti"le

gl'cose loering agents incl'ding ins'lin

Intensive !l$e%i Cont"ol and


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Intensive !l$e%i Cont"ol andCa"diovas-la" O-to%es) ACCORD

Gerstein C5 et al5 for t9e Action to Control Cardiovasc'lar RisB in Dia!etes St'dy Gro'".N Engl J Med $0:3%0;$%4%-$%%+.

$2%%& New England Journal of Medicine' sed with )ermission'

*rimar+ ,utcome# -on"atal MI. non"atal stroke. 01 death

34%'% (%'6&78'%9!



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Intensive !l$e%i Cont"ol andCa"diovas-la" O-to%es) ADANCE

$2%%& New England Journal of Medicine' sed with )ermission'

*rimar+ ,utcome# Microvascular )lus macrovascular

(non"atal MI. non"atal stroke. 01 death!

#atel A5 et al5. for t9e AD,ANCE Colla!orative Gro'". N Engl J Med $0:3%0;$%*-$%/$.

34%'% (%'&27%'&!



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Intensive !l$e%i Cont"ol andCa"diovas-la" O-to%es) ADT

D'cBort9 5 et al.5 for t9e ,AD Investigators. N Engl J Med$+:3*;1$+-13+.

*rimar+ ,utcome# -on"atal MI. non"atal stroke. 01 death.

hos)itali:ation "or heart "ailure. revasculari:ation34%'&& (%'6978'%5!

$2%% New England Journal of Medicine' sed with )ermission'

!l$e%i Reo%%endations fo"


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!l$e%i Reo%%endations fo"Non,"e#nant Ad-lts 8it' Diabetes .1/

A1C H/.?

#re"randial ca"illary

"lasma gl'cose

/13 mgd2

(3.+/.$ mmol2)

#eaB "ost"randial

ca"illary "lasma gl'coseMH10 mgd2

(H1. mmol2)

Individ'ali6e goals !ased on t9ese val'es.;#ost"randial gl'cose meas'rements s9o'ld !e made 1$ 9 after t9e !eginning of t9e meal5 generally"eaB levels in "atients it9 dia!etes.

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S$. a!le +.



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Goals s9o'ld !e individ'ali6ed !ased on

D'ration of dia!etes

Agelife e7"ectancy

Comor!id conditions

Jnon C,D or advanced microvasc'larcom"lications

y"oglycemia 'naareness

Individ'al "atient considerations

!l$e%i Reo%%endations fo"Non,"e#nant Ad-lts 8it' Diabetes .2/




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&ore- or less-stringent glycemic goals may!e a""ro"riate for individ'al "atients

#ost"randial gl'cose may !e targeted if

A1C goals are not met des"ite reac9ing

"re"randial gl'cose goals

!l$e%i Reo%%endations fo"Non,"e#nant Ad-lts 8it' Diabetes ./


Reo%%ended T'e"a,$ fo" T$,e 1


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Reo%%ended T'e"a,$ fo" T$,e 1Diabetes) T'"ee Co%,onents

Fse of m'lti"le-dose ins'lin inKections(34 inKectionsday of !asal and "randialins'lin) or contin'o's s'!c'taneo's ins'lininf'sion (CSII)

&atc9ing "randial ins'lin to car!o9ydrateintaBe5 "remeal !lood gl'cose5 andantici"ated activity

@or many "atients (es"ecially if

9y"oglycemia is a "ro!lem)5 'se ofins'lin analogs

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S$1.

Reo%%endations)


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Reo%%endations)T'e"a,$ fo" T$,e 2 Diabetes .1/

At t9e time of ty"e $ dia!etes diagnosis5initiate metformin t9era"y along it9lifestyle interventions5 'nless metformin iscontraindicated (A)

In nely diagnosed ty"e $ dia!etes"atients it9 marBedly sym"tomaticandor elevated !lood gl'cose levels orA1C5 consider ins'lin t9era"y5 it9 or

it9o't additional agents5 from t9eo'tset (E)


Reo%%endations)


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Reo%%endations)T'e"a,$ fo" T$,e 2 Diabetes .2/

If nonins'lin monot9era"y at ma7imaltolerated dose does not ac9ieve ormaintain t9e A1C target over 3* mont9s5add a second oral agent5 a G2#-1 rece"tor

agonist5 or ins'lin (E)


Nonins-lin T'e"a,ies fo"


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Nonins-lin T'e"a,ies fo"9$,e"#l$e%ia in T$,e 2 Diabetes .1/

Class 8ig'anides

Com"o'nd &etformin

&ec9anism Activates A-Binase

Action(s) e"atic gl'cose "rod'ction Intestinal gl'cose a!sor"tion Ins'lin action

Advantages No eig9t gain No 9y"oglycemia Red'ction in cardiovasc'lar events and mortality

(FJ#DS f')

Disadvantages Gastrointestinal side effects (diarr9ea5 a!dominal

cram"ing) 2actic acidosis (rare)

,itamin 81$deficiency

Contraindications; red'ced Bidney f'nction

Cost 2o

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S$$.Ada"ted it9 "ermission from Silvio In6'cc9i5 ale Fniversity.



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Class S'lfonyl'reas ($ndgeneration)

Com"o'nd Gli!enclamideGly!'ride Gli"i6ide Glicla6ide Glime"iride

&ec9anism Closes JA#c9annels on


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Nonins-lin T'e"a,ies fo"9$,e"#l$e%ia in T$,e 2 Diabetes ./

Class &eglitinides

Com"o'nd Re"aglinide Nateglinide

&ec9anism Closes JA#c9annels on


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Nonins-lin T'e"a,ies fo"9$,e"#l$e%ia in T$,e 2 Diabetes .4a/

Class 9ia6olidinediones (Glita6ones)

Com"o'nd #ioglita6one&ec9anism Activates t9e n'clear transcri"tion factor ##AR-

Action(s) #eri"9eral ins'lin sensitivity

Advantages No 9y"oglycemia D2 c9olesterol riglycerides

Disadvantages eig9t gain Edema eart fail're 8one fract'res

Cost ig9




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Nonins-lin T'e"a,ies fo"9$,e"#l$e%ia in T$,e 2 Diabetes .4b/

Class 9ia6olidinediones (Glita6ones)

Com"o'nd Rosiglita6one&ec9anism Activates t9e n'clear transcri"tion factor ##AR-

Action(s) #eri"9eral ins'lin sensitivity

Advantages No 9y"oglycemia

Disadvantages 2D2 c9olesterol eig9t gain Edema eart fail're 8one fract'res Increased cardiovasc'lar events (mi7ed

evidence) @DA arnings on cardiovasc'lar safety Contraindicated in "atients it9 9eart disease

Cost ig9




55/150


Class Q-Gl'cosidase in9i!itors

Com"o'nd Acar!ose &iglitol

&ec9anism In9i!its intestinal Q-gl'cosidase

Action(s) Intestinal car!o9ydrate digestion (and

consec'tively5 a!sor"tion) sloed

Advantages Nonsystemic medication #ost"randial gl'cose

Disadvantages Gastrointestinal side effects (gas5 flat'lence5diarr9ea)

Dosing fre'ency

Cost &edi'm




56/150


Class G2#-1 rece"tor agonists (incretin mimetics)

Com"o'nd E7enatide 2iragl'tide

&ec9anism Activates G2#-1 rece"tors (


57/150


Class D##-4 in9i!itors (incretin en9ancers)

Com"o'nd Sitagli"tin ,ildagli"tin Sa7agli"tin 2inagli"tin

&ec9anism In9i!its D##-4 activity5 "rolongs s'rvival of

endogeno'sly released incretin 9ormones

Action(s) Active G2#-1 concentration Active GI# concentration

Ins'lin secretion Gl'cagon secretion

Advantages No 9y"oglycemia eig9t One'tralityP

Disadvantages =ccasional re"orts of 'rticariaangioedema Cases of "ancreatitis o!served 2ong-term safety 'nBnon

Cost ig9ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S$3.Ada"ted it9 "ermission from Silvio In6'cc9i5 ale Fniversity.



58/150

Nonins-lin T'e"a,ies fo"9$,e"#l$e%ia in T$,e 2 Diabetes .:/

Class 8ile acid se'estrants

Com"o'nd Colesevelam

&ec9anism 8inds !ile acidsc9olesterol

Action(s) FnBnon

Advantages No 9y"oglycemia 2D2 c9olesterol

Disadvantages Consti"ation riglycerides &ay interfere it9 a!sor"tion of ot9er

medications

Cost ig9

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S$3.Ada"ted it9 "ermission from Silvio In6'cc9i5 ale Fniversity.



59/150

Nonins-lin T'e"a,ies fo"9$,e"#l$e%ia in T$,e 2 Diabetes .;/

Class Do"amine-$ agonists

Com"o'nd 8romocri"tine

&ec9anism Activates do"aminergic rece"tors

Action(s) Alters 9y"ot9alamic reg'lation of meta!olism Ins'lin sensitivity

Advantages No 9y"oglycemia

Disadvantages Di66inesssynco"e Na'sea @atig'e R9initis 2ong-term safety 'nBnon

Cost &edi'm

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S$3.Ada"ted it9 "ermission from Silvio In6'cc9i5 ale Fniversity.

Reo%%endations)


60/150

o oMedial N-t"ition T'e"a,$ .MNT/


Individ'als 9o 9ave "redia!etes ordia!etes s9o'ld receive individ'ali6ed &Nas needed to ac9ieve treatment goals5"refera!ly "rovided !y a registered

dietitian familiar it9 t9e com"onents ofdia!etes &N (A)

8eca'se &N can res'lt in cost-savingsand im"roved o'tcomes (8)5 &N s9o'ld

!e ade'ately covered !y ins'rance andot9er "ayers (E)

Loo< A9EAD .Ation fo" 9ealt' in


61/150

.Diabetes/) One=+ea" Res-lts

1. 2ooB AEAD Researc9 Gro'". Diabetes Care. $/:3;13/4-1303:$. 2ooB AEAD Researc9 Gro'".Arch Intern Med. 2%8%


62/150

Self=Mana#e%ent Ed-ation .DSME/

#eo"le it9 dia!etes s9o'ld receive DS&E according

to national standards and dia!etes self-managements'""ort at diagnosis and as needed t9ereafter (8)

Effective self-management5 'ality of life are Beyo'tcomes of DS&E: s9o'ld !e meas'red5 monitored

as "art of care (C) DS&E s9o'ld address "syc9osocial iss'es5 since

emotional ell-!eing is associated it9 "ositiveo'tcomes (C)

8eca'se DS&E can res'lt in cost-savings andim"roved o'tcomes (8)5 DS&E s9o'ld !e reim!'rsed!y t9ird-"arty "ayers (E)


Reo%%endations) ('$sial Ativit$


63/150

Reo%%endations) ('$sial Ativit$

Advise "eo"le it9 dia!etes to "erform atleast 1% mineeB of moderate-intensityaero!ic "9ysical activity (%/? ofma7im'm 9eart rate)5 s"read over at least

3 days "er eeB it9 no more t9an$ consec'tive days it9o't e7ercise (A)

In a!sence of contraindications5 "eo"leit9 ty"e $ dia!etes s9o'ld !e enco'raged

to "erform resistance training at leasttice "er eeB (A)

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S$%.

Reo%%endations)


64/150

(s$'osoial Assess%ent and Ca"e

=ngoing "art of medical management of

dia!etes (E)

#syc9osocial screeningfollo-'"; attit'des

a!o't dia!etes5 medical managemento'tcomes

e7"ectations5 affectmood5 'ality of life5reso'rces5 "syc9iatric 9istory (E)

9en self-management is "oor5 screen for

"syc9osocial "ro!lems; de"ression5 dia!etes-

related an7iety5 eating disorders5 cognitiveim"airment (C)

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S$*.

Reo%%endations) 9$,o#l$e%ia


65/150

Reo%%endations) 9$,o#l$e%ia

Gl'cose (1%$ g) "referred treatment forconscio's individ'al it9 9y"oglycemia (E)

Gl'cagon s9o'ld !e "rescri!ed for allindivid'als at significant risB of severe

9y"oglycemia and caregiversfamilymem!ers instr'cted in administration (E)

9ose it9 9y"oglycemia 'naarenessor one or more e"isodes of severe

9y"oglycemia s9o'ld raise glycemictargets to red'ce risB of f't're e"isodes(8)

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S$/.

Reo%%endations) Ba"iat"i S-"#e"$


66/150

Reo%%endations) Ba"iat"i S-"#e"$

Consider !ariatric s'rgery for ad'lts it98&I 3% Bgm$and ty"e $ dia!etes (8)

After s'rgery5 life-long lifestyle s'""ortand medical monitoring is necessary (8)

Ins'fficient evidence to recommends'rgery in "atients it9 8&I H3% Bgm$o'tside of a researc9 "rotocol (E)

ell-designed5 randomi6ed controlled

trials com"aring o"timal medicallifestylet9era"y needed to determine long-term!enefits5 cost-effectiveness5 risBs (E)

ADA. ,. Dia!etes Care. Diabetes Care $1$:3%(s'""l 1);S$/.

Reo%%endations) I%%-ni>ation


67/150

Reo%%endations) I%%-ni>ation

#rovide infl'en6a vaccine ann'ally to all dia!etic

"atients >* mont9s of age (C)

Administer "ne'mococcal "olysacc9aride vaccine to all

dia!etic "atients >$ years (C)

=ne-time revaccination recommended for t9ose *4 years

"revio'sly imm'ni6ed at H*% yearsif administered % years ago

=t9er indications for re"eat vaccination; ne"9rotic syndrome5

c9ronic renal disease5 imm'nocom"romised states

Administer 9e"atitis 8 vaccination "er CDCrecommendations (C)



68/150

I& (REENTION ANDMANA!EMENT OFDIABETES COM(LICATIONS

Ca"diovas-la" Disease .CD/ in


69/150

C,D is t9e maKor ca'se of mor!idity5mortality for t9ose it9 dia!etes

Common conditions coe7isting it9 ty"e $dia!etes (e.g.5 9y"ertension5 dysli"idemia)

are clear risB factors for C,D Dia!etes itself confers inde"endent risB

8enefits o!served 9en individ'alcardiovasc'lar risB factors are controlled

to "reventslo C,D in "eo"le it9dia!etes

Individ-als 8it' Diabetes

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S$0.

Reo%%endations)


70/150

9$,e"tension3Blood ("ess-"e Cont"ol

Screening and diagnosis

&eas're !lood "ress're at every ro'tinedia!etes visit (C)

If "atients 9ave systolic !lood "ress're

>13 mmg or diastolic !lood "ress're>0 mmg (C) Confirm !lood "ress're on a se"arate day

Re"eat systolic !lood "ress're >13 mmg or

diastolic !lood "ress're >0 mmg confirms adiagnosis of 9y"ertension

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S$0-S$+.

Reo%%endations)


71/150


Goals

A goal systolic !lood "ress're H13 mmgis a""ro"riate for most "atients it9dia!etes (C)

8ased on "atient c9aracteristics andres"onse to t9era"y5 9ig9er or loersystolic !lood "ress're targets may !ea""ro"riate (8)

#atients it9 dia!etes s9o'ld !e treated toa diastolic !lood "ress're H0 mmg (8)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S$+.

Reo%%endations)


72/150


reatment (1)

#atients it9 a systolic !lood "ress're1313+ mmg or a diastolic !lood"ress're 00+ mmg (E)

&ay !e given lifestyle t9era"y alone for ama7im'm of 3 mont9s

If targets are not ac9ieved5 "atients s9o'ld !etreated it9 t9e addition of "9armacological

agents


Reo%%endations)


73/150


reatment ($)

#atients it9 more severe 9y"ertension(systolic !lood "ress're >14 mmg ordiastolic !lood "ress're >+ mmg) at

diagnosis or follo-'" (A) S9o'ld receive "9armacologic t9era"y in

addition to lifestyle t9era"y


Reo%%endations)


74/150


reatment (3)

2ifestyle t9era"y for 9y"ertension (8) eig9t loss if overeig9t

DAS-style dietary "attern incl'ding red'cing

sodi'm5 increasing "otassi'm intaBe &oderation of alco9ol intaBe

Increased "9ysical activity

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S$/.

Reo%%endations)


75/150


reatment (4)

#9armacologic t9era"y for "atients it9dia!etes and 9y"ertension A regimen t9at incl'des eit9er an ACE in9i!itor

or angiotensin II rece"tor !locBer If one class is not tolerated5 t9e ot9er s9o'ld!e s'!stit'ted

&'lti"le dr'g t9era"y (to or more agents

at ma7imal doses) is generally re'ired toac9ieve !lood "ress're targets (8)


Reo%%endations)


76/150


reatment (%)

If ACE in9i!itors5 AR8s5 or di'retics are'sed5 Bidney f'nction5 ser'm "otassi'mlevels s9o'ld !e monitored (E)

In "regnant "atients it9 dia!etes andc9ronic 9y"ertension5 !lood "ress'retarget goals of 111$+*%/+ mmg ares'ggested in interest of long-term

maternal 9ealt9 and minimi6ing im"airedfetal grot9: ACE in9i!itors5 AR8s5contraindicated d'ring "regnancy (E)


Reo%%endations)


77/150

D$sli,ide%ia3Li,id Mana#e%ent

Screening

In most ad'lt "atients5 meas're fastingli"id "rofile at least ann'ally (E)

In ad'lts it9 lo-risB li"id val'es

(2D2 c9olesterol H1 mgd25 D2c9olesterol % mgd25 and triglyceridesH1% mgd2)5 li"id assessments may !ere"eated every $ years (E)


Reo%%endations)


78/150


reatment recommendations and goals (1)

o im"rove li"id "rofile in "atients it9dia!etes5 recommend lifestyle modification(A)5 foc'sing on

Red'ction of sat'rated fat5 trans fat5c9olesterol intaBe

Increased n-3 fatty acids5 visco's fi!er5"lant stanolssterols

eig9t loss (if indicated) Increased "9ysical activity

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S3.

Reo%%endations)


79/150


reatment recommendations and goals ($)

Statin t9era"y s9o'ld !e added to lifestylet9era"y5 regardless of !aseline li"id levels it9 overt C,D (A)

it9o't C,D 4 years of age 9o 9ave oneor more ot9er C,D risB factors (A)

@or "atients at loer risB (e.g.5 it9o'tovert C,D5 H4 years of age) (E)

Consider statin t9era"y in addition to lifestylet9era"y if 2D2 c9olesterol remains 1 mgd2

In t9ose it9 m'lti"le C,D risB factors

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S3-31.

Reo%%endations)li id i 3 i id


80/150



In individ'als it9o't overt C,D #rimary goal is an 2D2 c9olesterol

H1 mgd2 ($.* mmol2) (A)

In individ'als it9 overt C,D 2oer 2D2 c9olesterol goal of H/ mgd2

(1.0 mmol2)5 'sing a 9ig9 dose of a statin5is an o"tion (8)


Reo%%endations)li id i 3 i id


81/150



If targets not reac9ed on ma7imal toleratedstatin t9era"y Alternative t9era"e'tic goal; red'ce 2D2

c9olesterol L34? from !aseline (A) riglyceride levels H1% mgd2

(1./ mmol2)5 D2 c9olesterol 4 mgd2(1. mmol2) in men and % mgd2

(1.3 mmol2) in omen5 are desira!le oever5 2D2 c9olesteroltargeted statin t9era"y

remains t9e "referred strategy (C)


Reo%%endations)D li id i 3Li id M


82/150


reatment recommendations and goals (%)

If targets are not reac9ed on ma7imallytolerated doses of statins (E) Com!ination t9era"y 'sing statins and ot9er

li"id loering agents may !e considered toac9ieve li"id targets

as not !een eval'ated in o'tcome st'dies foreit9er C,D o'tcomes or safety

Statin t9era"y is contraindicated in"regnancy (8)


Reo%%endations) !l$e%i* Blood( Li id C t l i Ad lt


83/150

("ess-"e* Li,id Cont"ol in Ad-lts

A1C H/.?

8lood "ress're H130 mmgM

2i"ids2D2 c9olesterol H1 mgd2

(H$.* mmol2)

&ore or less stringent glycemic goals may !e a""ro"riate for individ'al "atients. Goals s9o'ld !eindivid'ali6ed !ased on; d'ration of dia!etes5 agelife e7"ectancy5 comor!id conditions5 Bnon C,D oradvanced microvasc'lar com"lications5 9y"oglycemia 'naareness5 and individ'al "atientconsiderations.

M8ased on "atient c9aracteristics and res"onse to t9era"y5 9ig9er or loer systolic !lood "ress're targetsmay !e a""ro"riate.

In individ'als it9 overt C,D5 a loer 2D2 c9olesterol goal of H/ mgd2 (1.0 mmol2)5 'sing a 9ig9dose of statin5 is an o"tion.

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S3$. a!le 11.

Reo%%endations)A ti l t l t A t .1/


84/150

Anti,latelet A#ents .1/

Consider as"irin t9era"y (/%1*$ mgday)

(C) As a "rimary "revention strategy in t9ose it9

ty"e 1 or ty"e $ dia!etes at increasedcardiovasc'lar risB (1-year risB 1?)

Incl'des most men % years of age or omen* years of age 9o 9ave at least oneadditional maKor risB factor

@amily 9istory of C,D

y"ertension SmoBing

Dysli"idemia

Al!'min'ria

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care$1$:3%(s'""l 1);S3$.

Reo%%endations)A ti l t l t A t .2/


85/150

Anti,latelet A#ents .2/

As"irin s9o'ld not !e recommended for

C,D "revention for ad'lts it9 dia!etes atlo C,D risB5 since "otential adverseeffects from !leeding liBely offset "otential!enefits (C) 1-year C,D risB H%?; men H% and omen

H* years of age it9 no maKor additional C,DrisB factors

In "atients in t9ese age gro'"s it9m'lti"le ot9er risB factors (1-year risB%1?)5 clinical K'dgment is re'ired (E)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S3$.

Reo%%endations)A ti l t l t A t ./


86/150

Anti,latelet A#ents ./

Fse as"irin t9era"y (/%1*$ mgday) Secondary "revention strategy in t9ose it9

dia!etes it9 a 9istory of C,D (A)

@or "atients it9 C,D and doc'mentedas"irin allergy Clo"idogrel (/% mgday) s9o'ld !e 'sed (8)

Com!ination t9era"y it9 ASA (/%1*$mgday) and clo"idogrel (/% mgday)

Reasona!le for '" to a year after an ac'tecoronary syndrome (8)


Reo%%endations)S


87/150

S%o


88/150

Co"ona"$ 9ea"t Disease S"eenin#

In asym"tomatic "atients5 ro'tine

screening for CAD is not recommended5 asit does not im"rove o'tcomes as long asC,D risB factors are treated (A)


Reo%%endations)C 9 t Di T t t .1/


89/150

Co"ona"$ 9ea"t Disease T"eat%ent .1/

o red'ce risB of cardiovasc'lar events in

"atients it9 Bnon C,D5 'se ACE in9i!itor(C)

As"irin(A)

Statin t9era"y(A)

In "atients it9 a "rior &I 8eta-!locBers s9o'ld !e contin'ed for at least

$ years after t9e event (8)


If not contraindicated.

Reo%%endations)Co"ona"$ 9ea"t Disease T"eat%ent .2/


90/150

Co"ona"$ 9ea"t Disease T"eat%ent .2/

2onger-term 'se of !eta-!locBers in t9e

a!sence of 9y"ertension Reasona!le if ell tolerated5 !'t data are

lacBing (E)

Avoid D treatment In "atients it9 sym"tomatic 9eart fail're (C)

&etformin 'se in "atients it9 sta!le C@ Indicated if renal f'nction is normal

S9o'ld !e avoided in 'nsta!le or 9os"itali6ed"atients it9 C@ (C)


Reo%%endations) Ne,'"o,at'$


91/150

, , $

o red'ce risB or slo t9e "rogression of

ne"9ro"at9y ="timi6e gl'cose control (A)

="timi6e !lood "ress're control (A)


Reo%%endations)Ne,'"o,at'$ S"eenin#


92/150

Ne,'"o,at'$ S"eenin#

Assess 'rine al!'min e7cretion ann'ally

(8) In ty"e 1 dia!etic "atients it9 dia!etes

d'ration of >% years

In all ty"e $ dia!etic "atients at diagnosis

&eas're ser'm creatinine at least ann'ally(E) In all ad'lts it9 dia!etes regardless of degree

of 'rine al!'min e7cretion Ser'm creatinine s9o'ld !e 'sed to estimateG@R and stage level of c9ronic Bidney disease5if "resent


Reo%%endations)Ne,'"o,at'$ T"eat%ent .1/


93/150

Ne,'"o,at'$ T"eat%ent .1/

Non"regnant "atient it9 micro- or

macroal!'min'ria Fse eit9er ACE in9i!itors or AR8s (A)

If one class is not tolerated5 t9e ot9er s9o'ld!e s'!stit'ted (E)

Red'ction of "rotein intaBe may im"rovemeas'res of renal f'nction ('rine al!'mine7cretion rate5 G@R) (8)

o .01. g 7 Bg !ody t1

7 day1

in t9oseit9 dia!etes5 earlier stages of CJD

o .0 g 7 Bg !ody t17 day1in later stagesof CJD


Reo%%endations)Ne,'"o,at'$ T"eat%ent .2/


94/150

Ne,'"o,at'$ T"eat%ent .2/

9en ACE in9i!itors5 AR8s5 or di'retics

are 'sed5 monitor ser'm creatinine and"otassi'm levels for t9e develo"ment ofincreased creatinine and 9y"erBalemia (E)

Contin'ed monitoring of 'rine al!'mine7cretion to assess !ot9 res"onse tot9era"y and "rogression of disease isreasona!le (E)

9en estimated G@R is H* m2 7min1./3 m$5 eval'ate and manage"otential com"lications of CJD (E)

ADA. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S34.

Reo%%endations)Ne,'"o,at'$ T"eat%ent ./


95/150

Ne,'"o,at'$ T"eat%ent ./

Consider referral to a "9ysician

e7"erienced in care of Bidney disease (8) Fncertainty a!o't etiology of Bidney disease

Diffic'lt management iss'es

Advanced Bidney disease


Definitions of Abno"%alities inAlb-%in E?"etion


96/150

Alb-%in E?"etion

Category

S"ot collection(Tgmg

creatinine)

Normal H3&icroal!'min'ria 3-$++

&acroal!'min'ria(clinical)

>3

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S34. a!le 1$.

Sta#es of C'"oni @idne$ Disease


97/150

Stage Descri"tion

G@R (m2min

"er 1./3 m$!ody s'rface

area)

1 Jidney damageit9 normal or

increased G@R

>+

$ Jidney damageit9 mildlydecreased G@R

*0+

3 &oderately decreased G@R 3%+

4 Severely decreased G@R 1%$+% Jidney fail're H1% or dialysis

>idne+ damage de"ined as abnormalities on )athologic. urine. blood. or imaging tests'

?@3 4 glomerular "iltration rate

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S3%. a!le 13.

Mana#e%ent of C@D in Diabetes .1/


98/150

G@R (m2min

1./3 m$

) RecommendedAll "atients early meas'rement of creatinine5 'rinary

al!'min e7cretion5 "otassi'm

4%-* Referral to ne"9rology if "ossi!ility for

nondia!etic Bidney disease e7ists

Consider dose adK'stment of medications

&onitor eG@R every * mont9s

&onitor electrolytes5 !icar!onate5 9emoglo!in5

calci'm5 "9os"9or's5 "arat9yroid 9ormone at

least yearly

Ass're vitamin D s'fficiency

Consider !one density testing

Referral for dietary co'nselling

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S3%. a!le 14:Ada"ted from 9tt";.Bidney.org"rofessionalsJD=UIg'idelineVdia!etes.

Mana#e%ent of C@D in Diabetes .2/


99/150

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S3%. a!le 14:Ada"ted from 9tt";.Bidney.org"rofessionalsJD=UIg'idelineVdia!etes.

G@R (mlmin

1./3 m$) Recommended3-44 &onitor eG@R every 3 mont9s

&onitor electrolytes5 !icar!onate5

calci'm5 "9os"9or's5 "arat9yroid

9ormone5 9emoglo!in5 al!'min5 eig9tevery 3* mont9s

Consider need for dose adK'stment of

medications

H3 Referral to ne"9rologists

Reo%%endations) Retino,at'$


100/150

o red'ce risB or slo "rogression of

retino"at9y ="timi6e glycemic control (A)

="timi6e !lood "ress're control (A)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care$1$:3%(s'""l 1);S3%.

Reo%%endations)Retino,at'$ S"eenin# .1/


101/150

Retino,at'$ S"eenin# .1/

Initial dilated and com"re9ensive eye

e7amination !y an o"9t9almologist oro"tometrist Ad'lts and c9ildren aged 1 years or older

it9 ty"e 1 dia!etes it9in % years after dia!etes onset (8)

#atients it9 ty"e $ dia!etes S9ortly after diagnosis of dia!etes (8)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S3%.



102/150


S'!se'ent e7aminations for ty"e 1 and

ty"e $ dia!etic "atients S9o'ld !e re"eated ann'ally !y an

o"9t9almologist or o"tometrist

2ess fre'ent e7ams (every $3 years) &ay !e considered folloing one or more

normal eye e7ams

&ore fre'ent e7aminations re'ired if

retino"at9y is "rogressing (8)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S3%-S3*.

Reo%%endations)Retino,at'$ S"eenin# ./


103/150

Retino,at'$ S"eenin# ./

ig9-'ality f'nd's "9otogra"9s

Can detect most clinically significantdia!etic retino"at9y (E)

Inter"retation of t9e images #erformed !y a trained eye care "rovider (E)

9ile retinal "9otogra"9y may serve as ascreening tool for retino"at9y5 it is not as'!stit'te for a com"re9ensive eye e7am

#erform com"re9ensive eye e7am at leastinitially and at intervals t9ereafter asrecommended !y an eye care "rofessional (E)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S3*.



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omen it9 "ree7isting dia!etes 9o are

"lanning "regnancy or 9o 9ave !ecome"regnant (8) Com"re9ensive eye e7amination

Co'nseled on risB of develo"ment andor"rogression of dia!etic retino"at9y

Eye e7amination s9o'ld occ'r in t9e firsttrimester (8)

Close follo-'" t9ro'g9o't "regnancy @or 1 year "ost"art'm


Reo%%endations)Retino,at'$ T"eat%ent .1/


105/150

Retino,at'$ T"eat%ent .1/

#rom"tly refer "atients it9 any level of

mac'lar edema5 severe N#DR5 or any #DR o an o"9t9almologist Bnoledgea!le and

e7"erienced in management5 treatment ofdia!etic retino"at9y (A)

2aser "9otocoag'lation t9era"y isindicated (A) o red'ce risB of vision loss in "atients it9

ig9-risB #DR

Clinically significant mac'lar edema

Some cases of severe N#DR


Reo%%endations)Retino,at'$ T"eat%ent .2/


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Retino,at'$ T"eat%ent .2/

#resence of retino"at9y

Not a contraindication to as"irin t9era"y forcardio"rotection5 as t9is t9era"y does notincrease t9e risB of retinal 9emorr9age (A)


Reo%%endations)Ne-"o,at'$ S"eenin#* T"eat%ent .1/


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Ne-"o,at'$ S"eenin#* T"eat%ent .1/

All "atients s9o'ld !e screened for distal

symmetric "olyne'ro"at9y (D#N) (8) At diagnosis of ty"e $ dia!etes it9 % years

after diagnosis of ty"e 1 dia!etes

At least ann'ally t9ereafter 'sing sim"le

clinical tests

Electro"9ysiological testing rarely needed E7ce"t in sit'ations 9ere clinical feat'res are

aty"ical (E)


Reo%%endations)Ne-"o,at'$ S"eenin#* T"eat%ent .2/


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Ne-"o,at'$ S"eenin#* T"eat%ent .2/

Screening for signs and sym"toms of

cardiovasc'lar a'tonomic ne'ro"at9y S9o'ld !e instit'ted at diagnosis of ty"e $

dia!etes and % years after t9e diagnosis ofty"e 1 dia!etes

S"ecial testing rarely needed: may not affectmanagement or o'tcomes (E)

&edications for relief of s"ecific sym"tomsrelated to D#N5 a'tonomic ne'ro"at9y arerecommended Im"rove 'ality of life of t9e "atient (E)


Reo%%endations) Foot Ca"e .1/


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@or all "atients it9 dia!etes5 "erform an

ann'al com"re9ensive foot e7amination toidentify risB factors "redictive of 'lcersand am"'tations Ins"ection

Assessment of foot "'lses

est for loss of "rotective sensation; 1-gmonofilament "l's testing any one of

,i!ration 'sing 1$0-6 t'ning forB

#in"ricB sensation

AnBle refle7es

,i!ration "erce"tion t9res9old (8)

ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $1$:3%(s'""l 1);S3/.



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,,e" ,anel

o "erform t9e 1-gmonofilament test5 "lacet9e device "er"endic'larto t9e sBin5 it9 "ress'rea""lied 'ntil t9e

monofilament !'cBles old in "lace for 1 second

and t9en release

Lo8e" ,anel

9e monofilament tests9o'ld !e "erformed att9e 9ig9lig9ted sites9ile t9e "atients eyesare closed

8o'lton AW&5 et al. Diabetes Care. $0:31;1*/+-1*0%.

Reo%%endations) Foot Ca"e ./


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#rovide general foot self-care ed'cation (8)

Fse m'ltidisci"linary a""roac9 Individ'als it9 foot 'lcers5 9ig9-risB feet:

es"ecially "rior 'lcer or am"'tation (8)

Refer "atients to foot care s"ecialists forongoing "reventive care5 life-longs'rveillance (C) SmoBers

2oss of "rotective sensation or str'ct'rala!normalities

istory of "rior loer-e7tremity com"lications




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Initial screening for "eri"9eral arterial

disease (#AD) Incl'de a 9istory for cla'dication5 assessment

of "edal "'lses

Consider o!taining an anBle-!rac9ial inde7

(A8I): many "atients it9 #AD areasym"tomatic (C)

Refer "atients it9 significant cla'dicationor a "ositive A8I for f'rt9er vasc'larassessment Consider e7ercise5 medications5 s'rgical

o"tions (C)



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II& ASSESSMENT OF COMMONCOMORBID CONDITIONS

Reo%%endations) Assess%ent ofCo%%on Co%o"bid Conditions


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Co%%on Co%o"bid Conditions

@or "atients it9 risB factors5 signs or

sym"toms5 consider assessment andtreatment for common dia!etes-associatedconditions (8)

Common comor!idities for 9ic9 increasedrisB is associated it9 dia!etes

ADA. ,II. Assessment of Common Comor!id Conditions. Diabetes Care. $1$:3%(s'""l 1);S30: a!le 1%.

earing im"airment #eriodontal disease

=!str'ctive slee" a"nea Certain cancers

@atty liver disease @ract'res2o testosterone in men Cognitive im"airment


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III& DIABETES CARE INS(ECIFIC (O(LATIONS

Reo%%endations) (ediat"i!l$e%i Cont"ol .T$,e 1 Diabetes/


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$ . $, /

Consider age 9en setting glycemic goals

in c9ildren and adolescents it9 ty"e 1dia!etes (E)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $1$:3%(s'""l 1);S4.

Reo%%endations) (ediat"iNe,'"o,at'$ .T$,e 1 Diabetes/


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, , $ . $, /

Ann'al screening for microal!'min'ria5 it9 a

random s"ot 'rine sam"le for al!'min-to-creatinine (ACR) ratio

Consider once c9ild is 1 years of age and

9as 9ad dia!etes for % years (E)

Confirmed5 "ersistently elevated ACR

on to additional 'rine s"ecimens from different

days

reat it9 an ACE in9i!itor5 titrated to normali6ation

of al!'min e7cretion5

if "ossi!le (E)


Reo%%endations) (ediat"i9$,e"tension .T$,e 1 Diabetes/ .1/


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$, . $, / . /

reat 9ig9-normal !lood "ress're (systolic

or diastolic !lood "ress're consistentlya!ove t9e +t9"ercentile for age5 se75 and9eig9t) it9 Dietary intervention

E7ercise aimed at eig9t control and increased"9ysical activity5 if a""ro"riate

If target !lood "ress're is not reac9ed

it9 3* mont9s of lifestyle intervention Consider "9armacologic treatment (E)


Reo%%endations) (ediat"i9$,e"tension .T$,e 1 Diabetes/ .2/


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#9armacologic treatment of 9y"ertension

Systolic or diastolic !lood "ress're consistentlya!ove t9e +%t9"ercentile for age5 se75 and9eig9t

Or

Consistently 130 mmg5 if +%? e7ceedst9at val'e

Initiate treatment as soon as diagnosis isconfirmed (E)


$, . $, / . /

Reo%%endations) (ediat"i9$,e"tension .T$,e 1 Diabetes/ ./


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ACE in9i!itors

Consider for initial treatment of 9y"ertension5folloing a""ro"riate re"rod'ctive co'nselingd'e to "otential teratogenic effects (E)

Goal of treatment 8lood "ress're consistently H130 mmg or

!elo t9e +t9"ercentile for age5 se75 and9eig9t5 9ic9ever is loer (E)


$, . $, / . /

Reo%%endations) (ediat"iD$sli,ide%ia .T$,e 1 Diabetes/ .1/


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$ , . $, / . /

Screening (1)

If family 9istory of 9y"erc9olesterolemia(total c9olesterol $4 mgd2) or acardiovasc'lar event !efore age %% years5or if family 9istory is 'nBnon #erform fasting li"id "rofile on c9ildren

$ years of age soon after diagnosis (aftergl'cose control 9as !een esta!lis9ed)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $1$:3%(s'""l 1);S4-S41.



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Screening ($)

If family 9istory is not of concern Consider first li"id screening at "'!erty

(>1 years)

All c9ildren diagnosed it9 dia!etes at orafter "'!erty #erform fasting li"id "rofile soon after

diagnosis (after gl'cose control 9as !eenesta!lis9ed) (E)


$ , . $, / . /

Reo%%endations) (ediat"iD$sli,ide%ia .T$,e 1 Diabetes/ ./


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Screening (3)

@or !ot9 age-gro'"s5 if li"ids are a!normal Ann'al monitoring is recommended

If 2D2 c9olesterol val'es are it9in

acce"ted risB levels (H1 mgd2X$.* mmol2Y) Re"eat li"id "rofile every % years (E)


$ , . $, / . /



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reatment

Initial t9era"y; o"timi6e gl'cose control5 &N'sing Ste" II AA diet aimed at decreasingdietary sat'rated fat (E)

age 1 years5 statin reasona!le in t9ose(after &N and lifestyle c9anges) it9 2D2 c9olesterol 1* mgd2 (4.1 mmol2) or

2D2 c9olesterol 13 mgd2 (3.4 mmol2) and

one or more C,D risB factors (E) Goal; 2D2 c9olesterol H1 mgd2

($.* mmol2) (E)


&NZmedical n'trition t9era"y

Reo%%endations) (ediat"iRetino,at'$ .T$,e 1 Diabetes/


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@irst o"9t9almologic e7amination

=!tain once c9ild is 1 years of age: 9as 9addia!etes for 3% years (E)

After initial e7amination Ann'al ro'tine follo-'" generally

recommended

2ess fre'ent e7aminations may !e acce"ta!leon advice of an eye care "rofessional (E)


Reo%%endations) (ediat"iCelia Disease .T$,e 1 Diabetes/ .1/


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C9ildren it9 ty"e 1 dia!etes

Screen for celiac disease !y meas'ring tiss'etransgl'taminase or antiendomysial anti!odies5it9 doc'mentation of normal total ser'm IgAlevels5 soon after t9e diagnosis of dia!etes (E)

Re"eat testing in c9ildren it9 Grot9 fail're

@ail're to gain eig9t5 eig9t loss

Diarr9ea5 flat'lence5 a!dominal "ain5 or signs

of mala!sor"tion

@re'ent 'ne7"lained 9y"oglycemia ordeterioration in glycemic control (E)


Reo%%endations) (ediat"iCelia Disease .T$,e 1 Diabetes/ .2/


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C9ildren it9 "ositive anti!odies

Refer to a gastroenterologist for eval'ationit9 endosco"y and !io"sy (E)

C9ildren it9 !io"sy-confirmed celiacdisease #lace on a gl'ten-free diet

Cons'lt it9 a dietitian e7"erienced inmanaging !ot9 dia!etes and celiac disease (E)


Reo%%endations) (ediat"i9$,ot'$"oidis% .T$,e 1 Diabetes/


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C9ildren it9 ty"e 1 dia!etes

Screen for t9yroid "ero7idase5 t9yroglo!'linanti!odies at diagnosis (E)

9yroid-stim'lating 9ormone (S)concentrations &eas're after meta!olic control esta!lis9ed

If normal5 rec9ecB every 1-$ years: or

If "atient develo"s sym"toms of t9yroid dysf'nction5t9yromegaly5 or an a!normal grot9 rate


Reo%%endations) T"ansition f"o%(ediat"i to Ad-lt Ca"e


129/150

As teens transition into emerging

ad'lt9ood5 9ealt9 care "roviders andfamilies m'st recogni6e t9eir manyv'lnera!ilities (8) and "re"are t9edevelo"ing teen5 !eginning in early to mid

adolescence and at least 1 year "rior tot9e transition (E)

8ot9 "ediatricians and ad'lt 9ealt9 care

"roviders s9o'ld assist in "rovidings'""ort and linBs to reso'rces for t9eteen and emerging ad'lt (8)

ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $1$:3%(s'""l 1);S4$.

Reo%%endations)("eone,tion Ca"e .1/


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A1C levels s9o'ld !e as close to normal as

"ossi!le (/?) in an individ'al "atient!efore conce"tion is attem"ted (8)

Starting at "'!erty5 incor"orate"reconce"tion co'nseling in ro'tinedia!etes clinic visit for all omen ofc9ild!earing "otential (C)

omen it9 dia!etes contem"lating

"regnancy s9o'ld !e eval'ated and5 ifindicated5 treated for dia!etic retino"at9y5ne"9ro"at9y5 C,D (8)


Reo%%endations)("eone,tion Ca"e .2/


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&edications s9o'ld !e eval'ated "rior to

conce"tion5 since dr'gs commonly 'sed totreat dia!etes and its com"lications may !econtraindicated or not recommended in"regnancy5 incl'ding statins5 ACE in9i!itors5

AR8s5 and most nonins'lin t9era"ies (E)

Since many "regnancies are 'n"lanned5consider "otential risBs!enefits of

medications contraindicated in "regnancy inall omen of c9ild!earing "otential: co'nselaccordingly (E)


Reo%%endations) Olde" Ad-lts .1/


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@'nctional5 cognitively intact older ad'lts

it9 significant life e7"ectancies s9o'ldreceive dia!etes care 'sing goalsdevelo"ed for yo'nger ad'lts (E)

Glycemic goals for t9ose not meeting t9ea!ove criteria may !e rela7ed 'singindivid'al criteria5 !'t 9y"erglycemialeading to sym"toms or risB of ac'te

9y"erglycemic com"lications s9o'ld !eavoided in all "atients (E)


Reo%%endations) Olde" Ad-lts .2/


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reat ot9er cardiovasc'lar risB factors it9

consideration of t9e time frame of !enefitand t9e individ'al "atient

reatment of 9y"ertension is indicated invirt'ally all older ad'lts: li"id5 as"irint9era"y may !enefit t9ose it9 lifee7"ectancy e'al to time frame of"rimarysecondary "revention trials (E)

Individ'ali6e screening for dia!etescom"lications it9 attention to t9oseleading to f'nctional im"airment (E)


Reo%%endations) C$sti Fib"osis=Related Diabetes .CFRD/


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Ann'al screening for C@RD it9 =G

s9o'ld !egin !y age 1 years in all"atients it9 cystic fi!rosis 9o do not9ave C@RD (8) Fse of A1C as a screening test for C@RD is not

recommended (8)

D'ring a "eriod of sta!le 9ealt95 diagnosisof C@RD can !e made in "atients it9

cystic fi!rosis according to 's'al diagnosticcriteria (E)


Reo%%endations) C$sti Fib"osis=Related Diabetes .CFRD/


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#atients it9 C@RD s9o'ld !e treated it9

ins'lin to attain individ'ali6ed glycemicgoals (A)

Ann'al monitoring for com"lications ofdia!etes is recommended5 !eginning %years after t9e diagnosis of C@RD (E)



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I& DIABETES CARE INS(ECIFIC SETTIN!S

Reo%%endations)Diabetes Ca"e in t'e 9os,ital .1/


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All "atients it9 dia!etes admitted to t9e

9os"ital s9o'ld 9ave t9eir dia!etes clearlyidentified in t9e medical record (E)

All "atients it9 dia!etes s9o'ld 9ave anorder for !lood gl'cose monitoring5 it9res'lts availa!le to all mem!ers of t9e9ealt9 care team (E)

ADA. I. Dia!etes Care in S"ecific Settings. Diabetes Care. $1$:3%(s'""l 1);S44.



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Goals for !lood gl'cose levels

Critically ill "atients; 14-10 mgd2(/.01 mmol2) (A)

&ore stringent goals5 s'c9 as 11-14 mgd2(*.1/.0 mmol2) may !e a""ro"riate for

selected "atients5 if ac9ieva!le it9o'tsignificant 9y"oglycemia (C)

Critically ill "atients re'ire an I, ins'lin"rotocol t9at 9as demonstrated efficacy and

safety in ac9ieving t9e desired gl'cose rangeit9o't increasing risB for severe9y"oglycemia (E)


Reo%%endations)Diabetes Ca"e in t'e 9os,ital ./


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Goals for !lood gl'cose levels

Noncritically ill "atients; No clear evidence fors"ecific !lood gl'cose goals

If treated it9 ins'lin5 "remeal !lood gl'cosetargets (if safely ac9ieved)

Generally H14 mgd2 (/.0 mmol2) it9 random!lood gl'cose H10 mgd2 (1. mmol2)

&ore stringent targets may !e a""ro"riate insta!le "atients it9 "revio's tig9t glycemiccontrol

2ess stringent targets may !e a""ro"riate int9ose it9 severe comor!idities (E)




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Sc9ed'led s'!c'taneo's ins'lin it9 !asal5

n'tritional5 and correction com"onents ist9e "referred met9od for ac9ieving andmaintaining gl'cose control in noncriticallyill "atients




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Initiate gl'cose monitoring in any "atient

not Bnon to !e dia!etic 9o receivest9era"y associated it9 9ig9-risB for9y"erglycemia ig9-dose gl'cocorticoid t9era"y5 initiation of

enteral or "arenteral n'trition5 or ot9ermedications s'c9 as octreotide orimm'nos'""ressive medications (8)

If 9y"erglycemia is doc'mented and

"ersistent5 consider treating s'c9 "atientsto t9e same glycemic goals as "atients it9Bnon dia!etes (E)




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A 9y"oglycemia management "rotocol

s9o'ld !e ado"ted and im"lemented !yeac9 9os"ital or 9os"ital system Esta!lis9 a "lan for treating 9y"oglycemia for

eac9 "atient: doc'ment e"isodes of

9y"oglycemia in medical record and tracB (E) =!tain A1C for all "atients if res'lts it9in

"revio's $3 mont9s 'navaila!le (E)

#atients it9 9y"erglycemia it9o't adiagnosis of dia!etes; doc'ment "lans forfollo-'" testing and care at disc9arge (E)

ADA. I. Dia!etes Care in S"ecific Settings.Diabetes Care

. $1$:3%(s'""l 1);S44.

Diabetes Ca"e in t'e 9os,ital)NICE=S!AR St-d$ .1/


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2argest randomi6ed controlled trial to date

ested effect of tig9t glycemic control(target 0110 mgd2) on o'tcomesamong *514 critically ill "artici"ants

&aKority (+%?) re'ired mec9anicalventilation

ADA. I. Dia!etes Care in S"ecific Settings. Diabetes Care. $1$:3%(s'""l 1);S4%.

Diabetes Ca"e in t'e 9os,ital)NICE=S!AR St-d$ .2/


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In !ot9 s'rgicalmedical "atients5 +-day

mortality significantly 9ig9er in intensivelytreated vs conventional gro'" (target14410 mgd2) /0 more deat9s ($/.%? vs $4.+?: PZ.$)

/* more deat9s from cardiovasc'lar ca'ses(41.*? vs 3%.0?: PZ.$)

Severe 9y"oglycemia more common(*.0? vs .%?: PH.1)

ADA. I. Dia!etes Care in S"ecific Settings. Diabetes Care. $1$:3%(s'""l 1);S4%.


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& STRATE!IES FORIM(ROIN!DIABETES CARE

Reo%%endations) St"ate#ies fo"I%,"ovin# Diabetes Ca"e .1/


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ADA. . Strategies for Im"roving Dia!etes Care. Diabetes Care. $1$:3%(s'""l 1);S40.

Care s9o'ld !e aligned it9 com"onents

of t9e C9ronic Care &odel to ens're"rod'ctive interactions !eteen a"re"ared "roactive "ractice team and aninformed activated "atient (A)

9en feasi!le5 care systems s9o'lds'""ort team-!ased care5 comm'nityinvolvement5 "atient registries5 and

em!edded decision s'""ort tools to meet"atient needs (8)

Reo%%endations) St"ate#ies fo"I%,"ovin# Diabetes Ca"e .2/


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ADA. . Strategies for Im"roving Dia!etes Care. Diabetes Care. $1$:3%(s'""l 1);S40.

reatment decisions s9o'ld !e timely

and !ased on evidence-!ased g'idelinest9at are tailored to individ'al "atient"references5 "rognoses5 and comor!idities(8)

A "atient-centered comm'nication styles9o'ld !e em"loyed t9at incor"orates"atient "references5 assesses literacy and

n'meracy5 and addresses c'lt'ral !arriersto care (8)


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Obetive 2)S-,,o"t (atient Be'avio" C'an#e


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Im"lement a systematic a""roac9 to

s'""ort "atient !e9avior c9ange efforts a) ealt9y lifestyle; "9ysical activity5 9ealt9y

eating5 non'se of to!acco5 eig9tmanagement5 effective co"ing

!) Disease self-management; medicationtaBing and management5 self-monitoring ofgl'cose and !lood "ress're 9en clinicallya""ro"riate

c) #revention of dia!etes com"lications;self-monitoring of foot 9ealt95 active"artici"ation in screening for eye5 foot5 andrenal com"lications5 and imm'ni6ations

ADA. . Strategies for Im"roving Dia!etes Care. Diabetes Care. $1$:3%(s'""l 1);S4+.

Obetive )C'an#e t'e S$ste% of Ca"e


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9e most s'ccessf'l "ractices 9ave an

instit'tional "riority for "roviding 9ig9'ality of care 8asing care on evidence-!ased g'idelines

E7"anding t9e role of teams and staff

Redesigning t9e "rocesses of care

Im"lementing electronic 9ealt9 record tools

Activating and ed'cating "atients

Identifying andor develo"ing comm'nityreso'rces and "'!lic "olicy t9at s'""orts9 lt9 lif t l

ADA Standards of Medical Care 2012 FINAL (1).pptx

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Transcript of ADA Standards of Medical Care 2012 FINAL (1).pptx