Abridged Standards of Medical Care in Diabetes 2017 0

P O S I T I O N SETD
ATI TEO
MREI N
ATL
Clinical Diabetes Papers In Press, published online December 15, 2016
Standards of Medical Care in Diabetes2017

Abridged for Primary Care Providers
American Diabetes Association
T
he American Diabetes Associa- PROMOTING HEALTH AND
tions (ADAs) Standards of Med- REDUCING DISPARITIES IN
ical Care in Diabetes is updated POPULATIONS
and published annually in a supple-
Recommendations
ment to the January issue of Diabetes
Treatment plans should align
Care. The ADAs Professional Practice
with the Chronic Care Model,
Committee, comprised of physicians,
emphasizing productive interac-
diabetes educators, registered dieti-
tions between a prepared proactive
tians, and public health experts, de-
practice team and an informed
velops the Standards. Formerly called
Clinical Practice Recommendations, the activated patient. A
Standards includes the most current When feasible, care systems
evidence-based recommendations for should support team-based care,
diagnosing and treating adults and community involvement, patient
children with all forms of diabetes. registries, and decision support
ADAs grading system uses A, B, C, tools to meet patient needs. B
or E to show the evidence level that Diabetes and Population
supports each recommendation. Health
AClear evidence from well-con- Clinical practice guidelines are key
ducted, generalizable randomized to improving population health;
controlled trials that are ade- however, for optimal outcomes, di-
quately powered abetes care must be individualized
B Supportive evidence from for each patient. Thus, efforts to im-
well-conducted cohort studies prove population health will require
C Supportive evidence from a combination of systems-level and
poorly controlled or uncontrolled patient-level approaches. With such
studies an integrated approach in mind, the
E Expert consensus or clinical ADA highlights the importance of
This is an abridged version of the experience
American Diabetes Association Position
patient-centered care, defined as care
Statement: Standards of Medical Care that is respectful of and responsive to
in Diabetes2017. Diabetes Care This is an abridged version of the individual patient preferences, needs,
2017;40(Suppl. 1):S1S138. current Standards containing the
and values and ensuring that patient
The complete 2017 Standards supplement, evidence-based recommendations
including all supporting references, is values guide all clinical decisions.
most pertinent to primary care. The
available at professional.diabetes.org/
standards. tables and figures have been renum- Care Delivery Systems
DOI: 10.2337/cd16-0067 bered from the original document Despite the many advances in diabe-
to match this version. The complete tes care, 3349% of patients still do
2017 by the American Diabetes Association.
Readers may use this article as long as the work
2017 Standards of Care document, not meet targets for glycemic, blood
is properly cited, the use is educational and not including all supporting references, pressure, or cholesterol control, and
for profit, and the work is not altered. See http://
creativecommons.org/licenses/by-nc-nd/3.0
is available at professional.diabetes. only 14% meet targets for all three
for details. org/standards. measures while also avoiding smok-
C L I N I C A L D I A B E T E S 1
P O S I T I O N S TAT E M E N T

ing. Certain segments of the popu- TABLE. 1. Criteria for the Diagnosis of Diabetes
lation, such as young adults and pa-
FPG 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at
tients with complex comorbidities, least 8 h.*
financial or other social hardships,
and/or limited English proficiency, OR
face particular challenges to care. 2-h plasma glucose 200 mg/dL (11.1 mmol/L) during an OGTT. The test
Even after adjusting for these factors, should be performed as described by the World Health Organization,
using a glucose load containing the equivalent of 75 g anhydrous glucose
the persistent variability in the quality dissolved in water.*
of diabetes care across providers and
OR
practice settings indicates that sub-
stantial system-level improvements A1C 6.5% (48 mmol/mol). The test should be performed in a laboratory
using a method that is NGSP certified and standardized to the Diabetes
are still needed. Control and Complications Trial assay.*
Chronic Care Model OR
Numerous interventions to improve In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis,
adherence to the recommended a random plasma glucose 200 mg/dL (11.1 mmol/L).
standards have been implemented. *In the absence of unequivocal hyperglycemia, results should be confirmed
However, a major barrier to optimal by repeat testing.
care is a delivery system that is often
fragmented, lacks clinical information are fundamental to the success- and change the societal determinants
capabilities, duplicates services, and is ful implementation of the CCM. of these problems.
poorly designed for the coordinated Collaborative, multidisciplinary
delivery of chronic care. The Chronic Recommendations
teams are best suited to provide care
Care Model (CCM) takes these fac- Providers should assess social
for people with chronic conditions
tors into consideration and is an ef- context, including potential food
such as diabetes and to facilitate
fective framework for improving the insecurity, housing stability, and
patients self-management.
quality of diabetes care. financial barriers, and apply that
Strategies for System-Level information to treatment deci-
Six Core Elements
Improvement sions. A
The CCM includes six core elements
Optimal diabetes management re- Patients should be referred to local
to optimize the care of patients with
chronic disease: quires an organized, systematic ap- community resources when avail-
1. Delivery system design (moving
proach and the involvement of a co- able. B
from a reactive to a proactive care ordinated team of dedicated health Patients should be provided with
delivery system where planned care professionals working in an en- self-management support from
visits are coordinated through a vironment where patient-centered, lay health coaches, navigators, or
team-based approach) high-quality care is a priority. Three community health workers when
2. Self-management support objectives to achieve this include: available. A
3. Decision support (basing care Optimizing provider and team
CLASSIFICATION AND
on evidence-based, effective care behavior
DIAGNOSIS OF DIABETES
guidelines) Supporting patient self-manage-
Diabetes can be classified into the fol-
4. Clinical information systems ment
lowing general categories:
(using registries that can provide Changing the care system
1. Type 1 diabetes (due to auto-
patient-specific and popula- Tailoring Treatment to Reduce immune -cell destruction,
tion-based support to the care Disparities usually leading to absolute insu-
team)
Social determinants of health can be lin deficiency)
5. Community resources and pol-
defined as the economic, environmen- 2. Type 2 diabetes (due to a pro-
icies (identifying or developing
tal, political, and social conditions in gressive loss of -cell insulin
resources to support healthy
lifestyles) which people live and are responsible secretion frequently on the back-
6. Health systems (to create a qual-
for a major part of health inequality ground of insulin resistance)
worldwide. Given the tremendous 3. Gestational diabetes mellitus
ity-oriented culture)
burden that obesity, unhealthy eat- (GDM) (diabetes diagnosed in
Redefining the roles of the health ing, physical inactivity, and smoking the second or third trimester
care delivery team and empow- place on the health of patients with of pregnancy that is not clearly
ering patient self-management diabetes, efforts are needed to address overt diabetes prior to gestation)
2 CLINICAL.DIABETESJOURNALS.ORG
a b r i d g e d s ta n d a r d s o f c a r e
TABLE 2. Criteria for Testing for Diabetes or Prediabetes in

The American Diabetes Association
Asymptomatic Adults Risk Test is an additional option for
screening.
1. Testing should be considered in overweight or obese (BMI 25 kg/m2
or 23 kg/m2 in Asian Americans) adults who have one or more of the COMPREHENSIVE
following risk factors: MEDICAL EVALUATION
A1C 5.7% (39 mmol/mol), impaired glucose tolerance, or impaired AND ASSESSMENT OF
fasting glucose on previous testing COMORBIDITIES
First-degree relative with diabetes The comprehensive medical evalua-
High-risk race/ethnicity (e.g., African American, Latino, Native tion includes the initial and ongoing
American, Asian American, Pacific Islander) evaluations, assessment of complica-
Women who were diagnosed with GDM tions, management of comorbid con-
ditions, and engagement of the pa-
History of CVD
tient throughout the process. People
Hypertension (140/90 mmHg or on therapy for hypertension) with diabetes should receive health
HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglycer- care from a team that may include
ide level >250 mg/dL (2.82 mmol/L) physicians, nurse practitioners, physi-
Women with polycystic ovary syndrome cian assistants, nurses, dietitians, exer-
Physical inactivity cise specialists, pharmacists, dentists,
Other clinical conditions associated with insulin resistance (e.g., podiatrists, and mental health pro-
severe obesity, acanthosis nigricans) fessionals. Individuals with diabetes
2. For all patients, testing should begin at age 45 years.
must assume an active role in their
care. The patient, family, physician,
3. If results are normal, testing should be repeated at a minimum of 3-year
intervals, with consideration of more frequent testing depending on
and health care team should formu-
initial results (e.g., those with prediabetes should be tested yearly) and late the management plan, which in-
risk status. cludes lifestyle management.
Lifestyle management and psy-
TABLE 3. Referrals for Initial Care Management chosocial care are the cornerstones of
Eye care professional for annual dilated eye exam diabetes management. Patients should
Family planning for women of reproductive age
be referred for diabetes self-manage-
ment education (DSME), diabetes
Registered dietitian for MNT self-management support (DSMS),
DSME and DSMS medical nutrition therapy (MNT),
Dentist for comprehensive dental and periodontal examination and psychosocial/emotional health
Mental health professional, if indicated concerns if indicated. Additional
referrals should be arranged as neces-
4. Other specific types, including Type 2 Diabetes and sary (Table 3). Patients should receive
monogenic forms of diabetes Prediabetes recommended preventive care ser-
vices (e.g., immunizations and cancer
Diagnostic Tests for Diabetes Recommendations screening); smoking cessation coun-
Diabetes may be diagnosed based on Screening to assess prediabetes seling; and ophthalmological, dental,
plasma glucose criteriaeither the and risk for future diabetes with and podiatric referrals. Clinicians
fasting plasma glucose (FPG) or the an informal assessment of risk should ensure that individuals with
2-h plasma glucose value after a 75-g factors or validated tools should diabetes are appropriately screened
be considered in asymptomatic for complications and comorbidities.
oral glucose tolerance test (OGTT)
adults. B
or A1C (Table 1). Comprehensive Medical
To test for prediabetes, FPG,
The same tests are used to screen OGTT, and A1C are equally Evaluation
for and diagnose diabetes and to appropriate. B The components of the comprehen-
detect individuals with prediabetes Testing for prediabetes and type 2 sive diabetes medical evaluation are
(Table 2). Prediabetes is defined as diabetes should be considered in listed in Table 4.
FPG of 100125 mg/dL (5.66.9 children and adolescents who are Recommendations
mmol/L); 2-hr OGTT of 140199 overweight or obese and who have A complete medical evaluation should
mg/dL (7.811.0 mmol/L); or A1C two or more additional risk factors be performed at the initial visit to
of 5.76.4% (3947 mmol/mol). for diabetes. E Confirm the diagnosis and classify
TABLE 4. Components of the Comprehensive Diabetes Medical Evaluation*

Medical history
Age and characteristics of onset of diabetes (e.g., diabetic ketoacidosis [DKA], asymptomatic laboratory finding)
Eating patterns, nutritional status, weight history, sleep behaviors (pattern and duration), and physical activity
habits; nutrition education and behavioral support history and needs
Complementary and alternative medicine use
Presence of common comorbidities and dental disease
Screen for depression, anxiety, and disordered eating using validated and appropriate measures**
Screen for diabetes distress using validated and appropriate measures**
Screen for psychosocial problems and other barriers to diabetes self-management such as limited financial,
logistical, and support resources
History of tobacco use, alcohol consumption, and substance use
DSME and DSMS history and needs
Review of previous treatment regimens and response to therapy (A1C records)
Assess medication-taking behaviors and barriers to medication adherence
Results of glucose monitoring and patients use of data
DKA frequency, severity, and cause
Hypoglycemia episodes, awareness, frequency, and causes
History of increased blood pressure and abnormal lipids
Microvascular complications: retinopathy, nephropathy, and neuropathy (sensory, including history of foot
lesions; autonomic, including sexual dysfunction and gastroparesis)
Macrovascular complications: coronary heart disease, cerebrovascular disease, and peripheral arterial disease
For women with child-bearing capacity, review contraception and preconception planning
Physical examination
Height, weight, and BMI; growth and pubertal development in children and adolescents
Blood pressure determination, including orthostatic measurements when indicated
Fundoscopic examination
Thyroid palpation
Skin examination (e.g., for acanthosis nigricans and insulin injection or infusion set insertion sites)
Comprehensive foot examination:
Inspection
Palpation of dorsalis pedis and posterior tibial pulses
Presence/absence of patellar and Achilles reflexes
Determination of proprioception, vibration, and monofilament sensation
Laboratory evaluation
A1C, if results not available within the past 3 months
If not performed/available within the past year:
Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides, as needed
Liver function tests
Spot urinary albumintocreatinine ratio
Serum creatinine and eGFR
Thyroid-stimulating hormone in patients with type 1 diabetes
*The comprehensive medical evaluation should all ideally be done on the initial visit, but if time is limited different
components can be done as appropriate on follow-up visits
**Refer to the ADA position statement Psychochsocial Care for People With Diabetes for additional details on
diabetes-specific screening measures.

diabetes. B thyroid disease and celiac disease (relative risk 1.7) diabetes in both
Detect diabetes complications and soon after diagnosis. E sexes. Type 1 diabetes is associated
potential comorbid conditions. E with osteoporosis, but in type 2 dia-
Cancer
Review previous treatment and betes, an increased risk of hip fracture
Diabetes is associated with increased
risk factor control in patients with is seen despite higher bone mineral
risk of cancers of the liver, pancreas,
established diabetes. E endometrium, colon/rectum, breast, density.
Begin patient engagement in the and bladder. The association may re- Hearing Impairment
formulation of a care management sult from shared risk factors between Hearing impairment, both in high-
plan. B diabetes and cancer (older age, obesi- frequency and low- to mid-frequen-
Develop a plan for continuing ty, and physical inactivity) or diabe- cy ranges, is more common in peo-
care. B tes-related factors such as underlying ple with diabetes than in those with-
Immunization disease physiology or diabetes treat- out, perhaps due to neuropathy and/
ments, although evidence for these or vascular disease.
Recommendations links is scarce. Patients with diabetes
Provide routine vaccinations for should be encouraged to undergo rec- Low Testosterone in Men
children and adults with diabetes ommended age- and sex-appropriate Mean levels of testosterone are lower
according to age-related recom- cancer screenings and to reduce their in men with diabetes compared with
mendations. C modifiable cancer risk factors (obesity, age-matched men without diabetes,
Annual vaccination against influ- physical inactivity, and smoking). but obesity is a major confounder.
enza is recommended for all Treatment in asymptomatic men is
people with diabetes 6 months Cognitive Impairment/ controversial. The evidence that tes-
of age. C Dementia tosterone replacement affects out-
Vaccination against pneumonia is Diabetes is associated with a signifi- comes is mixed, and recent guidelines
recommended for all people with cantly increased risk and rate of cog- do not recommend testing or treating
diabetes who are 264 years of age nitive decline and an increased risk men without symptoms.
with pneumococcal polysaccha- of dementia. In a 15-year prospective
study of community-dwelling peo- Obstructive Sleep Apnea
ride vaccine (PPSV23). At age 65
ple >60 years of age, the presence Age-adjusted rates of obstructive sleep
years, administer the pneumococ-
of diabetes at baseline significantly apnea, a risk factor for cardiovascu-
cal conjugate vaccine (PCV13) at
increased the age- and sex-adjust- lar disease (CVD), are significantly
least 1 year after vaccination with
ed incidence of all-cause dementia, higher (4- to 10-fold) with obesity,
PPSV23, followed by another dose
Alzheimers disease, and vascular de- and especially with central obesity.
of vaccine PPSV23 at least 1 year
mentia compared with rates in those The prevalence of obstructive sleep
after PCV13 and at least 5 years
with normal glucose tolerance. apnea in the population with type 2
after the last dose of PPSV23. C
diabetes may be as high as 23%, and
Administer three-dose series of Fatty Liver Disease the prevalence of any sleep disordered
hepatitis B vaccine to unvacci- Elevations of hepatic transaminase breathing may be as high as 58%.
nated adults with diabetes who concentrations are associated with
are aged 1959 years. C higher BMI, waist circumference, Periodontal Disease
Consider administering three- and triglyceride levels and lower Periodontal disease is more severe
dose series of hepatitis B vaccine to HDL cholesterol levels. In a prospec- and may be more prevalent in people
unvaccinated adults with diabetes tive analysis, diabetes was significantly with diabetes than in those without.
who are 60 years of age. C associated with incident nonalcoholic Current evidence suggests that peri-
chronic liver disease and with hepato- odontal disease adversely affects di-
Comorbidities
cellular carcinoma. Interventions that abetes outcomes, although evidence
Besides assessing diabetes-related
improve metabolic abnormalities in for treatment benefits on diabetes
complications, clinicians and their
patients with diabetes (weight loss, control remains unclear.
patients need to be aware of com-
mon comorbidities that affect people glycemic control, and treatment with Psychosocial Disorders
with diabetes and may complicate specific drugs for hyperglycemia or Prevalence of clinically significant
dyslipidemia) are also beneficial for psychopathology in people with di-
management.
fatty liver disease.
abetes ranges across diagnostic cate-
Autoimmune Diseases
Fractures gories, and some diagnoses are con-
Recommendations Age-specific hip fracture risk is signifi- siderably more common in people
Consider screening patients with cantly increased in people with both with diabetes than for those without
type 1 diabetes for autoimmune type 1 (relative risk 6.3) and type 2 the disease. Symptoms, both clinical

and subclinical, that interfere with a in conjunction with collaborative self-management, both at diagno-
persons ability to carry out diabetes care with the patients diabetes sis and as needed thereafter. B
self-management must be addressed. treatment team. A Effective self-management and
Diabetes distress is very common and improved clinical outcomes,
distinct from a psychological disorder. Disordered Eating Behavior
health status, and quality of
Anxiety Disorders Recommendations life are key goals of DSME and
Providers should consider reeval- DSMS that should be measured
Recommendations uating the treatment regimen of and monitored as part of routine
Consider screening for anxiety people with diabetes who present care. C
in people exhibiting anxiety or with symptoms of disordered eat- DSME and DSMS should be
worries regarding diabetes com- ing behavior, an eating disorder, patient-centered, respectful, and
plications, insulin injections or or disrupted patterns of eating. B responsive to individual patient
infusion, taking medications, Consider screening for disor- preferences, needs, and values,
and/or hypoglycemia that interfere dered or disrupted eating using
with self-management behaviors and should help guide clinical
validated screening measures decisions. A
and those who express fear, dread, when hyperglycemia and weight
or irrational thoughts and/or show DSME and DSMS programs
loss are unexplained based on have the necessary elements in
anxiety symptoms such as avoid-
self-reported behaviors related to their curricula to delay or prevent
ance behaviors, excessive repetitive
medication dosing, meal plan, the development of type 2 diabe-
behaviors, or social withdrawal.
Refer for treatment if anxiety is and physical activity. In addition, tes. DSME and DSMS programs
present. B a review of the medical regimen is should therefore be able to tailor
People with hypoglycemic recommended to identify poten- their content when prevention of
unawareness, which can co-occur tial treatment-related effects on diabetes is the desired goal. B
with fear of hypoglycemia, should hunger/caloric intake. B Because DSME and DSMS can
be treated using Blood Glucose Serious Mental Illness improve outcomes and reduce
Awareness Training (or another costs B , DSME and DSMS
similar evidence-based interven- Recommendations
should be adequately reimbursed
tion) to help re-establish awareness Annually screen people who are by third-party payers. E
of hypoglycemia and reduce fear prescribed atypical antipsychotic
of hyperglycemia. A medications for prediabetes or The overall objectives of DSME
diabetes. B and DSMS are to support informed
Depression Incorporate monitoring of diabetes decision-making, self-care behaviors,
Recommendations self-care activities into treatment problem-solving, and active collabo-
Providers should consider annual goals in people with diabetes and ration with the health care team to
screening of all patients with serious mental illness. B improve clinical outcomes, health
diabetes, especially those with a status, and quality of life in a cost-
LIFESTYLE MANAGEMENT
self-reported history of depres- effective manner.
Lifestyle management is a fundamen-
sion, for depressive symptoms Four critical time points have
with age-appropriate depression tal aspect of diabetes care, and in-
cludes DSME and DSMS, nutrition, been defined when the need for
screening measures, recognizing DSME and DSMS should be eval-
that further evaluation will be physical activity, smoking cessation,
and psychosocial care. uated by the medical care provider
necessary for individuals who have
and/or multidisciplinary team, with
a positive screen. B DSME and DSMS
Beginning at diagnosis of com- referrals made as needed:
Recommendations 1. At diagnosis
plications or when there are
significant changes in medical In accordance with the national 2. Annually for assessment of edu-
status, consider assessment for standards for DSME and DSMS, cation, nutrition, and emotional
depression. B all people with diabetes should needs
Referrals for treatment of depres- participate in DSME to facilitate 3. When new complicating factors
sion should be made to mental the knowledge, skills, and ability (health conditions, physical lim-
health providers with experience necessary for diabetes self-care itations, emotional factors, or
using cognitive behavioral therapy, and in DSMS to assist with imple- basic living needs) arise that influ-
interpersonal therapy, or other evi- menting and sustaining skills and ence self-management
dence-based treatment approaches behaviors needed for ongoing 4. When transitions in care occur
TABLE 5. MNT Recommendations

Topic Recommendations Evidence Rating
Effectiveness of An individualized MNT program, preferably provided by a registered A
nutrition therapy dietitian, is recommended for all people with type 1 or type 2 diabetes.
For people with type 1 diabetes and those with type 2 diabetes who are A
prescribed a flexible insulin therapy program, education on how to use
carbohydrate counting and, in some cases, fat and protein gram
estimation to determine mealtime insulin dosing can improve glycemic
control.
For individuals whose daily insulin dosing is fixed, having a consistent B
pattern of carbohydrate intake with respect to time and amount can
result in improved glycemic control and a reduced risk of hypoglycemia.
A simple and effective approach to glycemia and weight management B
emphasizing portion control and healthy food choices may be more
helpful for those with type 2 diabetes who are not taking insulin, who
have limited health literacy or numeracy, or who are elderly and prone to
hypoglycemia.
Because diabetes nutrition therapy can result in cost savings B and B, A, E
improved outcomes (e.g., A1C reduction) A, MNT should be adequately
reimbursed by insurance and other payers. E
Energy balance Modest weight loss achievable by the combination of reduction of A
caloric intake and lifestyle modification benefits overweight or
obese adults with type 2 diabetes and also those with prediabetes.
Intervention programs to facilitate this process are recommended.
Eating patterns Because there is no single ideal dietary distribution of calories among E
and macronutrient carbohydrates, fats, and proteins for people with diabetes, macronutri-
distribution ent distribution should be individualized while keeping total caloric and
metabolic goals in mind.
A variety of eating patterns are acceptable for the management of type B
2 diabetes and prediabetes including the Mediterranean diet, DASH,
and plant-based diets.
Carbohydrate intake from whole grains, vegetables, fruits, legumes, and B
dairy products, with an emphasis on foods higher in fiber and lower in
glycemic load, should be advised over other sources, especially those
containing sugars.
People with diabetes and those at risk should avoid sugar-sweetened B, A
beverages to control weight and reduce their risk for CVD and fatty liver
disease B and should minimize their consumption of foods with added
sugar that have the capacity to displace healthier, more nutrient-dense
food choices. A
Protein In individuals with type 2 diabetes, ingested protein appears to increase B
insulin response without increasing plasma glucose concentrations.
Therefore, carbohydrate sources high in protein should not be used to
treat or prevent hypoglycemia.
Dietary fat Whereas data on the ideal total dietary fat content for people with B
diabetes are inconclusive, an eating plan emphasizing elements of a
Mediterranean-style diet rich in monounsaturated fats may improve
glucose metabolism and lower CVD risk and can be an effective
alternative to a diet low in total fat but relatively high in carbohydrates.
Eating foods rich in long-chain -3 fatty acids, such as fatty fish (EPA B, A
and DHA) and nuts and seeds (ALA) is recommended to prevent or treat
CVD B; however, evidence does not support a beneficial role for -3
dietary supplements. A
TABLE CONTINUED ON P. 8
TABLE 5. MNT Recommendations,

TABLE continued from p. 7
5. MNT Recommendations
Topic Recommendations Evidence Rating
Micronutrients There is no clear evidence that dietary supplementation with vitamins, C
and herbal minerals, herbs, or spices can improve outcomes in people with
supplements diabetes who do not have underlying deficiencies, and there may
be safety concerns regarding the long-term use of antioxidant
supplements such as vitamins E and C and carotene.
Alcohol Adults with diabetes who drink alcohol should do so in moderation C
(no more than one drink per day for adult women and no more than
two drinks per day for adult men).
Alcohol consumption may place people with diabetes at increased B
risk for hypoglycemia, especially if they are taking insulin or insulin
secretagogues. Education and awareness regarding the recognition
and management of delayed hypoglycemia are warranted.
Sodium As for the general population, people with diabetes should limit sodium B
consumption to <2,300 mg/day, although further restriction may be
indicated for those with both diabetes and hypertension.
Non-nutritive The use of nonnutritive sweeteners has the potential to reduce overall B
Sweeteners caloric and carbohydrate intake if substituted for caloric sweeteners and
without compensation by intake of additional calories from other food
sources. Nonnutritive sweeteners are generally safe to use within the
defined acceptable daily intake levels.
Nutrition Therapy abetes should engage in 60 min/ diabetes. Yoga and tai chi may
For many individuals with diabe- day or more of moderate or vigor- be included based on individual
tes, the most challenging part of the ous intensity aerobic activity, with preferences to increase flexibility,
treatment plan is determining what vigorous, muscle-strengthening, muscular strength, and balance. C
to eat and following a food plan. and bone-strengthening activities
There is not a one-size-fits-all eating included at least 3 days/week. C Exercise in the Presence
pattern for individuals with diabe- Most adults with with type 1 C or of Specific Long-Term
tes. The Mediterranean diet, Dietary type 2 B diabetes should engage Complications of Diabetes
Approaches to Stop Hypertension in 150 min or more of moder- Retinopathy
(DASH) diet, and plant-based diets ate-to-vigorous intensity activity If proliferative diabetic retinopathy or
are all examples of healthful eating per week, spread over at least 3
severe nonproliferative diabetic reti-
patterns. See Table 5 for specific nu- days/week, with no more than 2
nopathy is present, then vigorous-in-
trition recommendations. consecutive days without activity.
In overweight and obese patients Shorter durations (minimum 75 tensity aerobic or resistance exercise
with type 2 diabetes, modest weight min/week) of vigorous-intensity or may be contraindicated because of the
loss, defined as sustained reduc- interval training may be sufficient risk of triggering vitreous hemorrhage
tion of 5% of initial body weight, for younger and more physically or retinal detachment. Consultation
has been shown to improve glyce- fit individuals. with an ophthalmologist prior to en-
mic control and to reduce the need Adults with type 1 C or type 2 gaging in an intense exercise regimen
for glucose-lowering medications. B diabetes should engage in 23 may be appropriate.
However, sustaining weight loss can sessions/week of resistance exercise Peripheral Neuropathy
be challenging. Weight loss can be on nonconsecutive days.
Decreased pain sensation and a high-
attained with lifestyle programs that All adults, and particularly those
er pain threshold in the extremities
achieve a 500750 kcal/day energy with type 2 diabetes, should
deficit or provide ~1,2001,500 kcal/ decrease the amount of time spent result in an increased risk of skin
day for women and 1,5001,800 in daily sedentary behavior. B breakdown, infection, and Charcot
kcal/day for men, adjusted for the Prolonged sitting should be inter- joint destruction with some forms of
individual's baseline body weight. rupted every 30 min for blood exercise. Therefore, a thorough assess-
glucose benefits, particularly in ment should be done to ensure that
Physical Activity neuropathy does not alter kinesthetic
adults with type 2 diabetes. C
Recommendations Flexibility training and balance or proprioceptive sensation during
Children and adolescents with training are recommended 23 physical activity, particularly in those
type 1 or type 2 diabetes or predi- times/week for older adults with with more severe neuropathy.

Smoking Cessation: Tobacco Patients with prediabetes should Recommendation
and e-Cigarettes be referred to an intensive Most patients using intensive
behavioral lifestyle intervention insulin regimens (multiple-dose
Recommendations
program modelled on the Diabetes insulin or insulin pump therapy)
Advise all patients not to use ciga-
Prevention Program to achieve should perform SMBG prior to
rettes and other tobacco products
and maintain 7% loss of initial meals and snacks, at bedtime,
A or e-cigarettes. E
body weight and increase mod- occasionally postprandially, prior
Include smoking cessation
erate-intensity physical activity to exercise, when they suspect low
counseling and other forms of
(such as brisk walking) to at least blood glucose, after treating low
treatment as a routine component
150 min/week. A blood glucose until they are nor-
of diabetes care. B
Metformin therapy for prevention moglycemic, and prior to critical
Psychosocial Issues
of type 2 diabetes should be con- tasks such as driving. B
Recommendations sidered in those with prediabetes, SMBG allows patients to evaluate
Psychosocial care should be especially for those with a BMI their individual responses to therapy
integrated with a collaborative, 35 kg/m 2, those <60 years of and assess whether glycemic targets
patient-centered approach and age, and women with prior GDM, are being achieved. Results of SMBG
provided to all people with diabe- and/or those with rising A1C can be useful in preventing hypogly-
tes, with the goals of optimizing despite lifestyle intervention. A cemia and adjusting medications
health outcomes and health-re- Screening for and treatment of (particularly prandial insulin doses),
lated quality of life. A modifiable risk factors for CVD MNT, and physical activity. Evidence
Psychosocial screening and fol- is suggested for those with predi- also supports a correlation between
low-up may include, but are not abetes. B SMBG frequency and meeting A1C
limited to, attitudes about the targets.
illness, expectations for medi- Intensive lifestyle modification pro- SMBG accuracy is instrument-
cal management and outcomes, grams have been shown to be very and user-dependent. Evaluate each
affect or mood, general and diabe- effective (58% risk reduction after patients monitoring technique, both
tes-related quality of life, available 3 years). In addition, pharmacologic initially and at regular intervals
resources (financial, social, and agents including metformin, -glu- thereafter. The ongoing need for and
emotional), and psychiatric his- cosidase inhibitors, orlistat, gluca- frequency of SMBG should be reeval-
tory. E gon-like peptide 1 (GLP-1) receptor uated at each routine visit.
Providers should consider assess- agonists, and thiazolidinediones have
ment for symptoms of diabetes A1C Testing
been shown to decrease incident dia-
distress, depression, anxiety, and betes to various degrees. Metformin Recommendations
disordered eating, as well as has demonstrated long-term safety as Perform the A1C test at least two
cognitive capacities, using pharmacologic therapy for diabetes times a year in patients who are
patient-appropriate standardized meeting treatment goals (and who
prevention.
and validated tools at the initial have stable glycemic control). E
visit, at periodic intervals, and GLYCEMIC TARGETS Perform the A1C test quarterly
when there is a change in disease, in patients whose therapy has
Assessment of Glycemic
treatment, or life circumstances. changed or who are not meeting
Control
Including caregivers and family glycemic goals. E
members in this assessment is rec- Self-monitoring of blood glucose
(SMBG) frequency and timing Point-of-care testing for A1C pro-
ommended. B vides the opportunity for more
Consider screening older adults should be dictated by patients spe-
cific needs and goals. SMBG is es- timely treatment changes. E
(aged 65 years) with diabetes for
cognitive impairment and depres- pecially important for patients treat- For patients in whom A1C and
sion. B ed with insulin to monitor for and measured blood glucose appear dis-
prevent asymptomatic hypoglycemia crepant, clinicians should consider
PREVENTION OR DELAY OF and hyperglycemia. For patients on the possibilities of hemoglobinopathy
TYPE 2 DIABETES nonintensive insulin regimens such as or altered red blood cell turnover and
Recommendations those with type 2 diabetes using bas- the options of more frequent and/or
At least annual monitoring for the al insulin, when to prescribe SMBG different timing of SMBG or con-
development of diabetes in those and at what testing frequency are less tinuous glucose monitoring. Other
with prediabetes is suggested. E established. measures of chronic glycemia such

as fructosamine are available, but Approach to the Management of Hyperglycemia
their linkage to average glucose and Patient / Disease Features More stringent A1C 7% Less stringent
their prognostic significance are not
Risks potentially associated
as clear as for A1C. with hypoglycemia and
other drug adverse effects
A1C Goals low high
Recommendations
Usually not modifiable

A reasonable A1C goal for many Disease duration newly diagnosed long-standing
nonpregnant adults is <7% (53
mmol/mol). A
Life expectancy
Providers might reasonably sug- long short
gest more stringent A1C goals

(such as <6.5% [48 mmol/mol]) Relevant comorbidities
for selected individual patients if absent few / mild severe
this can be achieved without sig-

Established vascular
nificant hypoglycemia or other complications absent few / mild severe
adverse effects of treatment (i.e.,
polypharmacy). Appropriate
Potentially modifiable
patients might include those with Patient attitude and highly motivated, adherent, less motivated, nonadherent,
a short duration of diabetes, type expected treatment efforts excellent self-care capabilities poor self-care capabilities
2 diabetes treated with lifestyle or

metformin only, long life expec- Resources and support
system
tancy, or no significant CVD. C readily available limited
Less stringent A1C goals (such FIGURE 1. Depicted are patient and disease factors used to determine optimal
as <8% [64 mmol/mol]) may be A1C targets. Characteristics and predicaments toward the left justify more stringent
appropriate for patients with a efforts to lower A1C; those toward the right suggest less stringent efforts. Adapted
history of severe hypoglycemia, with permission from Inzucchi et al. Diabetes Care 2015;38:140149.
limited life expectancy, advanced
microvascular or macrovascular provided in Table 6. The recommen- to prevent recurrence of hypogly-
complications, extensive comor- dations include blood glucose levels cemia. E
bid conditions, or long-standing that appear to correlate with achieve- Glucagon should be prescribed
diabetes in whom the goal is dif- ment of an A1C of 7% (53 mmol/ for all individuals at increased
ficult to achieve despite DSME, mol). risk of clinically significant hypo-
appropriate glucose monitoring, glycemia, defined as blood glucose
Hypoglycemia
and effective doses of multiple <54 mg/dL (3.0 mmol/L), so it is
The 2017 Standards of Care provides
glucose-lowering agents, including available should it be needed.
a new classification of hypoglycemia.
insulin. B Caregivers, school personnel, or
Recommendations family members of these individ-
The complete 2017 Standards of Individuals at risk for hypogly- uals should know where it is and
Care includes additional goals for cemia should be asked about when and how to administer it.
children and pregnant women. symptomatic and asymptomatic The use of glucagon is indicated
Glycemic control achieved using hypoglycemia at each encounter. for the treatment of hypoglycemia
A1C targets of <7% (53 mmol/mol) C in people unable or unwilling to
has been shown to reduce micro- Glucose (1520 g) is the pre- consume carbohydrates by mouth.
vascular complications of diabetes, ferred treatment for conscious Glucagon administration is not
and, in type 1 diabetes, mortality. individuals with hypoglycemia limited to health care profession-
There is evidence for cardiovascular (glucose alert value of 70 mg/ als. E
benefit of intensive glycemic control dL), although any form of car- Hypoglycemia unawareness or
after long-term follow-up of people bohydrate that contains glucose one or more episodes of severe
treated early in the course of type 1 may be used. Fifteen minutes after hypoglycemia should trigger
and type 2 diabetes, however optimal treatment, if SMBG shows contin- reevaluation of the treatment reg-
A1C targets should be individualized ued hypoglycemia, the treatment imen. E
based on several patient-specific and should be repeated. Once SMBG Insulin-treated patients with
disease-specific factors (Figure 1). returns to normal, the individual hypoglycemia unawareness or an
Recommended glycemic targets are should consume a meal or snack episode of clinically significant
TABLE 6. Summary of Glycemic Recommendations for Many Nonpregnant Adults With Diabetes
A1C <7.0% (53 mmol/mol)*
Preprandial capillary plasma glucose 80130 mg/dL* (4.47.2 mmol/L)
Peak postprandial capillary plasma glucose
<180 mg/dL* (10.0 mmol/L)
*More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized
based on duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular com-
plications, hypoglycemia unawareness, and individual patient considerations.Postprandial glucose may be targeted
if A1C goals are not met despite reaching preprandial glucose goals. Postprandial glucose measurements should be
made 12 h after the beginning of the meal, generally peak levels in patients with diabetes.
hypoglycemia should be advised loss and jointly determine weight loss titioners in medical care settings
to raise their glycemic targets to goals and intervention strategies. with close medical monitoring. To
strictly avoid hypoglycemia for maintain weight loss, such pro-
Diet, Physical Activity, and
at least several weeks to partially grams must incorporate long-term
Behavioral Therapy
reverse hypoglycemia unawareness comprehensive weight mainte-
and reduce the risk of future epi- Recommendations nance counseling. B
sodes. A Diet, physical activity, and behav-
Pharmacotherapy
Ongoing assessment of cogni- ioral therapy designed to achieve
tive function is suggested with >5% weight loss should be pre- Recommendations
increased vigilance for hypoglyce- scribed for overweight and obese When choosing glucose-lowering
mia by the clinician, patient, and patients with type 2 diabetes ready medications for overweight or
to achieve weight loss. A obese patients with type 2 diabe-
caregivers if low cognition and/or
Such interventions should be tes, consider their effect on weight.
declining cognition is found. B
high intensity (16 sessions in E
OBESITY MANAGEMENT FOR 6 months) and focus on diet, Whenever possible, minimize the
THE TREATMENT OF TYPE 2 physical activity, and behavioral medications for comorbid con-
DIABETES strategies to achieve a 500750 ditions that are associated with
Obesity management can delay pro- kcal/day energy deficit. A weight gain. E
gression from prediabetes to type 2 Diets should be individualized; Weight loss medications may
diabetes and may be beneficial in the eating patterns that provide the be effective as adjuncts to diet,
treatment of type 2 diabetes. In over- same caloric restriction but differ physical activity, and behavioral
weight and obese patients with type 2 in protein, carbohydrate, and fat counseling for selected patients
diabetes, modest and sustained weight content are equally effective in with type 2 diabetes and a BMI
achieving weight loss. A 27 kg/m2. Potential benefits must
loss has been shown to improve gly-
For patients who achieve short- be weighed against the potential
cemic control and to reduce the need
term weight loss goals, long-term risks of the medications. A
for glucose-lowering medications. (1-year) comprehensive weight If a patients response to weight
Assessment maintenance programs should be loss medications is <5% weight
prescribed. Such programs should loss after 3 months or if there are
Recommendation provide at least monthly contact any safety or tolerability issues at
At each patient encounter, BMI and encourage ongoing moni- any time, the medication should
should be calculated and docu- toring of body weight (weekly be discontinued and alterna-
mented in the medical record. B or more frequently), continued tive medications or treatment
consumption of a reduced-calorie approaches should be considered.
In Asian Americans, the BMI diet, and participation in high lev- A
cutoff points to define overweight els of physical activity (200300
and obesity are lower than in other Metabolic Surgery
min/week). A
populations. To achieve weight loss of >5%, Recommendations
Providers should advise over- short-term (3-month) high-inten- Metabolic surgery should be rec-
weight and obese patients that higher sity lifestyle interventions that use ommended to treat type 2 diabetes
BMIs increase the risk of CVD and very-low-calorie diets (800 kcal/ in appropriate surgical candidates
all-cause mortality. day) or total meal replacements with a BMI 40 kg/m 2 (BMI
Providers should assess each may be prescribed for carefully 37.5 kg/m2 in Asian Americans)
patients readiness to achieve weight selected patients by trained prac- regardless of the level of glycemic

control or complexity of glu- remission and/or lower risk of recid- Consider initiating insulin ther-
cose-lowering regimens and in ivism. Beyond improving glycemia, apy (with or without additional
adults with a BMI of 35.039.9 metabolic surgery has been shown to agents) in patients with newly
kg/m2 (32.537.4 kg/m2 in Asian confer additional health benefits in diagnosed type 2 diabetes who
Americans) when hyperglycemia randomized controlled trials, includ- are symptomatic and/or have an
is inadequately controlled despite ing greater reductions in CVD risk A1C 10% (86 mmol/mol) and/
lifestyle and optimal medical ther- factors and enhancements in quality or blood glucose levels 300 mg/
apy. A of life. dL (16.7 mmol/L). E
Metabolic surgery should be con- If noninsulin monotherapy at
PHARMACOLOGIC maximum tolerated dose does not
sidered for adults with type 2
APPROACHES TO achieve or maintain the A1C tar-
diabetes and a BMI of 30.034.9
GLYCEMIC TREATMENT get after 3 months, add a second
kg/m2 (27.532.4 kg/m2 in Asian
Americans) if hyperglycemia is Pharmacologic Therapy for oral agent, a second oral agent, a
inadequately controlled despite Type 1 Diabetes GLP-1 receptor agonist, or basal
optimal medical control by either insulin. A
Recommendations A patient-centered approach
oral or injectable medications
(including insulin). B Most people with type 1 diabetes should be used to guide the
Metabolic surgery should be per- should be treated with multiple choice of pharmacologic agents.
formed in high-volume centers daily injection (MDI) therapy Considerations include efficacy,
with multidisciplinary teams who including prandial and basal hypoglycemia risk, impact on
understand and are experienced in insulin or continuous subcutane- weight, potential side effects, cost,
the management of diabetes and ous insulin infusion (CSII; insulin and patient preferences. E
gastrointestinal (GI) surgery. C pump therapy). A For patients with type 2 diabetes
Long-term lifestyle support and Most individuals with type 1 who are not achieving glycemic
routine monitoring of micronutri- diabetes should use rapid-acting goals, insulin therapy should not
ent and nutritional status must be insulin analogs to reduce hypo- be delayed. B
provided to patients after surgery, glycemia risk. A In patients with long-standing
according to guidelines for postop- Consider educating individuals suboptimally controlled type 2
erative management of metabolic with type 1 diabetes on matching diabetes and established athero-
surgery by national and interna- prandial insulin doses to carbo- sclerotic cardiovascular disease
tional professional societies. C hydrate intake, premeal blood (ASCVD), empaglif lozin or
People presenting for metabolic glucose levels, and anticipated liraglutide should be considered
surgery should receive a compre- physical activity. E because they have been shown
hensive mental health assessment. Individuals with type 1 diabetes to reduce cardiovascular and all-
B Surgery should be postponed in who have been successfully using cause mortality when added to
patients with a history of alcohol CSII should have continued access standard care. Ongoing studies
or substance abuse, significant to this therapy after they turn 65 are investigating the cardiovascu-
depression, suicidal ideation, or years of age. E lar benefits of other agents in these
other mental health conditions drug classes. B
Pharmacologic Therapy for
until these conditions have been Type 2 Diabetes Figure 2 and Figure 3 outline mono-
fully addressed. E therapy and combination therapy
People who undergo metabolic Recommendations
Metformin, if not contraindicated emphasizing drugs commonly used
surgery should be evaluated to in the United States and/or Europe.
assess their need for ongoing men- and if tolerated, is the preferred
tal health services to help them initial pharmacologic agent for CVD AND RISK MANAGEMENT
adjust to medical and psychosocial the treatment of type 2 diabetes. ASCVD is the leading cause of mor-
changes after surgery. C A bidity and mortality for individuals
Long-term use of metformin may with diabetes and is the largest con-
Several GI operations promote be associated with biochemical tributor to the direct and indirect
dramatic and durable improvement vitamin B12 deficiency, and peri- costs of diabetes. In all patients with
of type 2 diabetes. Younger age, odic measurement of vitamin B12 diabetes, cardiovascular risk factors
shorter duration of diabetes (e.g., <8 levels should be considered in met- should be systematically assessed at
years), nonuse of insulin, and better formin-treated patients, especially least annually. These risk factors in-
glycemic control are consistently asso- in those with anemia or peripheral clude hypertension, dyslipidemia,
ciated with higher rates of diabetes neuropathy. B smoking, family history of premature
Start with Monotherapy unless:

A1C is greater than or equal to 9%, consider Dual Therapy.
A1C is greater than or equal to 10%, blood glucose is greater than or equal to 300 mg/dl,
or patient is markedly symptomatic, consider Combination Injectable Therapy (See Figure 8.2).
Monotherapy Metformin Lifestyle Management

EFFICACY* high
HYPO RISK low risk
WEIGHT neutral/loss
SIDE EFFECTS GI/lactic acidosis
COSTS* low
If A1C target not achieved after approximately 3 months of monotherapy, proceed to 2-drug combination (order not
meant to denote any specific preference choice dependent on a variety of patient- & disease-specific factors):
Dual Therapy Metformin + Lifestyle Management

Sulfonylurea Thiazolidinedione DPP-4 inhibitor SGLT2 inhibitor GLP-1 receptor agonist Insulin (basal)
EFFICACY* high high intermediate intermediate high highest

HYPO RISK moderate risk low risk low risk low risk low risk high risk
WEIGHT gain gain neutral loss loss gain
SIDE EFFECTS hypoglycemia edema, HF, fxs rare GU, dehydration, fxs GI hypoglycemia
COSTS* low low high high high high
If A1C target not achieved after approximately 3 months of dual therapy, proceed to 3-drug combination (order not
meant to denote any specific preference choice dependent on a variety of patient- & disease-specific factors):
Triple Therapy Metformin + Lifestyle Management

Sulfonylurea + Thiazolidinedione + DPP-4 inhibitor + SGLT2 inhibitor + GLP-1 receptor agonist + Insulin (basal) +
TZD SU SU SU SU TZD
or DPP-4-i or DPP-4-i or TZD or TZD or TZD or DPP-4-i
or SGLT2-i or SGLT2-i or SGLT2-i or DPP-4-i or SGLT2-i or SGLT2-i
or GLP-1-RA or GLP-1-RA or Insulin or GLP-1-RA or Insulin or GLP-1-RA
or Insulin or Insulin or Insulin
If A1C target not achieved after approximately 3 months of triple therapy and patient (1) on oral combination, move to
basal insulin or GLP-1 RA, (2) on GLP-1 RA, add basal insulin or (3) on optimally titrated basal insulin, add GLP-1 RA or
mealtime insulin. Metformin therapy should be maintained, while other oral agents may be discontinued on an individual
basis to avoid unnecessarily complex or costly regimens (i.e. adding a fourth antihyperglycemic agent).
Combination Injectable Therapy (See Figure 3)

FIGURE 2. Antihyperglycemic therapy in type 2 diabetes: general recommendations. The order in the chart was determined
by historical availability and the route of administration, with injectables to the right; it is not meant to denote any specific pref-
erence. Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, with the usual transition
moving vertically from top to bottom (although horizontal movement within therapy stages is also possible, depending on the
circumstances). DPP-4-i, DPP-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1 RA, GLP-1 receptor agonist; GU, geni-
tourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, SGLT2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione. *See
original source for description of efficacy categorization. Usually a basal insulin (NPH, glargine, detemir, degludec). Adapted
with permission from Inzucchi et al. Diabetes Care 2015;38:140149.
coronary disease, and albuminuria. Blood pressure should be mea- mmHg, may be appropriate for
Large benefits are seen when multiple sured at every routine visit. individuals at high risk of CVD
risk factors are addressed simultane- Patients found to have elevated if they can be achieved without
ously. There is evidence that measures blood pressure should have blood undue treatment burden. C
of 10-year coronary heart disease risk pressure confirmed on a separate Patients with confirmed office-
day. B based blood pressure >140/90
among U.S. adults with diabetes have
Most patients with diabetes and mmHg should, in addition to
improved significantly over the past hypertension should be treated to lifestyle therapy, have prompt
decade and that ASCVD morbidity a systolic blood pressure goal of initiation and timely titration of
and mortality have decreased. <140 mmHg and a diastolic blood pharmacologic therapy to achieve
Blood Pressure Control pressure goal of 90 mmHg. A blood pressure goals. A
Lower systolic and diastolic blood Patients with confirmed office-
Recommendations pressure targets, such as 130/80 based blood pressure >160/100

thereafter because it may help to
Initiate Basal Insulin
Usually with metformin +/- other noninsulin agent
monitor the response to therapy
and inform adherence. E
Start: 10 U/day or 0.10.2 U/kg/day
Adjust: 1015% or 24 units once or twice weekly to reach FBG target
Lifestyle modification focusing on
For hypo: Determine & address cause; if no clear reason for hypo, weight loss (if indicated); reduc-
dose by 4 units or 1020%
tion of saturated fat, trans fat,

If A1C not controlled, consider

combination injectable therapy
and cholesterol intake; increase
in omega-3 fatty acids, viscous
fiber, and plant stanols/sterols
Add 1 rapid-acting Change to premixed intake; and increase in physical
insulin injection before
largest meal
Add GLP-1 RA insulin twice daily (before
breakfast and supper)
activity should be recommended
Start: 4 units, 0.1 U/kg, or 10% If not tolerated or A1C Start: Divide current basal dose
to improve the lipid profile in
basal dose. If A1C <8%, consider target not reached, into AM, PM or AM, PM patients with diabetes. A
basal by same amount change to 2 injection
Adjust: dose by 12 units or insulin regimen
Adjust: dose by 12 units or
1015% once or twice weekly Intensify lifestyle therapy and
1015% once or twice weekly
until SMBG target reached
until SMBG target reached
For hypo: Determine and
optimize glycemic control for
If goals not met, consider
For hypo: Determine and changing to alternative address cause; if no clear reason patients with elevated triglyceride
address cause; if no clear reason insulin regimen for hypo, corresponding dose
for hypo, corresponding dose by 24 units or 1020% levels (150 mg/dL [1.7 mmol/L])
by 24 units or 1020%
and/or low HDL cholesterol (<40
If A1C not controlled,
advance to basal-bolus
If A1C not controlled,
advance to 3rd injection mg/dL [1.0 mmol/L] for men, <50
mg/dL [1.3 mmol/L] for women).
Add 2 rapid-acting Change to premixed
C
insulin injections before analog insulin 3 times daily For patients with fasting tri-
meals (basal-bolus) (breakfast, lunch, supper)
glyceride levels 500 mg/dL (5.7
Start: 4 units, 0.1 U/kg, or 10%
basal dose/meal. If A1C <8%,
Start: Add additional injection
before lunch mmol/L), evaluate for secondary
consider basal by same amount
Adjust: dose(s) by 12 units or
If goals not met, consider Adjust: doses by 12 units or
1015% once or twice weekly to
causes of hypertriglyceridemia
changing to alternative
1015% once or twice weekly to
achieve SMBG target
insulin regimen achieve SMBG target and consider medical therapy to
For hypo: Determine and
For hypo: Determine and address cause; if no clear reason reduce the risk of pancreatitis. C
address cause; if no clear reason
for hypo, corresponding dose
for hypo, corresponding dose
by 24 units or 1020% In clinical practice, providers may
by 24 units or 1020%
need to adjust intensity of sta-
tin therapy based on individual
FIGURE 3. Combination injectable therapy for type 2 diabetes. FBG, fasting
patient response to medication
blood glucose; GLP-1 RA, GLP-1 receptor agonist; hypo, hypoglycemia; U, units.
(e.g., side effects, tolerability, LDL
Adapted with permission from Inzucchi et al. Diabetes Care 2015;38:140149.
cholesterol levels). E
mmHg should, in addition to potassium levels should be mon- The addition of ezetimibe to mod-
lifestyle therapy, have prompt ini- itored. B erate-intensity statin therapy has
tiation and timely titration of two For patients with blood pressure been shown to provide additional
drugs to reduce CVD events in >120/80 mmHg, lifestyle inter- cardiovascular benefit compared
patients with diabetes. A vention consists of weight loss, with moderate-intensity statin
An ACE inhibitor or an angio- if overweight or obese; a DASH- therapy alone for patients with
tensin receptor blocker (ARB) at style dietary pattern, including recent acute coronary syndrome
the maximum tolerated dose indi- reduced sodium and increased and LDL cholesterol 50 mg/dL
cated for blood pressure treatment potassium intake; moderation (1.3 mmol/L) and should be con-
of alcohol intake; and increased sidered for these patients A and
is the recomended first-line treat-
physical activity. B also in patients with diabetes and
ment for hyperytension in patients
history of ASCVD who cannot
with diabetes and urine albu- Lipid Management
tolerate high-intensity statin ther-
min-to-creatinine ratio (UACR) Recommendations apy. E
300 mg/g creatinine A or UACR In adults not taking statins, it is Combination therapy (statin/
30299 mg/g creatinine. B If one reasonable to obtain a lipid profile fibrate) has not been shown to
class is not tolerated, the other at the time of diabetes diagnosis, improve ASCVD outcomes and
should be substituted. B at an initial medical evaluation, is generally not recommended. A
For patients treated with an ACE and every 5 years thereafter, or However, therapy with statin and
inhibitor, ARB, or diuretic, serum more frequently if indicated. E fenofibrate may be considered for
creatinine/estimated glomerular Obtain a lipid profile at initiation men with both triglyceride level
filtration rate (eGFR) and serum of statin therapy and periodically 204 mg/dL (2.3 mmol/L) and
TABLE 7. Recommendations for Statin and Combination Treatment in People With Diabetes
Age (years) Risk Factors Recommended Statin Intensity*
<40 None None
ASCVD risk factor(s)** Moderate or high
ASCVD High
4075 None Moderate
ASCVD risk factors High
ASCVD High
ACS and LDL cholesterol 50 mg/dL (1.3 mmol/L) Moderate plus ezetimibe
or in patients with a history of ASCVD who cannot
tolerate high-dose statins
>75 None Moderate
ASCVD risk factors Moderate or high
ASCVD High
ACS and LDL cholesterol 50 mg/dL (1.3 mmol/L) Moderate plus ezetimibe
or in patients with a history of ASCVD who cannot
tolerate high-dose statins
*In addition to lifestyle therapy.
**ASCVD risk factors include LDL cholesterol 100 mg/dL (2.6 mmol/L), high blood pressure, smoking, chronic kidney
disease, albuminuria, and family history of premature ASCVD.
HDL cholesterol level 34 mg/dL mg/day) as a primary preven- In patients with symptomatic
(0.9 mmol/L). B tion strategy in those with type heart failure, thiazolidinedione
Combination therapy (statin/nia- 1 or type 2 diabetes who are at treatment should not be used. A
cin) has not been shown to provide increased cardiovascular risk. This In patients with type 2 diabetes
additional cardiovascular benefit includes most men or women with with stable congestive heart fail-
above statin therapy alone and diabetes aged 50 years who have ure, metformin may be used if
may increase the risk of stroke and at least one additional major risk eGFR remains >30 mL/min but
is not generally recommended. A factor (family history of premature should be avoided in unstable or
ASCVD, hypertension, smoking,
Table 7 provides recommendations hospitalized patients with conges-
dyslipidemia, or albuminuria) and
for statin and combination therapy tive heart failure. B
are not at increased risk of bleed-
in people with diabetes. Table 8 out- ing. C MICROVASCULAR
lines high- and moderate-intensity COMPLICATIONS AND FOOT
statin therapy. Coronary Heart Disease
CARE
Antiplatelet Agents Recommendations Intensive diabetes management with
In asymptomatic patients, routine the goal of achieving near-normogly-
Recommendations screening for coronary artery dis- cemia has been shown in large, pro-
Use aspirin therapy (75162 mg/ ease is not recommended because spective, randomized studies to delay
day) as a secondary prevention it does not improve outcomes as
strategy in those with diabetes and the onset and progression of micro-
long as ASCVD risk factors are
a history of ASCVD. A vascular complications.
treated. A
For patients with ASCVD and In patients with known ASCVD, Diabetic Kidney Disease
documented aspirin allergy, use aspirin and statin therapy (if
clopidogrel (75 mg/day) should not contraindicated) A, and con- Recommendations
be used. B sider ACE inhibitor therapy C to At least once a year, assess uri-
Dual antiplatelet therapy is rea- reduce the risk of cardiovascular nary albumin (e.g., spot UACR)
sonable for up to 1 year after an events. and eGFR in patients with type
acute coronary syndrome and may In patients with prior myocardial 1 diabetes with a duration of 5
have benefits beyond this period. infarction, -blockers should be years, in all patients with type 2
B continued for at least 2 years after diabetes, and in all patients with
Consider aspirin therapy (75162 the event. B comorbid hypertension. B
TABLE 8. High- and Moderate-Intensity Statin Therapy*

etrist at the time of the diabetes
diagnosis. B
High-Intensity Statin Therapy Moderate-Intensity Statin Therapy If there is no evidence of retinop-
(Lowers LDL cholesterol by 50%) (Lowers LDL cholesterol by 30 to <50%) athy for one or more annual eye
Atorvastatin 4080 mg Atorvastatin 1020 mg exams and glycemia is well con-
Rosuvastatin 2040 mg Rosuvastatin 510 mg trolled, then exams every 2 years
may be considered. If any level of
Simvastatin 2040 mg
diabetic retinopathy is present,
Pravastatin 4080 mg subsequent dilated retinal exam-
Lovastatin 40 mg inations should be repeated at least
Fluvastatin XL 80 mg annually by an ophthalmologist or
Pitavastatin 24 mg optometrist. If retinopathy is pro-
gressing or sight-threatening, then
*Once-daily dosing.
examinations will be required
Optimize glucose control to states that metformin is contraindi- more frequently B
reduce the risk or slow the progres- cated in patients with an eGFR <30 Neuropathy
sion of diabetic kidney disease. A mL/min/1.73 m 2, eGFR should be
Optimize blood pressure control Recommendations
monitored while taking metformin,
to reduce the risk or slow the the benefits and risks of continuing All patients should be assessed for
progression of diabetic kidney treatment should be reassessed when diabetic peripheral neuropathy
disease. A (DPN) starting at diagnosis of
eGFR falls to <45 mL/min/1.73 m2,
In nonpregnant patients with type 2 diabetes and 5 years after
metformin should not be initiated
diabetes and hypertension, either the diagnosis of type 1 diabetes
for patients with an eGFR <45 mL/
an ACE inhibitor or an ARB and at least annually thereafter. B
min/1.73 m2, and metformin should
is recommended for those with Assessment for distal symmetric
be temporarily discontinued at the
modestly elevated UACR (30299 polyneuropathy should include
time of or before iodinated contrast a careful history and assessment
mg/g creatinine) B, and is strongly imaging procedures in patients with
recommended for those with of either temperature or pinprick
an eGFR of 3060 mL/min/1.73 m2. sensation (for small-fiber function)
UACR >300 mg/g creatinine and/ Other glucose-lowering medications
or eGFR <60 mL/min/1.73 m2. A and vibration sensation using a
also require dose adjustment or dis- 128-Hz tuning fork (for large-fi-
Screening for albuminuria can continuation at low eGFR. ber function). All patients should
be most easily performed by UACR Recommendations for the man- have annual 10-g monofilament
in a random spot urine collection. agement of CKD in people with testing to identify feet at risk of
UACR determined for two of three diabetes are summarized in Table 9. ulceration and amputation. B
specimens collected within a 3- to Diabetic Retinopathy Optimize glucose control to pre-
6-month period should be abnormal vent or delay the development of
before considering a patient to have Recommendations neuropathy in patients with type
albuminuria. Optimize glycemic control to 1 diabetes A and to slow the pro-
Blood pressure levels <140/90 reduce the risk or slow the progression of neuropathy in patients
mmHg in diabetes are recommended gression of diabetic retinopathy. A with type 2 diabetes. B
to reduce CVD mortality and slow Optimize blood pressure and Either pregabalin or duloxetine are
chronic kidney disease (CKD) serum lipid control to reduce the recommended as initial pharma-
progression. risk or slow the progression of dia- cologic treatments for neuropathic
With reduced eGFR, drug dos- betic retinopathy. A pain in diabetes. A
ing may require modification. The Adults with type 1 diabetes should
have an initial dilated and com- Foot Care
U.S. Food and Drug Administration
(FDA) revised guidance for the use prehensive eye examination by an Recommendations
metformin in diabetic kidney disease ophthalmologist or optometrist Perform a comprehensive foot
in 2016, recommending use of eGFR within 5 years after the onset of evaluation each year to identify
instead of serum creatinine to guide diabetes. B risk factors for ulcers and ampu-
treatment and expanding the pool of Patients with type 2 diabetes tations. B
patients with kidney disease for whom should have an initial dilated and All patients with diabetes should
metformin treatment should be con- comprehensive eye examination have their feet inspected at every
sidered. The revised FDA guidance by an ophthalmologist or optom- visit. C
TABLE 9. Management of CKD in Diabetes

geriatric domains in older adults to
provide a framework to determine
eGFR Recommended Management targets and therapeutic approaches
(mL/min/1.73 m2)
for diabetes management. C
All patients Yearly measurement of UACR, serum creatinine, Screening for geriatric syndromes
and potassium
may be appropriate in older adults
4560 Refer to a nephrologist if possibility for nondiabetic experiencing limitations in their
kidney disease exists (duration of type 1 diabetes
<10 years, persistent albuminuria, abnormal find-
basic and instrumental activities
ings on renal ultrasound, resistant hypertension, of daily living because they may
rapid fall in eGFR, or active urinary sediment on affect diabetes self-management
urine microscopic examination) and be related to health-related
Consider the need for dose adjustment of quality of life. C
medications Annual screening for early detec-
Monitor eGFR every 6 months tion of mild cognitive impairment
Monitor electrolytes, bicarbonate, hemoglobin, or dementia is indicated for adults
calcium, phosphorus, and parathyroid hormone at 65 years of age. B
least yearly Older adults (65 years of age)
Assure vitamin D sufficiency with diabetes should be consid-
Vaccinate against hepatitis B virus
ered a high-priority population
for depression screening and treat-
Consider bone density testing
ment. B
Refer for dietary counseling Hypoglycemia should be avoided
3044 Monitor eGFR every 3 months in older adults with diabetes. It
Monitor electrolytes, bicarbonate, calcium, should be assessed and managed
phosphorus, parathyroid hormone, hemoglobin, by adjusting glycemic targets and
albumin, and weight every 36 months pharmacologic interventions. B
Consider the need for dose adjustment of Older adults who are cognitively
medications and functionally intact and have
<30 Refer to a nephrologist significant life expectancy may
receive diabetes care with goals
Obtain a history of ulceration, (e.g., dialysis patients and those similar to those developed for
amputation, Charcot foot, with Charcot foot, prior ulcers, or younger adults. C
angioplasty or vascular surgery, amputation). B Glycemic goals for some older
cigarette smoking, retinopathy, Refer patients who smoke or who adults might reasonably be
and renal disease and assess cur- have a history of prior lower-ex- relaxed using individual criteria,
rent symptoms of neuropathy tremity complications, loss of but hyperglycemia leading to
(pain, burning, numbness) and protective sensation, structural symptoms or risk of acute hyper-
vascular disease (leg fatigue, clau- abnormalities, or peripheral arte- glycemic complications should be
dication). B rial disease to foot care specialists avoided in all patients. C
The examination should include for ongoing preventive care and Screening for diabetes complica-
inspection of the skin, assessment lifelong surveillance. C tions should be individualized in
of foot deformities, neurological Provide general preventive foot older adults. Particular attention
assessment (10-g monofilament self-care education to all patients should be paid to complications
testing), and vascular assessment, with diabetes. B that would lead to functional
including pulses in the legs and The use of specialized therapeu- impairment. C
feet. B tic footwear is recommended for Treatment of hypertension to indi-
Patients who are 50 years of age high-risk patients with diabe- vidualized target levels is indicated
and any patients with symptoms tes, including those with severe in most older adults. C
of claudication or decreased or neuropathy, foot deformities, or Treatment of other cardiovascular
absent pedal pulses should be history of amputation. B risk factors should be individual-
referred for further vascular assess- ized in older adults considering
OLDER ADULTS
ment as appropriate. C the time frame of benefit. Lipid-
A multidisciplinary approach is Recommendations lowering therapy and aspirin
recommended for individuals Consider the assessment of medi- therapy may benefit those with a
with foot ulcers and high-risk feet cal, mental, functional, and social life expectancy at least equal to the

time frame of primary prevention Older adults with diabetes in At diagnosis and during routine
or secondary intervention trials. E LTC are especially vulnerable to follow-up care, assess psychoso-
When palliative care is needed in hypoglycemia because of their dis- cial issues and family stresses that
older adults with diabetes, strict proportionately higher number of could affect adherence to diabetes
blood pressure control may not be complications and comorbidities. management and provide appro-
necessary, and withdrawal of ther- Alert strategies should be in place for priate referrals to trained mental
apy may be appropriate. Similarly, hypoglycemia (blood glucose 70 health professionals, preferably
the intensity of lipid management mg/dL [3.9 mmol/L]) and hypergly- experienced in childhood diabe-
can be relaxed, and withdrawal cemia (blood glucose >250 mg/dL tes. E
of lipid-lowering therapy may be [13.9 mmol/L]). Starting at puberty, preconception
appropriate. E For patients in the LTC setting, counseling should be incorporated
Consider diabetes education for special attention should be given to into routine diabetes care for all
the staff of long-term care facili- nutritional considerations, end-of-life girls of childbearing potential. A
ties to improve the management of care, and changes in diabetes man- Glycemic Control
older adults with diabetes. E agement with respect to advanced
disease. Acknowledging the limited Recommendations
Treatment Goals
benefit of intensive glycemic control An A1C goal of <7.5% (58 mmol/
The care of older adults with diabetes mol) is recommended across all
in people with advanced disease can
is complicated by their clinical and pediatric age-groups. E
guide A1C goals and determine the
functional heterogeneity. Providers
use or withdrawal of medications. For Autoimmune Conditions
caring for older adults with diabetes
more information, see ADAs position
must take this heterogeneity into con- Recommendations
statement Management of Diabetes
sideration when setting and prioritiz- Assess for the presence of auto-
in Long-Term Care and Skilled
ing treatment goals (Table 10). immune conditions associated
Nursing Facilities.
Older adults with diabetes are with type 1 diabetes soon after
likely to benefit from control of CHILDREN AND the diagnosis and if symptoms
other cardiovascular risk factors. ADOLESCENTS develop. E
Evidence is strong for treatment of Children and adolescents with diabe-
hypertension. There is less evidence tes have unique aspects of care such as Hypertension
for lipid-lowering and aspirin therapy, changes in insulin sensitivity related Recommendations
although the benefits of these inter- to physical growth and sexual mat- Blood pressure should be measured
ventions are likely to apply to older uration, ability to provide self-care, at each routine visit. Children
adults whose life expectancies equal supervision in the child care and found to have high-normal blood
or exceed the time frames of clinical school environment, and neurologi- pressure (systolic or diastolic blood
prevention trials. cal vulnerability to hypoglycemia and pressure 90th percentile for age,
hyperglycemia (in young children), as sex, and height) or hypertension
Pharmacologic Therapy
well as possible adverse neurocogni- (systolic or diastolic blood pressure
Special care is required in prescribing
tive effects of diabetic ketoacidosis 95th percentile for age, sex, and
and monitoring pharmacologic ther-
(DKA). Attention to family dynam- height) should have elevated blood
apy in older adults. Factors include
ics, developmental stages, and physi- pressure confirmed on three sepa-
hypoglycemia, cost, and coexisting
ological differences related to sexual rate days. B
conditions (e.g., renal status). The
maturity are all essential in develop- ACE inhibitors or ARBs should be
patients living situation must be con-
ing and implementing an optimal considered for the initial pharma-
sidered because it may affect diabetes
diabetes regimen. cologic treatment of hypertension,
management and support.
Support Services to be initiated after reproductive
Treatment in Skilled Nursing counseling and implementation
Facilities and Nursing Homes Recommendations of effective birth control due to
Management of diabetes is unique in Youth with type 1 diabetes and the potential teratogenic effects of
the long-term care (LTC) setting (i.e., parents/caregivers (for patients <18 both drug classes. E
nursing homes and skilled nursing years of age) should receive cultur- The goal of treatment is blood
facilities). Individualization of health ally sensitive and developmentally pressure consistently <90th per-
care is important for all patients. appropriate individualized DSME centile for age, sex, and height. E
However, practical guidance is needed and DSMS according to national
for both medical providers and LTC standards at diagnosis and rou- Blood pressure measurements
staff and caregivers. tinely thereafter. B should be determined using the
TABLE 10. Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older Adults
With Diabetes
Patient Rationale Reasonable A1C Fasting or Bedtime Glucose Blood Pressure Lipids
Characteristics/ Goal Preprandial (mg/dL [mmol/L]) (mmHg)
Health Status Glucose
(% [mmol/mol])
(mg/dL [mmol/L])
Healthy (few coexisting Longer remaining life <7.5 (58) 90130 (5.07.2) 90150 (5.08.3) <140/90 Statin unless con-
chronic illnesses, intact expectancy traindicated or not
cognitive and function- tolerated
al status)
Complex/intermediate Intermediate remain- <8.0 (64) 90150 (5.08.3) 100180 (5.610.0) <140/90 Statin unless con-
(multiple coexisting ing life expectancy, traindicated or not
chronic illnesses* high treatment burden, tolerated
or 2+ instrumental hypoglycemia vulnera-
ADL impairments or bility, fall risk
mild-to-moderate cog-
nitive impairment)
Very complex/ Limited remaining life <8.5 (69) 100180 (5.610.0) 110200 (6.111.1) <150/90 Consider likelihood
poor health (LTC or expectancy makes of benefit with statin
end-stage chronic benefit uncertain (secondary preven-
illnesses** or moder- tion more so than
ate-to-severe cognitive primary)
impairment or 2+ ADL
dependencies)
This represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes. The patient
characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consideration of patient and caregiver preferences is
an important aspect of treatment individualization. Additionally, a patients health status and preferences may change over time. ADL, activities of daily living.
A lower A1C goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden.
*Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, congestive heart
failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse CKD, myocardial infarction, and stroke. By multiple, we mean at least three,
but many patients may have five or more.
**The presence of a single end-stage chronic illness, such as stage 34 congestive heart failure or oxygen-dependent lung disease, CKD requiring dialysis, or
uncontrolled metastatic cancer, may cause significant symptoms or impairment of functional status and significantly reduce life expectancy.
A1C of 8.5% (69 mmol/mol) equates to an estimated average glucose of ~200 mg/dL (11.1 mmol/L). Looser A1C targets >8.5% (69 mmol/mol) are not rec-
ommended because they may expose patients to more frequent higher glucose values and the acute risks from glycosuria, dehydration, hyperglycemic
hyperosmolar syndrome, and poor wound healing.

appropriate size cuff and with the After the initial examination, and may suffice for treatment for
child seated and relaxed. Lifestyle annual routine follow-up is gener- many women. Medications should
modifications, including dietary ally recommended. Less frequent be added if needed to achieve gly-
modification and increased exer- examinations, every 2 years, may cemic targets. A
cise, should be implemented for 36 be acceptable on the advice of an Insulin is the preferred medica-
months. If target blood pressure has eye care professional. E tion for treating hyperglycemia in
not been reached within 36 months, Neuropathy GDM because it does not cross the
pharmacotherapy should be initiated. placenta to a measurable extent.
Recommendations Metformin and glyburide may be
Dyslipidemia
Consider an annual comprehen- used, but both cross the placenta
Recommendations sive foot exam for a child at the to the fetus, with metformin likely
Obtain a fasting lipid profile on start of puberty or at age 10 crossing to a greater extent than
children 10 years of age soon after years, whichever is earlier, once glyburide. All oral agents lack
diabetes diagnosis (after glucose the youth has had type 1 diabetes long-term safety data. A
control has been established). E for 5 years. E Metformin, when used to treat
If lipids are abnormal, annual MANAGEMENT OF DIABETES polycystic ovary syndrome and
monitoring is reasonable. If IN PREGNANCY induce ovulation, need not be con-
LDL cholesterol values are tinued once pregnancy has been
within the accepted risk levels Preexisting Diabetes confirmed. A
(<100 mg/dL [2.6 mmol/L]), a Recommendations
lipid profile repeated every 35 General Principles for the
Starting at puberty, preconception Management of Diabetes in
years is reasonable. E counseling should be incorporated
After the age of 10 years, the Pregnancy
into routine diabetes care for all
addition of a statin is suggested in girls of childbearing potential. A Recommendations
patients who, despite MNT and Family planning should be dis- Potentially teratogenic medica-
lifestyle changes, continue to have cussed and effective contraception tions (e.g., ACE inhibitors and
LDL cholesterol >160 mg/dL (4.1 should be prescribed and used statins) should be avoided in sexu-
mmol/L) or LDL cholesterol >130 until a woman is prepared and ally active women of childbearing
mg/dL (3.4 mmol/L) and one or ready to become pregnant. A age who are not using reliable con-
more CVD risk factors, initiated Preconception counseling should traception. B
after reproductive counseling and address the importance of glyce- Fasting and postprandial SMBG
implementation of effective birth mic control as close to normal as is are recommended in both GDM
control due to the potential tera- safely possible, ideally A1C <6.5% and preexisting diabetes in preg-
togenic effects of statins. E (48 mmol/mol), to reduce the risk nancy to achieve glycemic control.
The goal of therapy is an LDL of congenital anomalies. B Some women with preexisting
cholesterol value <100 mg/dL (2.6 Women with preexisting type 1 or diabetes should also test blood
mmol/L). E type 2 diabetes who are planning glucose preprandially. B
Nephropathy pregnancy or who have become The A1C target in pregnancy is
pregnant should be counseled on 66.5% (4248 mmol/mol); <6%
Recommendations the risk of development and/or (42 mmol/mol) may be optimal if
Annual screening for albuminuria progression of diabetic retinop- this can be achieved without sig-
with a random spot urine sample athy. Dilated eye examinations nificant hypoglycemia, but the
for UACR should be considered should occur before pregnancy target may be relaxed to <7% (53
once a child has had type 1 diabe- or in the first trimester, and then mmol/mol) if necessary to prevent
tes for 5 years. B patients should be monitored hypoglycemia. B
Retinopathy
every trimester and for 1 year post-
partum as indicated by degree of Preconception Counseling
Recommendations retinopathy and as recommended Observational studies show an in-
An initial dilated and com- by the eye care provider. B creased risk of diabetic embryopathy,
prehensive eye examination is especially anencephaly, microcephaly,
GDM
recommended at age 10 years or congenital heart disease, and caudal
after puberty has started, which- Recommendations regression directly proportional to el-
ever is earlier, once a youth has had Lifestyle change is an essential evations in A1C during the first 10
type 1 diabetes for 35 years. B component of GDM management weeks of pregnancy.

Preconception counseling visits with diabetes or hyperglycemia There should be a structured
should include rubella, syphilis, hep- admitted to the hospital if not per- discharge plan tailored to the indi-
atitis B virus, and HIV testing, as formed in the prior 3 months. B vidual patient with diabetes. B
well as Pap smear, cervical cultures, Insulin therapy should be initi-
Considerations on Admission
blood typing, prescription of prenatal ated for treatment of persistent
Initial admission documentation
vitamins (with at least 400 g of folic hyperglycemia starting at a thresh-
should state that the patient has type
acid), and smoking cessation counsel- old 180 mg/dL (10.0 mmol/L).
1 or type 2 diabetes or no history of
ing if indicated. Once insulin therapy is started, a
diabetes. Both hyperglycemia and
Diabetes-specific testing should target glucose range of 140180
hypoglycemia are associated with
include A1C, thyroid-stimulating mg/dL (7.810.0 mmol/L) is rec-
adverse outcomes, including death.
hormone, creatinine, and UACR. The ommended for the majority of High-quality care can often be en-
medication list should be reviewed for critically ill patients A and non- sured by the use of structured order
potentially teratogenic drugs, and critically ill patients. C sets consistent with quality assurance
patients should be referred for a com- More stringent goals such as <140 standards.
prehensive eye exam. Women with mg/dL (<7.8 mmol/L) may be
preexisting diabetic retinopathy will appropriate for selected patients, Glycemic Targets in
need close monitoring during preg- as long as this can be achieved Hospitalized Patients
nancy to ensure that retinopathy does without significant hypoglyce- Standard Definition of Glucose
not progress. mia. C Abnormalities
Preconception counseling resourc- Intravenous (IV) insulin infusions Hyperglycemia: >140 mg/dL
es tailored for adolescents are avail- should be administered using val- (7.8 mmol/L)
able at no cost through the ADA. idated written or computerized Hypoglycemia: <54 mg/dL (3.0
protocols that allow for pre- mmol/L) or severe cognitive
Postpartum Care defined adjustments in the insulin
Because GDM may represent pre- impairment. (See the section on
infusion rate based on glycemic Hypoglycemia [p. 10] for addi-
existing undiagnosed type 2 or even fluctuations and insulin dose. E
type 1 diabetes, women with GDM tional details on the new criteria.)
Basal insulin or a basal-plus-bo-
should be tested for persistent diabe- lus-correction insulin regimen is A glucose value 70 mg/dL (3.9
tes or prediabetes at 412 weeks post- the preferred treatment for non- mmol/L) may be used as an alert
partum with a 75-g OGTT using the critically ill patients with poor value and as a threshold for further
nonpregnancy criteria as outlined in oral intake or those who are tak- titration of insulin regimens.
the section on classification and diag- ing nothing by mouth. An insulin
nosis of diabetes above. regimen with basal, nutritional, Antihyperglycemic Agents in
Because GDM is associated with and correction components is the Hospitalized Patients
increased maternal risk for diabe- preferred treatment for noncriti- In most instances in the hospital set-
tes, women should also be tested cally ill hospitalized patients with ting, insulin is the preferred treatment
every 13 years thereafter if the 4- good nutritional intake. A for glycemic control, but in certain
to 12-week 75-g OGTT is normal, Sole use of sliding-scale insulin circumstances, a previous home regi-
with frequency of testing depend- in the inpatient hospital setting is men may be continued.
ing on other risk factors, including strongly discouraged. A Insulin Therapy
family history, prepregnancy BMI, A hypoglycemia management IV insulin protocols should be used
and need for insulin or oral glu- protocol should be adopted and for critically ill patients. Basal-bolus
cose-lowering medication during implemented by each hospital regimens that include correction dos-
pregnancy. Ongoing evaluation may or hospital system. A plan for es and account for oral intake may
be performed with any recommended preventing and treating hypogly- be used for many noncritical-care
glycemic test (e.g., A1C, FPG, or cemia should be established for patients. Scheduled subcutaneous
75-g OGTT using nonpregnant each patient. Episodes of hypo- insulin injections should align with
thresholds). glycemia in the hospital should be meals and bedtime or be given every
DIABETES CARE IN THE
documented in the medical record 46 hours if no meals are taken or if
and tracked. E continuous enteral/parenteral therapy
HOSPITAL, NURSING HOME,
The treatment regimen should be is being used.
AND SKILLED NURSING
reviewed and changed as necessary Subcutaneous insulin should be
FACILITY
to prevent further hypoglycemia administered 12 hours before IV
Recommendations when a blood glucose value is 70 insulin is discontinued. Converting
Perform an A1C for all patients mg/dL (3.9 mmol/L). C to basal insulin at 6080% of the

daily infusion dose has been shown Transition From the Acute Care and Driving and Diabetes and
to be effective. Premixed insulins are Setting Employment, refer to Section 15
not routinely recommended for hos- Tailor a structured discharge plan (Diabetes Advocacy) of the com-
pital use. beginning at admission and update plete 2017 Standards.
as patient needs change. It is import-
Standards for Special Situations ant that patients be provided with
Refer to the full 2017 Standards of appropriate durable medical equip- Acknowledgments
Care for guidance on enteral/paren- ment, medications, supplies, and This abridged version of the ADA posi-
tion statement Standards of Medical Care
teral feedings, DKA and hyperosmo- prescriptions, along with appropriate in Diabetes2017 was created by ADAs
lar hyperglycemic state, and glucocor- education at the time of discharge. Primary Care Advisory Group, with special
ticoid therapy. Psychosocial factors should be con- thanks to Jay Shubrook, DO, Vallejo, CA,
Primary Care Advisory Group, Chair;
sidered, including social determinants Amy Butts, PA-C, MPAS, CDE, James J.
Perioperative Care of care. An outpatient follow-up visit Chamberlain, MD, Salt Lake City, UT; Eric
On the morning of surgery or a within 1 month of discharge is ad- L. Johnson, MD, Grand Forks, ND; Sandra
procedure, hold any oral hypoglyce- vised for all patients having hyper- Leal, PharmD, MPH, FAPhA, CDE,
Tucson, AZ; Andrew S. Rhinehart, MD,
mic agents; give half of the patients glycemia in the hospital. Continuing FACP, FACE, CDE, BC-ADM, CDTC,
NPH insulin dose or 6080% doses contact may also be needed. Clear Abingdon, VA; and Neil Skolnik, MD,
of long-acting analog or pump basal communication with outpatient pro- Jenkintown, PA, with staff support from
viders either directly or via structured Sarah Bradley. Editorial assistance was
insulin. Monitor blood glucose every provided by Florence M. Jaffa, DO.
hospital discharge summaries facil-
46 hours while a patient is taking The full Standards of Medical Care in
itates safe transitions to outpatient
nothing by mouth and dose with care. If oral medications are held in
Diabetes2017 was developed by the ADAs
Professional Practice Committee: William
short-acting insulin as needed with the hospital, there should be proto- H. Herman, MD, MPH (Co-Chair), Rita
a target of 80180 mg/dL (4.410.0 cols for resuming them 12 days be- R. Kalyani, MD, MHS, FACP (Co-Chair),*
mmol/L). Andrea L. Cherrington, MD, MPH, Donald
fore discharge. Factors to prevent re- R. Coustan, MD, Ian de Boer, MD, MS,
MNT in the Hospital admissions need to be considered. See Robert James Dudl, MD, Hope Feldman,
the section above on older adults with CRNP, FNP-BC, Hermes J. Florez, MD,
The goals of MNT are to optimize PhD, MPH,* Suneil Koliwad, MD, PhD,*
diabetes regarding long-term care and
glycemic control, provide adequate skilled nursing facilities.
Melinda Maryniuk, MEd, RD, CDE,
Joshua J. Neumiller, PharmD, CDE,
calories to meet metabolic demands, FASCP,* and Joseph Wolfsdorf, MB, BCh,
and address personal food preferenc- DIABETES ADVOCACY with staff support from Erika Gebel Berg,
es. The term ADA diet is no longer Advocacy Position Statements PhD, Sheri Colberg-Ochs, PhD, Alicia H.
McAuliffe-Fogarty, PhD, CPsychol, Sacha
used. A registered dietitian can serve For a list of ADA advocacy position Uelmen, RDN, CDE, and Robert Ratner,
as an inpatient team member. statements, including Diabetes MD, FACP, FACE. *Subgroup leaders.

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Clinical Diabetes Papers In Press, published online December 15, 2016

Standards of Medical Care in Diabetes2017

Clinical Diabetes Papers In Press, published online December 15, 2016

Clinical Diabetes Papers In Press, published online December 15, 2016

TABLE 2. Criteria for Testing for Diabetes or Prediabetes in

Clinical Diabetes Papers In Press, published online December 15, 2016

TABLE 4. Components of the Comprehensive Diabetes Medical Evaluation*

Clinical Diabetes Papers In Press, published online December 15, 2016

Clinical Diabetes Papers In Press, published online December 15, 2016

Clinical Diabetes Papers In Press, published online December 15, 2016

TABLE 5. MNT Recommendations

Clinical Diabetes Papers In Press, published online December 15, 2016

TABLE 5. MNT Recommendations,

Clinical Diabetes Papers In Press, published online December 15, 2016

Clinical Diabetes Papers In Press, published online December 15, 2016

Usually not modifiable

gest more stringent A1C goals

this can be achieved without sig-

2 diabetes treated with lifestyle or

Clinical Diabetes Papers In Press, published online December 15, 2016

Clinical Diabetes Papers In Press, published online December 15, 2016

Clinical Diabetes Papers In Press, published online December 15, 2016

Start with Monotherapy unless:

Monotherapy Metformin Lifestyle Management

Dual Therapy Metformin + Lifestyle Management

EFFICACY* high high intermediate intermediate high highest

Triple Therapy Metformin + Lifestyle Management

or DPP-4-i or DPP-4-i or TZD or TZD or TZD or DPP-4-i

or SGLT2-i or SGLT2-i or SGLT2-i or DPP-4-i or SGLT2-i or SGLT2-i

or GLP-1-RA or GLP-1-RA or Insulin or GLP-1-RA or Insulin or GLP-1-RA

or Insulin or Insulin or Insulin

Combination Injectable Therapy (See Figure 3)

Clinical Diabetes Papers In Press, published online December 15, 2016

If A1C not controlled, consider

Clinical Diabetes Papers In Press, published online December 15, 2016

Clinical Diabetes Papers In Press, published online December 15, 2016

TABLE 8. High- and Moderate-Intensity Statin Therapy*

Clinical Diabetes Papers In Press, published online December 15, 2016

TABLE 9. Management of CKD in Diabetes

Clinical Diabetes Papers In Press, published online December 15, 2016

Clinical Diabetes Papers In Press, published online December 15, 2016

Clinical Diabetes Papers In Press, published online December 15, 2016

Clinical Diabetes Papers In Press, published online December 15, 2016

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