Anda di halaman 1dari 24

P O S I T I O N SETD

ATI TEO
MREI N
ATL

Standards of Medical Care in Diabetes—2018


Abridged for Primary Care Providers
American Diabetes Association

T
he American Diabetes Associ- document, including all supporting
ation’s (ADA’s) Standards of references, is available at professional.
Medical Care in Diabetes are diabetes.org/standards.
published each year in a supplement
IMPROVING CARE AND
to the January issue of Diabetes Care.
PROMOTING HEALTH IN
The ADA’s Professional Practice
POPULATIONS
Committee develops the Standards
Over the past 10 years, the proportion
and updates them annually, or more
of patients with diabetes who achieve
frequently online should it determine
recommended A1C, blood pressure,
that new evidence or regulatory chang-
and LDL cholesterol levels has in-
es (e.g., drug approvals, label changes)
creased. The mean A1C nationally
merit immediate incorporation. The among people with diabetes has de-
Standards include the most current clined from 7.6% (60 mmol/mol) in
evidence-based recommendations for 1999–2002 to 7.2% (55 mmol/mol)
diagnosing and treating adults and in 2007–2010 based on the National
children with diabetes. ADA’s grad- Health and Nutrition Examination
ing system uses A, B, C, or E to show Survey, with younger adults less likely
the evidence level that supports each to meet treatment targets than older
recommendation. adults. This has been accompanied
• A —Clear evidence from well- by improvements in cardiovascular
conducted, generalizable random- outcomes and has led to substantial
ized controlled trials that are ade- reductions in end-stage microvascular
quately powered complications. Nevertheless, 33–49%
• B —Supportive evidence from of patients still do not meet targets for
well-conducted cohort studies glycemic, blood pressure, or cholester-
• C —Supportive evidence from ol control, and only 14% meet targets
poorly controlled or uncontrolled for all three measures while also avoid-
studies ing smoking.
This is an abridged version of the American • E —Expert consensus or clinical Optimal diabetes management
Diabetes Association’s Standards of experience requires an organized, systematic
Medical Care in Diabetes—2018. Diabetes
Care 2018;41(Suppl. 1):S1–S159.
This is an abridged version of approach and the involvement of a
The complete 2018 Standards supplement,
the Standards containing the evi- coordinated team of dedicated health
including all supporting references, is
dence-based recommendations most care professionals working in an
available at professional.diabetes.org/
standards. pertinent to primary care. The tables environment where patient-centered
high-quality care is a priority.
https://doi.org/10.2337/cd17-0119 and figures have been renumbered
from the original document to match Recommendations
©2018 by the American Diabetes Association.
Readers may use this article as long as the work is
this version. All of the recommenda- • Ensure treatment decisions are
properly cited, the use is educational and not for tions (bulleted text) are precisely the timely, rely on evidence-based
profit, and the work is not altered. See http://
creativecommons.org/licenses/by-nc-nd/3.0
same as in the full Standards of Care. guidelines, and are made collab-
for details. The complete 2018 Standards of Care oratively with patients based on

14 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 2 018

individual preferences, prognoses, mune β-cell destruction, usually small percentage of patients have
and comorbidities. B leading to absolute insulin defi- conditions such as sickle cell trait or
• Align approaches to diabetes ciency) hemoglobinopathies that skew A1C
management with the Chronic 2. Type 2 diabetes (due to a pro- results. See the full 2018 Standards
Care Model, emphasizing pro- gressive loss of β-cell insulin of Care for conditions causing dis-
ductive interactions between a secretion frequently on the back- crepancies. Unless there is a clear
prepared proactive care team and ground of insulin resistance) clinical diagnosis based on overt
an informed activated patient. A 3. Gestational diabetes mellitus signs of hyperglycemia, a second test
• Care systems should facilitate (GDM) (diabetes diagnosed in is required for confirmation, either
team-based care, patient regis- the second or third trimester of repeating the same test used initially
tries, decision support tools, and pregnancy that was not clearly or a different test. If patients have
community involvement to meet overt diabetes prior to gestation) test results near the margins of the
patient needs. B 4. Specific types of diabetes due diagnostic threshold, the health care
• Efforts to assess the quality of to other causes, e.g., monogenic professional should follow the patient
diabetes care and create quality diabetes syndromes (such as neo- closely and repeat the test in 3–6
improvement strategies should natal diabetes and maturity-onset months.
incorporate reliable data metrics, diabetes of the young), diseases
of the exocrine pancreas (such as Categories of Increased Risk
to promote improved processes of
cystic fibrosis and pancreatitis), for Diabetes (Prediabetes)
care and health outcomes, with
and drug- or chemical-induced “Prediabetes” is the term used for in-
simultaneous emphasis on costs. E
diabetes (such as with gluco- dividuals whose glucose levels do not
Tailoring Treatment for Social corticoid use, in the treatment meet the criteria for diabetes but are
Context of HIV/AIDS, or after organ too high to be considered normal (see
Health inequities related to diabetes transplantation) Table 1). Prediabetes should not be
and its complications are well docu- viewed as a clinical entity in its own
mented and are heavily influenced by Diagnostic Tests for Diabetes right but rather as an increased risk
social determinants of health. Social Diabetes and prediabetes may be for diabetes and cardiovascular disease
determinants of health are defined as screened based on plasma glucose cri- (CVD).
the economic, environmental, polit- teria, either the fasting plasma glucose
(FPG) or the 2-h plasma glucose (2-h Recommendations
ical, and social conditions in which • Screening for prediabetes and risk
people live and are responsible for a PG) value during a 75-g oral glucose
tolerance test (OGTT), or A1C cri- for future diabetes with an infor-
major part of health inequality world- mal assessment of risk factors or
teria (Table 1).
wide. The ADA recognizes the associ- validated tools should be consid-
There is incomplete concordance
ation between social and environmen- ered in asymptomatic adults. B
between A1C, FPG, and 2-h PG, and
tal factors and risk for diabetes and its • Testing for prediabetes and risk
the 2-h PG diagnoses more people
complications. for future diabetes in asymptom-
with diabetes than the FPG or A1C.
Recommendations Marked discrepancies between mea- atic people should be considered
• Providers should assess social sured A1C and plasma glucose levels in adults of any age who are over-
context, including potential food should prompt consideration that weight or obese (BMI ≥25 kg/m2
insecurity, housing stability, the A1C assay may not be reliable or ≥23 kg/m2 in Asian Americans)
and financial barriers, and apply for that individual, since a relatively and who have one or more addi-
that information to treatment
decisions. A TABLE 1. Criteria for the Screening and Diagnosis of Diabetes
• Refer patients to local community Prediabetes Diabetes
resources when available. B A1C 5.7–6.4%* ≥6.5%†
• Provide patients with self-man- FPG 100–125 mg/dL (5.6–6.9 mmol/L)* ≥126 mg/dL (7.0 mmol/L)†
agement support from lay health
OGTT 140–199 mg/dL (7.8–11.0 mmol/L)* ≥200 mg/dL (11.1 mmol/L)†
coaches, navigators, or community
health workers when available. A RPG — ≥200 mg/dL (11.1 mmol/L)‡
*For all three tests, risk is continuous, extending below the lower limit of the
CLASSIFICATION AND
range and becoming disproportionately greater at the higher end of the range.
DIAGNOSIS OF DIABETES
†In the absence of unequivocal hyperglycemia, results should be confirmed
Diabetes can be classified into the
by repeat testing. ‡Only diagnostic in a patient with classic symptoms of
following general categories:
hyperglycemia or hyperglycemic crisis. RPG, random plasma glucose.
1. Type 1 diabetes (due to autoim-

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 15
P O S I T I O N S TAT E M E N T

sex, weight for height >85th per-


TABLE 2. Criteria for Testing for Diabetes or Prediabetes
in Asymptomatic Adults
centile, or weight >120% of ideal
for height) and who have additional
1. Testing should be considered in overweight or obese (BMI ≥25 kg/m2 risk factors for diabetes (Table 3). E
or ≥23 kg/m2 in Asian Americans) adults who have one or more of the
following risk factors: COMPREHENSIVE
• First-degree relative with diabetes MEDICAL EVALUATION
• High-risk race/ethnicity (e.g., African American, Latino, Native AND ASSESSMENT OF
American, Asian American, Pacific Islander) COMORBIDITIES
• History of CVD Patient-Centered Collaborative
• Hypertension (≥140/90 mmHg or on therapy for hypertension) Care
• HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a Recommendation
triglyceride level >250 mg/dL (2.82 mmol/L)
• A patient-centered communica-
• Women with polycystic ovary syndrome tion style that uses person-centered
• Physical inactivity and strength-based language, uses
• Other clinical conditions associated with insulin resistance (e.g., active listening, elicits patient pref-
severe obesity, acanthosis nigricans) erences and beliefs, and assesses
2. Patients with prediabetes (A1C ≥5.7% [39 mmol/mol], IGT, or IFG) literacy, numeracy, and potential
should be tested yearly. barriers to care should be used to
3. Women who were diagnosed with GDM should have lifelong testing optimize patient health outcomes
at least every 3 years. and health-related quality of life. B
4. For all other patients, testing should begin at age 45 years. Comprehensive Medical
5. If results are normal, testing should be repeated at a minimum of 3-year Evaluation
intervals, with consideration of more frequent testing depending on
initial results and risk status. Recommendations
• A complete medical evaluation
should be performed at the initial
TABLE 3. Risk-Based Screening for Type 2 Diabetes
visit to:
or Prediabetes in Asymptomatic Children and Adolescents
❍❍ Confirm the diagnosis and classify
in a Clinical Setting*
diabetes. B
Criteria ❍❍ Evaluate for diabetes complica-
• Overweight (BMI >85th percentile for age and sex, weight for height tions and potential comorbid
>85th percentile, or weight >120% of ideal for height) A conditions. E
Plus one or more additional risk factors based on the strength of their ❍❍ Begin patient engagement in the
association with diabetes as indicated by evidence grades: formulation of a care management
• Maternal history of diabetes or GDM during the child’s gestation A plan. B
❍❍ Develop a plan for continuing
• Family history of type 2 diabetes in first- or second-degree relative A
care. B
• Race/ethnicity (Native American, African American, Latino, Asian
American, Pacific Islander) A • A follow-up visit should include
most components of the initial
• Signs of insulin resistance or conditions associated with insulin
resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic comprehensive medical evalu-
ovary syndrome, or small-for-gestational-age birth weight) B ation including: interval medical
*Persons aged <18 years.
history; assessment of medication-
taking behavior and intolerance/
side effects; physical examination;
tional risk factors for diabetes test, and A1C are equally appro- laboratory evaluation as appro-
(Table 2). B priate. B priate to assess attainment of
• For all people, testing should • In patients with prediabetes, iden- A1C and metabolic targets; and
begin at age 45 years. B tify and, if appropriate, treat other assessment of risk for complica-
• If tests are normal, repeat test- CVD risk factors. B tions, diabetes self-management
ing carried out at a minimum of • Testing for prediabetes should be behaviors, nutrition, psychosocial
3-year intervals is reasonable. C considered in children and adoles- health, and the need for referrals,
• To test for prediabetes, FPG, 2-h cents who are overweight or obese immunizations, or other routine
PG during 75-g OGTT tolerance (BMI >85th percentile for age and health maintenance screening. B

16 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 2 018

Table 4 lists the components of physiology or diabetes treatments. • Because DSMES can improve
the diabetes medical evaluation. Patients with diabetes should be en- outcomes and reduce costs B,
couraged to undergo recommended adequate reimbursement by third-
Immunization
age- and sex-appropriate cancer party payers is recommended. E
Children and adults with diabetes
should receive vaccinations accord- screenings and to reduce their mod-
Nutrition Therapy
ing to age-specific recommendations. ifiable cancer risk factors (obesity, For a complete discussion and refer-
See the Centers for Disease Control physical inactivity, and smoking). ences, see the ADA position statement
and Prevention website for current LIFESTYLE MANAGEMENT “Nutrition Therapy Recommendations
recommendations. Lifestyle management is a funda- for the Management of Adults With
mental aspect of diabetes care and Diabetes.”
Assessment of Comorbidities
Besides assessing diabetes-related includes diabetes self-management Goals of nutrition therapy for
complications, clinicians and their education and support (DSMES), adults with diabetes are to promote
patients need to be aware of com- medical nutrition therapy (MNT), and support healthful eating patterns
mon comorbidities that affect people physical activity, smoking cessation in achieving and maintaining body
with diabetes and may complicate counseling, and psychosocial care. weight, glycemic, blood pressure,
management. Patients and care providers should and lipid goals while addressing
focus together on how to optimize individual issues, including access to
Autoimmune Diseases lifestyle from the time of the initial healthful foods, personal and cultural
Recommendation comprehensive medical evaluation, preferences, and other factors.
• Consider screening patients with throughout all subsequent evaluations Evidence suggests that there is not
type 1 diabetes for autoimmune and follow-up, and during the assess- an ideal percentage of calories from
thyroid disease and celiac disease ment of complications and manage- carbohydrate, protein, and fat for
soon after diagnosis. B ment of comorbid conditions in order all people with diabetes. Therefore,
to enhance diabetes care. macronutrient distribution should
Cognitive Impairment/ be based on an individualized assess-
Dementia DSMES ment of current eating patterns,
See Psychosocial Care and Older Recommendations preferences, and metabolic goals.
Adults sections. • In accordance with the national The diabetes plate method is com-
Recommendation standards for DSMES, all people monly used for providing basic meal
• In people with a history of cog- with diabetes should participate planning guidance. See the full 2018
nitive impairment/dementia, inten- in diabetes self-management edu- Standards of Care for a complete
sive glucose control cannot be cation to facilitate the knowledge, discussion.
expected to remediate deficits. skills, and ability necessary for Weight Management
Treatment should be tailored to diabetes self-care and in diabetes Management and reduction of weight
avoid significant hypoglycemia. B self-management support to assist is important for overweight and obese
with implementing and sustaining people with type 1 and type 2 diabe-
Other conditions, including fatty skills and behaviors needed for tes. Lifestyle intervention programs
liver disease, hepatocellular carcino- ongoing self-management. B should be intensive and have frequent
ma, hip fractures, low testosterone • There are four critical times to follow-up to achieve significant re-
in men, obstructive sleep apnea, and evaluate the need for DSMES: at ductions in excess body weight and
periodontal disease are all more com- diagnosis, annually, when com- improve clinical indicators. There is
mon in persons with diabetes. See plicating factors arise, and when strong and consistent evidence that
the full 2018 Standards of Care for transitions in care occur. E modest persistent weight loss can
discussion on these topics. • Facilitating appropriate diabetes delay the progression from predia-
Cancer self-management and improving betes to type 2 diabetes and is ben-
Diabetes is associated with increased clinical outcomes, health status, eficial to the management of type 2
risk of cancers of the liver, pancreas, and quality of life are key goals of diabetes (see Obesity Management
endometrium, colon/rectum, breast, DSMES to be measured and mon- for the Treatment of Type 2 Diabetes
and bladder. The association may re- itored as part of routine care. C section).
sult from shared risk factors between • Effective DSMES should be See the full 2018 Standards of
type 2 diabetes and cancer (older age, patient centered, may be given Care regarding specific recommen-
obesity, and physical inactivity) but in group or individual settings or dations for carbohydrates, protein,
may also be due to diabetes-related using technology, and should help fats, sodium, micronutrients, and
factors, such as underlying disease guide clinical decisions. A supplements.

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 17
P O S I T I O N S TAT E M E N T

TABLE 4. Components of the Comprehensive Diabetes Medical Evaluation at Initial and Follow-Up Visits

TABLE CONTINUED ON P. 19 →

18 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 2 018

TABLE 4. Components of the Comprehensive Diabetes Medical Evaluation at Initial and Follow-Up Visits,
continued from p. 18

Tables 9.2 and 10. 1 are in the full 2018 Standards of Care. *≥65 years. †May be needed more frequently in patients with
known CKD or with changes in medications that affect kidney function and serum potassium (see Table 10.2 in the full
Standards of Care). #May also need to be checked after initiation or dose changes of medications that affect these
laboratory values (i.e., diabetes, blood pressure, cholesterol, or thyroid medications). ^In people without dyslipidemia
and not on cholesterol-lowering therapy, testing may be less frequent. ABI, ankle-brachial pressure index.

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 19
P O S I T I O N S TAT E M E N T

Routine supplementation with min/week) of vigorous-intensity or ropathy is also an independent risk


antioxidants, such as vitamins E and interval training may be sufficient factor for cardiovascular death and
C and carotene, is not advised due to for younger and more physically silent myocardial ischemia. Therefore,
lack of evidence of efficacy and con- fit individuals. individuals with diabetic autonomic
cern related to long-term safety. In • Adults with type 1 C and type 2 neuropathy should undergo cardiac
addition, there is insufficient evidence B diabetes should engage in 2–3 investigation before beginning physi-
to support the routine use of herbals sessions/week of resistance exercise cal activity more intense than that to
and micronutrients, such as cinnamon on nonconsecutive days. which they are accustomed.
and vitamin D, to improve glycemic • All adults, and particularly those
Psychosocial Issues
control in people with diabetes. with type 2 diabetes, should
decrease the amount of time spent Recommendations
Alcohol
in daily sedentary behavior. B • Psychosocial care should be inte-
Moderate alcohol intake does not
Prolonged sitting should be inter- grated with a collaborative, patient-
have major detrimental effects on
rupted every 30 min for blood centered approach and provided
long-term blood glucose control in
glucose benefits, particularly in to all people with diabetes, with
people with diabetes. Risks associat-
adults with type 2 diabetes. C the goals of optimizing health out-
ed with alcohol consumption include
• Flexibility training and balance comes and health-related quality
hypoglycemia (particularly for those
training are recommended 2–3 of life. A
using insulin or insulin secretagogue
times/week for older adults with • Psychosocial screening and follow-
therapies), weight gain, and hypergly-
diabetes. Yoga and tai chi may up may include, but are not lim-
cemia (for those consuming excessive
be included based on individual ited to, attitudes about diabetes,
amounts). People with diabetes can
preferences to increase flexibility, expectations for medical man-
follow the same guidelines as those
muscular strength, and balance. C agement and outcomes, affect or
without diabetes if they choose to
drink. Exercise in the Presence mood, general and diabetes-related
of Specific Long-term quality of life, available resources
Nonnutritive Sweeteners (financial, social, and emotional),
Complications of Diabetes
For some people with diabetes who and psychiatric history. E
are accustomed to sugar-sweetened Retinopathy • Providers should consider assess-
products, nonnutritive sweeteners If proliferative diabetic retinopathy ment for symptoms of diabetes
(containing few or no calories) may be or severe nonproliferative diabetic distress, depression, anxiety, dis-
an acceptable substitute for nutritive retinopathy is present, then vigorous- ordered eating, and cognitive
sweeteners. Most systematic reviews intensity aerobic or resistance exercise capacities using patient-appropriate
and meta-analyses show benefits for may be contraindicated because of the standardized and validated tools at
nonnutritive sweetener use in weight risk of triggering vitreous hemorrhage the initial visit, at periodic inter-
loss; however, some studies suggest an or retinal detachment. Consultation vals, and when there is a change in
association with weight gain. with an ophthalmologist prior to en- disease, treatment, or life circum-
gaging in an intense exercise regimen stance. Including caregivers and
Physical Activity
may be appropriate. family members in this assessment
Recommendations is recommended. B
Peripheral Neuropathy
• Children and adolescents with • Consider screening older adults
Decreased pain sensation and a higher
type 1 or type 2 diabetes or predia- (aged ≥65 years) with diabetes
pain threshold in the extremities result
betes should engage in 60 min/day for cognitive impairment and
in an increased risk of skin breakdown,
or more of moderate- or vigorous- depression. B
infection, and Charcot joint destruc-
intensity aerobic activity, with vig-
tion with some forms of exercise. Diabetes Distress
orous muscle-strengthening and
bone-strengthening activities at Autonomic Neuropathy Recommendation
least 3 days/week. C Autonomic neuropathy can increase • Routinely monitor people with
• Most adults with type 1 C and the risk of exercise-induced injury or diabetes for diabetes distress
type 2 B diabetes should engage adverse events through decreased car- (DD), particularly when treat-
in 150 min or more of moderate- diac responsiveness to exercise, pos- ment targets are not met and/or
to-vigorous intensity aerobic activ- tural hypotension, impaired thermo- at the onset of diabetes compli-
ity per week, spread over at least 3 regulation, impaired night vision due cations. B
days/week, with no more than 2 to impaired papillary reaction, and
consecutive days without activity. greater susceptibility to hypoglyce- DD is very common and is distinct
Shorter durations (minimum 75 mia. Cardiovascular autonomic neu- from other psychological disorders.

20 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 2 018

DD refers to significant negative psy-


TABLE 5. Situations That Warrant Referral of a Person
chological reactions related to emo-
With Diabetes to a Mental Health Provider for Evaluation
tional burdens and worries specific to
and Treatment
an individual’s experience in having
to manage a severe, complicated, and • If self-care remains impaired in a person with DD after tailored
diabetes education
demanding chronic disease such as
diabetes. • If a person has a positive screen on a validated screening tool for
depressive symptoms
DD should be routinely mon-
itored using patient-appropriate • In the presence of symptoms or suspicions of disordered eating
behavior, an eating disorder, or disrupted patterns of eating
validated measures. If DD is iden-
tified, the person should be referred • If intentional omission of insulin or oral medication to cause weight
loss is identified
for specific diabetes education to
address areas of diabetes self-care that • If a person has a positive screen for anxiety or fear of hypoglycemia
are most relevant to the patient and • If a serious mental illness is suspected
impact clinical management. • In youth and families with behavioral self-care difficulties, repeated
hospitalizations for diabetic ketoacidosis, or significant distress
Serious Mental Illness
• If a person screens positive for cognitive impairment
Recommendations • Declining or impaired ability to perform diabetes self-care behaviors
• Annually screen people who are
• Before undergoing bariatric or metabolic surgery and after surgery if
prescribed atypical antipsychotic assessment reveals an ongoing need for adjustment support
medications for prediabetes or
diabetes. B moderate-intensity physical activ- Metformin has the strongest evidence
• If a second-generation antipsy- ity (such as brisk walking) to at base and demonstrated long-term
chotic medication is prescribed least 150 min/week. A safety as pharmacologic therapy for
for adolescents or adults with diabetes prevention. For other drugs,
diabetes, changes in weight, glyce- Pharmacologic Interventions
cost, side effects, and durable efficacy
mic control, and cholesterol levels Recommendations require consideration.
should be carefully monitored and • Metformin therapy for prevention
the treatment regimen should be of type 2 diabetes should be con- GLYCEMIC TARGETS
reassessed. C sidered in those with prediabetes, Assessment of Glycemic
• Incorporate monitoring of diabetes especially for those with BMI ≥35 Control
self-care activities into treatment kg/m2, those aged <60 years, and Self-monitoring of blood glucose
goals in people with diabetes and women with prior gestational dia-
serious mental illness. B (SMBG) frequency and timing should
betes mellitus. A
be dictated by patients’ specific needs
• Long-term use of metformin may
Table 5 lists considerations regarding and goals. SMBG is especially import-
be associated with biochemical
referral to a mental health specialist. ant for patients treated with insulin to
vitamin B12 deficiency, and peri-
Refer to the ADA position statement odic measurement of vitamin B12 monitor for and prevent asymptomat-
“Psychosocial Care for People With levels should be considered in met- ic hypoglycemia and hyperglycemia.
Diabetes” for a list of assessment tools formin-treated patients, especially Data indicate similar A1C and safety
and additional details. in those with anemia or peripheral with the use of continuous glucose
PREVENTION OR DELAY OF neuropathy. B monitoring (CGM) compared with
TYPE 2 DIABETES SMBG.
Pharmacologic agents including met-
Recommendations
Recommendations formin, α-glucosidase inhibitors, orli-
• At least annual monitoring for the stat, glucagon-like peptide 1 (GLP-1) • Most patients using intensive
development of diabetes in those receptor agonists, and thiazolidinedi- insulin regimens (a multiple daily
with prediabetes is suggested. E ones have each been shown to de- injection [MDI] regimen or insu-
• Patients with prediabetes should crease incident diabetes to various lin pump therapy) should perform
be referred to an intensive degrees in those with prediabetes in SMBG prior to meals and snacks,
behavioral lifestyle intervention research studies, though none are ap- at bedtime, occasionally postpran-
program modeled on the Diabetes proved by the U.S. Food and Drug dially, prior to exercise, when
Prevention Program to achieve Administration specifically for dia- they suspect low blood glucose,
and maintain 7% loss of ini- betes prevention. One has to balance after treating low blood glucose
tial body weight and increase the risk/benefit of each medication. until they are normoglycemic,

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 21
P O S I T I O N S TAT E M E N T

and prior to critical tasks such as TABLE 6. Summary of Glycemic Recommendations for Many
driving. B Nonpregnant Adults With Diabetes
SMBG allows patients to evaluate A1C <7.0% (53 mmol/mol)*
their responses to therapy and assess Preprandial capillary plasma glucose 80–130 mg/dL (4.4–7.2 mmol/L)*
whether glycemic targets are being Peak postprandial capillary plasma <180 mg/dL (10.0 mmol/L)*
met. It can help in preventing hypo- glucose†
glycemia and adjusting medications *More or less stringent glycemic goals may be appropriate for individual
(particularly prandial insulin), MNT, patients. Goals should be individualized based on duration of diabetes,
and physical activity. Evidence sup- age/life expectancy, comorbid conditions, known CVD or advanced
ports a correlation between SMBG microvascular complications, hypoglycemia unawareness, and individual
frequency and lower A1C in insulin- patient considerations. †Postprandial glucose may be targeted if A1C goals
treated patients. However, evidence are not met despite reaching preprandial glucose goals. Postprandial glucose
is lacking on when and how often measurements should be made 1–2 h after the beginning of the meal,
SMBG is needed for patients who do generally peak levels in patients with diabetes.
not use intensive insulin regimens
A1C Goals these populations. Table 6 summarizes
such as those with type 2 diabetes
glycemic recommendations for many
using oral agents and/or basal insu- Recommendations
• A reasonable A1C goal for many nonpregnant adults. Figure 1 depicts
lin. Randomized trials have called
nonpregnant adults is <7% (53 factors used to determine A1C targets
into question the clinical utility and
mmol/mol). A for individual patients.
cost-effectiveness of routine SMBG in
noninsulin-treated patients. • Providers might reasonably sug- Hypoglycemia
SMBG accuracy is dependent on gest more stringent A1C goals
(such as <6.5% [48 mmol/mol]) Recommendations
both the instrument and the user. • Individuals at risk for hypogly-
Evaluate each patient’s technique for selected individual patients
if this can be achieved with- cemia should be asked about
initially and at regular intervals symptomatic and asymptomatic
out significant hypoglycemia or
thereafter. Evaluate the ongoing need hypoglycemia at each encounter. C
other adverse effects of treatment
for and frequency of SMBG at each (i.e., polypharmacy). Appropriate • Glucose (15–20 g) is the preferred
visit. A guide to SMBG products can patients might include those with treatment for the conscious indi-
be found at forecast.diabetes.org/ short duration of diabetes, type 2 vidual with blood glucose ≤70
consumerguide. diabetes treated with lifestyle or mg/dL [3.9 mmol/L]), although
CGM measures interstitial glucose metformin only, long life expec- any form of carbohydrate that
(which correlates well with plasma tancy, or no significant CVD. C contains glucose may be used.
glucose), and most CGM devices • Less stringent A1C goals (such Fifteen minutes after treatment,
include alarms for both hypoglyce- as <8% [64 mmol/mol]) may be if SMBG shows continued hypo-
mic and hyperglycemic excursions. A appropriate for patients with a glycemia, the treatment should be
“flash” CGM device, which does not history of severe hypoglycemia, repeated. Once SMBG returns to
have alarm functions, was recently limited life expectancy, advanced normal, the individual should con-
approved for use in adults. microvascular or macrovascular sume a meal or snack to prevent
complications, extensive comorbid recurrence of hypoglycemia. E
A1C Testing conditions, or long-standing diabe- • Glucagon should be prescribed
Recommendations tes in whom the goal is difficult to for all individuals at increased
• Perform the A1C test at least two achieve despite diabetes self-man- risk of clinically significant
times a year in patients who are agement education, appropriate hypoglycemia, defined as blood
meeting treatment goals (and who glucose monitoring, and effective
glucose <54 mg/dL (3.0 mmol/L),
have stable glycemic control). E doses of multiple glucose-lowering
so it is available should it be
• Perform the A1C test quarterly agents including insulin. B
needed. Caregivers, school per-
in patients whose therapy has The full 2018 Standards of Care sonnel, or family members of these
changed or who are not meeting provide the justification for current individuals should know where it
glycemic goals. E glycemic control recommendations. is and when and how to adminis-
• Point-of-care (POC) testing for See Children and Adolescents and ter it. Glucagon administration is
A1C provides the opportunity for Management of Diabetes in not limited to health care profes-
more timely treatment changes. E Pregnancy sections for A1C goals for sionals. E

22 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 2 018

>5% weight loss should be pre-


scribed for overweight and obese
patients with type 2 diabetes ready
to achieve weight loss. A
• Such interventions should be
high intensity (≥16 sessions in
6 months) and focus on diet,
physical activity, and behavioral
strategies to achieve a 500–750
kcal/day energy deficit. A
• Diets should be individualized, as
those that provide the same caloric
restriction but differ in protein,
carbohydrate, and fat content
are equally effective in achieving
weight loss. A
• For patients who achieve short-
term weight-loss goals, long-term
(≥1 year) comprehensive weight
maintenance programs should be
prescribed. Such programs should
provide at least monthly contact
and encourage ongoing moni-
■ FIGURE 1. Depicted are patient and disease factors used to determine optimal toring of body weight (weekly
A1C targets. Characteristics and predicaments toward the left justify more stringent or more frequently), continued
efforts to lower A1C; those toward the right suggest less stringent efforts. Adapted consumption of a reduced-calorie
with permission from Inzucchi et al. Diabetes Care 2015;38:140–149. diet, and participation in high lev-
els of physical activity (200–300
• Hypoglycemia unawareness or one beneficial in the treatment of type min/week). A
or more episodes of severe hypogly- 2 diabetes. In overweight and obese Pharmacotherapy
cemia should trigger reevaluation patients with type 2 diabetes, modest
of the treatment regimen. E and sustained weight loss has been Recommendations
• Insulin-treated patients with hypo- shown to improve glycemic control • When choosing glucose-lower-
glycemia unawareness or an episode and to reduce the need for glucose- ing medications for overweight or
of clinically significant hypoglyce- lowering medications. obese patients with type 2 diabetes,
mia should be advised to raise their consider their effect on weight. E
Recommendation
glycemic targets to strictly avoid • Whenever possible, minimize the
hypoglycemia for at least several • At each patient encounter, BMI
medications for comorbid con-
weeks in order to partially reverse should be calculated and docu-
ditions that are associated with
hypoglycemia unawareness and mented in the medical record. B
weight gain. E
reduce risk of future episodes. A Providers should advise overweight • Weight loss medications may
• Ongoing assessment of cogni- and obese patients that, in general, be effective as adjuncts to diet,
tive function is suggested with higher BMIs increase the risk of CVD physical activity, and behavioral
increased vigilance for hypogly- and all-cause mortality. Providers counseling for selected patients
cemia by the clinician, patient, should assess each patient’s readiness with type 2 diabetes and BMI ≥27
and caregivers if low cognition or to achieve weight loss and jointly de- kg/m2. Potential benefits must be
declining cognition is found. B termine weight loss goals and inter- weighed against the potential risks
OBESITY MANAGEMENT FOR vention strategies. of the medications. A
THE TREATMENT OF TYPE 2 • If a patient’s response to weight
Diet, Physical Activity, and
DIABETES loss medications is <5% weight
Behavioral Therapy
There is strong and consistent evi- loss after 3 months or if there are
dence that obesity management can Recommendations any safety or tolerability issues at
delay the progression from predia- • Diet, physical activity, and behav- any time, the medication should be
betes to type 2 diabetes and may be ioral therapy designed to achieve discontinued and alternative med-

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 23
P O S I T I O N S TAT E M E N T

ications or treatment approaches tal health services to help them type 2 diabetes who have A1C
should be considered. A adjust to medical and psychosocial ≥9% (75 mmol/mol). E
changes after surgery. C • In patients without atherosclerotic
Metabolic Surgery
CVD (ASCVD), if monotherapy
Recommendations A substantial body of evidence or dual therapy does not achieve
• Metabolic surgery should be rec- has now accumulated, including or maintain the A1C goal over 3
ommended as an option to treat data from numerous randomized months, add an additional anti-
type 2 diabetes in appropriate controlled clinical trials, regarding hyperglycemic agent based on
surgical candidates with BMI ≥40 benefit of metabolic surgery in appro- drug-specific and patient factors.
kg/m2 (BMI ≥37.5 kg/m2 in Asian priate patients.
A
Americans), regardless of the level PHARMACOLOGIC • A patient-centered approach should
of glycemic control or complex- APPROACHES TO GLYCEMIC be used to guide the choice of phar-
ity of glucose-lowering regimens, TREATMENT macologic agents. Considerations
and in adults with BMI 35.0–39.9 include efficacy, hypoglycemia
kg/m2 (32.5–37.4 kg/m2 in Asian Pharmacologic Therapy for
Type 1 Diabetes
risk, history of ASCVD, impact
Americans) when hyperglycemia on weight, potential side effects,
is inadequately controlled despite Recommendations renal effects, delivery method (oral
lifestyle and optimal medical ther- • Most people with type 1 diabetes versus subcutaneous), cost, and
apy. A should be treated with an MDI patient preferences. E
• Metabolic surgery should be con- regimen of prandial insulin and • In patients with type 2 diabetes
sidered as an option for adults basal insulin or continuous subcu- and established ASCVD, anti-
with type 2 diabetes and BMI taneous insulin infusion (CSII). A hyperglycemic therapy should
30.0–34.9 kg/m 2 (27.5–32.4 • Most individuals with type 1 begin with lifestyle management
kg/m 2 in Asian Americans) if diabetes should use rapid-acting and metformin and subsequently
hyperglycemia is inadequately insulin analogs to reduce hypo- incorporate an agent proven to
controlled despite optimal medical glycemia risk. A reduce major adverse cardiovas-
control by either oral or injectable • Consider educating individuals cular events and cardiovascular
medications (including insulin). B with type 1 diabetes on matching mortality (currently empagliflozin
• Metabolic surgery should be per- prandial insulin doses to carbo- and liraglutide), after considering
formed in high-volume centers hydrate intake, premeal blood
with multidisciplinary teams that drug-specific and patient factors.
glucose levels, and anticipated
understand and are experienced in (Table 7) A*
physical activity. E
the management of diabetes and • In patients with type 2 diabetes
• Individuals with type 1 diabetes
gastrointestinal surgery. C and established ASCVD, after
who have been successfully using
• Long-term lifestyle support and lifestyle management and met-
CSII should have continued access
routine monitoring of micronutri- to this therapy after they turn 65 formin, the antihyperglycemic
ent and nutritional status must be years of age. E agent canagliflozin may be con-
provided to patients after surgery, sidered to reduce major adverse
Pharmacologic Therapy for Type cardiovascular events, based on
according to guidelines for postop-
2 Diabetes drug-specific and patient factors
erative management of metabolic
surgery by national and interna- Recommendations (Table 7). C*
tional professional societies. C • Metformin, if not contraindicated • Continuous reevaluation of the
• People presenting for metabolic and if tolerated, is the preferred medication regimen and adjust-
surgery should receive a compre- initial pharmacologic agent for ment as needed to incorporate
hensive mental health assessment. the treatment of type 2 diabetes. A patient factors (Table 7) and
B Surgery should be postponed in • Consider initiating insulin therapy regimen complexity is recom-
patients with histories of alcohol (with or without additional agents) mended. E
or substance abuse, significant in patients with newly diagnosed • For patients with type 2 diabetes
depression, suicidal ideation, or type 2 diabetes who are symptom- who are not achieving glycemic
other mental health conditions atic and/or have A1C ≥10% (86 goals, drug intensification, includ-
until these conditions have been mmol/mol) and/or blood glucose ing consideration of insulin
fully addressed. E levels ≥300 mg/dL (16.7 mmol/L). therapy, should not be delayed. B
• People who undergo metabolic E • Metformin should be continued
surgery should be evaluated to • Consider initiating dual therapy when used in combination with
assess the need for ongoing men- in patients with newly diagnosed other agents, including insulin, if

24 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 2 018

not contraindicated and if toler- • Most patients with diabetes and treatment, is the recommended
ated. A hypertension should be treated to first-line treatment for hyperten-
*See Figure 2 for more information. a systolic blood pressure goal of sion in patients with diabetes and
<140 mmHg and a diastolic blood urinary albumin–to–creatinine
Table 7 highlights considerations pressure goal of <90 mmHg. A ratio (UACR) ≥300 mg/g creati-
for a patient-centered approach to • Lower systolic and diastolic blood nine (Cr) A or 30–299 mg/g Cr.
diabetes pharmacologic therapies. pressure targets, such as 130/80 B If one class is not tolerated, the
Figure 2 and Figure 3 outline mono- mmHg, may be appropriate for other should be substituted. B
therapy and combination therapy individuals at high risk of CVD, • For patients treated with an ACE
emphasizing drugs commonly used if they can be achieved without inhibitor, ARB, or diuretic, serum
in the United States and/or Europe. undue treatment burden. C creatinine/estimated glomerular
See Table 8.2 in the full Standards • For patients with blood pres- filtration rate (eGFR) and serum
of Care for information on the phar- sure >120/80 mmHg, lifestyle potassium levels should be mon-
macology of glucose-lowering agents intervention consists of weight itored at least annually. B
available in the United States for the loss if overweight or obese; a
treatment of type 2 diabetes. Dietary Approaches to Stop Figure 9.1 in the full 2018
CVD AND RISK MANAGEMENT Hypertension–style dietary pat- Standards of Care summarizes rec-
ASCVD—defined as coronary heart tern including reducing sodium ommendations for the treatment
disease, cerebrovascular disease, or and increasing potassium intake; of confirmed hypertension in peo-
peripheral arterial disease (PAD) moderation of alcohol intake; and ple with diabetes. Based on current
presumed to be of atherosclerotic or- increased physical activity. B evidence, ADA recommends hyper-
igin—is the leading cause of morbid- • Patients with confirmed office- tension diagnosis and treatment as
ity and mortality for individuals with based blood pressure ≥140/90 outlined, emphasizing individualiza-
diabetes and is the largest contributor mmHg should, in addition to tion of blood pressure targets. ADA
to the direct and indirect costs of dia- lifestyle therapy, have prompt is aware of hypertension recommen-
betes. Common conditions coexisting initiation and timely titration of dations from other organizations.
with type 2 diabetes (e.g., hyperten- pharmacologic therapy to achieve The ADA Professional Practice
sion and dyslipidemia) are clear risk blood pressure goals. A Committee continuously reviews
factors for ASCVD, and diabetes it- • Patients with confirmed office- and considers all studies, particularly
self confers independent risk. based blood pressure ≥160/100 high-quality trials including people
Therefore, cardiovascular risk fac- mmHg should, in addition to with diabetes, for potential incorpo-
tors should be systematically assessed lifestyle therapy, have prompt ini- ration in future recommendations.
at least annually in all patients with tiation and timely titration of two Lipid Management
diabetes. These risk factors include drugs or a single-pill combination
hypertension, dyslipidemia, smok- of drugs demonstrated to reduce Recommendations
ing, a family history of premature cardiovascular events in patients • Lifestyle modification focus-
coronary disease, chronic kidney with diabetes. A ing on weight loss (if indicated);
disease (CKD), and the presence of • Treatment for hypertension should the reduction of saturated fat,
albuminuria. include drug classes demonstrated trans fat, and cholesterol intake;
to reduce cardiovascular events in increase of dietary ω-3 fatty acids,
Hypertension/Blood Pressure viscous fiber, and plant stanols/ste-
patients with diabetes (ACE inhib-
Control rols intake; and increased physical
itors, angiotensin receptor blockers
Recommendations [ARBs], thiazide-like diuretics, or activity should be recommended
• Blood pressure should be mea- dihydropyridine calcium channel to improve the lipid profile in
sured at every routine clinical visit. blockers). A patients with diabetes. A
Patients found to have elevated • Multiple-drug therapy is generally • Intensify lifestyle therapy and opti-
blood pressure (≥140/90 mmHg) required to achieve blood pressure mize glycemic control for patients
should have blood pressure con- targets. However, combinations with elevated triglyceride levels
firmed using multiple readings, of ACE inhibitors and ARBs and (≥150 mg/dL [1.7 mmol/L]) and/or
including measurements on a combinations of ACE inhibitors or low HDL cholesterol (<40 mg/dL
separate day, to diagnose hyper- ARBs with direct renin inhibitors [1.0 mmol/L] for men, <50 mg/dL
tension. B should not be used. A [1.3 mmol/L] for women). C
• All hypertensive patients with dia- • An ACE inhibitor or ARB, at • Obtain a lipid profile at initiation
betes should monitor their blood the maximumly tolerated dose of statins or other lipid-lowering
pressure at home. B indicated for blood pressure therapy, 4–12 weeks after ini-

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 25
26
TABLE 7. Drug-Specific and Patient Factors to Consider When Selecting Antihyperglycemic Treatment in Adults With Type 2 Diabetes
P O S I T I O N S TAT E M E N T

*See Inzucchi et al. Diabetes Care 2015;38:140–149 for description of efficacy. †U.S. Food and Drug Administration–approved for CVD benefit. NASH,
nonalcoholic steatohepatitis; RAs, receptor agonists; SQ, subcutaneous; T2DM, type 2 diabetes.

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 2 018

(See Figure 3).

(See Table 7)

(see recommendations with * on p. 24 and Table 7)

(See Table 7)

(See Table 7)

(See Figure 3).

(See Figure 3)

■ FIGURE 2. Antihyperglycemic therapy in type 2 diabetes: general recommendations. *If patient does not tolerate or has
contraindications to metformin, consider agents from another class in Table 7. #GLP-1 receptor agonists and DPP-4 inhibitors
should not be prescribed in combination. If a patient with ASCVD is not yet on an agent with evidence of cardiovascular risk
reduction, consider adding.

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 27
P O S I T I O N S TAT E M E N T

■ FIGURE 3. Combination injectable therapy for type 2 diabetes. FBG, fasting blood glucose; hypo, hypoglycemia. Adapted
with permission from Inzucchi et al. Diabetes Care 2015;38:140–149.

tiation or a change in dose, and provider should consider using patient response to medication
annually thereafter as it may help moderate-intensity statin in addi- (e.g., side effects, tolerability, LDL
to monitor the response to therapy tion to lifestyle therapy. C cholesterol levels, or percent LDL
and inform adherence. E • For patients with diabetes aged reduction on statin therapy). For
• For patients of all ages with dia- 40–75 years A and >75 years B patients who do not tolerate the
betes and ASCVD, high-intensity without ASCVD, use moderate- intended intensity of the statin,
statin therapy should be added to intensity statin in addition to life- the maximally tolerated statin
lifestyle therapy. A style therapy. dose should be used. E
• For patients with diabetes aged • In clinical practice, providers may • For patients with diabetes and
<40 years with additional ASCVD need to adjust the intensity of sta- ASCVD, if LDL cholesterol is
risk factors, the patient and tin therapy based on individual ≥70 mg/dL (3.9 mmol/L) on maxi-

28 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 2 018

mally tolerated statin dose, women with diabetes aged ≥50 claudication, or PAD; or electro-
consider adding additional LDL- years who have at least one addi- cardiogram abnormalities (e.g., Q
lowering therapy (such as ezeti- tional major risk factor (family waves). E
mibe or PCSK9 inhibitor) after history of premature ASCVD, • In patients with known ASCVD,
evaluating the potential for further hypertension, dyslipidemia, consider ACE inhibitor or ARB
ASCVD risk reduction, drug-spe- smoking, or albuminuria) and therapy to reduce the risk of car-
cific adverse effects, and patient are not at increased risk of bleed- diovascular events. B
preferences. Ezetimibe may be ing. C • In patients with type 2 diabetes
preferred due to lower cost. A with stable congestive heart fail-
Coronary Heart Disease
• Statin therapy is contraindicated ure, metformin may be used if
in pregnancy. B Recommendations
eGFR remains >30 mL/min but
• For patients with fasting tri- • In asymptomatic patients, routine
should be avoided in unstable or
glyceride levels ≥500 mg/dL (5.7 screening for coronary artery dis-
hospitalized patients with conges-
mmol/L), evaluate for secondary ease is not recommended as it does
causes of hypertriglyceridemia tive heart failure. B
not improve outcomes as long as
and consider medical therapy to ASCVD risk factors are treated. A • In patients with type 2 diabetes
reduce the risk of pancreatitis. C • Consider investigations for coro- and established ASCVD, anti-
• Combination therapy (statin/ nary artery disease in the pres- hyperglycemic therapy should
fibrate) has not been shown to ence of any of the following: begin with lifestyle management
improve ASCVD outcomes and atypical cardiac symptoms (e.g., and metformin and subsequently
is generally not recommended. A unexplained dyspnea, chest dis- incorporate an agent proven to
• Combination therapy (statin/ comfort); signs or symptoms reduce major adverse cardiovas-
niacin) has not been shown to of associated vascular disease cular events and cardiovascular
provide additional cardiovascular including carotid bruits, tran- mortality (currently empagliflozin
benefit above statin therapy alone, sient ischemic attack, stroke, and liraglutide), after considering
may increase the risk of stroke
with additional side effects, and TABLE 8. Recommendations for Statin and Combination
is generally not recommended. A Treatment in Adults With Diabetes
Age ASCVD Recommended statin intensity^ and combination
Table 8 and Table 9 provide rec- treatment*
ommendations on high-intensity and <40 years No None†
moderate-intensity statin therapy.
Yes High
Antiplatelet Agents • If LDL cholesterol ≥70 mg/dL (3.9 mmol/L) despite
Recommendations maximally tolerated statin dose, consider adding
additional LDL-lowering therapy (such as ezetimibe
• Use aspirin therapy (75–162 or PCSK9 inhibitor)#
mg/day) as a secondary prevention
≥40 years No Moderate‡
strategy in those with diabetes and
a history of ASCVD. A Yes High
• For patients with ASCVD and • If LDL cholesterol ≥70 mg/dL (3.9 mmol/L) despite
documented aspirin allergy, maximally tolerated statin dose, consider adding
additional LDL-lowering therapy (such as ezetimibe
clopidogrel (75 mg/day) should or PCSK9 inhibitor)
be used. B
• Dual antiplatelet therapy (with *In addition to lifestyle therapy. ^For patients who do not tolerate the
low-dose aspirin and a P2Y12 intended intensity of statin, the maximally tolerated statin dose should be
inhibitor) is reasonable for a year used. †Moderate-intensity statin may be considered based on risk-benefit
after an acute coronary syndrome profile and presence of ASCVD risk factors. ASCVD risk factors include
LDL cholesterol ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking,
A and may have benefits beyond
CKD, albuminuria, and family history of premature ASCVD. ‡High-intensity
this period. B
statin may be considered based on risk-benefit profile and presence of
• Aspirin therapy (75–162 mg/day)
ASCVD risk factors. #Adults aged <40 years with prevalent ASCVD were
may be considered as a primary
not well represented in clinical trials of nonstatin-based LDL reduction.
prevention strategy in those with
Before initiating combination lipid-lowering therapy, consider the potential
type 1 or type 2 diabetes who
for further ASCVD risk reduction, drug-specific adverse effects, and
are at increased cardiovascular
patient preferences.
risk. This includes most men and

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 29
P O S I T I O N S TAT E M E N T

TABLE 9. High-Intensity and Moderate-Intensity Statin Therapy* • When eGFR is <60 mL/min/1.73
m2, evaluate and manage potential
High-intensity statin therapy Moderate-intensity statin therapy
(lowers LDL cholesterol by ≥50%) (lowers LDL cholesterol by 30–50%)
complications of chronic kidney
disease. E
Atorvastatin 40–80 mg Atorvastatin 10–20 mg • Patients should be referred for
Rosuvastatin 20–40 mg Rosuvastatin 5–10 mg evaluation for renal replacement
Simvastatin 20–40 mg treatment if they have an eGFR
Pravastatin 40–80 mg <30 mL/min/1.73 m2. A
• Promptly refer to a physician
Lovastatin 40 mg
experienced in the care of kidney
Fluvastatin XL 80 mg disease for uncertainty about the
Pitavastatin 2–4 mg etiology of kidney disease, difficult
*Once-daily dosing. XL, extended release. management issues, and rapidly
progressing kidney disease. B
drug-specific and patient factors Recommendations
Interventions
(see Table 7). A
Screening
• In patients with type 2 diabetes Specific Glucose-Lowering
• At least once a year, assess urinary
and established ASCVD, after Medications
albumin (e.g., spot UACR) and
lifestyle management and met- A number of large cardiovascular
eGFR in patients with type 1 dia-
formin, the antihyperglycemic outcomes trials in patients with type
betes with duration of ≥5 years, in
agent canagliflozin may be con- 2 diabetes at high risk for CVD or
all patients with type 2 diabetes, with existing CVD (EMPA-REG
sidered to reduce major adverse
and in all patients with comorbid OUTCOME [BI 10773 (Empagli-
cardiovascular events, based on
hypertension. B flozin) Cardiovascular Outcome
drug-specific and patient factors
(see Table 7). C Treatment Event Trial in Type 2 Diabetes
• Optimize glucose control to Mellitus Patients], CANVAS [Canagli-
MICROVASCULAR flozin Cardiovascular Assessment
reduce the risk or slow the pro-
COMPLICATIONS AND Study], LEADER [Liraglutide Effect
gression of DKD. A
FOOT CARE and Action in Diabetes: Evaluation of
• Optimize blood pressure control
Diabetic Kidney Disease to reduce the risk or slow the pro- Cardiovascular Outcome Results—
Diabetic kidney disease (DKD) is a gression of DKD. A A Long Term Evaluation], and
clinical diagnosis usually made based • For people with nondialysis-de- SUSTAIN-6 [Trial to Evaluate
on the presence of albuminuria and/or pendent DKD, dietary protein Cardiovascular and Other Long-
reduced eGFR in the absence of signs intake should be approximately term Outcomes With Semaglutide
or symptoms of other primary causes 0.8 g/kg body weight per day (the in Subjects With Type 2 Diabetes])
of kidney damage. CKD is diagnosed recommended daily allowance). examined kidney effects as secondary
by the persistent presence of elevated For patients on dialysis, higher outcomes with some positive results.
urinary albumin excretion (albumin- levels of dietary protein intake Additional trials with primary kidney
uria), low eGFR, or other manifesta- should be considered. B outcomes are needed to definitively
tions of kidney damage (Table 10). • In nonpregnant patients with determine whether other specific glu-
DKD, or CKD attributed to diabetes, diabetes and hypertension, cose-lowering drugs improve renal
occurs in 20–40% of patients with either an ACE inhibitor or an outcomes. See the full 2018 Standards
diabetes. DKD typically develops af- ARB is recommended for those of Care for additional discussion.
ter diabetes duration of 10 years in with modestly elevated UACR CVD and Blood Pressure
type 1 diabetes, but may be present ratio (30–299 mg/g Cr) B and is Hypertension is a strong risk factor
at diagnosis of type 2 diabetes. DKD strongly recommended for those for the development and progression
can progress to end-stage renal disease with UACR ≥300 mg/g Cr and/or of DKD. Antihypertensive therapy
(ESRD) requiring dialysis or kidney eGFR <60 mL/min/1.73 m2. A reduces the risk of albuminuria, and
transplantation and is the leading • An ACE inhibitor or an ARB is not among patients with type 1 or type
cause of ESRD in the United States. recommended for the primary pre- 2 diabetes with established DKD
In addition, among people with type vention of DKD in patients with (eGFR <60 mL/min/1.73 m 2 and
1 or type 2 diabetes, the presence of diabetes who have normal blood UACR ≥300 mg/g Cr), ACE inhib-
CKD markedly increases cardiovas- pressure, normal UACR (<30 mg/g itor or ARB therapy reduces the risk
cular risk. Cr), and normal eGFR. B of progression to ESRD. Moreover,

30 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 2 018

TABLE 10. CKD Stages and Corresponding Focus of Kidney-Related Care


CKD Stage† Focus of Kidney-Related Care
Stage eGFR Evidence Diagnose Evaluate and Evaluate and Prepare
(ml/min/1.73 m2) of Kidney Cause of Treat Risk Treat CKD for Renal
Damage* Kidney Factors for CKD Complications*** Replacement
Injury Progression** Therapy
No clinical ≥60 —
evidence of
CKD
1 ≥90 + ✓ ✓
2 60–89 + ✓ ✓
3 30–59 +/– ✓ ✓ ✓
4 15–29 +/– ✓ ✓ ✓
5 <15 +/– ✓ ✓
†CKD stages 1 and 2 are defined by evidence of kidney damage (+), while CKD stages 3–5 are defined by reduced
eGFR with or without evidence of kidney damage (+/–). *Kidney damage is most often manifest as albuminuria (UACR
≥30 mg/g Cr) but can also include glomerular hematuria, other abnormalities of the urinary sediment, radiographic
abnormalities, and other presentations. **Risk factors for CKD progression include elevated blood pressure, glycemia,
and albuminuria. ***See Table 10.2 in the full 2018 Standards of Care.

antihypertensive therapy reduces to determine whether this improves • Patients with type 2 diabetes
risks of cardiovascular events. renal outcomes. should have an initial dilated and
Blood pressure levels <140/90 ACE inhibitors or ARBs are not comprehensive eye examination
mmHg are generally recommended recommended for patients without by an ophthalmologist or optom-
to reduce CVD mortality and slow hypertension to prevent the develop- etrist at the time of the diabetes
CKD progression among people ment of DKD. diagnosis. B
with diabetes. Lower blood pressure Two clinical trials studied the • If there is no evidence of retinop-
targets (e.g., <130/80 mmHg) may combinations of ACE inhibitors athy for one or more annual eye
be considered for patients based on and ARBs and found no benefits on exam and glycemia is well con-
individual anticipated benefits and CVD or DKD, and the drug com- trolled, then exams every 1–2 years
risks. ACE inhibitors or ARBs are bination had higher adverse event may be considered. If any level of
the preferred first-line agent for rates (hyperkalemia and/or acute diabetic retinopathy is present,
blood pressure treatment among kidney injury). Therefore, the com- subsequent dilated retinal exam-
patients with diabetes, hyperten- bined use of ACE inhibitors and ARBs inations should be repeated at least
should be avoided. annually by an ophthalmologist or
sion, eGFR <60 mL/min/1.73 m 2 ,
optometrist. If retinopathy is pro-
and UACR ≥300 mg/g Cr because Diabetic Retinopathy gressing or sight-threatening, then
of their proven benefits for pre-
Recommendations examinations will be required
vention of CKD progression. In
• Optimize glycemic control to more frequently. B
general, ACE inhibitors and ARBs • While retinal photography may
are considered to have similar bene- reduce the risk or slow the pro-
gression of diabetic retinopathy. A serve as a screening tool for reti-
fits and risks. In the setting of lower nopathy, it is not a substitute for a
levels of albuminuria (30–299 mg/g • Optimize blood pressure and
serum lipid control to reduce the comprehensive eye exam. E
Cr), ACE inhibitor or ARB therapy • Women with preexisting type 1 or
has been demonstrated to reduce risk or slow the progression of dia-
betic retinopathy. A type 2 diabetes who are planning
progression to more advanced pregnancy or who are pregnant
albuminuria (≥300 mg/g Cr) and Screening should be counseled on the risk of
cardiovascular events but not pro- • Adults with type 1 diabetes should development and/or progression of
gression to ESRD. While ACE have an initial dilated and com- diabetic retinopathy. B
inhibitors or ARBs are often pre- prehensive eye examination by an • Eye examinations should occur
scribed for albuminuria without ophthalmologist or optometrist before pregnancy or in the first
hypertension, clinical trials have within 5 years after the onset of trimester in patients with preex-
not been performed in this setting diabetes. B isting type 1 or type 2 diabetes,

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 31
P O S I T I O N S TAT E M E N T

and then patients should be mon- a careful history and assessment ral to a neurologist is rarely needed,
itored every trimester and for 1 of either temperature or pinprick except in situations where the clinical
year postpartum as indicated by sensation (small-fiber function) features are atypical or the diagno-
the degree of retinopathy. B and vibration sensation using a sis is unclear. See the ADA position
128-Hz tuning fork (for large- statement “Diabetic Neuropathy” for
Treatment
fiber function). All patients should more details.
• Promptly refer patients with any
have annual 10-g monofilament
level of macular edema, severe Foot Care
testing to identify feet at risk for
nonproliferative diabetic retinop-
ulceration and amputation. B Recommendations
athy (a precursor of proliferative
• Symptoms and signs of autonomic • Perform a comprehensive foot
diabetic retinopathy), or any pro-
neuropathy should be assessed in evaluation at least annually to
liferative diabetic retinopathy
patients with microvascular com- identify risk factors for ulcers and
to an ophthalmologist who is
plications. E amputations. B
knowledgeable and experienced
• All patients with diabetes should
in the management of diabetic Treatment
have their feet inspected at every
retinopathy. A • Optimize glucose control to pre-
visit. C
• The traditional standard treat- vent or delay the development of
• Obtain a prior history of ulcer-
ment, panretinal laser photoco- neuropathy in patients with type
ation, amputation, Charcot foot,
agulation therapy, is indicated to 1 diabetes A and to slow the pro-
angioplasty or vascular surgery,
reduce the risk of vision loss in gression of neuropathy in patients
cigarette smoking, retinopathy,
patients with high-risk prolifera- with type 2 diabetes. B
and renal disease and assess cur-
tive diabetic retinopathy and, in • Assess and treat patients to reduce
rent symptoms of neuropathy
some cases, severe nonproliferative pain related to diabetic peripheral
(pain, burning, numbness) and
diabetic retinopathy. A neuropathy B and symptoms of
vascular disease (leg fatigue, clau-
• Intravitreous injections of anti– autonomic neuropathy and to
dication). B
vascular endothelial growth factor improve quality of life. E
• The examination should include
ranibizumab are not inferior to • Either pregabalin or duloxetine are
inspection of the skin, assessment
traditional panretinal laser photo- recommended as initial pharma-
of foot deformities, neurological
coagulation and are also indicated cologic treatments for neuropathic
assessment (10-g monofilament
to reduce the risk of vision loss in pain in diabetes. A
testing with at least one other
patients with proliferative diabetic
The diabetic neuropathies are a assessment: pinprick, temperature,
retinopathy. A
diagnosis of exclusion and are a het- vibration), and vascular assess-
• Intravitreous injections of anti–
erogeneous group of disorders with ment including pulses in the legs
vascular endothelial growth factor
diverse clinical manifestations. The and feet. B
are indicated for central-involved
early recognition and appropriate • Patients with symptoms of clau-
diabetic macular edema, which
management of neuropathy in the dication or decreased or absent
occurs beneath the foveal center
patient with diabetes is important. pedal pulses should be referred
and may threaten reading vision. A
for ankle-brachial index and for
• The presence of retinopathy is not Diagnosis further vascular assessment as
a contraindication to aspirin ther-
Diabetic Peripheral Neuropathy appropriate. C
apy for cardioprotection, as aspirin
The following clinical tests may be • A multidisciplinary approach is
does not increase the risk of retinal
used to assess small- and large-fiber recommended for individuals
hemorrhage. A
function and protective sensation: with foot ulcers and high-risk feet
Neuropathy 1. Small-fiber function: pinprick (e.g., dialysis patients and those
and temperature sensation with Charcot foot, prior ulcers, or
Recommendations
2. Large-fiber function: vibration amputation). B
Screening perception and 10-g monofila- • Refer patients who smoke or
• All patients should be assessed ment who have histories of prior lower-
for diabetic peripheral neuropa- 3. Protective sensation: 10-g mono- extremity complications, loss of
thy starting at diagnosis of type filament protective sensation, structural
2 diabetes and 5 years after the abnormalities, or PAD to foot care
diagnosis of type 1 diabetes and These tests not only screen for specialists for ongoing preventive
at least annually thereafter. B the presence of dysfunction but also care and life-long surveillance. C
• Assessment for distal symmetric predict future risk of complications. • The use of specialized therapeu-
polyneuropathy should include Electrophysiological testing or refer- tic footwear is recommended for

32 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 2 018

high-risk patients with diabe- should be paid to complications The care of older adults with dia-
tes including those with severe that would lead to functional betes is complicated by their clinical,
neuropathy, foot deformities, or impairment. C cognitive, and functional heterogene-
history of amputation. B • Treatment of hypertension to indi- ity. Providers caring for older adults
vidualized target levels is indicated with diabetes should prioritize treat-
OLDER ADULTS
in most older adults. C ment goals (Table 11). For patients
Recommendations • Treatment of other cardiovascular with complications and reduced
• Consider the assessment of medi- risk factors should be individual- functionality, it is reasonable to set
cal, psychological, functional, and ized in older adults considering less intensive glycemic goals. Factors
social geriatric domains in older the time frame of benefit. Lipid- to consider in individualizing glyce-
adults to provide a framework to lowering therapy and aspirin mic goals are outlined in Figure 1.
determine targets and therapeutic therapy may benefit those with life Pharmacologic Therapy
approaches for diabetes manage- expectancies at least equal to the Special care is required in prescribing
ment. C time frame of primary prevention and monitoring pharmacologic ther-
• Screening for geriatric syndromes or secondary intervention trials. E apy in older adults (see Table 7). The
may be appropriate in older adults • Consider diabetes education for patient’s living situation must be con-
experiencing limitations in their the staff of long-term care facili- sidered because it may affect diabe-
basic and instrumental activities ties to improve the management of tes management and support. When
of daily living as they may affect older adults with diabetes. E patients are found to have a regimen
diabetes self-management and be • Patients with diabetes residing beyond their self-management abili-
related to health-related quality of in long-term care facilities need ties, treatment should be deintensified
life. C careful assessment to establish (or simplified) to reduce hypoglyce-
• Screening for early detection of glycemic goals and to make appro- mia and disease-related distress while
mild cognitive impairment or priate choices of glucose-lowering avoiding a substantial worsening of
dementia and depression is indi- agents based on their clinical and glycemic control.
cated for adults 65 years of age or functional status. E Older adults with diabetes are
older at the initial visit and annu-
Diabetes is an important health likely to benefit from control of
ally as appropriate. B
condition for the aging population as other cardiovascular risk factors.
• Hypoglycemia should be avoided
approximately one-quarter of people Evidence is strong for treatment of
in older adults with diabetes. It
over the age of 65 years have diabetes. hypertension. There is less evidence
should be assessed and managed
Older individuals with diabetes have for lipid-lowering and aspirin therapy,
by adjusting glycemic targets and
higher rates of premature death, func- although the benefits of these inter-
pharmacologic interventions. B
tional disability, and coexisting illness. ventions are likely to apply to older
• Older adults who are other-
People with diabetes have higher adults whose life expectancies equal
wise healthy with few coexisting
incidences of all-cause dementia, or exceed the time frames of clinical
chronic illnesses and intact cogni-
Alzheimer disease, and vascular prevention trials.
tive function and functional status
should have lower glycemic goals dementia than people with normal Treatment in Skilled Nursing
(A1C <7.5% [58 mmol/mol]), glucose tolerance. Poor glycemic Facilities and Nursing Homes
while those with multiple co- control is associated with decline in Management of diabetes is unique in
existing chronic illnesses, cognitive cognitive function. the long-term care (LTC) setting (i.e.,
impairment, or functional depen- It is important to prevent hypogly- nursing homes and skilled nursing
dence should have less stringent cemia to reduce the risk of cognitive facilities). Individualization of health
glycemic goals (A1C <8.0–8.5% decline and other major adverse out- care is important for all patients. For
[64–69 mmol/mol]). C comes. Older adults are at higher risk patients in the LTC setting, special
• Glycemic goals for some older of hypoglycemia for many reasons, attention should be given to nutri-
adults might reasonably be including insulin deficiency necessi- tional considerations, end-of-life
relaxed as part of individualized tating insulin therapy and progressive care, and changes in diabetes man-
care, but hyperglycemia leading to renal insufficiency. Hypoglycemic agement with respect to advanced
symptoms or risk of acute hyper- events should be diligently monitored disease. Withdrawal of medications
glycemic complications should be and avoided, whereas glycemic targets may be appropriate. For more infor-
avoided in all patients. C and pharmacologic interventions may mation, see the ADA position state-
• Screening for diabetes complica- need to be adjusted to accommodate ment “Management of Diabetes in
tions should be individualized in for the changing needs of the older Long-Term Care and Skilled Nursing
older adults. Particular attention adult. Facilities.”

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 33
P O S I T I O N S TAT E M E N T

CHILDREN AND ADOLESCENTS macologic treatment of choice if (48 mmol/mol), to reduce the risk
See the full 2018 Standards of Care renal function is >30 mL/min/ of congenital anomalies. B
regarding the treatment of children 1.73 m 2. A • Women with preexisting type 1 or
with type 1 diabetes and for infor- • Youth with marked hyperglyce- type 2 diabetes who are planning
mation on hypertension and dyslip- mia (blood glucose ≥250 mg/dL pregnancy or who have become
idemia in children. [13.9 mmol/L], A1C ≥8.5% [69 pregnant should be counseled on
Glycemic Control mmol/mol]) without ketoacidosis the risk of development and/or
at diagnosis who are symptomatic progression of diabetic retinop-
Recommendations with polyuria, polydipsia, noctu- athy. Dilated eye examinations
• An A1C goal of <7.5% (58 mmol/ ria, and/or weight loss should be should occur before pregnancy
mol) is recommended across all treated initially with basal insulin or in the first trimester, and then
pediatric age-groups. E while metformin is initiated and patients should be monitored every
Type 2 Diabetes titrated to maximally tolerated trimester and for 1 year postpar-
In the past 20 years, the incidence dose to achieve A1C goal. E tum as indicated by the degree of
and prevalence of type 2 diabetes in • When the A1C target is no longer retinopathy and as recommended
youth has increased, especially in ra- met with metformin monother- by the eye care provider. B
cial and ethnic minority populations. apy, or if contraindications or See the full 2018 Standards
Evidence suggests that type 2 diabetes intolerable side effects of met- of Care for more information on
in youth is different not only from formin develop, basal insulin management of diabetes during
type 1 diabetes but also from type therapy should be initiated. E pregnancy.
2 diabetes in adults and has unique • In patients initially treated with
features, such as a more rapidly pro- basal insulin and metformin who Postpartum Care
gressive decline in β-cell function and are meeting glucose targets based Postpartum care should include psy-
accelerated development of diabetes on home blood glucose monitor- chosocial assessment and support for
complications. Risk factors associated ing, basal insulin can be tapered self-care.
with type 2 diabetes in youth include, over 2–6 weeks by decreasing the Women with GDM should be
in addition to racial/ethnic minority insulin dose by 10–30% every few tested for persistent diabetes or pre-
group status, adiposity, family history days. A diabetes at 4–12 weeks postpartum
of diabetes, female sex, and low socio- with a 75-g OGTT using nonpreg-
economic status. MANAGEMENT OF DIABETES nancy criteria. Women should also
IN PREGNANCY be tested every 1–3 years thereafter
Recommendations The majority of diabetes in pregnancy if the 4- to 12-week 75-g OGTT is
Screening and Diagnosis is GDM, with the remainder primari- normal. Ongoing evaluation may be
• Risk-based screening for pre- ly preexisting type 1 diabetes and type performed with any recommended
diabetes and/or type 2 diabetes 2 diabetes. Good preconception care glycemic test (e.g., A1C, FPG, or
should be considered in children for women with existing diabetes has 75-g OGTT using nonpregnant
and adolescents after the onset been shown to dramatically improve thresholds).
of puberty or ≥10 years of age, outcomes for both mother and child. In women with preexisting type 1
whichever occurs earlier, who are or type 2 diabetes taking insulin, par-
overweight (BMI >85th %) or Preconception Counseling ticular attention should be directed to
obese (BMI >95th %) and who Recommendations hypoglycemia prevention in the set-
have one or more additional risk • Starting at puberty, preconception ting of breastfeeding and erratic sleep
factors for diabetes (see Table 4). A counseling should be incorporated and eating schedules.
• If tests are normal, repeat testing into routine diabetes care for all All women with diabetes of child-
at a minimum of 3-year intervals girls of childbearing potential. A bearing potential should have family
E , or more frequently if BMI is • Family planning should be dis- planning options reviewed at regular
increasing. C cussed and effective contraception intervals.
Pharmacologic Management should be prescribed and used DIABETES CARE IN THE
• Initiate pharmacologic therapy, until a woman is prepared and HOSPITAL
in addition to lifestyle therapy, at ready to become pregnant. A Hospitals should promote the short-
diagnosis of type 2 diabetes. A • Preconception counseling should est safe hospital stay and provide an
• In metabolically stable patients address the importance of glyce- effective transition out of the hospital
(A1C <8.5% and asymptomatic), mic control as close to normal as is that prevents acute complications and
metformin is the initial phar- safely possible, ideally A1C <6.5% readmission. Prevention of hypogly-

34 CLINICAL.DIABETESJOURNALS.ORG
TABLE 11. Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older Adults With Diabetes
Patient Characteristics/ Rationale Reasonable Fasting or Bedtime Blood Lipids
Health Status A1C Goal‡ Preprandial Glucose Glucose Pressure
Healthy (few coexisting chronic Longer remaining life <7.5% 90–130 mg/dL 90–150 mg/dL <140/90 Statin unless
illnesses, intact cognitive and expectancy (58 mmol/mol) (5.0–7.2 mmol/L) (5.0–8.3 mmol/L) mmHg contraindicated
functional status) or not tolerated
Complex/intermediate Intermediate remaining <8.0% 90–150 mg/dL 100–180 mg/dL <140/90 Statin unless
(multiple coexisting chronic life expectancy, high (64 mmol/mol) (5.0–8.3 mmol/L) (5.6–10.0 mmol/L) mmHg contraindicated
illnesses* or 2+ instrumental treatment burden, or not tolerated
ADL impairments or mild-to- hypoglycemia
moderate cognitive impairment) vulnerability, fall risk
Very complex/poor health (LTC Limited remaining life <8.5%† 100–180 mg/dL 110–200 mg/dL <150/90 Consider likelihood
or end-stage chronic illnesses** expectancy makes (69 mmol/mol) (5.6–10.0 mmol/L) (6.1–11.1 mmol/L) mmHg of benefit with
or moderate-to-severe benefit uncertain statin (secondary
cognitive impairment or 2+ ADL prevention more so
dependencies) than primary)
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 patient’s health status and preferences may change over time. ‡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 chronic kidney disease, 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 3–4 congestive heart failure or oxygen-dependent lung disease, chronic kidney
disease 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 above 8.5% (69 mmol/mol)
are not recommended as they may expose patients to more frequent higher glucose values and the acute risks from glycosuria, dehydration, hyperglycemic
hyperosmolar syndrome, and poor wound healing. ADL, activities of daily living.
A1C.

standards.
Standards

fluctuations. E
sociated with both.

Recommendation
Recommendation

Recommendations

cally ill patients. A


Glycemic Targets in
Hospitalized Patients
Physician Order Entry
Hospital Care Delivery

nificant hypoglycemia. C
Considerations on Admission
formed in the prior 3 months. B

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 35
cemia and hyperglycemia should be

140 mg/dL (6.1–7.8 mmol/L), may


puterized protocols that allow
assessed on admission in addition to

The hypoglycemia alert value in hos-


levels >140 mg/dL (7.8 mmol/L).
patients is defined as blood glucose
Hyperglycemia in hospitalized
if this can be achieved without sig-
• More stringent goals, such as 110–
critically ill patients and noncriti-
ommended for the majority of
mg/dL (7.8–10.0 mmol/L) is rec-
target glucose range of 140–180
old ≥180 mg/dL (10.0 mmol/L).
hyperglycemia starting at a thresh-
• Insulin therapy should be initi-
for predefined adjustments in the
using validated written or com-
• Insulin should be administered
sets consistent with quality assurance
sured by the use of structured order
Best practice care can often be en-
Diabetes self-management should be
admitted to the hospital if not per-
(blood glucose >140 mg/dL)
• Perform an A1C on all patients
with diabetes or hyperglycemia
goals, since adverse outcomes are as-
a b r i d g e d s ta n d a r d s o f c a r e 2 018

glucose ≤70 mg/dL (3.9 mmol/L)


pitalized patients is defined as blood
be appropriate for selected patients,
Once insulin therapy is started, a
ated for treatment of persistent
insulin dosage based on glycemic
P O S I T I O N S TAT E M E N T

and clinically significant hypoglyce- If the patient is eating, insulin MNT in the Hospital
mia as glucose values <54 mg/dL (3.0 injections should align with meals. The goals of MNT are to optimize
mmol/L). In such instances, POC glucose test- glycemic control, provide adequate
ing should be performed immediately calories to meet metabolic demands,
Bedside Blood Glucose
before meals. Type 1 diabetes patients and address personal food preferences.
Monitoring
should have basal-bolus plus nutri- The ADA does not endorse any single
In the patient who is eating meals,
tional insulin if the patient is eating. meal plan. A registered dietitian can
glucose monitoring should be per-
A transition protocol from insulin serve as an inpatient team member.
formed before meals. In the patient
who is not eating, glucose monitoring infusion to subcutaneous insulin is Self-Management in the
is advised every 4–6 h. Testing every recommended. Hospital
30 min to 2 h is required for intrave- Noninsulin Therapies Diabetes self-management in the hos-
nous insulin infusion. The safety and efficacy of noninsulin pital may be appropriate for select
Glucose results from a POC antihyperglycemic therapies in the youth and adult patients. Sufficient
meter that do not correlate with the hospital setting is an area of active cognitive and physical skills, adequate
patient’s clinical status should be con- research. See the full 2018 Standards oral intake, proficiency in carbohy-
firmed with conventional laboratory drate estimation, and knowledge of
of Care for a comprehensive review of
measures. Several inpatient studies sick-day management are some of
the inpatient use of these medications.
have shown that CGM use did not the requirements. See the full 2018
improve glucose control but detected Hypoglycemia Standards of Care regarding self-
a greater number of hypoglycemic administered insulin with an MDI or
Recommendations
events than POC testing. However, CSII (insulin pump) regimen. A pro-
a recent review has recommended • A hypoglycemia management tocol should exist for these situations.
against using CGM in adults in a protocol should be adopted and
implemented by each hospital Standards for Special Situations
hospital setting until more safety and
or hospital system. A plan for See the full 2018 Standards of Care
efficacy data become available.
preventing and treating hypogly- for guidance on enteral/parenteral
Antihyperglycemic Agents in cemia should be established for feedings, diabetic ketoacidosis and
Hospitalized Patients each patient. Episodes of hypo- hyperosmolar hyperglycemic state,
glycemia in the hospital should be perioperative care, and glucocorticoid
Recommendations
documented in the medical record therapy.
• A basal plus bolus correction insu-
lin regimen, with the addition of and tracked. E Transition From the Acute Care
nutritional insulin in patients who • The treatment regimen should be Setting
have good nutritional intake, is reviewed and changed as necessary
Recommendation
the preferred treatment for non- to prevent further hypoglycemia
• There should be a structured
critically ill patients. A when a blood glucose value is ≤70
discharge plan tailored to the indi-
• Sole use of sliding scale insulin mg/dL (3.9 mmol/L). C
vidual patient with diabetes. B
in the inpatient hospital setting is
strongly discouraged. A While hypoglycemia is asso-
Tailor a structured discharge plan
ciated with increased mortality, beginning at admission and update as
In most instances in the hospital hypoglycemia may be a marker patient needs change. It is important
setting, insulin is the preferred treat- of underlying disease rather than that patients be provided with appro-
ment for glycemic control. However, the cause of increased mortality. priate durable medical equipment,
in certain circumstances, it may However, until it is proven not to medication reconciliation, supplies,
be appropriate to continue home be causal, it is prudent to avoid and prescriptions, along with appropri-
regimens including oral antihyper- hypoglycemia. ate education at the time of discharge.
glycemic medications. Iatrogenic triggers should be An outpatient follow-up visit within
Insulin Therapy considered. Studies of “bundled” 1 month of discharge is advised for
In the critical care setting, continu- preventative therapies including all patients who have hyperglycemia
ous intravenous insulin infusion has proactive surveillance of glycemic in the hospital. Continuing contact
been shown to be the best method for outliers and an interdisciplinary may also be needed. Clear commu-
achieving glycemic targets. Outside data-driven approach to glycemic nication with outpatient providers
of critical care units, scheduled insu- management showed that hypogly- either directly or via structured hospi-
lin regimens as described above are cemic episodes in the hospital could tal discharge summaries facilitates safe
recommended. be prevented. transitions to outpatient care. If oral

36 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 2 018

medications are held in the hospital, The full Standards of Medical Care in
there should be protocols for resuming Acknowledgments Diabetes—2018 was developed by the
ADA’s Professional Practice Committee:
them 1–2 days before discharge. This abridged version of the Standards of
Rita R. Kalyani, MD, MHS, FACP (Chair),
Medical Care in Diabetes—2018 was created
Refer to the full 2018 Standards by the ADA’s Primary Care Advisory
Christopher Cannon, MD, Andrea L.
of Care for a complete discussion of Group (PCAG) , with special thanks to
Cherrington, MD, MPH,* Donald R.
Coustan, MD, Ian de Boer, MD, MS,* Hope
readmission prevention. PCAG chair Jay Shubrook, DO, of Vallejo, Feldman, CRNP, FNP-BC, Judith Fradkin,
CA; PCAG vice-chair Eric L. Johnson, MD, MD, David Maahs, MD, PhD, Melinda
Diabetes Advocacy of Grand Forks, ND; Amy Butts, PA-C, Maryniuk, Med, RD, CDE, Medha N.
For a list of ADA advocacy position MPAS, CDE, of Weirton, WV; Sandra Munshi, MD,* Joshua J. Neumiller,
statements, including “Diabetes Leal, PharmD, MPH, FAPhA, CDE, of PharmD, CDE, FASCP, and Guillermo E.
and Driving” and “Diabetes and Tucson, AZ; Andrew S. Rhinehart, MD, Umpierrez.* ADA staff support includes
FACP, FACE, CDE, BC-ADM, CDTC, of Erika Gebel Berg, PhD, Tamara Darsow,
Employment,” see the Diabetes Marco Island, FL; and Neil Skolnik, MD, PhD, Matt Petersen, Sacha Uelmen,
Advocacy section of the full 2018 of Jenkintown, PA, with ADA staff support RDN, CDE, and William T. Cefalu, MD.
Standards of Care. from Sarah Bradley. (*Subgroup leaders)

V O L U M E 3 6 , N U M B E R 1 , W I N T E R 2 0 1 8 37