ADA Standards of Medical Care 2014 FINAL 8 Jan 2014 LOCKED

Standards of Medical Care
in Diabetes2014
Table of Contents
Section Slide No.
ADA Evidence Grading System of
Clinical Recommendations
3
I. Classification and Diagnosis
4-11
II. esting for Dia!etes in Asym"tomatic #atients
1$-1%
III. Detection and Diagnosis of
Gestational Dia!etes &ellit's (GD&)
1*-$$
I+. #revention,Delay of y"e $ Dia!etes
$3-$-
+. Dia!etes Care
$.-..
+I. #revention and &anagement of
Dia!etes Com"lications
.%-11/
+II. Assessment of Common Comor!id Conditions
111-11$
+III. Dia!etes Care in S"ecific #o"'lations
113-134
I0. Dia!etes Care in S"ecific Settings
13--144
0. Strategies for Im"roving Dia!etes Care
14--1-/
ADA Evidence Grading System for
Clinical ractice !ecommendations
1evel of
Evidence Descri"tion
A Clear or s'""ortive evidence from ade2'ately "o3ered
3ell-cond'cted4 generali5a!le4 randomi5ed controlled
trials
Com"elling none6"erimental evidence
7 S'""ortive evidence from 3ell-cond'cted co8ort st'dies
or case-control st'dy
C S'""ortive evidence from "oorly controlled or
'ncontrolled st'dies
Conflicting evidence 3it8 t8e 3eig8t of evidence
s'""orting t8e recommendation
E E6"ert consens's or clinical e6"erience
ADA. Diabetes Care 2014;37(suppl 1):S15; Table 1
"# Classification and
Diagnosis
Classification of Diabetes
9
Type 1 diabetes
:
!ell destru!ti"#
9
Type 2 diabetes
:
$r"%ressi&e i#suli# se!ret"ry de'e!t
9
(t)er spe!i'i! types "' diabetes
:
*e#eti! de'e!ts i# !ell 'u#!ti"#+ i#suli# a!ti"#
:
Diseases "' t)e e,"!ri#e pa#!reas
:
Dru% "r !)e-i!ali#du!ed
9
*estati"#al diabetes -ellitus (*D.)
ADA. /. Classi'i!ati"# a#d Dia%#"sis. Diabetes Care 2014;37(suppl 1):S14
Criteria for t$e Diagnosis of Diabetes
A1C ;..-<
OR
=asting "lasma gl'cose (=#G)
;1$. mg,d1 (%./ mmol,1)
OR
$-8 "lasma gl'cose ;$// mg,d1
(11.1 mmol,1) d'ring an >G
OR
A random "lasma gl'cose ;$// mg,d1 (11.1
mmol,1)
ADA. /. Classi'i!ati"# a#d Dia%#"sis. Diabetes Care 2014;37(suppl 1):S15; Table 2
A1C ;..-<
8e test s8o'ld !e "erformed in a la!oratory
'sing a met8od t8at is
NGS# certified and standardi5ed
to t8e DCC assay?
0/# t)e abse#!e "' u#e1ui&"!al )yper%ly!e-ia+ result s)"uld be !"#'ir-ed by repeat testi#%.
=asting "lasma gl'cose (=#G)
;1$. mg,d1 (%./ mmol,1)
=asting is defined as no caloric inta@e
for at least * 8?
$-8 "lasma gl'cose ;$// mg,d1
(11.1 mmol,1) d'ring an >G
8e test s8o'ld !e "erformed as descri!ed !y
t8e AB>4 'sing a
gl'cose load containing t8e e2'ivalent
of %- g an8ydro's gl'cose
dissolved in 3ater?
In a "atient 3it8 classic sym"toms of
8y"erglycemia or 8y"erglycemic crisis4
a random "lasma gl'cose ;$// mg,d1 (11.1
mmol,1)
=#G 1//21$- mg,d1 (-..2..C mmol,1)D I=G
OR
$-8 "lasma gl'cose in t8e %--g >G
14/21CC mg,d1 (%.*211./ mmol,1)D IG
OR
A1C -.%2..4<
03"r all t)ree tests+ ris4 is !"#ti#u"us+ e,te#di#% bel"5 t)e l"5er li-it "' a ra#%e a#d be!"-i#%
dispr"p"rti"#ately %reater at )i%)er e#ds "' t)e ra#%e.
Categories of "ncreased !is% for Diabetes
&rediabetes'(
""# Testing for Diabetes in
Asym)tomatic atients
!ecommendations* Testing for
Diabetes in Asym)tomatic atients
9
Test "&er5ei%)t7"bese adults (8./ 925
4%7-2) 5it) "#e "r -"re additi"#al ris4
'a!t"rs; i# t)"se 5it)"ut ris4 'a!t"rs+ be%i#
testi#% at a%e 45 years +
9
/' tests are #"r-al+ repeat testi#% at least at
3year i#ter&als is reas"#able E
9
T" test '"r diabetes7prediabetes+ t)e A1C+
3$*+ "r 2) 75% (*TT are appr"priate +
9
/# t)"se 5it) prediabetes+ ide#ti'y a#d+ i'
appr"priate+ treat "t)er C:D ris4 'a!t"rs +
ADA. //. Testi#% '"r Diabetes i# Asy-pt"-ati! $atie#ts. Diabetes Care 2014;37(suppl 1):S16
Criteria for Testing for Diabetes in
Asym)tomatic Ad,lt "ndivid,als &1'
9#8ysical inactivity
9 =irst-degree relative 3it8 dia!etes
9 Big8-ris@ race,et8nicity (e.g.4
African American4 1atino4 Native
American4 Asian American4 #acific
Islander)
9 Aomen 38o delivered a !a!y
3eig8ing EC l! or 3ere diagnosed
3it8 GD&
9 By"ertension (;14/,C/ mmBg or
on t8era"y for 8y"ertension)
9 ;D< !)"lester"l le&el
=35 -%7d< (0.>0 --"l7<)
a#d7"r a tri%ly!eride le&el
?250 -%7d< (2.@2 --"l7<)
9 A"-e# 5it) p"ly!ysti! "&aria#
sy#dr"-e ($C(S)
9 A1C 95.7B+ /*T+ "r /3* "#
pre&i"us testi#%
9 (t)er !li#i!al !"#diti"#s
ass"!iated 5it) i#suli#
resista#!e (e.%.+ se&ere
"besity+ a!a#t)"sis #i%ri!a#s)
9 ;ist"ry "' C:D
0Atris4 8./ -ay be l"5er i# s"-e et)#i! %r"ups.
1. esting s8o'ld !e considered in all ad'lts 38o are over3eig8t
(7&I ;$- @g,m$?) and 8ave additional ris@ factorsD
ADA. Testi#% '"r Diabetes i# Asy-pt"-ati! $atie#ts. Diabetes Care 2014;37(suppl 1):S17; Table 4
2. In t8e a!sence of criteria (ris@ factors on "revio's slide)4
testing for dia!etes s8o'ld !egin at age 4- years
3. If res'lts are normal4 testing s8o'ld !e re"eated at least
at 3-year intervals4 3it8 consideration of more fre2'ent
testing de"ending on initial res'lts (e.g.4 t8ose 3it8
"redia!etes s8o'ld !e tested yearly)4 and ris@ stat's
ADA. Testi#% '"r Diabetes i# Asy-pt"-ati! $atie#ts. Diabetes Care 2014;37(suppl 1):S17; Table 4
Criteria for Testing for Diabetes in
Asym)tomatic Ad,lt "ndivid,als &2'
9
Testi#% t" dete!t type 2 diabetes a#d
prediabetes s)"uld be !"#sidered i#
!)ildre# a#d ad"les!e#ts 5)" are
"&er5ei%)t a#d 5)" )a&e t5" "r -"re
additi"#al ris4 'a!t"rs '"r diabetes E
!ecommendation* Screening for
Ty)e 2 Diabetes in C$ildren
ADA. //. Testi#% '"r Diabetes i# Asy-pt"-ati! $atie#ts. Diabetes Care 2014;37(suppl 1):S172S1@
9
/#'"r- type 1 diabetes patie#ts "' t)e
"pp"rtu#ity t" )a&e t)eir relati&es
s!ree#ed '"r type 1 diabetes ris4 i# t)e
setti#% "' a !li#i!al resear!) study E
!ecommendation* Screening for
Ty)e 1 Diabetes
ADA. //. Testi#% '"r Diabetes i# Asy-pt"-ati! $atie#ts. Diabetes Care 2014;37(suppl 1):S1@
"""# Detection and Diagnosis
of Gestational diabetes
mellit,s &GDM'
!ecommendations*
Detection and Diagnosis of GDM &1'
9
S!ree# '"r u#dia%#"sed type 2 diabetes
at t)e 'irst pre#atal &isit i# t)"se 5it)
ris4 'a!t"rs+ usi#% sta#dard dia%#"sti!
!riteria +
9
S!ree# '"r *D. at 2422@ 5ee4s "'
%estati"# i# pre%#a#t 5"-e# #"t pre&i"usly
4#"5# t" )a&e diabetes A
9
S!ree# 5"-e# 5it) *D. '"r persiste#t
diabetes at 6212 5ee4s p"stpartu-+ usi#%
(*TT+ #"#pre%#a#!y dia%#"sti! !riteria E
ADA. ///. Dete!ti"# a#d Dia%#"sis "' *D.. Diabetes Care 2014;37(suppl 1):S1@
!ecommendations*
Detection and Diagnosis of GDM &2'
9
A"-e# 5it) a )ist"ry "' *D. s)"uld
)a&e li'el"#% s!ree#i#% '"r t)e de&el"p-e#t
"' diabetes "r prediabetes
at least e&ery 3 years +
9
A"-e# 5it) a )ist"ry "' *D. '"u#d t" )a&e
prediabetes s)"uld re!ei&e li'estyle
i#ter&e#ti"#s "r -et'"r-i# t" pre&e#t
diabetes A
9
3urt)er resear!) is #eeded t" establis) a
u#i'"r- appr"a!) t" dia%#"si#% *D. E
ADA. ///. Dete!ti"# a#d Dia%#"sis "' *D.. Diabetes Care 2014;37(suppl 1):S1@
Screening for and Diagnosis of GDM
-.ne/ste)0 &"ADSG Consens,s'
9 #erform a %--g >G4 3it8 "lasma gl'cose
meas'rement fasting and at 1 and $ 84 at $42$*
3ee@s of gestation in 3omen not "revio'sly
diagnosed 3it8 overt dia!etes
9 #erform >G in t8e morning after an overnig8t
fast of at least * 8
9
*D. dia%#"sis: 5)e# a#y "' t)e '"ll"5i#%
plas-a %lu!"se &alues are e,!eeded
2 =astingD ;C$ mg,d1 (-.1 mmol,1)
2
1 8D ;1*/ mg,d1 (1/./ mmol,1)
2
$ 8D ;1-3 mg,d1 (*.- mmol,1)
ADA. ///. Dete!ti"# a#d Dia%#"sis "' *D.. Diabetes Care 2014;37(suppl 1):S1>; Table 6
Screening for and Diagnosis of GDM
-T1o/ste)0 &2"3 Consens,s'
9 #erform -/-g G1 (nonfasting) 3it8 "lasma
gl'cose meas'rement at 1 8 (Ste" 1) at $42$*
3ee@s of gestation in 3omen not "revio'sly
diagnosed 3it8 overt dia!etes
9 If "lasma gl'cose level meas'red at 1 8 after
load is 9140 -%7d<0 (7.@ --"l7<)+ pr"!eed
t" 100% (*TT (Step 2) 5)e# patie#t is
'asti#%
9
*D. dia%#"sis: plas-a %lu!"se -easured
3 ) a'ter t)e test is 9140 -%7d<0
(7.@ --"l7<)
ADA. ///. Dete!ti"# a#d Dia%#"sis "' *D.. Diabetes Care 2014;37(suppl 1):S1>; Table 6
0AC(* re!"--e#ds 135 -%7d< i# )i%)ris4 et)#i! -i#"rities 5it) )i%)er pre&ale#!e "' *D..
"4# revention5Delay of Ty)e
2 Diabetes
!ecommendations*
revention5Delay of Ty)e 2 Diabetes
9
Ce'er patie#ts 5it) /*T A+ /3* E+ "r A1C
5.726.4B E t" "#%"i#% supp"rt pr"%ra-
:
Tar%eti#% 5ei%)t l"ss "' 7B "' b"dy 5ei%)t
:
/#!reasi#% p)ysi!al a!ti&ity t" at least 150
-i#75ee4 "' -"derate a!ti&ity (e%+ 5al4i#%)
9
3"ll"5up !"u#seli#% appears t" be
i-p"rta#t '"r su!!ess +
9
8ased "# !"ste''e!ti&e#ess "' diabetes
pre&e#ti"#+ su!) pr"%ra-s s)"uld be
!"&ered by t)irdparty payers +
ADA. /:. $re&e#ti"#7Delay "' Type 2 Diabetes. Diabetes Care 2014;37(suppl 1):S20
!ecommendations*
revention5Delay of Ty)e 2 Diabetes
9
C"#sider -et'"r-i# '"r pre&e#ti"# "' type
2 diabetes i' /*T A+ /3* E+ "r
A1C 5.726.4B E
:
Dspe!ially '"r t)"se 5it) 8./ ?35 4%7-2+
a%e =60 years+ a#d 5"-e# 5it) pri"r *D. A
9
/# t)"se 5it) prediabetes+ -"#it"r '"r
de&el"p-e#t "' diabetes a##ually E
9
S!ree# '"r a#d treat -"di'iable ris4
'a!t"rs '"r C:D +
ADA. /:. $re&e#ti"#7Delay "' Type 2 Diabetes. Diabetes Care 2014;37(suppl 1):S20
4# Diabetes Care
9 A !"-plete -edi!al e&aluati"# s)"uld be per'"r-ed t"
: Classi'y t)e diabetes
: Dete!t prese#!e "' diabetes !"-pli!ati"#s
: Ce&ie5 pre&i"us treat-e#t+ ris4 'a!t"r !"#tr"l i# patie#ts 5it) establis)ed
diabetes
: Assist i# '"r-ulati#% a -a#a%e-e#t pla#
: $r"&ide a basis '"r !"#ti#ui#% !are
9 $er'"r- lab"rat"ry tests #e!essary t" e&aluate ea!) patie#tEs
-edi!al !"#diti"#
Diabetes Care* "nitial Eval,ation
ADA. :. Diabetes Care. Diabetes Care 2014;37(suppl 1):S21
.edi!al )ist"ry (1)
9 A%e a#d !)ara!teristi!s "' "#set "' diabetes (e.%.+ DFA+
asy-pt"-ati! lab"rat"ry 'i#di#%
9 Dati#% patter#s+ p)ysi!al a!ti&ity )abits+ #utriti"#al status+ a#d
5ei%)t )ist"ry; %r"5t) a#d de&el"p-e#t i# !)ildre# a#d
ad"les!e#ts
9 Diabetes edu!ati"# )ist"ry
9 Ce&ie5 "' pre&i"us treat-e#t re%i-e#s a#d resp"#se t" t)erapy
(A1C re!"rds)
Com)onents of t$e Com)re$ensive
Diabetes Eval,ation &1'
ADA. :. Diabetes Care. Diabetes Care 2014;37(suppl 1):S21; Table 7
.edi!al )ist"ry (2)
9 Curre#t treat-e#t "' diabetes+ i#!ludi#% -edi!ati"#s+ ad)ere#!e
a#d barriers t)eret"+ -eal pla#+ p)ysi!al a!ti&ity patter#s+
readi#ess '"r be)a&i"r !)a#%e
9 Cesults "' %lu!"se -"#it"ri#%+ patie#tEs use "' data
9 DFA 're1ue#!y+ se&erity+ !ause
9 ;yp"%ly!e-i! epis"des
: ;yp"%ly!e-i! a5are#ess
: A#y se&ere )yp"%ly!e-ia: 're1ue#!y+ !ause
0See appr"priate re'errals '"r t)ese !ate%"ries.
.edi!al )ist"ry (3)
9
;ist"ry "' diabetesrelated !"-pli!ati"#s
: .i!r"&as!ular: reti#"pat)y+ #ep)r"pat)y+ #eur"pat)y
: Se#s"ry #eur"pat)y+ i#!ludi#% )ist"ry "' '""t lesi"#s
: Aut"#"-i! #eur"pat)y+ i#!ludi#% se,ual dys'u#!ti"# a#d %astr"paresis
: .a!r"&as!ular: C;D+ !erebr"&as!ular disease+ $AD
: (t)er: psy!)"s"!ial pr"ble-s+0 de#tal disease0
0See appr"priate re'errals '"r t)ese !ate%"ries.
$)ysi!al e,a-i#ati"# (1)
9 ;ei%)t+ 5ei%)t+ 8./
9 8l""d pressure deter-i#ati"#+ i#!ludi#% "rt)"stati!
-easure-e#ts 5)e# i#di!ated
9 3u#d"s!"pi! e,a-i#ati"#0
9 T)yr"id palpati"#
9 S4i# e,a-i#ati"# ('"r a!a#t)"sis #i%ri!a#s a#d i#suli#
i#Ge!ti"# sites)
$)ysi!al e,a-i#ati"# (2)
9
C"-pre)e#si&e '""t e,a-i#ati"#
9
/#spe!ti"#
9
$alpati"# "' d"rsalis pedis a#d p"steri"r tibial pulses
9
$rese#!e7abse#!e "' patellar a#d A!)illes re'le,es
9
Deter-i#ati"# "' pr"pri"!epti"#+ &ibrati"#+ a#d
-"#"'ila-e#t se#sati"#
<ab"rat"ry e&aluati"#
9 A1C+ i' results #"t a&ailable 5it)i# past
223 -"#t)s
9 /' #"t per'"r-ed7a&ailable 5it)i# past year
: 3asti#% lipid pr"'ile+ i#!ludi#% t"tal+ <D<+ a#d ;D< !)"lester"l a#d tri%ly!erides
: <i&er 'u#!ti"# tests
: Test '"r uri#e albu-i# e,!reti"# 5it) sp"t uri#e albu-i#t"!reati#i#e rati"
: Seru- !reati#i#e a#d !al!ulated *3C
: TS; i# type 1 diabetes+ dyslipide-ia+ "r 5"-e# "&er a%e 50 years
Ce'errals
9
Dye !are pr"'essi"#al '"r a##ual dilated eye e,a-
9
3a-ily pla##i#% '"r 5"-e# "' repr"du!ti&e a%e
9 Ce%istered dietitia# '"r .HT
9
Diabetes sel'-a#a%e-e#t edu!ati"#
9
De#tist '"r !"-pre)e#si&e peri"d"#tal e,a-i#ati"#
9
.e#tal )ealt) pr"'essi"#al+ i' #eeded
Diabetes Care* Management
9 $e"ple 5it) diabetes s)"uld re!ei&e -edi!al !are 'r"- a tea- t)at
-ay i#!lude
: $)ysi!ia#s+ #urse pra!titi"#ers+ p)ysi!ia#Es assista#ts+ #urses+ dietitia#s+
p)ar-a!ists+ -e#tal )ealt) pr"'essi"#als
: /# t)is !"llab"rati&e a#d i#te%rated tea- appr"a!)+ esse#tial t)at
i#di&iduals 5it) diabetes assu-e a# a!ti&e r"le i# t)eir !are
9 .a#a%e-e#t pla# s)"uld re!"%#iIe diabetes sel'-a#a%e-e#t
edu!ati"# (DS.D) a#d "#%"i#% diabetes supp"rt
Diabetes Care* Glycemic Control
9
T5" pri-ary te!)#i1ues a&ailable '"r )ealt)
pr"&iders a#d patie#ts t" assess e''e!ti&e#ess
"' -a#a%e-e#t pla# "# %ly!e-i! !"#tr"l
:
$atie#t sel'-"#it"ri#% "' bl""d %lu!"se (S.8*)+ "r
i#terstitial %lu!"se
:
A1C
!ecommendations*
Gl,cose Monitoring &1'
9
$atie#ts "# -ultipled"se i#suli# (.D/) "r
i#suli# pu-p t)erapy s)"uld d" S.8* +
:
$ri"r t" -eals a#d s#a!4s
:
(!!asi"#ally p"stpra#dially
:
At bedti-e
:
$ri"r t" e,er!ise
:
A)e# t)ey suspe!t l"5 bl""d %lu!"se
:
A'ter treati#% l"5 bl""d %lu!"se u#til t)ey are
#"r-"%ly!e-i!
:
$ri"r t" !riti!al tas4s su!) as dri&i#%
9 A)e# pres!ribed as part "' a br"ader edu!ati"#al !"#te,t+ S.8* results
-ay be )elp'ul t" %uide treat-e#t de!isi"#s a#d7"r patie#t sel'
-a#a%e-e#t '"r patie#ts usi#% less 're1ue#t i#suli# i#Ge!ti"#s "r #"#i#suli#
t)erapies E
9 A)e# pres!ribi#% S.8*+ e#sure t)at patie#ts re!ei&e "#%"i#% i#stru!ti"#
a#d re%ular e&aluati"# "' S.8* te!)#i1ue a#d S.8* results+ as 5ell as
t)eir ability t" use S.8* data t" adGust t)erapy E
!ecommendations*
9 C"#ti#u"us %lu!"se -"#it"ri#% (C*.) 5it) i#te#si&e i#suli#
re%i-e#s use'ul t""l t" l"5er A1C i# sele!ted adults (a%e 925
years) 5it) type 1 diabetes A
9 Alt)"u%) e&ide#!e '"r A1Cl"5eri#% less str"#% i# !)ildre#+ tee#s+
a#d y"u#%er adults+ C*. -ay be )elp'ul; su!!ess !"rrelates 5it)
ad)ere#!e t" de&i!e use C
: C*. -ay be a supple-e#tal t""l t" S.8* i# t)"se 5it) )yp"%ly!e-ia
u#a5are#ess a#d7"r 're1ue#t )yp"%ly!e-i! epis"des E
!ecommendations*
ADA. :. Diabetes Care. Diabetes Care 2014;37(suppl 1):S212S22
!ecommendations* A1C
9
$er'"r- t)e A1C test at least t5" ti-es a
year i# patie#ts -eeti#% treat-e#t %"als
(a#d )a&e stable %ly!e-i! !"#tr"l) E
9
$er'"r- t)e A1C test 1uarterly i# patie#ts
5)"se t)erapy )as !)a#%ed "r 5)" are
#"t -eeti#% %ly!e-i! %"als E
9
Jse "' p"i#t"'!are ($(C) testi#% '"r A1C
pr"&ides t)e "pp"rtu#ity '"r -"re ti-ely
treat-e#t !)a#%es E
ADA. :. Diabetes Care. Diabetes Care 2014;37(suppl 1):S222S23
Correlation of A1C 1it$
Average Gl,cose
&ean "lasma gl'cose
A1C (<) mg,d1 mmol,1
. 1$. %./
% 1-4 *..
* 1*3 1/.$
C $1$ 11.*
1/ $4/ 13.4
11 $.C 14.C
1$ $C* 1..-
ADA. :. Diabetes Care. Diabetes Care 2014;37(suppl 1):S23; Table @
T)ese esti-ates are based "# ADA* data "' K2+700 %lu!"se -easure-e#ts "&er 3 -"#t)s per A1C
-easure-e#t i# 507 adults 5it) type 1+ type 2+ a#d #" diabetes. T)e !"rrelati"# bet5ee# A1C a#d
a&era%e %lu!"se 5as 0.>2. A !al!ulat"r '"r !"#&erti#% A1C results i#t" esti-ated a&era%e %lu!"se (eA*)+
i# eit)er -%7d< "r --"l7<+ is a&ailable at )ttp:77pr"'essi"#al.diabetes."r%7eA*.
9
<"5eri#% A1C t" bel"5 "r ar"u#d 7B )as bee#
s)"5# t" redu!e -i!r"&as!ular !"-pli!ati"#s
a#d+ i' i-ple-e#ted s""# a'ter t)e dia%#"sis "'
diabetes+ is ass"!iated 5it) l"#%ter- redu!ti"#
i# -a!r"&as!ular disease
9
T)ere'"re+ a reas"#able A1C %"al '"r -a#y
#"#pre%#a#t adults is =7B +
!ecommendations*
Glycemic Goals in Ad,lts &1'
9 $r"&iders -i%)t reas"#ably su%%est -"re stri#%e#t
A1C %"als (su!) as =6.5B) '"r sele!ted i#di&idual
patie#ts+ i' t)is !a# be a!)ie&ed 5it)"ut si%#i'i!a#t
)yp"%ly!e-ia "r "t)er ad&erse e''e!ts "' treat-e#t
9 Appr"priate patie#ts -i%)t i#!lude t)"se 5it) s)"rt
durati"# "' diabetes+ l"#% li'e e,pe!ta#!y+ a#d #"
si%#i'i!a#t C:D C
!ecommendations*
!ecommendations*
9 <ess stri#%e#t A1C %"als (su!) as =@B) -ay be appr"priate '"r
patie#ts 5it) +
: ;ist"ry "' se&ere )yp"%ly!e-ia+ li-ited li'e e,pe!ta#!y+ ad&a#!ed
-i!r"&as!ular "r -a!r"&as!ular !"-pli!ati"#s+ e,te#si&e !"-"rbid !"#diti"#s
: T)"se 5it) l"#%sta#di#% diabetes i# 5)"- t)e %e#eral %"al is di''i!ult t"
attai# despite DS.D+ appr"priate %lu!"se -"#it"ri#%+ a#d e''e!ti&e d"ses "'
-ultiple %lu!"se l"5eri#% a%e#ts i#!ludi#% i#suli#
A))roac$ to Management of
3y)erglycemia
ADA. :. Diabetes Care. Diabetes Care 2014;37(suppl 1):S25. 3i%ure 1; adapted 5it) per-issi"#
'r"- /s-ail8ei%i 3+ et al. A## /#ter# .ed 2011;154:55455>
Glycemic !ecommendations for
2on)regnant Ad,lts 1it$ Diabetes &1'
A1C F%./<?
#re"randial ca"illary "lasma
gl'cose
%/:13/ mg,d1?
(3.C:%.$ mmol,1)
#ea@ "ost"randial ca"illary
"lasma gl'coseG
F1*/ mg,d1? (F1/./
mmol,1)
0*"als s)"uld be i#di&idualiIed based "# t)ese &alues.
G$"stpra#dial %lu!"se -easure-e#ts s)"uld be -ade 122 ) a'ter t)e be%i##i#% "' t)e -eal+ %e#erally
pea4 le&els i# patie#ts 5it) diabetes.
ADA. :. Diabetes Care. Diabetes Care 2014;37(suppl 1):S26; Table >
9
*"als s)"uld be i#di&idualiIed based "#
: Durati"# "' diabetes
: A%e7li'e e,pe!ta#!y
: C"-"rbid !"#diti"#s
: F#"5# C:D "r ad&a#!ed -i!r"&as!ular !"-pli!ati"#s
: ;yp"%ly!e-ia u#a5are#ess
: /#di&idual patie#t !"#siderati"#s
9
."re "r less stri#%e#t %ly!e-i! %"als -ay
be appr"priate '"r i#di&idual patie#ts
9
$"stpra#dial %lu!"se -ay be tar%eted i'
A1C %"als are #"t -et despite rea!)i#%
prepra#dial %lu!"se %"als
!ecommendations* "ns,lin T$era)y
for Ty)e 1 Diabetes &1'
."st pe"ple 5it) type 1 diabetes s)"uld
9
8e treated 5it) .D/ i#Ge!ti"#s (324 i#Ge!ti"#s
per day "' basal a#d pra#dial i#suli#) "r
!"#ti#u"us sub!uta#e"us i#suli# i#'usi"#
(CS//) A
9
8e edu!ated i# )"5 t" -at!) pra#dial i#suli#
d"se t" !arb")ydrate i#ta4e+ pre-eal bl""d
%lu!"se+ a#d a#ti!ipated a!ti&ity E
9
Jse i#suli# a#al"%s t" redu!e )yp"%ly!e-ia
ris4 A
S!ree#i#%
9
C"#sider s!ree#i#% t)"se 5it) type 1
diabetes '"r "t)er aut"i--u#e diseases
(t)yr"id+ &ita-i# 812 de'i!ie#!y+ !elia!) as
appr"priate +
!ecommendations* "ns,lin T$era)y
9
.et'"r-i#+ i' #"t !"#trai#di!ated a#d
i' t"lerated+ is t)e pre'erred i#itial
p)ar-a!"l"%i!al a%e#t '"r type 2
diabetes A
9
/# #e5ly dia%#"sed type 2 diabeti!
patie#ts 5it) -ar4edly sy-pt"-ati!
a#d7"r ele&ated bl""d %lu!"se le&els "r
A1C+ !"#sider i#suli# t)erapy+ 5it) "r
5it)"ut additi"#al a%e#ts+ 'r"- t)e
"utset E
!ecommendations* T$era)y
!ecommendations*
T$era)y for Ty)e 2 Diabetes &2'
9
/' #"#i#suli# -"#"t)erapy at -a,i-al
t"lerated d"se d"es #"t a!)ie&e "r
-ai#tai# t)e A1C tar%et "&er 3 -"#t)s+
add a se!"#d "ral a%e#t+ a *<$1 re!ept"r
a%"#ist+ "r i#suli# A
!ecommendations*
T$era)y for Ty)e 2 Diabetes &6'
9
A patie#t!e#tered appr"a!) s)"uld be
used t" %uide !)"i!e "' p)ar-a!"l"%i!al
a%e#ts
:
C"#siderati"#s i#!lude e''i!a!y+ !"st+ p"te#tial
side e''e!ts+ e''e!ts "# 5ei%)t+ !"-"rbidities+
)yp"%ly!e-ia ris4+ a#d patie#t pre'ere#!es E
9
Due t" t)e pr"%ressi&e #ature "' type 2
diabetes+ i#suli# t)erapy is e&e#tually
i#di!ated '"r -a#y patie#ts 5it) type 2
diabetes +
Anti$y)erglycemic T$era)y in
Ty)e 2 Diabetes
ADA. :. Diabetes Care. Diabetes Care 2014;37(suppl 1):S27. 3i%ure 2;
adapted 5it) per-issi"# 'r"- /#Iu!!)i SD+ et al. Diabetes Care 2012;35:13642136>
!ecommendations*
Medical 2,trition T$era)y &M2T' &1'
ADA. :. Diabetes Care. Diabetes Care 2014;37(suppl 1):S2@
9
Hutriti"# t)erapy is re!"--e#ded '"r all
pe"ple 5it) type 1 a#d type 2 diabetes as
a# e''e!ti&e !"-p"#e#t "' t)e "&erall
treat-e#t pla# A
9
/#di&iduals 5)" )a&e prediabetes "r
diabetes s)"uld re!ei&e i#di&idualiIed .HT
as #eeded t" a!)ie&e treat-e#t %"als+
pre'erably pr"&ided by a re%istered
dietitia# 'a-iliar 5it) t)e !"-p"#e#ts "'
diabetes .HT A
!ecommendations*
Medical 2,trition T$era)y &M2T' &2'
ADA. :. Diabetes Care. Diabetes Care 2014;37(suppl 1):S2@
9
8e!ause diabetes #utriti"# t)erapy !a#
result i# !"st sa&i#%s + a#d i-pr"&ed
"ut!"-es su!) as redu!ti"# i# A1C A+
#utriti"# t)erapy s)"uld be ade1uately
rei-bursed by i#sura#!e a#d "t)er
payers E
9 $e"ple 5it) diabetes s)"uld re!ei&e DS.D7DS.S a!!"rdi#% t" Hati"#al
Sta#dards '"r Diabetes Sel'.a#a%e-e#t Ddu!ati"# a#d Supp"rt at
dia%#"sis a#d as #eeded t)erea'ter +
9 D''e!ti&e sel'-a#a%e-e#t+ 1uality "' li'e are 4ey "ut!"-es "'
DS.D7DS.S; s)"uld be -easured+ -"#it"red as part "' !are C
9 DS.D7DS.S s)"uld address psy!)"s"!ial issues+ si#!e e-"ti"#al 5ell
bei#% is ass"!iated 5it) p"siti&e "ut!"-es C
!ecommendations* Diabetes
Self/Management Ed,cation: S,))ort
!ecommendations* Diabetes
Self/Management Ed,cation: S,))ort
9
DS.D7DS.S pr"%ra-s are appr"priate
&e#ues '"r pe"ple 5it) prediabetes t"
re!ei&e edu!ati"# a#d supp"rt t" de&el"p
a#d -ai#tai# be)a&i"rs t)at !a# pre&e#t
"r delay t)e "#set "' diabetes C
9
8e!ause DS.D7DS.S !a# result i# !"st
sa&i#%s a#d i-pr"&ed "ut!"-es ++
DS.D7DS.S s)"uld be ade1uately
rei-bursed by t)irdparty payers E
9 C)ildre# 5it) diabetes7prediabetes: e#%a%e i# at least 60
-i#7day p)ysi!al a!ti&ity +
9 Adults 5it) diabetes: at least 150 -i#754 "' -"derate
i#te#sity aer"bi! a!ti&ity
(50270B "' -a,i-u- )eart rate)+"&er at least 3 days754 5it)
#" -"re t)a# 2 !"#se!uti&e days 5it)"ut e,er!ise A
9 /' #"t !"#trai#di!ated+ adults 5it) type 2 diabetes s)"uld
per'"r- resista#!e trai#i#% at least t5i!e 5ee4ly A
!ecommendations* $ysical Activity
9 (#%"i#% part "' -edi!al -a#a%e-e#t "' diabetes +
9 $sy!)"s"!ial s!ree#i#%7'"ll"5up: attitudes+ -edi!al
-a#a%e-e#t7"ut!"-es e,pe!tati"#s+ a''e!t7-""d+ 1uality "' li'e+
res"ur!es+ psy!)iatri! )ist"ry E
9 C"uti#ely s!ree# '"r psy!)"s"!ial pr"ble-s: depressi"#+ diabetes
related distress+ a#,iety+ eati#% dis"rders+ !"%#iti&e i-pair-e#t +
!ecommendations*
syc$osocial Assessment and Care
9 /#di&iduals at ris4 '"r )yp"%ly!e-ia s)"uld be as4ed ab"ut
sy-pt"-ati! a#d asy-pt"-ati! )yp"%ly!e-ia at ea!)
e#!"u#ter C
9 *lu!"se (15220 %) pre'erred treat-e#t '"r !"#s!i"us i#di&idual
5it) )yp"%ly!e-ia E
9 *lu!a%"# s)"uld be pres!ribed '"r all i#di&iduals at si%#i'i!a#t
ris4 "' se&ere )yp"%ly!e-ia a#d !are%i&ers7'a-ily -e-bers
i#stru!ted i# ad-i#istrati"# E
!ecommendations* 3y)oglycemia &1'
9 ;yp"%ly!e-ia u#a5are#ess "r "#e "r -"re epis"des "' se&ere
)yp"%ly!e-ia s)"uld tri%%er ree&aluati"# "' t)e treat-e#t re%i-e# E
9 /#suli#treated patie#ts 5it) )yp"%ly!e-ia u#a5are#ess "r a# epis"de "'
se&ere )yp"%ly!e-ia
: Ad&ised t" raise %ly!e-i! tar%ets t" stri!tly a&"id 'urt)er )yp"%ly!e-ia '"r at least
se&eral 5ee4s+ t" partially re&erse )yp"%ly!e-ia u#a5are#ess+ a#d t" redu!e ris4
"' 'uture epis"des A
9
(#%"i#% assess-e#t "' !"%#iti&e 'u#!ti"#
is su%%ested 5it) i#!reased &i%ila#!e '"r
)yp"%ly!e-ia by t)e !li#i!ia#+ patie#t+ a#d
!are%i&ers i' l"5 !"%#iti"# a#d7"r de!li#i#%
!"%#iti"# is '"u#d +
9 C"#sider bariatri! sur%ery '"r adults 5it) 8./ 935 4%7-2 a#d
type 2 diabetes +
9 A'ter sur%ery+ li'el"#% li'estyle supp"rt a#d -edi!al -"#it"ri#%
is #e!essary +
9 /#su''i!ie#t e&ide#!e t" re!"--e#d sur%ery i# patie#ts 5it) 8./
=35 4%7-2 "utside "' a resear!) pr"t"!"l E
9 Aelldesi%#ed+ CCTs !"-pari#% "pti-al -edi!al7li'estyle t)erapy
#eeded t" deter-i#e l"#%ter- be#e'its+ !"ste''e!ti&e#ess+
ris4s E
!ecommendations* +ariatric S,rgery
!ecommendations* "mm,ni;ation &1'
9
$r"&ide i#'lue#Ia &a!!i#e a##ually t" all
diabeti! patie#ts 96 -"#t)s "' a%e C
9
Ad-i#ister p#eu-"!"!!al p"lysa!!)aride
&a!!i#e t" all diabeti! patie#ts 92 years C
:
(#eti-e re&a!!i#ati"# re!"--e#ded '"r t)"se
?65 years "' a%e i' i--u#iIed ?5 years a%"
:
(t)er i#di!ati"#s '"r repeat &a!!i#ati"#: #ep)r"ti!
sy#dr"-e+ !)r"#i! re#al disease+ "t)er
i--u#"!"-pr"-ised states (su!) as a'ter
tra#spla#tati"#)
!ecommendations* "mm,ni;ation &2'
9
Ad-i#ister )epatitis 8 &a!!i#ati"# t"
u#&a!!i#ated adults 5it) diabetes 5)" are
a%ed 1>25> years C
9
C"#sider ad-i#isteri#% )epatitis +
&a!!i#ati"# t" u#&a!!i#ated adults 5it)
diabetes 5)" are a%ed 960 years C
4"# revention and
management of
diabetes com)lications
9 C:D is t)e -aG"r !ause "' -"rbidity+ -"rtality '"r t)"se 5it) diabetes
: <ar%est !"#tribut"r t" dire!t7i#dire!t !"sts
9 C"--"# !"#diti"#s !"e,isti#% 5it) type 2 diabetes (e.%.+ )yperte#si"#+
dyslipide-ia) are !lear ris4 'a!t"rs '"r C:D
9 Diabetes itsel' !"#'ers i#depe#de#t ris4
9 8e#e'its "bser&ed 5)e# i#di&idual !ardi"&as!ular ris4 'a!t"rs are
!"#tr"lled t" pre&e#t7sl"5 C:D i# pe"ple 5it) diabetes
Cardiovasc,lar Disease
ADA. :/. $re&e#ti"#+ .a#a%e-e#t "' C"-pli!ati"#s. Diabetes Care 2014;37(suppl 1):S36
!ecommendations*
3y)ertension5+lood ress,re Control
S!ree#i#% a#d dia%#"sis
9
8l""d pressure s)"uld be -easured at
e&ery r"uti#e &isit
9
$atie#ts '"u#d t" )a&e ele&ated bl""d
pressure s)"uld )a&e bl""d pressure
!"#'ir-ed "# a separate day +
*"als
9 $e"ple 5it) diabetes a#d )yperte#si"# s)"uld be treated t" a
syst"li! bl""d pressure %"al "' =140 --;% +
9 <"5er syst"li! tar%ets+ su!) as =130 --;%+ -ay be appr"priate
'"r !ertai# i#di&iduals+ su!) as y"u#%er patie#ts+ i' it !a# be
a!)ie&ed 5it)"ut u#due treat-e#t burde# C
9 $atie#ts 5it) diabetes s)"uld be treated t" a diast"li! bl""d
pressure =@0 --;% +
!ecommendations*
Treat-e#t (1)
9 $atie#ts 5it) bl""d pressure ?1207@0 --;% s)"uld be ad&ised
"# li'estyle !)a#%es t" redu!e bl""d pressure +
9 $atie#ts 5it) !"#'ir-ed bl""d pressure )i%)er t)a# 1407@0
--;% s)"uld+ i# additi"# t" li'estyle t)erapy+ )a&e pr"-pt
i#itiati"# a#d ti-ely subse1ue#t titrati"# "' p)ar-a!"l"%i!al
t)erapy t" a!)ie&e bl""d pressure %"als +
!ecommendations*
Treat-e#t (2)
9
<i'estyle t)erapy '"r ele&ated bl""d pressure +
:
Aei%)t l"ss i' "&er5ei%)t
:
DAS;style dietary patter# i#!ludi#% redu!i#%
s"diu-+ i#!reasi#% p"tassiu- i#ta4e
: ."derati"# "' al!")"l i#ta4e
: /#!reased p)ysi!al a!ti&ity
!ecommendations*
Treat-e#t (3)
9 $)ar-a!"l"%i!al t)erapy '"r patie#ts 5it) diabetes a#d )yperte#si"# C
: A re%i-e# t)at i#!ludes eit)er a# ACD i#)ibit"r "r a#%i"te#si# // re!ept"r bl"!4er; i'
"#e !lass is #"t t"lerated+ substitute t)e "t)er
9 .ultiple dru% t)erapy (t5" "r -"re a%e#ts at -a,i-al d"ses) %e#erally
re1uired t" a!)ie&e bl""d pressure tar%ets +
9 Ad-i#ister "#e "r -"re a#ti)yperte#si&e -edi!ati"#s at bedti-e A
!ecommendations*
Treat-e#t (4)
9 /' ACD i#)ibit"rs+ AC8s+ "r diureti!s are used+ seru- !reati#i#e7e*3C
a#d p"tassiu- le&els s)"uld be -"#it"red E
9 /# pre%#a#t patie#ts 5it) diabetes a#d !)r"#i! )yperte#si"#+ bl""d
pressure tar%et %"als "' 110212>76527> --;% are su%%ested i#
i#terest "' l"#%ter- -ater#al )ealt) a#d -i#i-iIi#% i-paired 'etal
%r"5t); ACD i#)ibit"rs+ AC8s+ !"#trai#di!ated duri#% pre%#a#!y E
!ecommendations*
S!ree#i#%
9
/# -"st adult patie#ts 5it) diabetes+ -easure 'asti#%
lipid pr"'ile at least a##ually +
9
/# adults 5it) l"5ris4 lipid &alues
: <D< !)"lester"l =100 -%7d<
: ;D< !)"lester"l ?50 -%7d<
: Tri%ly!erides =150 -%7d<)
9
Cepeat lipid assess-e#ts e&ery 2 years E
!ecommendations*
Dysli)idemia5<i)id Management &1'
ADA. :/. $re&e#ti"#+ .a#a%e-e#t "' C"-pli!ati"#s. Diabetes Care 2014;37(suppl 1):S3@
Treat-e#t re!"--e#dati"#s a#d %"als (1)
9
T" i-pr"&e lipid pr"'ile i# patie#ts 5it) diabetes+
re!"--e#d li'estyle -"di'i!ati"# A+ '"!usi#% "#
: Cedu!ti"# "' saturated 'at+ tra#s 'at+ !)"lester"l i#ta4e
: /#!rease "' #3 'atty a!ids+ &is!"us 'iber+
pla#t sta#"ls7ster"ls
: Aei%)t l"ss (i' i#di!ated)
: /#!reased p)ysi!al a!ti&ity
!ecommendations*
9 Stati# t)erapy s)"uld be added t" li'estyle t)erapy+ re%ardless "' baseli#e
lipid le&els
: 5it) "&ert C:D A
: 5it)"ut C:D ?40 years "' a%e 5)" )a&e "#e "r -"re "t)er C:D ris4 'a!t"rs A
9 3"r patie#ts at l"5er ris4 (e.%.+ 5it)"ut "&ert C:D+ =40 years "' a%e) C
: C"#sider stati# t)erapy i# additi"# t" li'estyle t)erapy i' <D< !)"lester"l re-ai#s ?100
-%7d<
: /# t)"se 5it) -ultiple C:D ris4 'a!t"rs
!ecommendations*
9 /# i#di&iduals 5it)"ut "&ert C:D
: *"al is <D< !)"lester"l =100 -%7d<
(2.6 --"l7<) +
9 /# i#di&iduals 5it) "&ert C:D
: <"5er <D< !)"lester"l %"al "' =70 -%7d<
(1.@ --"l7<)+ 5it) a )i%) d"se "' a stati#+
is a# "pti"# +
!ecommendations*
9 /' tar%ets #"t rea!)ed "# -a,i-al t"lerated stati# t)erapy
: Alter#ati&e t)erapeuti! %"al: redu!e <D< !)"lester"l K30240B 'r"- baseli#e +
9 Tri%ly!eride le&els =150 -%7d<
(1.7 --"l7<)+ ;D< !)"lester"l ?40 -%7d< (1.0 --"l7<) i# -e# a#d ?50
-%7d<
(1.3 --"l7<) i# 5"-e#+ are desirable C
: ;"5e&er+ <D< !)"lester"l2tar%eted stati# t)erapy re-ai#s t)e pre'erred strate%y A
!ecommendations*
9
C"-bi#ati"# t)erapy )as bee# s)"5# #"t t"
pr"&ide additi"#al !ardi"&as!ular be#e'it ab"&e
stati# t)erapy al"#e a#d is #"t %e#erally
re!"--e#ded A
9
Stati# t)erapy is !"#trai#di!ated i# pre%#a#!y +
!ecommendations*
!ecommendations* Glycemic: +lood
ress,re: <i)id Control in Ad,lts
A1C F%./<?
7lood "ress're F14/,*/ mmBgG
1i"idsD 1D1
c8olesterol
F1// mg,d1 (F$.. mmol,1)H
Statin t8era"y for t8ose 3it8
8istory of &I or age E4/I or ot8er
ris@ factors
0."re "r less stri#%e#t %ly!e-i! %"als -ay be appr"priate '"r i#di&idual patie#ts. *"als s)"uld be
i#di&idualiIed based "# durati"# "' diabetes+ a%e7li'e e,pe!ta#!y+ !"-"rbid !"#diti"#s+ 4#"5# C:D "r
ad&a#!ed -i!r"&as!ular !"-pli!ati"#s+ )yp"%ly!e-ia u#a5are#ess+ a#d i#di&idual patie#t
!"#siderati"#s.
L8ased "# patie#t !)ara!teristi!s a#d resp"#se t" t)erapy+ l"5er S8$ tar%ets -ay be appr"priate.
M/# i#di&iduals 5it) "&ert C:D+ a l"5er <D< !)"lester"l %"al "' =70 -%7d< (1.@ --"l7<)+ usi#% a )i%)
d"se "' a stati#+ is a# "pti"#.
ADA. :/. $re&e#ti"#+ .a#a%e-e#t "' C"-pli!ati"#s. Diabetes Care 2014;37(suppl 1):S40; Table 10
9 C"#sider aspiri# t)erapy (752162 -%7day) C
: As a pri-ary pre&e#ti"# strate%y i# t)"se 5it) type 1 "r type 2 diabetes
at i#!reased !ardi"&as!ular ris4 (10year ris4 ?10B)
: /#!ludes -"st -e# ?50 years "' a%e "r 5"-e# ?60 years "' a%e 5)"
)a&e at least "#e additi"#al -aG"r ris4 'a!t"r
: 3a-ily )ist"ry "' C:D
: ;yperte#si"#
: S-"4i#%
: Dyslipide-ia
: Albu-i#uria
!ecommendations*
Anti)latelet Agents &1'
!ecommendations*
9 Aspiri# s)"uld #"t be re!"--e#ded '"r C:D pre&e#ti"# '"r adults
5it) diabetes at l"5 C:D ris4+ si#!e p"te#tial ad&erse e''e!ts 'r"-
bleedi#% li4ely "''set p"te#tial be#e'its C
<"5 ris4: 10year C:D ris4 =5B+ su!) as i# -e# =50 years+ 5"-e# =60
years 5it) #" -aG"r additi"#al C:D ris4 'a!t"rs
9 /# patie#ts i# t)ese a%e %r"ups 5it) -ultiple "t)er ris4 'a!t"rs (10
year ris4
5210B)+ !li#i!al Gud%-e#t is re1uired E
9 Jse aspiri# t)erapy (752162 -%7day)
: Se!"#dary pre&e#ti"# strate%y i# t)"se 5it) diabetes 5it) a
)ist"ry "' C:D A
9
3"r patie#ts 5it) C:D a#d d"!u-e#ted aspiri# aller%y
: Cl"pid"%rel (75 -%7day) s)"uld be used +
9 Dual a#tiplatelet t)erapy is reas"#able '"r up t" a year
a'ter a# a!ute !"r"#ary sy#dr"-e +
!ecommendations*
9
Ad&ise all patie#ts #"t t" s-"4e "r use
t"ba!!" pr"du!ts A
9
/#!lude s-"4i#% !essati"# !"u#seli#% a#d
"t)er '"r-s "' treat-e#t as a r"uti#e
!"-p"#e#t "' diabetes !are +
!ecommendations*
Smo%ing Cessation
!ecommendations*
Cardiovasc,lar Disease &1'
S!ree#i#%
9
/# asy-pt"-ati! patie#ts+ r"uti#e
s!ree#i#% '"r CAD is #"t re!"--e#ded
be!ause it d"es #"t i-pr"&e "ut!"-es as
l"#% as C:D ris4 'a!t"rs are treated A
Treat-e#t (1)
9 T" redu!e ris4 "' !ardi"&as!ular e&e#ts i# patie#ts 5it) 4#"5#
C:D+ !"#sider
: ACD i#)ibit"r C
: Aspiri#0 A
: Stati# t)erapy0 A
9 /# patie#ts 5it) a pri"r ./
: bl"!4ers s)"uld be !"#ti#ued '"r at least
2 years a'ter t)e e&e#t +
!ecommendations*
0/' #"t !"#trai#di!ated.
Treat-e#t (2)
9
/# patie#ts 5it) sy-pt"-ati! )eart 'ailure+ a&"id
t)iaI"lidi#edi"#e treat-e#t C
9
/# patie#ts 5it) stable C;3+ -et'"r-i# +
:
.ay be used i' re#al 'u#!ti"# is #"r-al
:
S)"uld be a&"ided i# u#stable "r )"spitaliIed patie#ts
5it) C;3
!ecommendations*
9
T" redu!e t)e ris4 "r sl"5 t)e pr"%ressi"#
"' #ep)r"pat)y
:
(pti-iIe %lu!"se !"#tr"l A
:
(pti-iIe bl""d pressure !"#tr"l A
!ecommendations* 2e)$ro)at$y
!ecommendations*
2e)$ro)at$y &1'
S!ree#i#%
9
Assess uri#e albu-i# e,!reti"# a##ually +
:
/# type 1 diabeti! patie#ts 5it) diabetes
durati"# "' 95 years
:
/# all type 2 diabeti! patie#ts at dia%#"sis
Treat-e#t (1)
9 ACD i#)ibit"r+ AC8 #"t re!"--e#ded i# diabeti! patie#ts 5it)
#"r-al bl""d pressure+ albu-i# e,!reti"# =30 -%724 ) '"r
pri-ary pre&e#ti"# "' diabeti! 4id#ey disease +
9 H"#pre%#a#t patie#t 5it) -"destly ele&ated (3022>> -%7day)
C "r )i%)er le&els (?300 -%7day) A "' uri#ary albu-i#
e,!reti"#
: Jse eit)er ACD i#)ibit"rs "r AC8s (#"t b"t))
!ecommendations*
2e)$ro)at$y &2'
Treat-e#t (2)
9
3"r pe"ple 5it) diabetes a#d diabeti! 4id#ey disease
(albu-i#uria ?30 -%724 ))+ redu!i#% dietary pr"tei#
bel"5 usual i#ta4e #"t re!"--e#ded A
: A)e# ACD i#)ibit"rs+ AC8s+ "r diureti!s are used+ -"#it"r
seru- !reati#i#e+ p"tassiu- le&els '"r i#!reased !reati#i#e
"r !)a#%es i# p"tassiu- E
!ecommendations*
2e)$ro)at$y &6'
ADA. :/. $re&e#ti"#+ .a#a%e-e#t "' C"-pli!ati"#s. Diabetes Care 2014;37(suppl 1):S422S43
Treat-e#t (3)
9 Ceas"#able t" !"#ti#ue -"#it"ri#% uri#e albu-i# e,!reti"# t" assess
b"t) resp"#se t" t)erapy a#d disease pr"%ressi"# E
9 A)e# e*3C is =60 -<7-i#71.73 -2+ e&aluate a#d -a#a%e p"te#tial
!"-pli!ati"#s "' CFD E
9 C"#sider re'erral t" a p)ysi!ia# e,perie#!ed i# !are "' 4id#ey disease +
: J#!ertai#ty ab"ut eti"l"%y; di''i!ult -a#a%e-e#t issues; ad&a#!ed 4id#ey
disease
!ecommendations*
2e)$ro)at$y &4'
Definitions of Abnormalities in
Alb,min E=cretion
Category
S"ot collection
(Jg,mg creatinine)
Normal F3/
Increased 'rinary al!'min
e6cretion? ;3/
0;ist"ri!ally+ rati"s bet5ee# 30 a#d 2>> )a&e bee# !alled -i!r"albu-i#uria a#d t)"se 300 "r %reater
)a&e bee# !alled -a!r"albu-i#uria ("r !li#i!al albu-i#uria).
Stages of C$ronic >idney Disease
Stage Descri"tion
G=R (m1,min
"er 1.%3 m$
!ody s'rface
area)
1 Kidney damage? 3it8 normal or
increased G=R
;C/
$ Kidney damage? 3it8 mildly
decreased G=R
./:*C
3 &oderately decreased G=R 3/:-C
4 Severely decreased G=R 1-:$C
- Kidney fail're F1- or dialysis
?Kidney damage defined as a!normalities on "at8ologic4 'rine4 !lood4 or imaging tests.
G=R L glomer'lar filtration rate
Management of C>D in Diabetes &1'
G=R Recommended
All "atients
Nearly -easure-e#t "' !reati#i#e+ uri#ary
albu-i# e,!reti"#+ p"tassiu-
4--./
Ce'erral t" a #ep)r"l"%ist i' p"ssibility '"r
#"#diabeti! 4id#ey disease e,ists
C"#sider d"se adGust-e#t "' -edi!ati"#s
."#it"r e*3C e&ery 6 -"#t)s
."#it"r ele!tr"lytes+ bi!arb"#ate+ )e-"%l"bi#+
!al!iu-+ p)"sp)"rus+ parat)yr"id )"r-"#e at
least yearly
Assure &ita-i# D su''i!ie#!y
C"#sider b"#e de#sity testi#%
Ce'erral '"r dietary !"u#selli#%
ADA. :/. $re&e#ti"#+ .a#a%e-e#t "' C"-pli!ati"#s. Diabetes Care 2014;37(suppl 1):S45; Table 13;
Adapted 'r"- )ttp:77555.4id#ey."r%7pr"'essi"#als7FD(O/7%uideli#ePdiabetes7
Management of C>D in Diabetes &2'
ADA. :/. $re&e#ti"#+ .a#a%e-e#t "' C"-pli!ati"#s. Diabetes Care 2014;37(suppl 1):S45; Table 13;
Adapted 'r"- )ttp:77555.4id#ey."r%7pr"'essi"#als7FD(O/7%uideli#ePdiabetes7
G=R Recommended
3/-44
."#it"r e*3C e&ery 3 -"#t)s
."#it"r ele!tr"lytes+ bi!arb"#ate+
!al!iu-+ p)"sp)"rus+ parat)yr"id
)"r-"#e+ )e-"%l"bi#+ albu-i#
5ei%)t e&ery 326 -"#t)s
C"#sider #eed '"r d"se adGust-e#t "'
-edi!ati"#s
F3/
Ce'erral t" a #ep)r"l"%ist
!ecommendations* !etino)at$y
9
T" redu!e t)e ris4 "r sl"5 t)e pr"%ressi"#
"' reti#"pat)y
:
(pti-iIe %ly!e-i! !"#tr"l A
:
(pti-iIe bl""d pressure !"#tr"l A
S!ree#i#% (1)
9
/#itial dilated a#d !"-pre)e#si&e eye e,a-i#ati"#
by a# "p)t)al-"l"%ist "r "pt"-etrist
: Adults 5it) type 1 diabetes
: Ait)i# 5 years a'ter diabetes "#set +
: $atie#ts 5it) type 2 diabetes
: S)"rtly a'ter dia%#"sis "' diabetes +
!ecommendations*
!etino)at$y &1'
S!ree#i#% (2)
9 /' #" e&ide#!e "' reti#"pat)y '"r "#e "r -"re eye e,a-
: D,a-s e&ery 2 years -ay be !"#sidered +
9 /' diabeti! reti#"pat)y i' prese#t
: Subse1ue#t e,a-i#ati"#s '"r type 1 a#d type 2 diabeti! patie#ts s)"uld be
repeated a##ually by a# "p)t)al-"l"%ist "r "pt"-etrist +
9 /' reti#"pat)y is pr"%ressi#%+ -"re 're1ue#t e,a-s re1uired +
!ecommendations*
!etino)at$y &2'
ADA. :/. $re&e#ti"#+ .a#a%e-e#t "' C"-pli!ati"#s. Diabetes Care 2014;37(suppl 1):S442S45
S!ree#i#% (3)
9 ;i%)1uality 'u#dus p)"t"%rap)s
: Ca# dete!t -"st !li#i!ally si%#i'i!a#t
diabeti! reti#"pat)y E
9 /#terpretati"# "' i-a%es
: $er'"r-ed by a trai#ed eye !are pr"&ider E
9 A)ile reti#al p)"t"%rap)y -ay ser&e as a s!ree#i#% t""l '"r reti#"pat)y+ it is
#"t a substitute '"r a !"-pre)e#si&e eye e,a-
: $er'"r- !"-pre)e#si&e eye e,a- at least i#itially a#d at re!"--e#ded i#ter&als E
!ecommendations*
!etino)at$y &6'
S!ree#i#% (4)
9 A"-e# 5it) pree,isti#% diabetes 5)" are pla##i#% pre%#a#!y
"r 5)" )a&e be!"-e pre%#a#t +
: C"-pre)e#si&e eye e,a-i#ati"#
: C"u#seled "# ris4 "' de&el"p-e#t a#d7"r pr"%ressi"# "' diabeti!
reti#"pat)y
9 Dye e,a-i#ati"# s)"uld "!!ur i# t)e 'irst tri-ester +
: Cl"se '"ll"5up t)r"u%)"ut pre%#a#!y
: 3"r 1 year p"stpartu-
!ecommendations*
!etino)at$y &4'
Treat-e#t (1)
9 $r"-ptly re'er patie#ts 5it) a#y le&el "' -a!ular ede-a+ se&ere
H$DC+ "r a#y $DC
: T" a# "p)t)al-"l"%ist 4#"5led%eable a#d e,perie#!ed i# -a#a%e-e#t+
treat-e#t "' diabeti! reti#"pat)y A
9 <aser p)"t"!"a%ulati"# t)erapy is i#di!ated A
: T" redu!e ris4 "' &isi"# l"ss i# patie#ts 5it)
: ;i%)ris4 $DC
: Cli#i!ally si%#i'i!a#t -a!ular ede-a
: S"-e !ases "' se&ere H$DC
!ecommendations*
!etino)at$y &7'
Treat-e#t (2)
9
A#ti&as!ular e#d"t)elial %r"5t) 'a!t"r (:D*3)
t)erapy is i#di!ated '"r diabeti! -a!ular ede-a A
9
$rese#!e "' reti#"pat)y
: H"t a !"#trai#di!ati"# t" aspiri# t)erapy '"r !ardi"pr"te!ti"#+
as t)is t)erapy d"es #"t i#!rease t)e ris4 "' reti#al
)e-"rr)a%e A
!ecommendations*
!etino)at$y &8'
9
All patie#ts s)"uld be s!ree#ed '"r distal sy--etri!
p"ly#eur"pat)y (D$H) +
: At dia%#"sis "' type 2 diabetes a#d 5 years a'ter dia%#"sis "' type
1 diabetes
: At least a##ually t)erea'ter usi#% si-ple !li#i!al tests
9 Dle!tr"p)ysi"l"%i!al testi#% rarely #eeded
: D,!ept i# situati"#s 5)ere !li#i!al 'eatures are atypi!al E
!ecommendations*
2e,ro)at$y Screening: Treatment &1'
9 S!ree#i#% '"r si%#s a#d sy-pt"-s "' !ardi"&as!ular
aut"#"-i! #eur"pat)y
: S)"uld be i#stituted at dia%#"sis "' type 2 diabetes a#d 5 years
a'ter t)e dia%#"sis "' type 1 diabetes
: Spe!ial testi#% rarely #eeded; -ay #"t a''e!t -a#a%e-e#t "r
"ut!"-es E
9 .edi!ati"#s '"r relie' "' spe!i'i! sy-pt"-s related t" D$H+
aut"#"-i! #eur"pat)y are re!"--e#ded
: Cedu!e pai# +; i-pr"&e 1uality "' li'e E
!ecommendations*
2e,ro)at$y Screening: Treatment &2'
9 3"r all patie#ts 5it) diabetes+ per'"r- a# a##ual !"-pre)e#si&e '""t
e,a-i#ati"# t" ide#ti'y ris4 'a!t"rs predi!ti&e "' ul!ers a#d a-putati"#s +
: /#spe!ti"#
: Assess-e#t "' '""t pulses
: Test '"r l"ss "' pr"te!ti&e se#sati"#: 10% -"#"'ila-e#t plus testi#% a#y "#e "'
: :ibrati"# usi#% 12@;I tu#i#% '"r4
: $i#pri!4 se#sati"#
: A#4le re'le,es
: :ibrati"# per!epti"# t)res)"ld
!ecommendations* ?oot Care &1'
@))er )anel
9
T" per'"r- t)e 10%
-"#"'ila-e#t test+ pla!e
t)e de&i!e perpe#di!ular
t" t)e s4i#+ 5it) pressure
applied u#til t)e
-"#"'ila-e#t bu!4les
9 ;"ld i# pla!e '"r 1 se!"#d
a#d t)e# release
<o1er )anel
9 T)e -"#"'ila-e#t test
s)"uld be per'"r-ed at
t)e )i%)li%)ted sites
5)ile t)e patie#tEs eyes
are !l"sed
8"ult"# AQ.+ et al. Diabetes Care 200@;31:167>216@5
9 $r"&ide %e#eral '""t sel'!are edu!ati"# +
9 Jse -ultidis!ipli#ary appr"a!)
: /#di&iduals 5it) '""t ul!ers+ )i%)ris4 'eet; espe!ially pri"r ul!er "r
a-putati"# +
9 Ce'er patie#ts t" '""t !are spe!ialists '"r "#%"i#% pre&e#ti&e
!are+ li'el"#% sur&eilla#!e C
: S-"4ers
: <"ss "' pr"te!ti&e se#sati"# "r stru!tural ab#"r-alities
: ;ist"ry "' pri"r l"5ere,tre-ity !"-pli!ati"#s
ADA. :/. $re&e#ti"#+ .a#a%e-e#t "' C"-pli!ati"#s. Diabetes Care 2014;37(suppl 1):S472S4@
9 /#itial s!ree#i#% '"r perip)eral arterial disease ($AD) C
: /#!lude a )ist"ry '"r !laudi!ati"#+ assess-e#t "' pedal pulses
: C"#sider "btai#i#% a# a#4lebra!)ial i#de, (A8/); -a#y patie#ts
5it) $AD are asy-pt"-ati!
9 Ce'er patie#ts 5it) si%#i'i!a#t !laudi!ati"# "r a p"siti&e A8/
'"r 'urt)er &as!ular assess-e#t C
: C"#sider e,er!ise+ -edi!ati"#s+ sur%i!al "pti"#s
4""# Assessment of Common
Comorbid Conditions
!ecommendation* Assessment of
Common Comorbid Conditions
9
C"#sider assessi#% '"r a#d addressi#%
!"--"# !"-"rbid !"#diti"#s t)at -ay
!"-pli!ate t)e -a#a%e-e#t "' diabetes +
9
C"--"# !"-"rbidities
ADA. ://. Assess-e#t "' C"--"# C"-"rbid C"#diti"#s. Diabetes Care 2014;37(suppl 1):S4>
De"ression Cognitive im"airment
>!str'ctive slee" a"nea 1o3 testosterone in men
=atty liver disease #eriodontal disease
Cancer Bearing im"airment
=ract'res
4"""# diabetes care in s)ecific
)o),lations
!ecommendations* ediatric
Glycemic Control &Ty)e 1 Diabetes'
9
C"#sider a%e 5)e# setti#% %ly!e-i! %"als
i# !)ildre# a#d ad"les!e#ts 5it) type 1
diabetes E
ADA. :///. Diabetes Care i# Spe!i'i! $"pulati"#s. Diabetes Care 2014;37(suppl 1):S50
S!ree#i#%
9 A##ual s!ree#i#% '"r albu-i# le&els; ra#d"- sp"t uri#e sa-ple
'"r albu-i#t"!reati#i#e (ACC) rati" at start "' puberty "r a%e
910 years+ 5)i!)e&er is earlier+ "#!e y"ut) )as )ad diabetes '"r
5 years +
Treat-e#t
9 ACD i#)ibit"r 5)e# ACC !"#'ir-ed "# t5" additi"#al di''ere#t
spe!i-e#s 'r"- di''ere#t days "&er 6-"#t) i#ter&al E
2e)$ro)at$y &Ty)e 1 Diabetes'
3y)ertension &Ty)e 1 Diabetes' &1'
S!ree#i#%
9
.easure bl""d pressure at ea!) r"uti#e
&isit; !"#'ir- )i%)#"r-al bl""d pressure
"r )yperte#si"# "# a separate day +
Treat-e#t (1)
9
/#itial treat-e#t "' )i%)#"r-al bl""d
pressure (S8$ "r D8$ !"#siste#tly ab"&e
>0t) per!e#tile '"r a%e+ se,+ a#d )ei%)t)
:
Dietary i#ter&e#ti"# a#d e,er!ise+ ai-ed at 5ei%)t
!"#tr"l; i#!reased p)ysi!al a!ti&ity+ i' appr"priate
9
/' tar%et bl""d pressure is #"t rea!)ed 5it)
326 -"#t)s "' li'estyle i#ter&e#ti"#+ !"#sider
p)ar-a!"l"%i! treat-e#t E
Treat-e#t (2)
9 $)ar-a!"l"%i! treat-e#t "' )yperte#si"#
: S8$ "r D8$ !"#siste#tly ab"&e t)e >5t) per!e#tile '"r a%e+ se,+ a#d
)ei%)t
Or
: C"#siste#tly ?1307@0 --;%+ i' >5B e,!eeds t)at &alue
9 C"#sider treat-e#t as s""# as dia%#"sis is !"#'ir-ed E
Treat-e#t (3)
9
ACD i#)ibit"rs
:
C"#sider '"r i#itial treat-e#t "' )yperte#si"#+
'"ll"5i#% appr"priate repr"du!ti&e !"u#seli#%
due t" p"te#tial terat"%e#i! e''e!ts E
9
*"al "' treat-e#t
:
8l""d pressure !"#siste#tly =1307@0 --;% "r
bel"5 t)e >0t) per!e#tile '"r a%e+ se,+ a#d
)ei%)t+ 5)i!)e&er is l"5er E
S!ree#i#% (1)
9
/' 'a-ily )ist"ry "' )yper!)"lester"le-ia "r a
!ardi"&as!ular e&e#t be'"re a%e 55 years+ "r
i' 'a-ily )ist"ry is u#4#"5#
:
C"#sider "btai#i#% 'asti#% lipid pr"'ile i# !)ildre#
?2 years "' a%e s""# a'ter dia%#"sis (a'ter %lu!"se
!"#tr"l )as bee# establis)ed) E
Dysli)idemia &Ty)e 1 Diabetes' &1'
S!ree#i#% (2)
9
/' 'a-ily )ist"ry is #"t "' !"#!er#
: C"#sider 'irst lipid s!ree#i#% at puberty
(910 years) E
9 C)ildre# dia%#"sed 5it) diabetes at "r a'ter puberty
: C"#sider "btai#i#% 'asti#% lipid pr"'ile s""# a'ter dia%#"sis (a'ter
%lu!"se !"#tr"l )as bee# establis)ed) E
S!ree#i#% (3)
9
3"r b"t) a%e%r"ups+ i' lipids are ab#"r-al
: A##ual -"#it"ri#% is reas"#able
9
/' <D< !)"lester"l &alues are 5it)i# a!!epted ris4
le&els (=100 -%7d<
R2.6 --"l7<S)
: Cepeat lipid pr"'ile e&ery 5 years E
Treat-e#t
9 /#itial t)erapy: "pti-iIe %lu!"se !"#tr"l+ .HT usi#% Step 2 A;A diet
ai-ed at de!reasi#% dietary saturated 'at E
9 ?10 years+ stati# reas"#able i# t)"se (a'ter .HT a#d li'estyle !)a#%es)
5it) E
: <D< !)"lester"l ?160 -%7d< (4.1 --"l7<) "r
: <D< !)"lester"l ?130 -%7d< (3.4 --"l7<) a#d "#e "r -"re C:D ris4 'a!t"rs
9 *"al: <D< !)"lester"l =100 -%7d<
(2.6 --"l7<) E
.HTT-edi!al #utriti"# t)erapy
9
/#itial dilated a#d !"-pre)e#si&e eye e,a-i#ati"#
s)"uld be !"#sidered
: Start "' puberty "r a%e 910 years+ 5)i!)e&er is earlier+
"#!e t)e y"ut) )as )ad diabetes '"r 325 years +
9
A'ter i#itial e,a-i#ati"#
: A##ual r"uti#e '"ll"5up %e#erally re!"--e#ded
: <ess 're1ue#t e,a-i#ati"#s -ay be a!!eptable "# ad&i!e "'
a# eye !are pr"'essi"#al E
!etino)at$y &Ty)e 1 Diabetes'
9 S!ree# '"r by -easuri#% /%A a#titissue tra#s%luta-i#ase "r
a#tie#d"-ysial a#tib"dies; d"!u-e#t #"r-al t"tal seru- /%A le&els
s""# a'ter diabetes dia%#"sis E
9 C"#sider testi#% i# !)ildre# 5it)
: $"siti&e 'a-ily )ist"ry "' !elia! disease
: *r"5t) 'ailure
: 3ailure t" %ai# 5ei%)t+ 5ei%)t l"ss
: Diarr)ea+ 'latule#!e+ abd"-i#al pai#+ si%#s "' -alabs"rpti"#
: 3re1ue#t u#e,plai#ed )yp"%ly!e-ia "r deteri"rati"# i# %ly!e-i! !"#tr"l E
Celiac Disease &Ty)e 1 Diabetes' &1'
9
Asy-pt"-ati! !)ildre# 5it) p"siti&e a#tib"dies
: C"#sider re'erral t" a %astr"e#ter"l"%ist '"r e&aluati"# 5it)
p"ssible e#d"s!"py a#d bi"psy '"r !"#'ir-ati"# "' !elia! disease E
9
C)ildre# 5it) bi"psy!"#'ir-ed !elia! disease
: $la!e "# a %lute#'ree diet
: C"#sult 5it) a dietitia# e,perie#!ed i# -a#a%i#% b"t) diabetes
a#d !elia! disease +
Celiac Disease &Ty)e 1 Diabetes' &2'
9 C)ildre# 5it) type 1 diabetes
: S!ree# '"r a#tit)yr"id per",idase+ a#tit)yr"%l"buli#
a#tib"dies s""# a'ter dia%#"sis E
9
T)yr"idsti-ulati#% )"r-"#e (TS;) !"#!e#trati"#s
: .easure a'ter -etab"li! !"#tr"l establis)ed
: /' #"r-al+ !"#sider re!)e!4i#% e&ery 122 years+ espe!ially i' patie#t
de&el"ps sy-pt"-s "' t)yr"id dys'u#!ti"#+ t)yr"-e%aly+ a# ab#"r-al
%r"5t) rate+ "r u#usual %ly!e-i! &ariati"# E
3y)ot$yroidism &Ty)e 1 Diabetes'
9 As tee#s tra#siti"# i#t" e-er%i#% adult)""d+ )ealt) !are pr"&iders
a#d 'a-ilies -ust re!"%#iIe t)eir -a#y &ul#erabilities + a#d prepare
t)e de&el"pi#% tee#+ be%i##i#% i# early t" -id ad"les!e#!e a#d at
least 1 year pri"r t" t)e tra#siti"# E
9 8"t) pediatri!ia#s a#d adult )ealt) !are pr"&iders s)"uld assist i#
pr"&idi#% supp"rt a#d li#4s t" res"ur!es '"r t)e
tee# a#d e-er%i#% adult +
!ecommendations* Transition from
ediatric to Ad,lt Care
9 A1C le&els s)"uld be as !l"se t" #"r-al as p"ssible (7B) i# a# i#di&idual
patie#t be'"re !"#!epti"# is atte-pted +
9 Starti#% at puberty+ i#!"rp"rate pre!"#!epti"# !"u#seli#% i# r"uti#e diabetes
!li#i! &isit '"r all 5"-e# "' !)ildbeari#% p"te#tial +
9 A"-e# 5it) diabetes !"#te-plati#% pre%#a#!y s)"uld be e&aluated a#d+ i'
i#di!ated+ treated '"r diabeti! reti#"pat)y+ #ep)r"pat)y+ #eur"pat)y+ C:D +
!ecommendations*
reconce)tion Care &1'
9 D&aluate -edi!ati"#s pri"r t" !"#!epti"#+ si#!e dru%s !"--"#ly used t" treat
diabetes7!"-pli!ati"#s -ay be !"#trai#di!ated "r #"t re!"--e#ded i# pre%#a#!y
: Stati#s+ ACD i#)ibit"rs+ AC8s+ -"st #"#i#suli# t)erapies E
9 .a#y pre%#a#!ies are u#pla##ed; !"#sider p"te#tial ris4s7be#e'its "' -edi!ati"#s
!"#trai#di!ated i# pre%#a#!y i# all 5"-e# "' !)ildbeari#% p"te#tial; !"u#sel
a!!"rdi#%ly E
!ecommendations*
reconce)tion Care &2'
9 3u#!ti"#al+ !"%#iti&ely i#ta!t "lder adults 5it) si%#i'i!a#t li'e
e,pe!ta#!ies s)"uld re!ei&e diabetes !are usi#% %"als
de&el"ped '"r y"u#%er adults E
9 *ly!e-i! %"als '"r s"-e "lder adults -i%)t reas"#ably be
related+ usi#% i#di&idual !riteria+ but )yper%ly!e-ia leadi#% t"
sy-pt"-s "r ris4 "' a!ute )yper%ly!e-i! !"-pli!ati"#s s)"uld
be a&"ided i# all patie#ts E
!ecommendations* .lder Ad,lts &1'
9 Treat "t)er !ardi"&as!ular ris4 'a!t"rs 5it) !"#siderati"# "' ti-e
'ra-e "' be#e'it a#d t)e i#di&idual patie#t
: Treat-e#t "' )yperte#si"# is i#di!ated i# &irtually all "lder adults; lipid+
aspiri# t)erapy -ay be#e'it t)"se 5it) li'e e,pe!ta#!y e1ual t" ti-e 'ra-e
"' pri-ary7se!"#dary pre&e#ti"# trials E
9 /#di&idualiIe s!ree#i#% '"r diabetes !"-pli!ati"#s 5it) atte#ti"# t"
t)"se leadi#% t" 'u#!ti"#al i-pair-e#t E
!ecommendations* .lder Ad,lts &2'
ADA. :///. Diabetes Care i# Spe!i'i! $"pulati"#s. Diabetes Care 2014;37(suppl 1):S542S55
!ecommendations* Cystic ?ibrosisA
!elated Diabetes &C?!D' &1'
9 A##ual s!ree#i#% '"r C3CD 5it) (*TT s)"uld be%i# by a%e 10 years
i# all patie#ts 5it) !ysti! 'ibr"sis 5)" d" #"t )a&e C3CD +
: A1C as a s!ree#i#% test '"r C3CD is #"t re!"--e#ded +
9 Duri#% a peri"d "' stable )ealt)+ dia%#"sis "' C3CD !a# be -ade i#
patie#ts 5it) !ysti! 'ibr"sis a!!"rdi#% t" usual %lu!"se !riteria E
!ecommendations* Cystic ?ibrosisA
!elated Diabetes &C?!D' &2'
9
$atie#ts 5it) C3CD s)"uld be treated 5it)
i#suli# t" attai# i#di&idualiIed %ly!e-i!
%"als A
9
A##ual -"#it"ri#% '"r !"-pli!ati"#s "'
diabetes is re!"--e#ded+ be%i##i#% 5
years a'ter t)e dia%#"sis "' C3CD E
"B# diabetes care in s)ecific
settings
!ecommendations*
Diabetes Care in t$e 3os)ital &1'
9
Diabetes dis!)ar%e pla##i#% s)"uld start
at )"spital ad-issi"#+ a#d !lear diabetes
-a#a%e-e#t i#stru!ti"#s s)"uld be
pr"&ided at dis!)ar%e E
9
T)e s"le use "' slidi#% s!ale i#suli# i# t)e
i#patie#t )"spital setti#% is dis!"ura%ed E
ADA. /U. Diabetes Care i# Spe!i'i! Setti#%s. Diabetes Care 2014;37(suppl 1):S56
!ecommendations*
9
All patie#ts 5it) diabetes ad-itted t" t)e
)"spital s)"uld )a&e t)eir diabetes !learly
ide#ti'ied i# t)e -edi!al re!"rd E
9
All patie#ts 5it) diabetes s)"uld )a&e a# "rder
'"r bl""d %lu!"se -"#it"ri#%+ 5it) results
a&ailable t" all -e-bers "' t)e )ealt) !are
tea- E
!ecommendations*
*"als '"r bl""d %lu!"se le&els
Criti!ally ill patie#ts (1)
9 /#itiate i#suli# t)erapy '"r persiste#t )yper%ly!e-ia starti#%
#" %reater t)a# 1@0 -%7d< (10 --"l7<); "#!e started+
%lu!"se ra#%e "' 14021@0 -%7d< (7.@210 --"l7<) is
re!"--e#ded A
9 ."re stri#%e#t %"als+ 1102140 -%7d< (6.127.@ --"l7<)
-ay be appr"priate '"r sele!ted patie#ts i' a!)ie&able
5it)"ut si%#i'i!a#t )yp"%ly!e-ia C
9 Criti!ally ill patie#ts re1uire a# /: i#suli# pr"t"!"l 5it)
de-"#strated e''i!a!y+ sa'ety i# a!)ie&i#% desired %lu!"se
ra#%e 5it)"ut i#!reasi#% ris4 '"r se&ere )yp"%ly!e-ia E
!ecommendations*
*"als '"r bl""d %lu!"se le&els
H"#2!riti!ally ill patie#ts
9 H" !lear e&ide#!e '"r spe!i'i! bl""d %lu!"se %"als
9 /' treated 5it) i#suli#+ pre-eal bl""d %lu!"se tar%ets (i' sa'ely a!)ie&ed)
*e#erally =140 -%7d< (7.@ --"l7<) 5it) ra#d"- bl""d %lu!"se =1@0 -%7d< (10.0 --"l7<)
9 ."re stri#%e#t tar%ets -ay be appr"priate i# stable patie#ts 5it) pre&i"us ti%)t %ly!e-i!
!"#tr"l
9 <ess stri#%e#t tar%ets -ay be appr"priate i# t)"se 5it) se&ere !"-"rbidities E
!ecommendations*
9
S!)eduled sub!uta#e"us i#suli# 5it) basal+
#utriti"#al+ a#d !"rre!ti"# !"-p"#e#ts is
t)e pre'erred -et)"d '"r a!)ie&i#% a#d
-ai#tai#i#% %lu!"se !"#tr"l i# #"#!riti!ally
ill patie#ts C
!ecommendations*
9 /#itiate %lu!"se -"#it"ri#% i# a#y patie#t #"t 4#"5# t" be diabeti! 5)"
re!ei&es t)erapy ass"!iated 5it) )i%)ris4 '"r )yper%ly!e-ia
: ;i%)d"se %lu!"!"rti!"id t)erapy+ i#itiati"# "' e#teral "r pare#teral #utriti"#+ "r "t)er
-edi!ati"#s su!) as "!tre"tide "r i--u#"suppressi&e -edi!ati"#s +
9 /' )yper%ly!e-ia is d"!u-e#ted a#d persiste#t+ !"#sider treati#% su!)
patie#ts t" t)e sa-e %ly!e-i! %"als as patie#ts 5it) 4#"5# diabetes E
9 A )yp"%ly!e-ia -a#a%e-e#t pr"t"!"l s)"uld be ad"pted a#d i-ple-e#ted
by ea!) )"spital "r )"spital syste- E
9 C"#sider "btai#i#% a# A1C i# patie#ts
: Ait) diabetes ad-itted t" t)e )"spital i' testi#% result i# pre&i"us 223 -" u#a&ailable
E
: Ait) ris4 'a!t"rs '"r u#dia%#"sed diabetes 5)" e,)ibit )yper%ly!e-ia i# t)e )"spital E
9 $atie#ts 5it) )yper%ly!e-ia 5it)"ut a pri"r dia%#"sis: d"!u-e#t pla#s '"r
'"ll"5up testi#% a#d !are at dis!)ar%e E
!ecommendations*
ADA. /U. Diabetes Care i# Spe!i'i! Setti#%s. Diabetes Care 2014;37(suppl 1):S562S57
9
<ar%est ra#d"-iIed !"#tr"lled trial t" date
9
Tested e''e!t "' ti%)t %ly!e-i! !"#tr"l
(tar%et @1210@ -%7d<) "# "ut!"-es
a-"#% 6+104 !riti!ally ill parti!ipa#ts
9
.aG"rity (?>5B) re1uired -e!)a#i!al
&e#tilati"#
Diabetes Care in t$e 3os)ital*
2"CE/S@GA! St,dy &1'
Diabetes Care in t$e 3os)ital*
2"CE/S@GA! St,dy &2'
9 /# b"t) sur%i!al7-edi!al patie#ts+ >0day -"rtality si%#i'i!a#tly
)i%)er i# i#te#si&ely treated &s !"#&e#ti"#al %r"up (tar%et 14421@0
-%7d<)
: Se&ere )yp"%ly!e-ia -"re !"--"#
(6.@B &s. 0.5B; P = 0.001)
: 3i#di#%s str"#%ly su%%est -ay #"t be #e!essary t" tar%et bl""d %lu!"se le&els
=140 -%7d<; )i%)ly stri#%e#t tar%et "'
=110 -%7d< -ay a!tually be da#%er"us
=# Strategies for im)roving
diabetes care
!ecommendations* Strategies for
"m)roving Diabetes Care &1'
ADA. U. Strate%ies '"r /-pr"&i#% Diabetes Care. Diabetes Care 2014;37(suppl 1):S61
9 Care s)"uld be ali%#ed 5it) !"-p"#e#ts "' t)e C)r"#i! Care ."del t"
e#sure pr"du!ti&e i#tera!ti"#s bet5ee# a prepared pr"a!ti&e pra!ti!e
tea- a#d a# i#'"r-ed a!ti&ated patie#t A
9 A)e# 'easible+ !are syste-s s)"uld supp"rt tea-based !are+
!"--u#ity i#&"l&e-e#t+ patie#t re%istries+ a#d e-bedded de!isi"#
supp"rt t""ls t" -eet patie#t #eeds +
!ecommendations* Strategies for
"m)roving Diabetes Care &2'
9 Treat-e#t de!isi"#s s)"uld be ti-ely+ based "# e&ide#!e
based %uideli#es tail"red t" i#di&idual patie#t pre'ere#!es+
pr"%#"ses+ a#d !"-"rbidities +
9 A patie#t!e#tered !"--u#i!ati"# style s)"uld be e-pl"yed
t)at i#!"rp"rates patie#t pre'ere#!es+ assesses litera!y a#d
#u-era!y+ a#d addresses !ultural barriers t" !are +
9 Care tea- s)"uld pri"ritiIe ti-ely+ appr"priate i#te#si'i!ati"#
"' li'estyle a#d7"r p)ar-a!euti!al t)erapy
: $atie#ts 5)" )a&e #"t a!)ie&ed be#e'i!ial le&els "' bl""d pressure+
lipid+ "r %lu!"se !"#tr"l
9 Strate%ies i#!lude
: D,pli!it %"al setti#% 5it) patie#ts
: /de#ti'yi#% a#d addressi#% barriers t" !are
: /#te%rati#% e&ide#!ebased %uideli#es
: /#!"rp"rati#% !are -a#a%e-e#t tea-s
.bCective 1*
.)timi;e rovider and Team +e$avior
.bCective 2*
S,))ort atient +e$avior C$ange
9 /-ple-e#t a syste-ati! appr"a!) t" supp"rt patie#t be)a&i"r !)a#%e e''"rts
a);ealt)y li'estyle: p)ysi!al a!ti&ity+ )ealt)y eati#%+ #"#use "' t"ba!!"+ 5ei%)t
-a#a%e-e#t+ e''e!ti&e !"pi#%
b)Disease sel'-a#a%e-e#t: -edi!ati"# ta4i#% a#d -a#a%e-e#t+ sel'-"#it"ri#% "'
%lu!"se a#d bl""d pressure 5)e# !li#i!ally appr"priate
!) $re&e#ti"# "' diabetes !"-pli!ati"#s:
sel'-"#it"ri#% "' '""t )ealt)+ a!ti&e parti!ipati"# i# s!ree#i#% '"r eye+ '""t+ a#d re#al
!"-pli!ati"#s+ a#d i--u#iIati"#s
9 T)e -"st su!!ess'ul pra!ti!es )a&e a# i#stituti"#al pri"rity '"r
pr"&idi#% )i%) 1uality "' !are
: 8asi#% !are "# e&ide#!ebased %uideli#es
: D,pa#di#% t)e r"le "' tea-s a#d sta''
: Cedesi%#i#% t)e pr"!esses "' !are
: /-ple-e#ti#% ele!tr"#i! )ealt) re!"rd t""ls
: A!ti&ati#% a#d edu!ati#% patie#ts
: /de#ti'yi#% a#d7"r de&el"pi#% !"--u#ity res"ur!es a#d publi! p"li!y t)at
supp"rts )ealt)y li'estyles
: Alterati"#s i# rei-burse-e#t
.bCective 6*
C$ange t$e System of Care

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