ADA Standards of Medical Care 2011

STANDARDS OF MEDICAL CARE
STANDARDS OF MEDICAL CARE

IN DIABETES2011
IN DIABETES2011
Table of Contents
Table of Contents
Section Section Slide No. Slide No.
ADA Evidence Grading System of
Clinical Recommendations
3
I. Classification and Diagnosis of Diabetes 4-
II. !esting for Diabetes in Asym"tomatic #atients $-%
III. Detection and Diagnosis of Gestational
Diabetes &ellit's (GD&)
*-+
I,. #revention-Delay of !y"e $ Diabetes $.-$
,. Diabetes Care $$-%.
,I. #revention and &anagement of Diabetes
Com"lications
%-.
,II. Diabetes Care in S"ecific #o"'lations .$-+
,III. Diabetes Care in S"ecific Settings $.-$*
I/. Strategies for Im"roving Diabetes Care $0-3.
ADA Evidene !"adin# S$ste% fo"
ADA Evidene !"adin# S$ste% fo"
Clinial Reo%%endations
Clinial Reo%%endations
1evel of 1evel of
Evidence Evidence Descri"tion Descri"tion
A Clear or s'""ortive evidence from ade2'ately
"o3ered 3ell-cond'cted4 generali5able4
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 $.934(s'""l ):S$. !able .
I& CLASSIFICATION AND
DIA!NOSIS OF DIABETES
Classifiation of Diabetes
Classifiation of Diabetes
!y"e diabetes
;-cell destr'ction
!y"e $ diabetes
#rogressive ins'lin secretory defect
<t8er s"ecific ty"es of diabetes
Genetic defects in ;-cell f'nction4 ins'lin action

Diseases of t8e e6ocrine "ancreas
Dr'g- or c8emical-ind'ced
Gestational diabetes mellit's

ADA. I. Classification and Diagnosis. Diabetes Care $.934(s'""l ):S$.
C"ite"ia fo" t'e Dia#nosis of Diabetes
AC =*.%>
OR
?asting "lasma gl'cose (?#G)
=$* mg-dl (0.. mmol-l)
OR
!3o-8o'r "lasma gl'cose =$.. mg-dl
(. mmol-l) d'ring an <G!!
OR
A random "lasma gl'cose =$.. mg-dl
(. mmol-l)
ADA. I. Classification and Diagnosis. Diabetes Care $.934(s'""l ):S3. !able $.
AC =*.%>
!8e test s8o'ld be "erformed in a
laboratory 'sing an NGS#-certified
met8od standardi5ed to t8e DCC! assay@
@In t8e absence of 'ne2'ivocal 8y"erglycemia4 res'lt s8o'ld be confirmed by re"eat testing.
?asting "lasma gl'cose (?#G)
=$* mg-dl (0.. mmol-l)
?asting: no caloric intaAe for
at least B 8@
@In t8e absence of 'ne2'ivocal 8y"erglycemia4 res'lt s8o'ld be confirmed by re"eat testing.
!3o-8o'r "lasma gl'cose =$.. mg-dl
(. mmol-l) d'ring an <G!!
!8e test s8o'ld be "erformed as
described by t8e Corld Dealt8
<rgani5ation4 'sing a gl'cose load
containing t8e e2'ivalent of 0% g
an8ydro's gl'cose dissolved in 3ater@
@n t8e absence of 'ne2'ivocal 8y"erglycemia4 res'lt s8o'ld be confirmed by re"eat testing.
In a "atient 3it8 classic sym"toms of
8y"erglycemia or 8y"erglycemic crisis4
a random "lasma gl'cose =$.. mg-dl
(. mmol-l)
("ediabetes) IF!* I!T* In"eased A1C
("ediabetes) IF!* I!T* In"eased A1C
Categories of increased risA for diabetes
(#rediabetes)@
?#G ..-$% mg-dl (%.*-*.+ mmol-l): I?G
or
$-8 "lasma gl'cose in t8e 0%-g <G!!
4.-++ mg-dl (0.B-.. mmol-l): IG!
or
AC %.0-*.4>
@?or all t8ree tests4 risA is contin'o's4 e6tending belo3 t8e lo3er limit of a range and becoming
dis"ro"ortionately greater at 8ig8er ends of t8e range.
ADA. I. Classification and Diagnosis. Diabetes Care $.934(s'""l ):S3. !able 3.
II& TESTIN! FOR DIABETES IN
II& TESTIN! FOR DIABETES IN
AS+M(TOMATIC (ATIENTS
AS+M(TOMATIC (ATIENTS
Reo%%endations) Testin# fo"
Reo%%endations) Testin# fo"
Diabetes in As$%,to%ati (atients
Diabetes in As$%,to%ati (atients
Consider testing over3eig8t-obese ad'lts 3it8

one or more additional risA factors
In t8ose 3it8o't risA factors4 begin testing at age 4%

years (7)
If tests are normal

Re"eat testing at least at 3-year intervals (E)
Ese AC4 ?#G4 or $-8 0%-g <G!! (7)
In t8ose 3it8 increased risA for f't're diabetes
Identify and4 if a""ro"riate4 treat ot8er C,D risA

factors (7)
ADA. II. !esting in Asym"tomatic #atients. Diabetes Care $.934(s'""l ):S3-S4.
C"ite"ia fo" Testin# fo" Diabetes in
As$%,to%ati Ad-lt Individ-als .1/
#8ysical inactivity
?irst-degree relative 3it8
diabetes
Dig8-risA race-et8nicity (e.g.4
African American4 1atino4
Native American4 Asian
American4 #acific Islander)
Comen 38o delivered a baby
3eig8ing F+ lb or 3ere
diagnosed 3it8 GD&
Dy"ertension (=4.-+.
mmDg or on t8era"y for
8y"ertension)
DD1 c8olesterol level
G3% mg-dl (..+. mmol-l)
and-or a triglyceride level
F$%. mg-dl ($.B$ mmol-l)
Comen 3it8 "olycystic ovarian
syndrome (#C<S)
AC =%.0>4 IG!4 or I?G on
"revio's testing
<t8er clinical conditions
associated 3it8 ins'lin
resistance (e.g.4 severe
obesity4 acant8osis nigricans)
Distory of C,D
@At-risA 7&I may be lo3er in some et8nic gro'"s.
1. Testing should be considered in all adults who are overweight
(BMI 25 kg/m
2
! and have additional risk "actors#
ADA. !esting in Asym"tomatic #atients. Diabetes Care $.934(s'""l ):S4. !able 4.
2& In t8e absence of criteria (risA factors on
"revio's slide)4 testing for diabetes s8o'ld begin
at age 4% years
0& If res'lts are normal4 testing s8o'ld be re"eated
at least at 3-year intervals4 3it8 consideration of
more fre2'ent testing de"ending on initial
res'lts and risA stat's
ADA. !esting in Asym"tomatic #atients. Diabetes Care $.934(s'""l ):S4. !able 4.
III& DETECTION AND
III& DETECTION AND
DIA!NOSIS OF
DIA!NOSIS OF
!ESTATIONAL DIABETES
!ESTATIONAL DIABETES
MELLIT1S
MELLIT1S
Reo%%endations)
Reo%%endations)
Detetion and Dia#nosis of !DM .1/
Screen for 'ndiagnosed ty"e $ diabetes at

t8e first "renatal visit in t8ose 3it8 risA
factors4 'sing standard diagnostic criteria
(7)
In "regnant 3omen not "revio'sly Ano3n

to 8ave diabetes4 screen for GD& at $4-$B
3eeAs gestation4 'sing a 0%-g <G!! and
t8e diagnostic c't"oints in !able * (7)
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.934(s'""l ):S%.
S"eenin# fo" and Dia#nosis of !DM
S"eenin# fo" and Dia#nosis of !DM
#erform a 0%-g <G!!4 3it8 "lasma gl'cose

meas'rement fasting and at and $ 84 at
$4-$B 3eeAs of gestation in 3omen not
"revio'sly diagnosed 3it8 overt diabetes
#erform <G!! in t8e morning after an

overnig8t fast of at least B 8
GD& diagnosis: 38en any of t8e follo3ing

"lasma gl'cose val'es are e6ceeded
H ?asting =+$ mg-dl (%. mmol-l)
H 8 =B. mg-dl (... mmol-l)
H $ 8 =%3 mg-dl (B.% mmol-l)
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.934(s'""l ):S%. !able *.
Reo%%endations)
Reo%%endations)
Screen 3omen 3it8 GD& for "ersistent

diabetes *-$ 3eeAs "ost"art'm (E)
Comen 3it8 a 8istory of GD& s8o'ld 8ave

lifelong screening for t8e develo"ment of
diabetes or "rediabetes at least every
t8ree years (E)
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.934(s'""l ):S%.
I2& (RE2ENTION3DELA+ OF
I2& (RE2ENTION3DELA+ OF
T+(E 2 DIABETES
T+(E 2 DIABETES
Reo%%endations)
Reo%%endations)
("evention3Dela$ of T$,e 2 Diabetes
("evention3Dela$ of T$,e 2 Diabetes
Refer "atients 3it8 IG! (A)4 I?G (E)4 or AC %.0-

*.4> (E) to s'""ort "rogram
Ceig8t loss 0> of body 3eig8t
At least %. min-3eeA moderate activity
?ollo3-'" co'nseling im"ortant (7)9

t8ird-"arty "ayors s8o'ld cover (E)
Consider metformin if m'lti"le risA factors4

es"ecially if 8y"erglycemia (e.g.4 ACF*>)
"rogresses des"ite lifestyle interventions (7)
In t8ose 3it8 "rediabetes4 monitor for develo"ment

of diabetes ann'ally (E)
ADA. I,. #revention-Delay of !y"e $ Diabetes. Diabetes Care $.934(s'""l ):S*.
2& DIABETES CARE
A com"lete medical eval'ation s8o'ld be "erformed to
H Classify t8e diabetes
H Detect "resence of diabetes com"lications
H Revie3 "revio's treatment4 glycemic control in "atients 3it8
establis8ed diabetes
H Assist in form'lating a management "lan
H #rovide a basis for contin'ing care
#erform laboratory tests necessary to eval'ate eac8 "atientIs
medical condition
Diabetes Ca"e) Initial Eval-ation
Diabetes Ca"e) Initial Eval-ation
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S*.
Co%,onents of t'e Co%,"e'ensive
Diabetes Eval-ation .1/
&edical 8istory
Age and c8aracteristics of onset of diabetes

(e.g.4 DJA4 asym"tomatic laboratory finding)
Eating "atterns4 "8ysical activity 8abits4

n'tritional stat's4 and 3eig8t 8istory9 gro3t8 and
develo"ment in c8ildren and adolescents
Diabetes ed'cation 8istory
Revie3 of "revio's treatment regimens and

res"onse to t8era"y (AC records)
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S0. !able B.
C'rrent treatment of diabetes4 incl'ding
medications4 meal "lan4 "8ysical activity "atterns4
and res'lts of gl'cose monitoring and "atientIs 'se
of data ()
DJA fre2'ency4 severity4 and ca'se
Dy"oglycemic e"isodes
H Dy"oglycemia a3areness
H Any severe 8y"oglycemia: fre2'ency and ca'se
C'rrent treatment of diabetes4 incl'ding
medications4 meal "lan4 "8ysical activity "atterns4
and res'lts of gl'cose monitoring and "atientIs 'se
of data ($)
Distory of diabetes-related com"lications

H &icrovasc'lar: retino"at8y4 ne"8ro"at8y4 ne'ro"at8y
Sensory ne'ro"at8y4 incl'ding 8istory of foot lesions
A'tonomic ne'ro"at8y4 incl'ding se6'al dysf'nction and
gastro"aresis
H &acrovasc'lar: CDD4 cerebrovasc'lar disease4 #AD
H <t8er: "syc8osocial "roblems@4 dental disease@
@See a""ro"riate referrals for t8ese categories.
#8ysical e6amination ()
Deig8t4 3eig8t4 7&I
7lood "ress're determination4 incl'ding

ort8ostatic meas'rements 38en indicated
?'ndosco"ic e6amination@
!8yroid "al"ation
SAin e6amination (for acant8osis nigricans and

ins'lin inKection sites)
#8ysical e6amination ($)
Com"re8ensive foot e6amination

HIns"ection
H #al"ation of dorsalis "edis and "osterior tibial "'lses
H #resence-absence of "atellar and Ac8illes refle6es
H Determination of "ro"rioce"tion4 vibration4 and
monofilament sensation
1aboratory eval'ation
AC4 if res'lts not available 3it8in "ast $H3

mont8s
If not "erformed-available 3it8in "ast year

H ?asting li"id "rofile4 incl'ding total4 1D1- and DD1-
c8olesterol and triglycerides
H 1iver f'nction tests
H !est for 'rine alb'min e6cretion 3it8 s"ot 'rine
alb'min-creatinine ratio
H Ser'm creatinine and calc'lated G?R
H !SD in ty"e diabetes4 dysli"idemia4 or 3omen
F%. years of age
Referrals
Ann'al dilated eye e6am
?amily "lanning for 3omen of re"rod'ctive age
Registered dietitian for &N!
Diabetes self-management ed'cation
Dental e6amination
&ental 8ealt8 "rofessional4 if needed

Reo%%endations) !l-ose Monito"in#
Reo%%endations) !l-ose Monito"in#
Self-monitoring of blood gl'cose s8o'ld be

carried o't 3L times daily for "atients 'sing
m'lti"le ins'lin inKections or ins'lin "'m"
t8era"y (A)
?or "atients 'sing less fre2'ent ins'lin

inKections4 nonins'lin t8era"y4 or medical
n'trition t8era"y alone
S&7G may be 'sef'l as a g'ide to s'ccess of t8era"y
(E)
Do3ever4 several recent trials 8ave called into
2'estion clinical 'tility4 cost-effectiveness4 of ro'tine
S&7G in nonHins'lin-treated "atients
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S0.
Reo%%endations) A1C
Reo%%endations) A1C
#erform AC test at least t3ice yearly in

"atients meeting treatment goals (and
8ave stable glycemic control) (E)
#erform AC test 2'arterly in "atients

38ose t8era"y 8as c8anged or 38o are
not meeting glycemic goals (E)
Ese of "oint-of-care testing for AC allo3s

for timely decisions on t8era"y c8anges4
38en needed (E)
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):SB.
Co""elation of A1C 8it' Esti%ated
Co""elation of A1C 8it' Esti%ated
Ave"a#e !l-ose .eA!/
Ave"a#e !l-ose .eA!/
&ean "lasma gl'cose
AC (>) mg-dl mmol-l
* $* 0..
0 %4 B.*
B B3 ..$
+ $$ .B
. $4. 3.4
$*+ 4.+
$ $+B *.%
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):SB. !able +.
!8ese estimates are based on ADAG data of M$40.. gl'cose meas'rements over 3 mont8s "er AC
meas'rement in %.0 ad'lts 3it8 ty"e 4 ty"e $4 and no diabetes. !8e correlation bet3een AC and
average gl'cose 3as ..+$. A calc'lator for converting AC res'lts into estimated average gl'cose (eAG)4
in eit8er mg-dl or mmol-l4 is available at 8tt":--"rofessional.diabetes.org-Gl'coseCalc'lator.as"6.
Reo%%endations)
Reo%%endations)
!l$e%i !oals in Ad-lts .1/
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S+.
1o3ering AC to belo3 or aro'nd 0>

HS8o3n to red'ce microvasc'lar and ne'ro"at8ic
com"lications of diabetes
HIf im"lemented soon after diagnosis of diabetes4
associated 3it8 long-term red'ction in
macrovasc'lar disease
!8erefore4 a reasonable AC goal for many

non-"regnant ad'lts is G0> (7)
Reo%%endations)
Reo%%endations)
Additional analysis from several

randomi5ed trials s'ggest a small b't
incremental benefit in microvasc'lar
o'tcomes 3it8 AC val'es closer to normal
#roviders mig8t reasonably s'ggest more

stringent AC goals for selected individ'al
"atients4 if t8is can be ac8ieved 3it8o't
significant 8y"oglycemia or ot8er adverse
effects of treatment
HS'c8 "atients mig8t incl'de t8ose 3it8 s8ort
d'ration of diabetes4 long life e6"ectancy4 and no
significant cardiovasc'lar disease (7)
Reo%%endations)
Reo%%endations)
Conversely4 less stringent AC goals may

be a""ro"riate for "atients 3it8
HDistory of severe 8y"oglycemia4 limited life
e6"ectancy4 advanced microvasc'lar or
macrovasc'lar com"lications4 e6tensive
comorbid conditions
H!8ose 3it8 longstanding diabetes in 38om t8e
general goal is diffic'lt to attain des"ite diabetes
self-management ed'cation4 a""ro"riate gl'cose
monitoring4 and effective doses of m'lti"le
gl'cose lo3ering agents incl'ding ins'lin (C)
Intensive !l$e%i Cont"ol and
Ca"diovas-la" O-to%es) ACCORD
Ca"diovas-la" O-to%es) ACCORD
Gerstein DC4 et al4 for t8e Action to Control Cardiovasc'lar RisA in Diabetes St'dy Gro'".
N Engl J Med $..B93%B:$%4%-$%%+.
$2%%& New England Journal of Medicine' (sed with )ermission'
*rimar+ ,utcome# -on"atal MI. non"atal stroke. /01 death
234%'5% (%'6&78'%9!
Ca"diovas-la" O-to%es) AD2ANCE
Ca"diovas-la" O-to%es) AD2ANCE
$2%%& New England Journal of Medicine' (sed with )ermission'
*rimar+ ,utcome# Microvascular )lus macrovascular
(non"atal MI. non"atal stroke. /01 death!
#atel A4 et al4. for t8e AD,ANCE Collaborative Gro'". N Engl J Med $..B93%B:$%*.-$%0$.
234%'5% (%'&27%'5&!
Ca"diovas-la" O-to%es) 2ADT
Ca"diovas-la" O-to%es) 2ADT
D'cA3ort8 C4 et al.4 for t8e ,AD! Investigators. N Engl J Med $..+93*.:$+-3+.
*rimar+ ,utcome# -on"atal MI. non"atal stroke. /01 death.
hos)itali:ation "or heart "ailure. revasculari:ation
234%'&& (%'6978'%5!
$2%%5 New England Journal of Medicine' (sed with )ermission'
!l$e%i Reo%%endations fo" Non9
("e#nant Ad-lts 8it' Diabetes .1/
AC G0..>@
#re"randial ca"illary
"lasma gl'cose
0.H3. mg-dl@
(3.+H0.$ mol-l)
#eaA "ost"randial ca"illary
"lasma gl'coseN
GB. mg-dl@
(G... mmol-l)
@#ost"randial gl'cose meas'rements s8o'ld be made H$ 8 after t8e beginning of t8e meal4 generally
"eaA levels in "atients 3it8 diabetes.
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S$. !able ..
Goals s8o'ld be individ'ali5ed based on

HD'ration of diabetes
HAge-life e6"ectancy
HComorbid conditions
HJno3n C,D or advanced microvasc'lar
com"lications
HDy"oglycemia 'na3areness
HIndivid'al "atient considerations
HDy"oglycemia 'na3areness
HIndivid'al "atient considerations
#ost"randial gl'cose may be targeted if

AC goals are not met des"ite reac8ing
"re"randial gl'cose goals
&ore or less stringent glycemic goals may

be a""ro"riate for individ'al "atients
Reo%%endations) Diabetes
Reo%%endations) Diabetes
Self9Mana#e%ent Ed-ation
Self9Mana#e%ent Ed-ation
#eo"le 3it8 diabetes s8o'ld receive DS&E

according to national standards at diagnosis
and as needed t8ereafter (7)
Effective self-management4 2'ality of life are

Aey o'tcomes of DS&E9 s8o'ld be meas'red4
monitored as "art of care (C)
DS&E s8o'ld address "syc8osocial iss'es9

emotional 3ell-being is associated 3it8 "ositive
o'tcomes (C)
DS&E s8o'ld be reimb'rsed by t8ird-"arty

"ayors (E)
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S$$.
Reo%%endations)
Reo%%endations)
Medial N-t"ition T'e"a,$ .MNT/
Medial N-t"ition T'e"a,$ .MNT/
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S$$.
Individ'als 38o 8ave "rediabetes or

diabetes s8o'ld receive individ'ali5ed &N!
as needed to ac8ieve treatment goals (A)
?or "eo"le 3it8 diabetes4 it is 'nliAely one

o"timal mi6 of macron'trients for meal "lans
e6ists
!8e best mi6 of carbo8ydrate4 "rotein4 and fat

a""ears to vary de"ending on individ'al
circ'mstances
Loo: A;EAD .Ation fo" ;ealt' in
Loo: A;EAD .Ation fo" ;ealt' in
Diabetes/) One9+ea" Res-lts
Diabetes/) One9+ea" Res-lts
. 1ooA ADEAD Researc8 Gro'". Diabetes Care. $..093.:304-3B39
$. 1ooA ADEAD Researc8 Gro'". Arch Intern Med. 2%8%;86%#85<<8565.
Intensive lifestyle intervention res'lted in
Average B.*> 3eig8t loss
Significant red'ction of AC
Red'ction in several C,D risA factors
7enefits s'stained at 4 years

$
?inal res'lts of 1ooA ADEAD to "rovide

insig8t into effects of long-term 3eig8t
loss on im"ortant clinical o'tcomes
Reo%%endations) ('$sial Ativit$
Reo%%endations) ('$sial Ativit$
Advise "eo"le 3it8 diabetes to "erform at

least %. min-3eeA of moderate-intensity
aerobic "8ysical activity (%.-0.> of
ma6im'm 8eart rate) (A)
In absence of contraindications4 "eo"le

3it8 ty"e $ diabetes s8o'ld be enco'raged
to "erform resistance training t8ree times
"er 3eeA (A)
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S$4.
Reo%%endations)
Reo%%endations)
(s$'osoial Assess%ent and Ca"e
(s$'osoial Assess%ent and Ca"e
<ngoing "art of medical management of

diabetes (E)
#syc8osocial screening-follo3-'": attit'des

abo't diabetes4 medical
management-o'tcomes e6"ectations4
affect-mood4 2'ality of life4 reso'rces4
"syc8iatric 8istory (E)
C8en self-management is "oor4 screen for

"syc8osocial "roblems: de"ression4 diabetes-
related an6iety4 eating disorders4 cognitive
im"airment (C)
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S$%.
Reo%%endations) ;$,o#l$e%ia
Reo%%endations) ;$,o#l$e%ia
Gl'cose (%-$. g) is "referred treatment for

conscio's individ'al 3it8 8y"oglycemia (E)
Gl'cagon s8o'ld be "rescribed for all

individ'als at significant risA of severe
8y"oglycemia4 and caregivers-family
members instr'cted in administration (E)
!8ose 3it8 8y"oglycemia 'na3areness or

one or more e"isodes of severe
8y"oglycemia s8o'ld raise glycemic targets
to red'ce risA of f't're e"isodes (7)
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S$%.
Reo%%endations) Ba"iat"i S-"#e"$
Reo%%endations) Ba"iat"i S-"#e"$
Consider bariatric s'rgery for ad'lts 3it8 7&I

F3% Ag-m
$
and ty"e $ diabetes (7)
After s'rgery4 life-long lifestyle s'""ort and

medical monitoring is necessary (E)
Ins'fficient evidence to recommend s'rgery in

"atients 3it8 7&I G3% Ag-m
$
o'tside of a
researc8 "rotocol (E)
Cell-designed4 randomi5ed controlled trials

com"aring o"timal medical-lifestyle t8era"y
needed to determine long-term benefits4 cost-
effectiveness4 risAs (E)
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S$*.
Reo%%endations) I%%-ni<ation
Reo%%endations) I%%-ni<ation
#rovide an infl'en5a vaccine ann'ally to all

diabetic "atients =* mont8s of age (C)
Administer "ne'mococcal "olysacc8aride

vaccine to all diabetic "atients =$ years
<ne-time revaccination recommended for

t8ose F*4 years "revio'sly imm'ni5ed at
G*% years if administered F% years ago
<t8er indications for re"eat vaccination:

ne"8rotic syndrome4 c8ronic renal disease4
imm'nocom"romised states (C)
ADA. ,. Diabetes Care. Diabetes Care $.934(s'""l ):S$0.
2I& (RE2ENTION AND
MANA!EMENT OF
DIABETES COM(LICATIONS
C,D is a maKor ca'se of morbidity4 mortality for t8ose 3it8
diabetes
Common conditions coe6isting 3it8 ty"e $ diabetes (e.g.4
8y"ertension4 dysli"idemia) are clear risA factors for C,D
Diabetes itself confers inde"endent risA
7enefits observed 38en individ'al cardiovasc'lar risA factors
are controlled to "revent-slo3 C,D in "eo"le 3it8 diabetes
Ca"diovas-la" Disease .C2D/ in
Ca"diovas-la" Disease .C2D/ in
Individ-als 8it' Diabetes
Individ-als 8it' Diabetes
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S$0.
Reo%%endations)
Reo%%endations)
;$,e"tension3Blood ("ess-"e Cont"ol
Screening and diagnosis
&eas're blood "ress're at every ro'tine diabetes visit
If "atients 8ave systolic blood "ress're

=3. mmDg or diastolic blood "ress're =B. mmDg
Confirm blood "ress're on a se"arate day
Re"eat systolic blood "ress're =3. mmDg or diastolic
blood "ress're =B. confirms a diagnosis of 8y"ertension (C)
Reo%%endations)
Reo%%endations)
Goals
A goal systolic blood "ress're G3. mmDg is a""ro"riate
for most "atients 3it8 diabetes (C)
7ased on "atient c8aracteristics and res"onse to t8era"y4
8ig8er or lo3er systolic blood "ress're targets may be
a""ro"riate (7)
#atients 3it8 diabetes s8o'ld be treated to a diastolic
blood "ress're GB. mmDg (7)
Reo%%endations)
Reo%%endations)
!reatment ()
#atients 3it8 a systolic blood "ress're 3.H3+

mmDg or a diastolic blood "ress're B.HB+ mmDg
&ay be given lifestyle t8era"y alone for a ma6im'm of
3 mont8s
If targets are not ac8ieved4 "atients s8o'ld be treated
3it8 t8e addition of "8armacological agents (E)
Reo%%endations)
Reo%%endations)
!reatment ($)
#atients 3it8 more severe 8y"ertension

(systolic blood "ress're =4. mmDg or
diastolic blood "ress're =+. mmDg) at
diagnosis or follo3-'"
S8o'ld receive "8armacologic t8era"y in addition to
lifestyle t8era"y (A)
Reo%%endations)
Reo%%endations)
!reatment (3)
1ifestyle t8era"y for 8y"ertension
Ceig8t loss if over3eig8t

DASD-style dietary "attern incl'ding red'cing sodi'm4
increasing "otassi'm intaAe
&oderation of alco8ol intaAe
Increased "8ysical activity (7)
Reo%%endations)
Reo%%endations)
!reatment (4)
#8armacologic t8era"y for "atients 3it8 diabetes and 8y"ertension
#air 3it8 a regimen t8at incl'des eit8er an ACE in8ibitor or angiotensin II
rece"tor blocAer
If one class is not tolerated4 t8e ot8er s8o'ld be s'bstit'ted
If needed to ac8ieve blood "ress're targets
!8ia5ide di'retic s8o'ld be added to t8ose 3it8 estimated G?R =3. ml 6
min-.03 m
$
1oo" di'retic for t8ose 3it8 an estimated G?R G3. ml 6 min-.03 m
$
(C)
Reo%%endations)
Reo%%endations)
!reatment (%)
&'lti"le dr'g t8era"y (t3o or more agents at

ma6imal doses)
Generally re2'ired to ac8ieve blood "ress're targets (7)
If ACE in8ibitors4 AR7s4 or di'retics are 'sed

Jidney f'nction4 ser'm "otassi'm levels s8o'ld be
monitored (E)
Reo%%endations)
Reo%%endations)
!reatment (*)
In "regnant "atients 3it8 diabetes and c8ronic

8y"ertension
7lood "ress're target goals of .H$+-*%H0+ mmDg are
s'ggested in interest of long-term maternal 8ealt8 and
minimi5ing im"aired fetal gro3t8
ACE in8ibitors4 AR7s4 contraindicated d'ring "regnancy

(E)
Reo%%endations)
Reo%%endations)
D$sli,ide%ia3Li,id Mana#e%ent
Screening
In most ad'lt "atients

&eas're fasting li"id "rofile at least ann'ally
In ad'lts 3it8 lo3-risA li"id val'es (1D1

c8olesterol G.. mg-dl4 DD1 c8olesterol F%.
mg-dl4 and triglycerides G%. mg-dl)
1i"id assessments may be re"eated every $ years (E)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S$+.
Reo%%endations)
Reo%%endations)
!reatment recommendations and goals ()
!o im"rove li"id "rofile in "atients 3it8 diabetes4
recommend lifestyle modification (A)4 foc'sing on
Red'ction of sat'rated fat4 trans fat4 c8olesterol intaAe
Increased n-3 fatty acids4 visco's fiber4
"lant stanols-sterols
Ceig8t loss (if indicated)
Increased "8ysical activity
Reo%%endations)
Reo%%endations)
!reatment recommendations and goals ($)
Statin t8era"y s8o'ld be added to lifestyle

t8era"y4 regardless of baseline li"id levels4 for
diabetic "atients:
3it8 overt C,D (A)

3it8o't C,D 38o are F4. years of age and 8ave one
or more ot8er C,D risA factors (A)
Reo%%endations)
Reo%%endations)
!reatment recommendations and goals (3)
?or "atients at lo3er risA (e.g.4 3it8o't overt

C,D and G4. years of age) (E)
Statin t8era"y s8o'ld be considered in addition to

lifestyle t8era"y if 1D1 c8olesterol remains F..
mg-dl
In t8ose 3it8 m'lti"le C,D risA factors

Reo%%endations)
Reo%%endations)
!reatment recommendations and goals (4)
In individ'als 3it8o't overt C,D
#rimary goal is an 1D1 c8olesterol
G.. mg-dl ($.* mmol-l) (A)
In individ'als 3it8 overt C,D
1o3er 1D1 c8olesterol goal of G0. mg-dl
(.B mmol-l)4 'sing a 8ig8 dose of a statin4 is an o"tion (7)
Reo%%endations)
Reo%%endations)
!reatment recommendations and goals (%)
If targets not reac8ed on ma6imal tolerated statin t8era"y
Alternative t8era"e'tic goal: red'ce 1D1 c8olesterol M3.H4.> from
baseline (A)
!riglyceride levels G%. mg-dl (.0 mmol-l)4 DD1 c8olesterol
F4. mg-dl (.. mmol-l) in men and F%. mg-dl (.3 mmol-l) in
3omen4 are desirable
Do3ever4 1D1 c8olesterolHtargeted statin t8era"y remains t8e "referred
strategy (C)
Reo%%endations)
Reo%%endations)
!reatment recommendations and goals (*)
If targets are not reac8ed on ma6imally tolerated doses
of statins
Combination t8era"y 'sing statins and ot8er li"id lo3ering
agents may be considered to ac8ieve li"id targets
Das not been eval'ated in o'tcome st'dies for eit8er C,D
o'tcomes or safety (E)
Statin t8era"y is contraindicated in "regnancy

Statins) Red-tion in 109+ea" Ris: of
Ma=o" C2D
Ma=o" C2D
> >
in (atients 8it' Diabetes
St-d$
"ef&
Statin dose and
o%,a"ato"
Ris:
"ed-tion
Relative
"is:
"ed-tion
Absol-te
"is:
"ed-tion
LDL
'oleste"ol
"ed-tion*
%#3dl .?/
4S-D&
Simvastatin $.-4.
mg vs. "lacebo
B%.0 to
43.$>
%.> 4$.%>
B* to +
(3*>)
AS#EN
$
Atorvastatin . mg
vs. "lacebo
3+.% to
$4.%>
34> $.0>
$ to 0+
($+>)
D#S-D&
3
Simvastatin 4. mg
vs. "lacebo
43.B to
3*.3>
0> 0.%>
$3 to B4
(3>)
CARE-D&
4
#ravastatin 4. mg
vs. "lacebo
4..B to
3%.4>
3> %.4>
3* to ++
($0>)
!N!-D&
%
Atorvastatin B. mg
vs. . mg
$*.3 to
$.*>
B> 4.0>
++ to 00
($$>)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S3.. !able .
@End"ointsOCDD deat84 nonfatal &I
Secondary Prevention
St-d$
"ef&
Statin dose and
o%,a"ato"
Ris:
"ed-tion
Relative
"is:
"ed-tion
Absol-te
"is:
"ed-tion
LDL
'oleste"ol
"ed-tion*
%#3dl .?/
D#S-D&
Simvastatin 4. mg
vs. "lacebo
0.% to
.%>
34> *..>
$4 to B*
(3>)
CARDS
$
Atorvastatin . mg
vs. "lacebo
.% to
0.%>
3%> 4..>
B to 0
(4.>)
AS#EN
3
Atorvastatin . mg
vs. "lacebo
+.B to
0.+>
+> .+>
4 to B.
(3.>)
ASC<!-D&
4
Atorvastatin . mg
vs. "lacebo
. to
..$>
B> ..+>
$% to B$
(34>)
@End"ointsOCDD deat84 nonfatal &I
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S3.. !able .
Primary Prevention
Ma=o" C2D
Ma=o" C2D
> >
Reo%%endations) !l$e%i* Blood
Reo%%endations) !l$e%i* Blood
("ess-"e* Li,id Cont"ol in Ad-lts
("ess-"e* Li,id Cont"ol in Ad-lts
AC G0..>
@
7lood "ress're G3.-B. mmDg
N
1i"ids
1D1 c8olesterol G.. mg-dl
(G$.* mmol-l)
P
@&ore or less stringent glycemic goals may be a""ro"riate for individ'al "atients. Goals s8o'ld be
individ'ali5ed based on: d'ration of diabetes4 age-life e6"ectancy4 comorbid conditions4 Ano3n C,D or
advanced microvasc'lar com"lications4 8y"oglycemia 'na3areness4 and individ'al "atient
considerations.
N7ased on "atient c8aracteristics and res"onse to t8era"y4 8ig8er or lo3er systolic blood "ress're targets
may be a""ro"riate.
PIn individ'als 3it8 overt C,D4 a lo3er 1D1 c8olesterol goal of G0. mg-dl (.B mmol-l)4 'sing a 8ig8
dose of statin4 is an o"tion.
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S3. !able $.
Reo%%endations)
Reo%%endations)
Anti,latelet A#ents .1/
Consider as"irin t8era"y (0%H*$ mg-day) (C)
As a "rimary "revention strategy in t8ose 3it8 ty"e or ty"e $
diabetes at increased cardiovasc'lar risA (.-year risA F.>)
Incl'des most men F%. years of age or 3omen F*. years of age
38o 8ave at least one additional maKor risA factor
?amily 8istory of C,D
Dy"ertension
SmoAing
Dysli"idemia
Alb'min'ria
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S3.
Reo%%endations)
Reo%%endations)
As"irin s8o'ld not be recommended for C,D "revention for
ad'lts 3it8 diabetes at lo3 C,D risA4 since "otential adverse
effects from bleeding liAely offset "otential benefits (C)
.-year C,D risA G%>: men G%. and 3omen G*. years of age
3it8 no maKor additional C,D risA factors
In "atients in t8ese age gro'"s 3it8 m'lti"le ot8er risA
factors (e.g.4 .-year risA %>-.>) clinical K'dgment is
re2'ired (E)
Reo%%endations)
Reo%%endations)
Ese as"irin t8era"y (0%H*$ mg-day)
Secondary "revention strategy in t8ose 3it8 diabetes 3it8 a
8istory of C,D (A)
?or "atients 3it8 C,D4 doc'mented as"irin allergy
Clo"idogrel (0% mg-day) s8o'ld be 'sed (7)
Combination t8era"y 3it8 ASA (0%H*$ mg-day) and
clo"idogrel (0% mg-day)
Reasonable for '" to a year after an ac'te coronary syndrome (7)
Reo%%endations)
Reo%%endations)
S%o:in# Cessation
S%o:in# Cessation
Advise all "atients not to smoAe (A)
Incl'de smoAing cessation co'nseling and

ot8er forms of treatment as a ro'tine
com"onent of diabetes care (7)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S3$.
Reo%%endations)
Reo%%endations)
Co"ona"$ ;ea"t Disease S"eenin#
Co"ona"$ ;ea"t Disease S"eenin#
In asym"tomatic "atients4 ro'tine

screening for CAD is not recommended4 as
it does not im"rove o'tcomes as long as
C,D risA factors are treated (A)
Reo%%endations)
Reo%%endations)
Co"ona"$ ;ea"t Disease T"eat%ent .1/
!o red'ce risA of cardiovasc'lar events in "atients 3it8
Ano3n C,D4 'se
ACE in8ibitor
@
(C)
As"irin
@
(A)
Statin t8era"y
@
(A)
In "atients 3it8 a "rior &I

7eta-blocAers s8o'ld be contin'ed for at least $ years after
t8e event (7)
@If not contraindicated.
Reo%%endations)
Reo%%endations)
1onger-term 'se of beta-blocAers in t8e absence of
8y"ertension
Reasonable if 3ell tolerated4 b't data are lacAing (E)
Avoid !QD treatment
In "atients 3it8 sym"tomatic 8eart fail're (C)
&etformin 'se in "atients 3it8 stable CD?
Indicated if renal f'nction is normal
S8o'ld be avoided in 'nstable or 8os"itali5ed "atients 3it8 CD? (C)
Reo%%endations) Ne,'"o,at'$
Reo%%endations) Ne,'"o,at'$
!o red'ce risA or slo3 t8e "rogression of

ne"8ro"at8y
<"timi5e gl'cose control (A)
<"timi5e blood "ress're control (A)

Reo%%endations)
Reo%%endations)
Ne,'"o,at'$ S"eenin#
Ne,'"o,at'$ S"eenin#
Assess 'rine alb'min e6cretion ann'ally (E)

In ty"e diabetic "atients 3it8 diabetes d'ration of % years
In all ty"e $ diabetic "atients at diagnosis
&eas're ser'm creatinine at least ann'ally (E)

In all ad'lts 3it8 diabetes regardless of degree of 'rine
alb'min e6cretion
Ser'm creatinine s8o'ld be 'sed to estimate G?R and stage
level of c8ronic Aidney disease4 if "resent
Reo%%endations)
Reo%%endations)
Ne,'"o,at'$ T"eat%ent .1/
Non"regnant "atient 3it8 micro- or

macroalb'min'ria
Eit8er ACE in8ibitors or AR7s s8o'ld be 'sed

(A)
Reo%%endations)
Reo%%endations)
In "atients 3it8 ty"e diabetes4 8y"ertension4 and

any degree of alb'min'ria
ACE in8ibitors 8ave been s8o3n to delay "rogression of
ne"8ro"at8y (A)
In "atients 3it8 ty"e $ diabetes4 8y"ertension4 and

microalb'min'ria
7ot8 ACE in8ibitors and AR7s 8ave been s8o3n to delay
"rogression to macroalb'min'ria (A)
ADA. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S33.
Reo%%endations)
Reo%%endations)
In "atients 3it8 ty"e $ diabetes4 8y"ertension4

macroalb'min'ria4 and renal ins'fficiency
(ser'm creatinine F.% mg-dl)
AR7s 8ave been s8o3n to delay "rogression of
ne"8ro"at8y (A)
If one class is not tolerated4 t8e ot8er s8o'ld be

s'bstit'ted (E)
Reo%%endations)
Reo%%endations)
Red'ction of "rotein intaAe may im"rove meas'res of
renal f'nction ('rine alb'min e6cretion rate4 G?R) (7)
!o ..B H.. g 6 Ag body 3t
H
6 day
H
in t8ose 3it8 diabetes4
earlier stages of CJD
!o ..B g 6 Ag body 3t
H
6 day
H
in later stages of CJD
C8en ACE in8ibitors4 AR7s4 or di'retics are 'sed4

monitor ser'm creatinine4 "otassi'm levels for
develo"ment of ac'te Aidney disease4 8y"erAalemia (E)
Reo%%endations)
Reo%%endations)
Contin'e monitoring 'rine alb'min e6cretion to assess bot8
res"onse to t8era"y4 disease "rogression (E)
C8en eG?R G*. ml-min-.03 m
$
4 eval'ate4 manage "otential
com"lications of CJD (E)
Consider referral to a "8ysician e6"erienced in care of Aidney
disease (7)
Encertainty abo't etiology of Aidney disease
Diffic'lt management iss'es
Advanced Aidney disease
Definitions of Abno"%alities in
Definitions of Abno"%alities in
Alb-%in E@"etion
Alb-%in E@"etion
Category
S"ot collection
(Rg-mg
creatinine)
Normal G3.
&icroalb'min'ria 3.-$++
&acroalb'min'ria
(clinical)
=3..
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S34. !able 3.
Sta#es of C'"oni Aidne$ Disease
Sta#es of C'"oni Aidne$ Disease
Stage Descri"tion
G?R (ml-min
"er .03 m
$

body s'rface
area)
Jidney damage
@
3it8 normal or
increased G?R
=+.
$ Jidney damage
@
3it8 mildly
decreased G?R
*.HB+
3 &oderately decreased G?R 3.H%+
4 Severely decreased G?R %H$+
% Jidney fail're G% or dialysis
=idne+ damage de"ined as abnormalities on )athologic. urine. blood. or imaging tests'
>?3 4 glomerular "iltration rate
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S34. !able 4.
Mana#e%ent of CAD in Diabetes .1/
G?R (ml-min-
.03 m
$
) Recommended
All "atients Searly meas'rement of creatinine4 'rinary
alb'min e6cretion4 "otassi'm
4%-*. Referral to ne"8rology if "ossibility for
nondiabetic Aidney disease e6ists
Consider dose adK'stment of medications
&onitor eG?R every * mont8s
&onitor electrolytes4 bicarbonate4 8emoglobin4
calci'm4 "8os"8or's4 "arat8yroid 8ormone at
least yearly
Ass're vitamin D s'fficiency
Consider bone density testing
Referral for dietary co'nselling
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S3%. !able %9
Ada"ted from 8tt":--333.Aidney.org-"rofessionals-JD<TI-g'idelineUdiabetes-.
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S3%. !able %9
Ada"ted from 8tt":--333.Aidney.org-"rofessionals-JD<TI-g'idelineUdiabetes-.
G?R (ml-min-
.03 m
$
) Recommended
3.-44 &onitor eG?R every 3 mont8s
&onitor electrolytes4 bicarbonate4
calci'm4 "8os"8or's4 "arat8yroid
8ormone4 8emoglobin4 alb'min4 3eig8t
every 3H* mont8s
Consider need for dose adK'stment of
medications
G3. Referral to ne"8rologist
Reo%%endations) Retino,at'$
Reo%%endations) Retino,at'$
!o red'ce risA or slo3 "rogression of

retino"at8y
<"timi5e glycemic control (A)
<"timi5e blood "ress're control (A)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S3%.
Reo%%endations)
Reo%%endations)
Retino,at'$ S"eenin# .1/
Initial dilated and com"re8ensive eye

e6amination by an o"8t8almologist or o"tometrist
Ad'lts and c8ildren aged . years or older 3it8 ty"e

diabetes
Cit8in % years after diabetes onset (7)
#atients 3it8 ty"e $ diabetes
S8ortly after t8e diagnosis of diabetes (7)
Reo%%endations)
Reo%%endations)
S'bse2'ent e6aminations for ty"e and ty"e $ diabetic

"atients
S8o'ld be re"eated ann'ally by an o"8t8almologist or
o"tometrist
1ess fre2'ent e6ams (every $H3 years)
&ay be considered follo3ing one or more normal eye e6ams
&ore fre2'ent e6aminations re2'ired if retino"at8y is

"rogressing (7)
Reo%%endations)
Reo%%endations)
Dig8-2'ality f'nd's "8otogra"8s
Can detect most clinically significant diabetic retino"at8y
Inter"retation of t8e images
#erformed by a trained eye care "rovider
C8ile retinal "8otogra"8y may serve as a screening tool for
retino"at8y4 it is not a s'bstit'te for a com"re8ensive eye
e6am
#erform com"re8ensive eye e6am at least initially and at intervals
t8ereafter as recommended by an eye care "rofessional (E)
Reo%%endations)
Reo%%endations)
Comen 3it8 "ree6isting diabetes 38o are "lanning
"regnancy or 38o 8ave become "regnant
Com"re8ensive eye e6amination
Co'nseled on risA of develo"ment and-or "rogression of
diabetic retino"at8y
Eye e6amination s8o'ld occ'r in t8e first trimester

Close follo3-'" t8ro'g8o't "regnancy
?or year "ost"art'm (7)
Reo%%endations)
Reo%%endations)
Retino,at'$ T"eat%ent .1/
#rom"tly refer "atients 3it8 any level of mac'lar edema4
severe N#DR4 or any #DR
!o an o"8t8almologist Ano3ledgeable and e6"erienced in
management4 treatment of diabetic retino"at8y (A)
1aser "8otocoag'lation t8era"y is indicated
!o red'ce risA of vision loss in "atients 3it8
Dig8-risA #DR
Clinically significant mac'lar edema
Some cases of severe N#DR (A)
Reo%%endations)
Reo%%endations)
#resence of retino"at8y
Not a contraindication to as"irin t8era"y for

cardio"rotection4 as t8is t8era"y does not
increase t8e risA of retinal 8emorr8age (A)
Reo%%endations)
Reo%%endations)
Ne-"o,at'$ S"eenin#* T"eat%ent .1/
All "atients s8o'ld be screened for distal symmetric
"olyne'ro"at8y (D#N)
At diagnosis
At least ann'ally t8ereafter 'sing sim"le clinical tests (7)
Electro"8ysiological testing rarely needed

E6ce"t in sit'ations 38ere clinical feat'res are aty"ical (E)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S3*.
Reo%%endations)
Reo%%endations)
Screening for signs and sym"toms of cardiovasc'lar
a'tonomic ne'ro"at8y
S8o'ld be instit'ted at diagnosis of ty"e $ diabetes and % years after
t8e diagnosis of ty"e diabetes
S"ecial testing rarely needed9 may not affect management or
o'tcomes (E)
&edications for relief of s"ecific sym"toms related to D#N4
a'tonomic ne'ro"at8y are recommended
Im"rove 2'ality of life of t8e "atient (E)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.934(s'""l ):S3*.
Reo%%endations) Foot Ca"e .1/
?or all "atients 3it8 diabetes4 "erform an ann'al com"re8ensive foot
e6amination to identify risA factors "redictive of 'lcers and
am"'tations
Ins"ection
Assessment of foot "'lses
!est for loss of "rotective sensation: .-g monofilament "l's testing any one of
,ibration 'sing $B-D5 t'ning forA
#in"ricA sensation
AnAle refle6es
,ibration "erce"tion t8res8old (7)
1,,e" ,anel
!o "erform t8e .-g
monofilament test4 "lace t8e
device "er"endic'lar to t8e
sAin4 3it8 "ress're a""lied
'ntil t8e monofilament
b'cAles
Dold in "lace for second
and t8en release
Lo8e" ,anel
!8e monofilament test s8o'ld
be "erformed at t8e
8ig8lig8ted sites 38ile t8e
"atientIs eyes are closed
7o'lton AV&4 et al. Diabetes Care. $..B93:*0+-*B%.
#rovide general foot self-care ed'cation
All "atients 3it8 diabetes (7)
Ese m'ltidisci"linary a""roac8
Individ'als 3it8 foot 'lcers4 8ig8-risA feet9 es"ecially "rior 'lcer or am"'tation
(7)
Refer "atients to foot care s"ecialists for ongoing "reventive care4 life-
long s'rveillance (C)
SmoAers
1oss of "rotective sensation or str'ct'ral abnormalities
Distory of "rior lo3er-e6tremity com"lications
Initial screening for "eri"8eral arterial disease (#AD)

Incl'de a 8istory for cla'dication4 assessment of "edal
"'lses
Consider obtaining an anAle-brac8ial inde6 (A7I)9 many
"atients 3it8 #AD are asym"tomatic (C)
Refer "atients 3it8 significant cla'dication or a

"ositive A7I for f'rt8er vasc'lar assessment
Consider e6ercise4 medications4 s'rgical o"tions (C)
2II& DIABETES CARE IN
S(ECIFIC (O(1LATIONS
Reo%%endations) (ediat"i
!l$e%i Cont"ol .T$,e 1 Diabetes/
!l$e%i Cont"ol .T$,e 1 Diabetes/
Consider age 38en setting glycemic goals

in c8ildren and adolescents 3it8 ty"e
diabetes (E)
ADA. ,II. Diabetes Care in S"ecific #o"'lations. Diabetes Care. $.934(s'""l ):S3B.
Ne,'"o,at'$ .T$,e 1 Diabetes/
Ne,'"o,at'$ .T$,e 1 Diabetes/
Ann'al screening for microalb'min'ria4 3it8

a random s"ot 'rine sam"le for alb'min-to-
creatinine (ACR)ratio
Consider once c8ild is . years of age and 8as

8ad diabetes for % years (E)
Confirmed4 "ersistently elevated ACR on t3o

additional 'rine s"ecimens from different
days
!reat 3it8 an ACE in8ibitor4 titrated to

normali5ation of alb'min e6cretion4 if "ossible (E)
ADA. ,II. Diabetes Care in S"ecific #o"'lations. Diabetes Care. $.934(s'""l ):S3B-S3+.
;$,e"tension .T$,e 1 Diabetes/ .1/
!reat 8ig8-normal blood "ress're (systolic

or diastolic blood "ress're consistently
above t8e +.
t8
"ercentile for age4 se64 and
8eig8t) 3it8
Dietary intervention
E6ercise aimed at 3eig8t control and increased

"8ysical activity4 if a""ro"riate
If target blood "ress're is not reac8ed

3it8 3-* mont8s of lifestyle intervention
Consider "8armacologic treatment (E)

ADA. ,II. Diabetes Care in S"ecific #o"'lations. Diabetes Care. $.934(s'""l ):S3+.
#8armacologic treatment of 8y"ertension

(systolic or diastolic blood "ress're
consistently above t8e +%
t8
"ercentile for
age4 se64 and 8eig8t or consistently
F3.-B. mmDg4 if +%> e6ceeds t8at
val'e)
Initiate as soon as diagnosis is confirmed (E)

ACE in8ibitors
Consider for initial treatment of 8y"ertension4

follo3ing a""ro"riate re"rod'ctive co'nseling
d'e to "otential teratogenic effects (E)
Goal of treatment
7lood "ress're consistently G3.-B. mmDg or

belo3 t8e +.
t8
"ercentile for age4 se64 and
8eig8t4 38ic8ever is lo3er (E)
D$sli,ide%ia .T$,e 1 Diabetes/ .1/
Screening ()
If family 8istory of 8y"erc8olesterolemia (total

c8olesterol F$4. mg-dl) or a cardiovasc'lar event
before age %% years4 or if family 8istory is 'nAno3n
#erform fasting li"id "rofile on c8ildren
F$ years of age soon after diagnosis (after gl'cose
control 8as been establis8ed)
Screening ($)
If family 8istory is not of concern

Consider first li"id screening at "'berty
(=. years)
All c8ildren diagnosed 3it8 diabetes at or after "'berty

#erform fasting li"id "rofile soon after diagnosis (after
gl'cose control 8as been establis8ed) (E)
Screening (3)
?or bot8 age-gro'"s4 if li"ids are abnormal
Ann'al monitoring is recommended
If 1D1 c8olesterol val'es are 3it8in acce"ted

risA levels (G.. mg-dl W$.* mmol-lX)
Re"eat li"id "rofile every % years (E)
!reatment
Initial t8era"y: o"timi5e gl'cose control4 &N! 'sing Ste" II ADA diet aimed
at decreasing dietary sat'rated fat (E)
F age . years4 statin reasonable in t8ose (after &N! and lifestyle
c8anges) 3it8
1D1 c8olesterol F*. mg-dl (4. mmol-l) or
1D1 c8olesterol F3. mg-dl (3.4 mmol-l) and
<ne or more C,D risA factors (E)
Goal of t8era"y: 1D1 c8olesterol
G.. mg-dl ($.* mmol-l) (E)
ADA. ,II. Diabetes Care in S"ecific #o"'lations. Diabetes Care. $.934(s'""l ):S4..
&N!Omedical n'trition t8era"y
?irst o"8t8almologic e6amination

<btain once c8ild is . years of age9 8as 8ad
diabetes for 3H% years (E)
After initial e6amination

Ann'al ro'tine follo3-'" generally recommended
1ess fre2'ent e6aminations may be acce"table on

advice of an eye care "rofessional (E)
Retino,at'$ .T$,e 1 Diabetes/
Retino,at'$ .T$,e 1 Diabetes/
Celia Disease .T$,e 1 Diabetes/ .1/
C8ildren 3it8 ty"e diabetes
Screen for celiac disease by meas'ring tiss'e transgl'taminase or
antiendomysial antibodies4 3it8 doc'mentation of normal total ser'm IgA
levels4 soon after t8e diagnosis of diabetes (E)
Re"eat testing in c8ildren 3it8
Gro3t8 fail're
?ail're to gain 3eig8t4 3eig8t loss
Diarr8ea4 flat'lence4 abdominal "ain4 or signs of malabsor"tion
?re2'ent 'ne6"lained 8y"oglycemia or deterioration in glycemic control (E)
C8ildren 3it8 "ositive antibodies

Refer to a gastroenterologist for eval'ation 3it8
endosco"y and bio"sy (E)
C8ildren 3it8 bio"sy-confirmed celiac disease

#lace on a gl'ten-free diet
Cons'lt 3it8 a dietitian e6"erienced in managing

bot8 diabetes and celiac disease (E)
;$,ot'$"oidis% .T$,e 1 Diabetes/
;$,ot'$"oidis% .T$,e 1 Diabetes/
C8ildren 3it8 ty"e diabetes

Screen for t8yroid "ero6idase4 t8yroglob'lin antibodies
at diagnosis (E)
!8yroid-stim'lating 8ormone (!SD) concentrations

&eas're after metabolic control establis8ed
If normal4 rec8ecA every -$ years9 or
If "atient develo"s sym"toms of t8yroid dysf'nction4
t8yromegaly4 or an abnormal gro3t8 rate
Reo%%endations)
Reo%%endations)
("eone,tion Ca"e .1/
7efore conce"tion is attem"ted4 AC levels
Close to normal as "ossible (G0>) (7)
Starting at "'berty
Incor"orate "reconce"tion co'nseling in ro'tine diabetes clinic visit for all 3omen
of c8ild-bearing "otential (C)
Eval'ate 3omen contem"lating "regnancy9 if indicated4 treat for
Diabetic retino"at8y
Ne"8ro"at8y
Ne'ro"at8y
C,D (E)
ADA. ,II. Diabetes Care in S"ecific #o"'lations. Diabetes Care. $.934(s'""l ):S4.
Eval'ate medications 'sed "rior to conce"tion
Dr'gs commonly 'sed to treat diabetes4 com"lications may
be contraindicated or not recommended in "regnancy4
incl'ding
Statins4 ACE in8ibitors4 AR7s4 most nonins'lin t8era"ies (E)
Since many "regnancies are 'n"lanned4 consider "otential
risAs-benefits of medications contraindicated in "regnancy in
all 3omen of c8ildbearing "otential9 co'nsel accordingly (E)
ADA. ,II. Diabetes Care in S"ecific #o"'lations. Diabetes Care. $.934(s'""l ):S4.
Reo%%endations)
Reo%%endations)
Reo%%endations) Olde" Ad-lts .1/
?'nctional4 cognitively intact older ad'lts 3it8
significant life e6"ectancies s8o'ld receive diabetes
care 'sing goals develo"ed for yo'nger ad'lts (E)
Glycemic goals for t8ose not meeting t8e above criteria

may be rela6ed 'sing individ'al criteria4 b't
8y"erglycemia leading to sym"toms or risA of ac'te
8y"erglycemic com"lications s8o'ld be avoided in all
"atients (E)
ADA. ,II. Diabetes Care in S"ecific #o"'lations. Diabetes Care. $.934(s'""l ):S4$.
!reat ot8er cardiovasc'lar risA factors 3it8 consideration
of time frame of benefit4 individ'al "atient
!reatment of 8y"ertension is indicated in virt'ally all older
ad'lts9 li"id4 as"irin t8era"y may benefit t8ose 3it8 life
e6"ectancy e2'al to time frame of "rimary-secondary
"revention trials (E)
Individ'ali5e screening for diabetes com"lications 3it8
attention to t8ose leading to f'nctional im"airment (E)
ADA. ,II. Diabetes Care in S"ecific #o"'lations. Diabetes Care. $.934(s'""l ):S4$.
2III& DIABETES CARE IN
S(ECIFIC SETTIN!S
Reo%%endations)
Reo%%endations)
Diabetes Ca"e in t'e ;os,ital .1/
All "atients 3it8 diabetes admitted to t8e

8os"ital s8o'ld 8ave
!8eir diabetes clearly identified in t8e medical

record (E)
An order for blood gl'cose monitoring4 3it8

res'lts available to t8e 8ealt8 care team (E)
ADA. ,III. Diabetes Care in S"ecific Settings. Diabetes Care. $.934(s'""l ):S43.
Reo%%endations)
Reo%%endations)
Goals for blood gl'cose levels

Critically ill "atients: 4.-B. mg-dl
(. mmol-l) (A)
&ore stringent goals4 s'c8 as .-4. mg-dl (*.-0.B
mmol-l) may be a""ro"riate for selected "atients4 if
ac8ievable 3it8o't significant 8y"oglycemia (C)
Non-critically ill "atients: base goals on glycemic control4
severe comorbidities (E)
Reo%%endations)
Reo%%endations)
Sc8ed'led s'bc'taneo's ins'lin 3it8 basal4 n'tritional4
correction com"onents (C)
Ese correction dose or Ys'""lemental ins'linZ to correct
"remeal 8y"erglycemia in addition to sc8ed'led "randial
and basal ins'lin (E)
Initiate gl'cose monitoring in any "atients not Ano3n to
be diabetic 38o receives t8era"y associated 3it8 8ig8 risA
for 8y"erglycemia (7)
Reo%%endations)
Reo%%endations)
A 8y"oglycemia management "rotocol s8o'ld be ado"ted and
im"lemented by eac8 8os"ital or 8os"ital system
Establis8 a "lan for treating 8y"oglycemia for eac8 "atient9 doc'ment
e"isodes of 8y"oglycemia in medical record and tracA (E)
<btain AC for all "atients if res'lts 3it8in "revio's $-3 mont8s
'navailable (E)
#atients 3it8 8y"erglycemia 38o do not 8ave a diagnosis of
diabetes s8o'ld 8ave a""ro"riate "lans for follo3-'" testing and
care doc'mented at disc8arge (E)
Diabetes Ca"e in t'e ;os,ital)
NICE9S1!AR St-d$ .1/
1argest randomi5ed controlled trial to date
!ested effect of tig8t glycemic control

(target B-.B mg-dl) on o'tcomes
among *4.4 critically ill "artici"ants
&aKority (F+%>) re2'ired mec8anical

ventilation
In bot8 s'rgical-medical "atients4 +.-day mortality
significantly 8ig8er in intensively treated vs
conventional gro'" (target 44-B. mg-dl)
0B more deat8s ($0.%> vs $4.+>9 PO...$)
0* more deat8s from cardiovasc'lar ca'ses
(4.*> vs 3%.B>9 PO...$)
Severe 8y"oglycemia more common
(*.B> vs ..%>9 PG....)
IB& STRATE!IES FOR
IM(RO2IN!
DIABETES CARE
Ob=etive 1
Ob=etive 1
("ovide" and Tea% Be'avio" C'an#e
("ovide" and Tea% Be'avio" C'an#e
ADA. I/. Strategies for Im"roving Diabetes Care. Diabetes Care. $..933(s'""l ):S40.
?acilitate timely and a""ro"riate

intensification of lifestyle and-or
"8armace'tical t8era"y of "atients 38o
8ave not ac8ieved beneficial levels of
blood "ress're4 li"id4 or gl'cose control
Ob=etive 2
Ob=etive 2
(atient Be'avio" C'an#e
(atient Be'avio" C'an#e
Im"lement a systematic a""roac8 to s'""ort "atientsI
be8avior c8ange efforts as needed incl'ding
) 8ealt8y lifestyle ("8ysical activity4 8ealt8y eating4 non'se of
tobacco4 3eig8t management4 effective co"ing4 medication
taAing and management)
$) "revention of diabetes com"lications (screening for eye4 foot4
and renal com"lications9 imm'ni5ations)
3) ac8ievement of a""ro"riate blood "ress're4 li"id4 and gl'cose
goals
ADA. I/. Strategies for Im"roving Diabetes Care. Diabetes Care. $.934(s'""l ):S40.
Ob=etive 0
Ob=etive 0
C'an#e t'e S$ste%s of Ca"e
C'an#e t'e S$ste%s of Ca"e
Researc8 on t8e com"re8ensive c8ronic care (CC&) model
s'ggests additional strategies to im"rove diabetes care
Consistent4 evidence-based care g'idelines
Collaborative4 m'ltidisci"linary teams
A'dit and feedbacA of "rocess and o'tcome data to "roviders
Care management
Identifying and-or develo"ing comm'nity reso'rces and "'blic "olicy
t8at s'""orts 8ealt8y lifestyles
Alterations in reimb'rsement
ADA. I/. Strategies for Im"roving Diabetes Care. Diabetes Care. $.934(s'""l ):S40.

ADA Standards of Medical Care 2011

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ADA Standards of Medical Care 2011

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STANDARDS OF MEDICAL CARE

STANDARDS OF MEDICAL CARE

#rogressive ins'lin secretory defect

<t8er s"ecific ty"es of diabetes

Genetic defects in ;-cell f'nction4 ins'lin action

Gestational diabetes mellit's

Consider testing over3eig8t-obese ad'lts 3it8

In t8ose 3it8o't risA factors4 begin testing at age 4%

If tests are normal

Ese AC4 ?#G4 or $-8 0%-g <G!! (7)

In t8ose 3it8 increased risA for f't're diabetes

Identify and4 if a""ro"riate4 treat ot8er C,D risA

Screen for 'ndiagnosed ty"e $ diabetes at

In "regnant 3omen not "revio'sly Ano3n

#erform a 0%-g <G!!4 3it8 "lasma gl'cose

#erform <G!! in t8e morning after an

GD& diagnosis: 38en any of t8e follo3ing

Screen 3omen 3it8 GD& for "ersistent

Comen 3it8 a 8istory of GD& s8o'ld 8ave

Refer "atients 3it8 IG! (A)4 I?G (E)4 or AC %.0-

?ollo3-'" co'nseling im"ortant (7)9

Consider metformin if m'lti"le risA factors4

In t8ose 3it8 "rediabetes4 monitor for develo"ment

Age and c8aracteristics of onset of diabetes

Eating "atterns4 "8ysical activity 8abits4

Diabetes ed'cation 8istory

Revie3 of "revio's treatment regimens and

DJA fre2'ency4 severity4 and ca'se

Distory of diabetes-related com"lications

Deig8t4 3eig8t4 7&I

7lood "ress're determination4 incl'ding

SAin e6amination (for acant8osis nigricans and

Com"re8ensive foot e6amination

AC4 if res'lts not available 3it8in "ast $H3

If not "erformed-available 3it8in "ast year

Ann'al dilated eye e6am

?amily "lanning for 3omen of re"rod'ctive age

Registered dietitian for &N!

Diabetes self-management ed'cation

&ental 8ealt8 "rofessional4 if needed

Self-monitoring of blood gl'cose s8o'ld be

?or "atients 'sing less fre2'ent ins'lin

#erform AC test at least t3ice yearly in

#erform AC test 2'arterly in "atients

Ese of "oint-of-care testing for AC allo3s

1o3ering AC to belo3 or aro'nd 0>

!8erefore4 a reasonable AC goal for many

Additional analysis from several

#roviders mig8t reasonably s'ggest more

Conversely4 less stringent AC goals may

Goals s8o'ld be individ'ali5ed based on

#ost"randial gl'cose may be targeted if

&ore or less stringent glycemic goals may

#eo"le 3it8 diabetes s8o'ld receive DS&E

Effective self-management4 2'ality of life are

DS&E s8o'ld address "syc8osocial iss'es9

DS&E s8o'ld be reimb'rsed by t8ird-"arty

Individ'als 38o 8ave "rediabetes or

?or "eo"le 3it8 diabetes4 it is 'nliAely one

!8e best mi6 of carbo8ydrate4 "rotein4 and fat

Intensive lifestyle intervention res'lted in

Average B.*> 3eig8t loss

Red'ction in several C,D risA factors

7enefits s'stained at 4 years