Diabetes Clinical Practice Guideline Based on American Diabetes Association Position Statement: Standards of Medical Care in Diabetes 2018

Transcription

1 Diabetes Clinical Practice Guideline Based n American Diabetes Assciatin Psitin Statement: Standards f Medical Care in Diabetes 2018 Apprved by CHP Quality Imprvement Cmmittee: 9/8/09, 5/10/11, 3/12/13, 3/10/15, 03/14/17, 3/6/18

2 Standards f Medical Care fr Patients with Diabetes Mellitus Criteria fr Diagnsis 1. A1C 6.5% (preferred) OR 2. Fasting plasma glucse 126 mg/dl OR 3. 2-hur plasma glucse 200 mg/dl during an ral glucse tlerance test, OR 4. Symptms f hyperglycemia r hyperglycemic crisis and randm plasma glucse 200mg/dL Initial Evaluatin (Evidence A) Medical Histry Age and characteristics f diabetes nset Eating patterns, physical activity habits, nutritinal status, weight histry, sleep behavirs, substance use, scial supprt Cmplementary and alternative medicine use, vaccinatin histry and needs Diabetes educatin histry/needs t include health apps and nline educatin Presence f cmmn c-mrbidities, psychscial prblems and dental issues Assess fr fd insecurity, husing stability, and financial barriers and prvide self-management supprt frm health caches r cmmunity health wrkers when available (Evidence A) Review f previus treatment regimens and respnse t therapy; include A1C histry Current treatment f diabetes, including medicatins, medicatin taking-behavir, eating pattern, and psychscial cnditins t include anxiety, depressin, and cgnitive impairment Results f glucse mnitring and patient s use f data Insulin pump settings, as indicated Hypglycemic episdes hypglycemia awareness any severe hypglycemia: frequency and cause Histry f increased bld pressure, abnrmal lipids Histry f diabetes-related cmplicatins and cmmn cmrbidities micrvascular: retinpathy, nephrpathy, neurpathy (sensry, including histry f ft lesins; autnmic, including sexual dysfunctin and gastrparesis) macrvascular: CHD, cerebrvascular disease, PAD presence f hemglbinpathies r anemias dental, eye, and specialty visits Fr wmen f childbearing capacity, review cntraceptin and precnceptin planning Physical examinatin Height, weight and BMI Bld pressure determinatin, including rthstatic measurements when indicated Fundscpic examinatin Thyrid palpatin Skin examinatin (fr acanthsis nigricans, lipdystrphy, insulin injectin r infusin set insertin sites) Cmprehensive ft examinatin: Inspectin skin integrity, ulcers, cnditin f tenails, ft defrmity, callus 2

3 palpatin f drsalis pedis and psterir tibial pulses refer t ABI if diminished determinatin f prpriceptin, vibratin, and mnfilament sensatin Labratry evaluatin A1C, if results nt available within past 3 mnths If nt perfrmed r available within past year: Lipid prfile, including ttal, LDL and HDL chlesterl and triglycerides Liver functin tests Test fr urine albumin excretin with spt urine albumin-t-creatinine rati Serum creatinine and calculated egfr Thyrid-stimulating hrmne in Type 1 diabetes Vitamin B12 if n Metfrmin (when indicated) Serum ptassium levels in patients n ACE inhibitrs, ARBs, r diuretics Mrning Serum Teststerne level in men with diabetes wh have symptms r signs f hypgnadism (Evidence B) Referrals Eye Care prfessinal fr annual dilated eye exam Family planning fr wmen f reprductive age Registered dietician fr medical nutritin therapy Diabetes Self-Management Educatin (DSME)/ Diabetes Self-Management Supprt (DSMS) Dentist fr cmprehensive dental and peridntal examinatin Mental health prfessinal, if indicated Management Plan Glycemic cntrl: A reasnable gal fr many nn-pregnant adults is <7% (53 mml/ml). (evidence A) Lwering A1C t belw 7% has been shwn t reduce micrvascular cmplicatins f diabetes. Less-stringent A1C gals (such as <8 r 64 mml/ml) may be apprpriate fr patients with: a histry f severe hypglycemia limited life expectancy advanced micrvascular r macrvascular cmplicatins extensive c-mrbid cnditins lng-standing diabetes with a difficult t achieve gal despite diabetes educatin and mnitring and effective dses f multiple glucse-lwering agents including insulin (evidence B) Preprandial capillary plasma glucse: mg/dl Peak pstprandial capillary plasma glucse: <180 mg/dl Frm the America Cllege f Physicians: Gals and target ranges fr glycemic cntrl shuld be persnalized based n a discussin f benefits and harms f pharmactherapy, patients preferences, patients general health and life expectancy, treatment burden, and csts f care rather than a fixed target A1c fr all Shared Decisin making is imprtant in setting A1c gals 3

4 A1C AIC testing shuld be perfrmed rutinely in all patients with diabetes. The frequency f A1C testing is dependent n the clinical situatin, the treatment regimen and the clinician s judgment. A1C testing is subject t limitatins. In cnditins that affect red bld cell turnver (hemlytic and ther anemias, recent bld transfusins, use f drugs that stimulate erythrpiesis, ESRD, and pregnancy) and in hemglbin variants, ptins include mre frequent use f SMBG, CGM use, fructmsamine, and 1,5-anhydrglucitl Pharmaclgic therapy fr Type 2 diabetes Metfrmin, if nt cntraindicated and if tlerated, is the preferred initial pharmaclgical agent fr type 2 diabetes. (Evidence A) Metfrmin shuld be cntinued when used in cmbinatin with ther agents, including insulin, if nt cntraindicated and if tlerated (Evidence A) Self-mnitring f bld glucse (SMBG) Patients n multiple-dse insulin (MDI), r insulin pump therapy shuld perfrm self-mnitring bld glucse (SMBG) prir t meals and snacks, ccasinally pstprandial, at bedtime, prir t exercise, when they suspect lw bld glucse, after treating lw bld glucse until they are nrmglycemic, and prir t critical tasks such as driving. (Evidence B) When prescribed as part f a brad educatinal prgram, SMBG may help t guide treatment decisin and/r self-management fr patients taking less frequent insulin injectins (evidence B) r nninsulin therapies (evidence E) When prescribing SMBG, ensure that patients receive nging instructin and regular evaluatin f SMBG techniques and results, as well as their ability t use SMBG data t adjust therapy. (Evidence E) When used prperly, cntinuus glucse mnitring (CGM) in cnjunctin with intensive insulin regimens is a useful tl t lwer A1c in adults with type 1 diabetes wh are nt meeting glycemic targets (Evidence A) Medical Nutritin Therapy (MNT) Individuals with prediabetes r diabetes shuld receive individualized MNT t achieve treatment gals, preferably by a registered dietician familiar with the cmpnents f diabetes MNT.(Evidence A) Mdest weight lss may prvide clinical benefits in sme individuals with diabetes, especially thse early in the disease prcess. Interventin prgrams t facilitate weight lss are recmmended (Evidence A) Fr individuals n a flexible insulin prgram, educatin n carbhydrate cunting, and in sme cases fat and prtein gram estimatin, t determine mealtime insulin dsage, can imprve glycemic cntrl. (Evidence A) Fr individuals n a fixed daily insulin dse, having a cnsistent pattern f carbhydrate intake with respect t time and amunt can imprve glycemic cntrl and reduce the risk f hypglycemia (Evidence B) Individuals with diabetes and thse at risk shuld avid sugar-sweetened beverages t cntrl weight and reduce their risk f CVD and fatty liver (Evidence B) and shuld 4

5 minimize the cnsumptin f fds with added sugar that have the capacity t displace healthier, mre nutrient-dense fd chices (Evidence A) Ingested prtein appears t increase insulin respnse withut increasing plasma glucse, s carbhydrate surces high in prtein shuld be avided when trying t treat r prevent hypglycemia (Evidence B) An eating plan emphasizing elements f a Mediterranean-style diet rich in mnunsaturated and plyunsaturated fats may be cnsidered t imprve glucse metablism and lwer CVD risk and can be an effective alternative t a diet lw in ttal fat but relatively high in carbhydrates. (Evidence B) Eating fds rich in lng-chain fatty acids, such as fatty fish (EPA and DHA) and nuts and seeds (ALA) is recmmended t prevent r treat CVD (Evidence B). Hwever, evidence des nt supprt a beneficial rle fr the rutine use f n-3 dietary supplements (Evidence A). Alchl cnsumptin may place peple with diabetes at increased risk fr hypglycemia, especially if taking insulin r insulin secretaggues. Educatin and awareness regarding the recgnitin and management f delayed hypglycemia are warranted (Evidence B) Sdium shuld be limited t <2,300 mg/day, althugh further restrictin may be indicated fr thse with bth diabetes and hypertensin (evidence B) Nnnutritive sweeteners as a substitute fr calric sweeteners have the ptential t reduce verall calrie and carbhydrate intake and are generally safe t use within the defined acceptable daily intake levels (Evidence B) Macrnutrient distributin shuld be based n an individualized assessment f current eating patterns, preferences, and metablic gals. A variety f eating patterns are acceptable fr the management f diabetes t include the Mediterranean, Dietary Appraches t Stp Hypertensin (DASH), and plant-based diets. Individual meal planning shuld fcus n persnal preferences, needs, and gals. The diabetes plate methd can be useful fr prviding a visual guide Diabetes Self-Management Educatin (DSME) and Supprt (DSMS) All peple with diabetes shuld participate in diabetes self-management educatin t facilitate the knwledge, skills, and ability necessary fr diabetes self-care and in diabetes self-management supprt t assist with implementing and sustaining skills and behavirs needed fr nging self-management (Evidence B) Self-management educatin and supprt shuld be patient centered, may be given in grup r individual settings r by using technlgy, and shuld help guide clinical decisins (Evidence A) Physical Activity Mst adults with type 1 (evidence C) and type 2 (evidence B) diabetes shuld engage in 150 minutes r mre f mderate-t-vigrus physical activity per week spread ver at least 3 days a week with n mre than 2 cnsecutive days withut activity; and they shuld engage in 2-3 sessins per week f resistant exercise. All adults, particularly thse with type 2 diabetes, shuld decrease the amunt f time spent in daily sedentary behavir (evidence B). Flexibility and balance training are recmmended 2-3 times per week and may include yga r tai chi (evidence C) Prlnged sitting shuld be interrupted every 30 minutes fr bld glucse benefits, particularly in adults with type 2 (evidence C) Behaviral Health Psychscial care shuld be integrated with a cllabrative, patient-centered apprach and prvided 5

6 t all peple with diabetes, with the gals f ptimizing health utcmes and health-related quality f life (Evidence A) Screen fr psychscial prblems such as depressin, diabetes-related distress, anxiety, eating disrders, and cgnitive impairment at peritic intervals and when there is a change in disease, treatment, r life circumstance. Include caregivers and family members in the assessment as warranted. (Evidence B) Older adults (>65 years) with diabetes shuld be cnsidered a high-pririty ppulatin fr depressin screening and treatment and fr cgnitive status (Evidence B) Cardivascular disease and Risk Management Measure bld pressure at every rutine visit (Evidence B). Mst peple with diabetes and hypertensin shuld be treated t a systlic bld pressure gal f <140 mmhg and a diastlic bld pressure gal f <90 mmhg. (Evidence A). All hypertensive patients with diabetes shuld mnitr their bld pressure at hme (Evidence B) Pharmaclgical therapy fr patients with diabetes and hypertensin shuld be with drug classes demnstrated t reduce cardivascular events t include ACE inhibitrs, angitensin receptr blckers (ARBs), thiazide-line diuretics, r dihydrpyridine calcium channel blckers (Evidence A) An ACE inhibitr r angitensin receptr blcker, at the maximally tlerated dse indicated fr bld pressure treatment, is the recmmended first line treatment fr hypertensin in patients with diabetes and urinary albumin-t-creatinine rati 300 (Evidence A) r mg/g creatinine (Evidence B). If ne class is nt tlerated, the ther shuld be substituted (Evidence B) Multiple-drug therapy is generally required t achieve bld pressure targets. Hwever, cmbinatins r ACE inhibitr and angitensin receptr blckers and cmbinatins f ACE inhibitrs r angitensin receptr blckers with direct renin inhibitrs shuld nt be used (Evidence A) Fr patients treated with an ACE inhibitr r ARB r diuretic, serum creatinine/egfr and serum ptassium levels shuld be mnitred at least annually (Evidence B) Fr patients with bld pressure >120/80 mmhg, lifestyle interventins cnsist f weight lss if verweight r bese, a DASH (Dietary Appraches t Stp Hypertensin) style diet, reducing dietary sdium, increasing dietary ptassium, mderatin f alchl, and increased physical activity (Evidence B) Fr patient f all ages with diabetes and vert athersclertic cardivascular disease, (CVD) high intensity Statin therapy shuld be added t lifestyle therapy. (Evidence A) Fr patients with diabetes aged years (Evidence A) and >75 years (Evidence B) withut additinal athersclertic CVD risk factrs, cnsider using mderate-intensity Statin and lifestyle therapy Cmbinatin therapy (Statin/fibrate and niacin/statin) has nt been shwn t imprve athersclertic CVD utcmes and is generally nt recmmended. Statin/niacin therapy may increase the risk f strke (Evidence A) Fr patients with diabetes and athersclertic cardivascular disease, if LDL chlesterl is 70 mg/dl n maximally tlerated statin dse, cnsider adding additinal LDL-lwering therapy (such as ezetimibe r PCSK9 inhibitr) after evaluating the ptential fr further athersclertic cardivascular disease risk reductin, drug-specific adverse effects, and patient preferences. 6

7 Ezetimibe may be preferred due t lwer cst (Evidence A) In patients with diabetes type 2 and established athersclertic cardivascular disease, antihyperglycemic therapy shuld begin with lifestyle management and metfrmin and subsequently incrprate an agent prven t reduce majr averse cardivascular events and cardivascular mrtality (currently empagliflzin and liraglutide), after cnsidering drug-specific and patient factrs (Evidence A) Statin therapy is cntraindicated in pregnancy (Evidence B) Antiplatelet Therapy Use aspirin therapy ( mg/day) as a secndary preventin strategy in thse with diabetes and a histry f CVD. (Evidence A) Fr thse with a dcumented aspirin allergy, clpidgrel (75 mg/day) shuld be used (Evidence B) Aspirin therapy ( mg/day) may be cnsidered as a primary preventin strategy in thse with type 1 r type 2 diabetes wh are at increased cardivascular risk and are nt at increased risk f bleeding(evidence C) Smking cessatin Advise all patients nt t smke r use tbacc prducts (Evidence A) r e-cigarettes (Evidence E) Include smking cessatin cunseling and ther frms f treatment as a rutine cmpnent f diabetes care. (Evidence B) Older Adults Screen fr cgnitive impairment and depressin in adults aged 65 and lder at initial visit and annually as apprpriate (Evidence B) Adjust glycemic targets and pharmaclgic interventins t avid hypglycemia (Evidence B) Avid vertreatment (Evidence B) Simplify cmplex regimens if it can be achieved within the individualized A1c target (Evidence B) Diabetic Kidney Disease T reduce the risk r slw the prgressin f diabetic kidney disease, ptimize glucse cntrl and bld pressure cntrl. (Evidence A) At least nce a year, quantitatively assess urinary albumin and egfr in patients with type 1 diabetes with duratin f 5 years and all patients with type 2 diabetes and in all patients with cmrbid hypertensin. (Evidence B) Treat all nn-pregnant patients with diabetes and hypertensin and urinary albumin excretin >300 mg/day r egfr <60 ml/min/1.73m² with ACE inhibitrs r ARBs. (Evidence A) Patients shuld be referred fr evaluatin fr renal replacement treatment if they have an egfr f <30 ml/min/1.73 m² Prmptly refer t a physician experienced in the care f kidney disease fr uncertainty abut the etilgy f kidney disease, difficult management issues, and rapidly prgressing kidney disease (Evidence B) 7

8 Retinpathy T reduce the risk r slw the prgressin f retinpathy, ptimize glucse cntrl and bld pressure cntrl. (Evidence A) Adults with type 1 diabetes shuld have an initial dilated and cmprehensive eye examinatin by an phthalmlgist r ptmetrist within 5 years after the nset f diabetes (Evidence B) Patients with type 2 diabetes shuld have an initial dilated and cmprehensive eye examinatin by an phthalmlgist r ptmetrist at the time f the diagnsis f diabetes (Evidence B) If there is n evidence f retinpathy fr ne r mre eye exams, then exams every 1-2 years may be cnsidered (Evidence B) If diabetic retinpathy is present, subsequent examinatin fr patients with type 1 and 2 diabetes shuld be repeated mre frequently by an phthalmlgist r ptmetrist Prmptly refer patients with any level f macular edema, severe nnprliferative diabetic retinpathy r any prliferative diabetic retinpathy t an phthalmlgist wh is knwledgeable and experienced in the management and treatment f diabetic retinpathy (Evidence A) The presence f retinpathy is nt a cntraindicatin t aspirin therapy fr cardi prtectin as this therapy des nt increase the risk f retinal hemrrhage (Evidence A) Neurpathy All patients shuld be screened fr diabetic peripheral neurpathy (DPN) starting at diagnsis f type 2 diabetes and 5 years after the diagnsis f type 1 diabetes and at least annually thereafter using simple clinical tests such as 10-g mnfilament. (Evidence B) Optimize glycemic cntrl t prevent r delay the develpment f DPN and cardivascular autnmic neurpathy (CAN) in patients with type 1 diabetes (Evidence A) and t slw the prgressin f neurpathy in sme patients with type 2 diabetes (Evidence B) Assess and treat patients t reduce pain related t DPN (Evidence B) Either pregabalin r dulxetine are recmmended as initial pharmaclgic treatments fr neurpathic pain in diabetes (Evidence A) Ft Care Perfrm at least an annual cmprehensive ft examinatin t include inspectin, assessment f ft and leg pulses and defrmities, and testing fr lss f prtective sensatin (10-g mnfilament plus any ne f the fllwing: vibratin using 128-Hz tuning frk, pinprick sensatin, ankle reflexes r vibratin perceptin threshld (Evidence B) A multidisciplinary apprach, including the use f specialized ftwear, is recmmended fr individuals with ft ulcers and high-risk feet t include dialysis patients and thse with Charct ft, prir ulcers, r amputatin (Evidence B) Prvide general ft self-care educatin t patients with diabetes (Evidence B) Immunizatin Annual influenza vaccine (Evidence C) Pneumcccal vaccine (Evidence C) Hepatitis B vaccine fr unvaccinated adults (Evidence C) Prvide rutine vaccinatins fr children and adults with diabetes by age (Evidence C) 8

9 Annual Measurement fr Effectiveness f Diabetes Guideline HEDIS Cmprehensive Diabetes Care, Cmmercial and Medicare ppulatins: HbA1c Testing Pr HbA1c cntrl (>9%) HbA1c Cntrl (<8%) HbA1c Cntrl (<7%) fr a selected ppulatin Statin Medicatin Adherence Retinal Eye Exam Medical Attentin fr Nephrpathy Bld Pressure Cntrlled <140/90 mm Hg ADA recmmendatins are assigned rating f A, B r C depending n the quality f evidence: Evidence A- recmmendatins are based n large well-designed clinical trials r well-dne meta-analyses Evidence B- recmmendatins are based n well-cnducted chrt studies Evidence C- supprtive evidence frm prly cntrlled r uncntrlled studies. There may be evidence frm bservatinal studies r cnflicting evidence where the weight f the evidence supprts the recmmendatin Evidence E- Expert pinin r clinical experience References: American Diabetes Assciatin; Diabetes Care; the Jurnal f Clinical and Applied Research and Educatin; Vlume 41; Supplement 1 January 2018 NCQA; Technical Specificatins fr Health Plans; HEDIS 2018; Vlume 2 American Cllege f Physicians (2018, March 6) Clinical Guideline: Hemglbin A1c Targets fr Glycemic Cntrl With Pharmaclgic Therapy fr Nnpregnant Adults With Type 2 Diabetes Mellitus: A Guidance Statement Update Frm the American Cllege f Physicians. Retrieved frm 9