CLINICAL PRACTICE GUIDELINE

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2 Pages: 2 f 11 V. GUIDELINE: The fllwing guidelines are cnsistent with the 2018 Standards f Medical Care in Diabetes frm the American Diabetes Assciatin (ADA). Sme specificatins fr HEDIS measures f diabetes care are incrprated. Denver Health recmmends a check-up fr diabetes management every 6 mnths if at gal n measures, and every 3 mnths if nt at gal. A. Initial/Cmprehensive Medical Evaluatin: Cnfirm and classify diabetes diagnsis; evaluate fr cmplicatins and ptential cmrbid cnditins; review previus treatment and risk factr cntrl; engage patient in frmulatin f care management plan; develp plan fr cntinuing care B. Additinal tasks as apprpriate fr Fllw-up Visits r Annual Evaluatin: 1. Interval medical histry 2. Assess medicatin cmpliance and behavir. Review any intlerance f side effects. 3. Physical examinatin (height, weight, BMI, bld pressure, thyrid palpatin 4. Cmprehensive ft exam: Inspectin; palpatin f pulses; determinatin f mnfilament sensatin and 1 additinal sensatin (prpriceptin, vibratin, pinprick, r ankle reflex.) 5. Labratry evaluatin: A1C, if results nt available within the past 6 mnths r last 3 mnths if previus value nt at gal. As necessary, lipid prfile, liver functins, sprt urinary albumin-t-creatinine rati, serum creatinine and egfr, and thyrid-stimulating hrmne fr thse with Type-1 diabetes every 3-5 years per ACC-AHA guidelines. 6. Assess risk fr cmplicatins, including cardivascular and micr/macrvascular cmplicatins (see additinal tab belw fr further discussin) 7. Diabetes self-management behavirs: nutritin, psychscial health, need fr referrals, immunizatins; r ther rutine health maintenance screening 8. Cmrbidities: cmmn cmrbidities with diabetes may cmplicate management. The physician and multidisciplinary team will assess and mnitr fr cmrbidities and prvide screening/plan interventins as necessary Autimmune Diseases: Cnsider screening type 1 diabetes patients fr autimmune thyrid disease and celiac disease Cancer: Diabetic patients are at increased risk f cancers f the liver, pancreas, endmetrium, cln/rectum, breast, and bladder. This may result frm shared risk factrs between diabetes and age, r with diabetes related factrs. Patients are encuraged t underg recmmended This guideline is designed t assist prviders by prviding an analytical framewrk fr the evaluatin and treatment f patients, and is nt intended either t replace a clinicians judgment r t establish a prtcl fr all patients with a particular cnditin.

3 Pages: 3 f 11 age and sex-apprpriate cancer screenings as well as reduce the mdifiable risk factrs (besity, inactivity, and smking). Cgnitive Impairment/Dementia Fatty Liver Disease: Interventins that imprve metablic abnrmalities (weight lss, glycemic cntrl, treatment fr dyslipidemia, etc.) are als beneficial fr fatty liver disease. Fractures: Age-specific hip fracture risk is increased in diabetes (bth male and female). Type 1 diabetes is assciated with an increased risk fr steprsis. Type 2 diabetes shws an increased risk f fracture despite higher bne mineral density. Hearing Impairment Obstructive Sleep Apnea Peridntal Disease Psychscial Disrders: Regular and cnsistent screening fr anxiety, depressin, disrdered eating, and serius mental illness. These can impact the patient s ability t self-manage their diabetes. If screening demnstrates psychscial impact, initiatin f a referral fr additinal services may be indicated. C. Lifestyle Management and Care Plan Develpment/Updates with patient regarding: 1. Diabetes self-management educatin (DSME) and diabetes self-management supprt (DSMS): All peple with diabetes shuld participate in self-management educatin and supprt t assist with btaining the knwledge, skills, and ability fr self-care as well as the behavirs needed fr nging self-management. These patient-centered tls cnsider the needs f the individual t imprve utcmes and reduce csts. Cntent may be tailred t preventin as well. a. Overall bjectives: supprt infrmed decisin-making, self-care behavirs, prblem-slving, and active cllabratin with health-care team. 2. Nutritin Therapy: Patient specific-gals include assisting the patient in determining what t eat and fllwing a fd plan. Specific dietary recmmendatins can be accessed at the ADA website. a. Fr verweight and bese type 2 Diabetic patients, mdest weight lss can imprve glycemic cntrl. Sustaining weight lss is challenging. Referral t ther resurces may be necessary t help the patient maintain r achieve nutritinal gals. Fr additinal infrmatin, please refer t 3. Physical Activity: a. Children and Adlescents: 60min/day r mre f mderate r vigrus activity at least 3 days/week. This guideline is designed t assist prviders by prviding an analytical framewrk fr the evaluatin and treatment f patients, and is nt intended either t replace a clinicians judgment r t establish a prtcl fr all patients with a particular cnditin.

4 Pages: 4 f 11 b. Adults: 150 minutes r mre f mderate t vigrus activity per week, spread ver at least 3 days/week unless cntraindicated. Flexibility and balance training 2-3/week fr lder adults with diabetes. 2-3 sessins/week f resistance exercise n nncnsecutive days fr adults with type 1C r type 2B diabetes. All adults with diabetes shuld decrease sedentary behavir. c. Preventin r Delay f Type 2 Diabetes: At least annual mnitring fr develpment f diabetes fr thse in which pre-diabetes is suggested alng with: Referral t lifestyle interventin prgram as indicated Cnsider Metfrmin therapy fr preventin f type 2 diabetes shuld fr thse with prediabetes, especially with BMI 35, aged <60 years, and wmen with prir gestatinal diabetes mellitus. Peridic measurement f vitamin B12 levels shuld be cnsidered in metfrmin-treated patients 4. Smking Cessatin: advise all patients nt t use tbacc. Include screening and cessatin cunseling as a rutine cmpnent f care. 5. Psychscial Issues: screening and fllw up regarding attitudes abut illness, expectatins fr management and utcmes, quality f life, and available resurces, depressin, anxiety, cgnitive capacities, etc. D. Glycemic Targets: The 2018 ADA update recmmends cntinuus glucse mnitring in all adults with type 1 diabetes wh are nt meeting glycemic targets, regardless f age. A1C HEDIS Frequency f Testing target classificatin <8% * Gd Cntrl Twice a year if meeting treatment gals with stable glycemic cntrl >9% Pr Cntrl Quarterly if nt meeting treatment gals r with recent changes in therapy The 2018 ADA psitin statement cnsiders <7% a reasnable A1C gal fr many nn-pregnant adults. Hwever, HEDIS classifies gd cntrl <8% fr mst ppulatins, <7% fr selected ppulatin. Clinical judgement is warranted t determine the apprpriate glycemic target based n the needs f the patient. Fr mre details and infrmatin, please refer t Glycemic Targets: Standards f Medical Care in Diabetes E. Pharmaclgic appraches t Glycemic Treatment (Frm ADA, 2018): This guideline is designed t assist prviders by prviding an analytical framewrk fr the evaluatin and treatment f patients, and is nt intended either t replace a clinicians judgment r t establish a prtcl fr all patients with a particular cnditin.

5 Pages: 5 f Insulin Therapy fr Type 1 diabetes: Mst patients shuld be treated with multiple daily injectins f prandial insulin and basal insulin r cntinuus subcutaneus insulin infusin and use rapid-acting insulin analgs t reduce hypglycemia risk 2. Type 2 Diabetes: a. Metfrmin, if nt cntraindicated and tlerated is the preferred initial agent fr treatment. Cnsider peridic measurement f vitamin B12 levels, especially in thse with anemia r peripheral neurpathy b. A patient-centered apprach shuld be used t guide the chice f pharmaclgic agents and medicatin adherence shuld be a cnsideratin when selecting pharmaclgic therapy. Prviders shuld als cnsider efficacy, hypglycemia risk, histry f athersclertic cardivascular disease, impact n weight, ptential side effects, renal effects, delivery methd (ral versus subcutaneus), cst, and patient preferences c. If A1C is abve target, selectin f pharmaclgic treatment is based n several factrs such as: the presence r absence f established athersclertic cardivascular disease (ASCVD) r chrnic kidney disease (CKD); whether r nt there is a cmpelling need t minimize hypglycemia; and cst. DHMP adheres t the clinical care guidelines specified by Denver Health (DH) Ambulatry Care Services (ACS) in their clinical care guideline, Diabetes Management fr Nn-Pregnant Adults in the Outpatient Setting. Further details can be accessed via titled, Management f Hyperglycemia in Type 2 Diabetes, 2018 cnsensus reprt by the American Diabetes Assciatin (ADA) and the Eurpean Assciatin fr the Study f Diabetes (EASD). d. Reevaluatin f the medicatin regimen and adjustment as needed t incrprate patient factrs and regimen cmplexity is recmmended. F. CVD and Risk Management: Leading cause f mrbidity and mrtality fr thse with diabetes; and largest cntributr t the csts f diabetes. 1. Risk factrs (hypertensin, dyslipidemia, smking, family histry f premature crnary disease, and albuminuria) shuld be assessed annually. 2. Bld Pressure Cntrl: ALL patients with hypertensin and diabetes shuld mnitr their bld pressure at hme t help identify masked hypertensin, as well as t imprve medicatin-taking behavir. Gal Screening Diagnsis <140/90mmHg Measured at each rutine visit If elevated, cnfirmed n separate visit/day *lwer BP targets may be apprpriate fr yunger patients, thse with albuminuria, and/r thse with hypertensin and ne r mre additinal ASCVD risk factrs if they can be achieved withut undue treatment r burden (ADA, 2017). This guideline is designed t assist prviders by prviding an analytical framewrk fr the evaluatin and treatment f patients, and is nt intended either t replace a clinicians judgment r t establish a prtcl fr all patients with a particular cnditin.

6 Pages: 6 f 11 a. Patients with BP >120/80 shuld be advised n lifestyle changes (weight lss, diet changes, increased physical activity, etc.) t reduce bld pressure. b. Patients with cnfirmed BP >140/90 n 2 ccasins: lifestyle therapy + initiatin and titratin f pharmaclgical therapy t achieve bld pressure gal unless cntraindicated. c. Patients with cnfirmed BP >160/100: lifestyle therapy + initiatin f titratin f 2 drugs t reduce CVD events in patients with diabetes. d. ACE inhibitr r ARB at the maximum tlerated dse indicated fr bld pressure treatment is the recmmended first line treatment fr hypertensin in patients with diabetes and urine albumin-t-creatinine rati 300 mg/g creatinine r UACR mg/g creatinine. If ne class is nt tlerated the ther shuld be substituted. e. Fr patients treated with ACE, ARB, r diuretic, serum creatinine/estimated glmerular filtratin rate (egfr) and serum ptassium levels shuld be mnitred. f. Fr patients with bld pressure >120/80, lifestyle interventin cnsists f weight lss (if indicated), a DASH-style dietary pattern (lw sdium and increased ptassium), mderatin f alchl intake, and increased physical activity. 3. Lipid Management: Lipid management is driven by risk status, nt LDL-C level. a. Lifestyle mdificatin educatin and recmmendatins: fcus n weight lss (if indicated) diet mdificatin, and increasing physical activity. Intensify lifestyle therapy and ptimize glycemic cntrl fr patients with elevated triglyceride levels. With triglyceride levels 500mg/dL (5.7mml/L), evaluate fr secndary causes and cnsider medical therapy t reduce the risk f pancreatitis. b. Adjust intensity f statin therapy based n individual respnse t medicatin. c. Patients with diabetes, years f age, shuld be cunseled n their risk fr a cardivascular event thrugh a recgnized shared decisin making aid. This guideline is designed t assist prviders by prviding an analytical framewrk fr the evaluatin and treatment f patients, and is nt intended either t replace a clinicians judgment r t establish a prtcl fr all patients with a particular cnditin.

7 Pages: 7 f 11 High-Intesity and Mderate-Intensity Statin Therapy (frm ADA, 2018) High-Intensity Statin Therapy: lwers LDL Mderate Intensity Statin Therapy: lwers LDL chlesterl by 50% chlesterl by 30-50% Atrvastatin 40-80mg Atrvastatin 10-20mg Rsuvastatin 20-40mg Rsuvastatin 5-10mg Simvastatin 20-40mg Pravastatin 40-80mg Lvastatin 40mg Fluvastatin XL 80mg Pitavastatin 2-4mg Recmmendatins fr Statin and Cmbinatin Treatment in Adults with Diabetes (Table 8-1: ADA, 2018) This guideline is designed t assist prviders by prviding an analytical framewrk fr the evaluatin and treatment f patients, and is nt intended either t replace a clinicians judgment r t establish a prtcl fr all patients with a particular cnditin.

8 Pages: 8 f Antiplatelet Agents: a. Use aspirin therapy ( mg/day) as a secndary preventin fr thse with diabetes and a histry f ASCVD. b. If the patient has a dcumented aspirin allergy and ASCVD, clpidgrel (75mg/day) may be used. c. Dual antiplatelet therapy is reasnable fr up t 1 year after an acute crnary syndrme. d. Cnsider aspirin therapy as a primary preventin strategy fr thse with diabetes at increased cardivascular risk (family histry f premature ASCVD, hypertensin, smking, dyslipidemia, r albuminuria) and nt at increased risk f bleeding. F. Crnary Heart Disease: 1. Patients with prir mycardial infarctin shuld be cntinued n beta blckers fr at least 2 years after the event. 2. Fr thse with knwn ASCVD, use aspirin and statin therapy if nt cntraindicated, and cnsider ACE therapy as necessary. 3. Fr thse with symptmatic heart failure, d nt use thiazlidinedine. G. Micrvascular Cmplicatins and Ft Care: 1. Diabetic Kidney Disease (DKD): Screening fr nephrpathy is als a cmpnent f HEDIS a. Assess urinary albumin and egfr annually (this applies t patients with type 2 diabetes, patients with cmrbid hypertensin, and type 1 diabetes with a duratin f 5 years). b. Optimize glucse cntrl and bld pressure cntrl t reduce risk r slw the prgressin. c. Fr patients (nn-pregnant) with diabetes and HTN, either and ACE r and ARB is recmmended fr thse with mdestly elevated UACR ( mg/g creatinine) and is strngly recmmended fr thse with UACR >300mg/g creatinine. d. Bld pressure levels <140/90 are recmmended t reduce CVD mrtality and slw chrnic kidney disease prgressin. Management f Chrnic Kidney Disease: GFR (ml/min/1.73m 2 ) Recmmended Management All Patients Yearly measurement f creatinine, UACR, ptassium Referral t a nephrlgist if pssibility fr nndiabetic kidney disease exists; cnsider need fr dse adjustment f medicatin; mnitr egfr every 6 mnths; mnitr electrlytes, bicarbnate, hemglbin, calcium, phsphrus, and parathyrid hrmne at least yearly; assure vitamin D sufficiency; cnsider bne density testing; referral fr dietary cunseling This guideline is designed t assist prviders by prviding an analytical framewrk fr the evaluatin and treatment f patients, and is nt intended either t replace a clinicians judgment r t establish a prtcl fr all patients with a particular cnditin.

9 Pages: 9 f Mnitr egfr every 3 mnths; mnitr electrlytes, bicarbnate, calcium, phsphrus, parathyrid hrmne, hemglbin, albumin, and weight every 3-6 mnths; cnsider dse adjustment f medicatins <30 Referral t a nephrlgist 2. Diabetic Retinpathy: Optimize glycemic cntrl, bld pressure, and serum lipid cntrl can reduce risk/slw prgressin. Retinal Eye Exam is a cmpnent f the HEDIS measurement. Fundus phtgraphs are a screening tl, nt a substitute fr a cmprehensive exam. If utilizing eye camera- interpretatin f images is t be cmpleted by a trained eye care prvider. Screening fr Diabetic Retinpathy: Ppulatin Exam/Finding Timeframe Adults with Type 1 Diabetes Patients with Type 2 Diabetes All diabetic patients after initial exam All diabetic patients after initial exam r with abnrmal findings Initial dilated and cmprehensive eye exam by an phthalmlgist r ptmetrist Initial dilated and cmprehensive eye examinatin by an phthalmlgist r ptmetrist n evidence f retinpathy fr ne r mre annual exams Any evidence f diabetic retinpathy present =>dilated retinal exam Retinpathy that is prgressing r sightthreatening Within 5 years after nset f diabetes At the time f the diabetes diagnsis Exams every 2 years may be cnsidered Dilated retinal exam repeated annually by an phthalmlgist r ptmetrist Requires mre frequent examinatins/mnitring *Cnsider a referral t phthalmlgist specializing in retinpathy with signs f any macular edema, r retinpathy 3. Neurpathy: a. Tight glycemic cntrl is the nly methd shwn t prevent/delay diabetic neurpathy in Type 1 diabetics, and t slw prgressin f diabetic neurpathy in Type 2 patients. b. Assessment and Screening: All patients shuld be assessed fr diabetic peripheral neurpathy (DPN) starting at diagnsis f type 2 diabetes and 5 years after the diagnsis f type 1diabetes. Annual assessment thereafter. Assessment fr distal symmetric plyneurpathy shuld include histry and assessment f either temperature r pinprick sensatin and vibratin sensatin using a 128-Hz tuning frk. All patients shuld have annual 10- This guideline is designed t assist prviders by prviding an analytical framewrk fr the evaluatin and treatment f patients, and is nt intended either t replace a clinicians judgment r t establish a prtcl fr all patients with a particular cnditin.

10 Pages: 10 f 11 g mnfilament testing t identify feet at risk f ulceratin and amputatin. Treatment can include pregabalin, r dulxetine. 4. Ft Care: a. An annual cmprehensive ft exam will identify risk factrs fr ulcers and amputatins. b. The annual exam shuld include: inspectin f the skin, assessment f ft defrmities, neurlgical assessment (10-g mnfilament testing), and vascular assessment, including pulses in legs and feet. c. Obtain a histry f ulceratin, amputatin, Charct ft, angiplasty r vascular surgery, cigarette smking, retinpathy, and renal disease. Als assess current symptms f neurpathy and vascular disease. d. Prvide general preventive ft self-care educatin including, ftwear selectin/behavirs, and hme care. H. Older Adults: Generally, lder adults ( 65 years) wh are functinal, cgnitively intact, and with a lng life expectancy have the same treatment gals as yunger adults. Older adults have a higher risk f premature death, cexisting illnesses, depressin and geriatric syndrmes, including neurcgnitive impairment. The ADA cnsensus reprt Diabetes in Older Adults cntains further details. 1. Cnsider the assessment f medical, functinal, mental, and scial geriatric dmains fr diabetes management in lder adults t prvide a framewrk t determine targets and therapeutic appraches. 2. Screening fr geriatric syndrmes may be apprpriate in lder adults experiencing limitatins in their basic and instrumental activities f daily living as they may affect diabetes self-management and be related t health-related quality f life. 3. Screening fr diabetes cmplicatins shuld be individualized in lder adults. Pay clse attentin t cmplicatins that lead t functinal impairment. 4. Glycemic levels may be relaxed in lder adults based n individual criteria. 5. Annual screening fr early detectin f mild cgnitive impairment r dementia fr thse 65 years and lder. 6. High pririty ppulatin fr depressin screening and treatment. 7. Hypglycemia shuld be avided. Assess and manage by adjusting targets as necessary. 8. Persns wh use cntinuus glucse mnitring and insulin pumps shuld cntinue with access as applicable after age 65. RELEVANT LINKS: 1. Standards f Medical Care in Diabetes-2018 Abridged fr Primary Care Prviders: 2. Management f Hyperglycemia in Type 2 Diabetes, 2018 cnsensus reprt by the American Diabetes Assciatin (ADA) and the Eurpean Assciatin fr the Study f Diabetes (EASD): This guideline is designed t assist prviders by prviding an analytical framewrk fr the evaluatin and treatment f patients, and is nt intended either t replace a clinicians judgment r t establish a prtcl fr all patients with a particular cnditin.

11 Pages: 11 f DH ACS Clinical Care Guideline: Diabetes Management fr Nn-Pregnant Adults in the Outpatient Setting: REFERENCES: American Assciatin f Clinical Endcrinlgists. (2015). AACE/ACE Cmprehensive Diabetes Management Algrithm (2015). American Diabetes Assciatin. (2018, January). Summary f Revisins: Standards f Medical Care in Diabetes American Diabetes Assciatin. (2018, January). Standards f Medical Care in Diabetes-2018 Abridged fr Primary Care Prviders. Management f Hyperglycemia in Type 2 Diabetes, A Cnsensus Reprt by the American Diabetes Assciatin (ADA) and the Eurpean Assciatin fr the Study f Diabetes (EASD). Diabetes Care published nline Octber 4, This guideline is designed t assist prviders by prviding an analytical framewrk fr the evaluatin and treatment f patients, and is nt intended either t replace a clinicians judgment r t establish a prtcl fr all patients with a particular cnditin.