Molina Healthcare of Washington, Inc. Diabetes Clinical Practice Guideline

Transcription

1 Molina Healthare of Washington, In. Diabetes Clinial Pratie Guideline The Amerian Diabetes Assoiation Clinial Pratie Reommendations Guideline was reviewed and approved for use by the Clinial Quality Improvement Committee on Marh 27, The updated 2004 guideline was reviewed and approved by Clinial Quality Improvement Committee to serve as the basis of the Healthy living with Diabetes program and as a guide for the are of Molina Healthare members on Marh 24, Guideline was updated January The Clinial Quality Improvement Committee reviewed and approved the update for use at the Marh 22, 2006 meeting. Guideline was updated January The Clinial Quality Improvement Committee reviewed and approved the update for use at the Marh 27, 2008 meeting. On Marh 25, 2010, Molina Healthare s Clinial Quality Improvement Committee reviewed and approved the urrent The Amerian Diabetes Assoiation Clinial Pratie Reommendations Guideline for use as the basis for the Healthy Living with Diabetes program and as a guide of are primarily for adult Molina Healthare Members. On Marh 22, 2012, Molina Healthare s Clinial Quality Improvement Committee reviewed and approved The Amerian Diabetes Assoiation Clinial Pratie Reommendations Guideline, whih was updated in 2012, for use as the basis for the Healthy Living with Diabetes program and as a guide of are primarily for adult Molina Healthare Members.

2 E X E C U T I V E S U M M A R Y Exeutive Summary: Standards of MedialCareinDiabetesd2012 Current riteria for the diagnosis of diabetes A1C $6.5%. The test should be performed in a laboratory using a method that is National Glyohemoglobin Standardization Program (NGSP)-ertified and standardized to the Diabetes Control and Compliations Trial (DCCT) assay; or fasting plasma gluose (FPG) $126 mg/dl (7.0 mmol/l). Fasting is defined as no alori intake for at least 8h;or 2-h plasma gluose $200 mg/dl (11.1 mmol/l) during an oral gluose tolerane test (OGTT). The test should be performed as desribed by the World Health Organization, using a gluose load ontaining the equivalent of 75 g anhydrous gluose dissolved in water; or in a patient with lassi symptoms of hyperglyemia or hyperglyemi risis, a random plasma gluose $200 mg/dl (11.1 mmol/l); in the absene of unequivoal hyperglyemia, the result should be onfirmed by repeat testing. Testing for diabetes in asymptomati patients Testing to detet type 2 diabetes and to assess risk for future diabetes in asymptomati people should be onsidered in adults of any age who are overweight or obese (BMI $25 kg/m 2 ) and who have one or more additional risk fators for diabetes (see Table 4 of the Standards of Medial Care in Diabetesd2012 ). In those without these risk fators, testing should begin at age 45 years. If tests are normal, repeat testing at least at 3-year intervals is reasonable. To test for diabetes or to assess risk of future diabetes, A1C, FPG, or 2-h 75-g OGTT are appropriate. In those identified with inreased risk for future diabetes, identify and, if appropriate, treat other ardiovasular disease (CVD) risk fators. Detetion and diagnosis of gestational diabetes mellitus (GDM) Sreen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk fators, using standard diagnosti riteria. In pregnant women not previously known to have diabetes, sreen for GDM at weeks gestation, using a 75-g 2-h OGTT and the diagnosti utpoints in Table 6 of the Standards of Medial Care in Diabetesd2012. Sreen women with GDM for persistent diabetes at 6 12 weeks postpartum, using a test other than A1C. Women with a history of GDM should have lifelong sreening for the development of diabetes or prediabetes at least every 3 years. Women with a history of GDM found to have prediabetes should reeive lifestyle interventions or metformin to prevent diabetes. (A) Prevention/delay of type 2 diabetes Patients with IGT (A), IFG, or an A1C of % should be referred to an effetive ongoing support program targeting weight loss of 7% of body weight and inreasing physial ativity to at least 150 min per week of moderate ativity suh as walking. Follow-up ounseling appears to be important for suess. Based on the ost-effetiveness of diabetes prevention, suh programs should be overed by third-party payers. Metformin therapy for prevention of type 2 diabetes may be onsidered in DOI: /d12-s by the Amerian Diabetes Assoiation. Readers may use this artile as long as the work is properly ited, the use is eduational and not for profit, and the work is not altered. See lienses/by-n-nd/3.0/ for details. those with IGT (A), IFG, or an A1C of %, espeially for those with BMI.35 kg/m 2,thoseaged,60 years, and those with prior GDM. (A) At least annual monitoring for the development of diabetes in those with prediabetes is suggested. Gluose monitoring Self-monitoring of blood gluose (SMBG) should be arried out three or more times daily for patients using multiple insulin injetions or insulin pump therapy. For patients using less frequent insulin injetions, noninsulin therapies, or medial nutrition therapy (MNT) alone, SMBG may be useful as a guide to management. To ahieve postprandial gluose targets, postprandial SMBG may be appropriate. When presribing SMBG, ensure that patients reeive initial instrution in, and routine follow-up evaluation of, SMBG tehnique and their ability to use data to adjust therapy. Continuous gluose monitoring (CGM) in onjuntion with intensive insulin regimens an be a useful tool to lower A1C in seleted adults (age $25 years) with type 1 diabetes. (A) Although the evidene for A1C-lowering is less strong in hildren, teens, and younger adults, CGM may be helpful in these groups. Suess orrelates with adherene to ongoing use of the devie. (C) CGM may be a supplemental tool to SMBG in those with hypoglyemia unawareness and/or frequent hypoglyemi episodes. A1C Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glyemi ontrol). Perform the A1C test quarterly in patients whose therapy has hanged or who are not meeting glyemi goals. Use of point-of-are testing for A1C provides the opportunity for more timely treatment hanges. S4 DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 are.diabetesjournals.org

3 Glyemi goals in adults Lowering A1C to below or around 7% has been shown to redue mirovasular ompliations of diabetes, and if implemented soon after the diagnosis of diabetes is assoiated with long-term redution in marovasular disease. Therefore, a reasonable A1C goal for many nonpregnant adults is,7%. Providers might reasonably suggest more stringent A1C goals (suh as,6.5%) for seleted individual patients, if this an be ahieved without signifiant hypoglyemia or other adverse effets of treatment. Appropriate patients might inlude those with short duration of diabetes, long life expetany, and no signifiant CVD. (C) Less stringent A1C goals (suh as,8%) may be appropriate for patients with a history of severe hypoglyemia, limited life expetany, advaned mirovasular or marovasular ompliations, and extensive omorbid onditions and for those with longstanding diabetes in whom the general goal is diffiult to attain despite diabetes self-management eduation, appropriate gluose monitoring, and effetive doses of multiple gluose-lowering agents inluding insulin. Therapy for type 2 diabetes At the time of type 2 diabetes diagnosis, initiate metformin therapy along with lifestyle interventions, unless metformin is ontraindiated. (A) In newly diagnosed type 2 diabeti patients with markedly symptomati and/or elevated blood gluose levels or A1C, onsider insulin therapy, with or without additional agents, from the outset. If noninsulin monotherapy at maximal tolerated dose does not ahieve or maintain the A1C target over 3 6 months, add a seond oral agent, a GLP-1 reeptor agonist, or insulin. Medial nutrition therapy (MNT) General Reommendations Individuals who have prediabetes or diabetes should reeive individualized MNT as needed to ahieve treatment goals, preferably provided by a registered dietitian familiar with the omponents of diabetes MNT. (A) Beause MNT an result in ost-savings andimprovedoutomes,mntshould be adequately overed by insurane and other payers. Reommendations for energy balane, overweight, and obesity Weight loss is reommended for all overweight or obese individuals who have or are at risk for diabetes. (A) For weight loss, either low-arbohydrate, low-fat alorie-restrited, or Mediterranean diets may be effetive in the short term (up to 2 years). (A) For patients on low-arbohydrate diets, monitor lipid profiles, renal funtion, and protein intake (in those with nephropathy) and adjust hypoglyemi therapy as needed. Physial ativity and behavior modifiation are important omponents of weight loss programs and are most helpful in maintenane of weight loss. Reommendations for primary prevention of diabetes Among individuals at high risk for developing type 2 diabetes, strutured programs that emphasize lifestyle hanges that inlude moderate weight loss (7% body weight) and regular physial ativity (150 min/week), with dietary strategies that inlude redued alories and redued intake of dietary fat, an redue the risk for developing diabetes and are therefore reommended. (A) Individuals at risk for type 2 diabetes should be enouraged to ahieve the U.S. Department of Agriulture (USDA) reommendation for dietary fiber (14 g fiber/ 1,000 kal) and foods ontaining whole grains (one-half of grain intake). Individuals at risk for type 2 diabetes should be enouraged to limit their intake of sugar-sweetened beverages. Reommendations for management of diabetes Maronutrients in diabetes management The mix of arbohydrate, protein, and fat may be adjusted to meet the metaboli goals and individual preferenes of the person with diabetes. (C) Monitoring arbohydrate intake, whether by arbohydrate ounting, hoies, or experiene-based estimation, remains a key strategy in ahieving glyemi ontrol. Saturated fat intake should be,7% of total alories. Reduing intake of trans fat lowers LDL holesterol and inreases HDL holesterol (A); therefore intake of trans fat should be minimized. Other nutrition reommendations. If adults with diabetes hoose to use alohol, they should limit intake to a Exeutive Summary moderate amount (one drink per day or less for adult women and two drinks per day or less for adult men) and should take extra preautions to prevent hypoglyemia. Routine supplementation with antioxidants, suh as vitamins E and C and arotene, is not advised beause of lak of evidene of effiay and onern related to long-term safety. (A) It is reommended that individualized meal planning inlude optimization of food hoies to meet reommended daily allowane (RDA)/dietary referene intake (DRI) for all mironutrients. Diabetes self-management eduation (DSME) People with diabetes should reeive DSME aording to national standards and diabetes self-management support at the time their diabetes is diagnosed and as needed thereafter. Effetive self-management and quality of life are the key outomes of DSME and should be measured and monitored as part of are. (C) DSME should address psyhosoial issues, sine emotional wellbeing is assoiated with positive diabetes outomes. (C) Beause DSME an result in ost-savings andimprovedoutomes,dsme should be adequately reimbursed by third-party payers. Physial ativity People with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobi physial ativity (50 70% of maximum heart rate), spread over at least 3 days per week with no more than 2 onseutive days without exerise. (A) In the absene of ontraindiations, people with type 2 diabetes should be enouraged to perform resistane training at least twie per week. (A) Psyhosoial assessment and are It is reasonable to inlude assessment of the patient s psyhologial and soial situation as an ongoing part of the medial management of diabetes. Psyhosoial sreening and follow-up may inlude, but is not limited to, attitudes about the illness, expetations for medial management and outomes, affet/mood, general and diabetes-related quality of life, resoures (finanial, soial, and emotional), and psyhiatri history. are.diabetesjournals.org DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 S5

4 Exeutive Summary Consider sreening for psyhosoial problems suh as depression and diabetesrelated distress, anxiety, eating disorders, and ognitive impairment when selfmanagement is poor. (C) Hypoglyemia Gluose (15 20 g) is the preferred treatment for the onsious individual with hypoglyemia, although any form of arbohydrate that ontains gluose may be used. If SMBG 15 min after treatment shows ontinued hypoglyemia, the treatment should be repeated. One SMBG gluose returns to normal, the individual should onsume a meal or snak to prevent reurrene of hypoglyemia. Gluagon should be presribed for all individuals at signifiant risk of severe hypoglyemia, and aregivers or family members of these individuals should be instruted in its administration. Gluagon administration is not limited to health are professionals. Individuals with hypoglyemia unawareness or one or more episodes of severe hypoglyemia should be advised to raise their glyemi targets to stritly avoid further hypoglyemia for at least several weeks, to partially reverse hypoglyemia unawareness and redue risk of future episodes. Bariatri surgery Bariatri surgery may be onsidered for adults with BMI.35 kg/m 2 and type 2 diabetes, espeially if the diabetes or assoiated omorbidities are diffiultto ontrol with lifestyle and pharmaologi therapy. Patients with type 2 diabetes who have undergone bariatri surgery need lifelong lifestyle support and medial monitoring. Although small trials have shown glyemi benefit of bariatri surgery in patients with type 2 diabetes and BMI of kg/m 2, there is urrently insuffiient evidene to generally reommend surgery in patients with BMI,35 kg/m 2 outside of a researh protool. The long-term benefits, ost-effetiveness, and risks of bariatri surgery in individuals with type 2 diabetes should be studied in well-designed ontrolled trials with optimal medial and lifestyle therapy as the omparator. Immunization Annually provide an influenza vaine to all diabeti patients $6 monthsof age. (C) Administer pneumooal polysaharide vaine to all diabeti patients $2 years of age. A one-time revaination is reommended for individuals.64 years of age previously immunized when they were,65 years of age if the vaine was administered.5 years ago. Other indiations for repeat vaination inlude nephroti syndrome, hroni renal disease, and other immunoompromised states, suh as after transplantation. (C) Administer hepatitis B vaination to adults with diabetes as per Centers for Disease Control and Prevention (CDC) reommendations. (C) Hypertension/blood pressure ontrol Sreening and diagnosis Blood pressure should be measured at every routine diabetes visit. Patients found to have systoli blood pressure $130 mmhg or diastoli blood pressure $80 mmhg should have blood pressure onfirmed on a separate day. Repeat systoli blood pressure $130 mmhg or diastoli blood pressure $80 mmhg onfirms a diagnosis of hypertension. (C) Goals A goal systoli blood pressure,130 mmhg is appropriate for most patients with diabetes. (C) Based on patient harateristis and response to therapy, higher or lower systoli blood pressure targets may be appropriate. Patients with diabetes should be treated to a diastoli blood pressure,80 mmhg. Patients with a systoli blood pressure of mmhg or a diastoli blood pressure of 80 89mmHgmay begiven lifestyle therapy alone for a maximum of 3 months and then, if targets are not ahieved, may be treated with the addition of pharmaologial agents. Patients with more severe hypertension (systoli blood pressure $140 or diastoli blood pressure $90 mmhg) at diagnosis or follow-up should reeive pharmaologi therapy in addition to lifestyle therapy. (A) Lifestyle therapy for hypertension onsists of weight loss, if overweight; DASHstyle dietary pattern, inluding reduing sodium and inreasing potassium intake; moderation of alohol intake; and inreased physial ativity. Patients with diabetes and hypertension should be treated with a pharmaologi therapy regimen that inludes either an ACE inhibitor or an ARB). If one lass is not tolerated, the other should be substituted. (C) Multiple drug therapy (two or more agents at maximal doses) is generally required to ahieve blood pressure targets. Administer one or more antihypertensive mediations at bedtime. (A) If ACE inhibitors, ARBs, or diuretis are used, kidney funtion and serum potassium levels should be monitored. In pregnant patients with diabetes and hroni hypertension, blood pressure target goals of /65 79 mmhg are suggestedintheinterestoflong-term maternal health and minimizing impaired fetal growth. ACE inhibitors and ARBs are ontraindiated during pregnany. Dyslipidemia/lipid management Sreening In most adult patients, measure fasting lipid profile at least annually. In adults with low-risk lipid values (LDL holesterol,100 mg/dl, HDL holesterol.50 mg/dl, and triglyerides,150 mg/dl), lipid assessments may be repeated every 2years. reommendations and goals Lifestyle modifiation fousing on the redution of saturated fat,trans fat, and holesterol intake; inrease of n-3 fatty aids, visous fiber and plant stanols/ sterols; weight loss (if indiated); and inreased physial ativity should be reommended to improve the lipid profile in patients with diabetes. (A) Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabeti patients: with overt CVD. (A) without CVD who are over the age of 40 years and have one or more other CVD risk fators. (A) For lower-risk patients than the above (e.g., without overt CVD and under the age of 40 years), statin therapy should be onsidered in addition to lifestyle therapy if LDL holesterol remains.100 mg/dl or in those with multiple CVD risk fators. In individuals without overt CVD, the primary goal is LDL holesterol,100 mg/dl (2.6 mmol/l). (A) S6 DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 are.diabetesjournals.org

5 In individuals with overt CVD, a lower LDL holesterol goal of,70 mg/dl (1.8 mmol/l), using a high dose of a statin, is an option. If drug-treated patients do not reah the above targets on maximal tolerated statin therapy, a redution in LDL holesterol of ;30 40% from baseline is an alternative therapeuti goal. (A) Triglyerides levels,150 mg/dl (1.7 mmol/l) and HDL holesterol.40 mg/ dl (1.0 mmol/l) in men and.50 mg/dl (1.3 mmol/l) in women, are desirable. However, LDL holesterol targeted statin therapy remains the preferred strategy. (C) If targets are not reahed on maximally tolerated doses of statins, ombination therapy using statins and other lipidlowering agents may be onsidered to ahieve lipid targets but has not been evaluated in outome studies for either CVD outomes or safety. Statin therapy is ontraindiated in pregnany. Antiplatelet agents Consider aspirin therapy ( mg/ day) as a primary prevention strategy in those with type 1 or type 2 diabetes at inreased ardiovasular risk (10-year risk.10%). This inludes most men.50 years of age or women.60 years of age who have at least one additional major risk fator (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). (C) Aspirin should not be reommended for CVD prevention for adults with diabetes at low CVD risk (10-year CVD risk,5%,suhasinmen,50 years and women,60 years of age with no major additional CVD risk fators), sine the potential adverse effets from bleeding likely offset the potential benefits. (C) In patients in these age-groups with multiple other risk fators (e.g., 10-year risk 5 10%), linial judgment is required. Use aspirin therapy ( mg/day) as a seondary prevention strategy in those with diabetes with a history of CVD. (A) For patients with CVD and doumented aspirin allergy, lopidogrel (75 mg/day) should be used. Combination therapy with ASA ( mg/day) and lopidogrel (75 mg/ day) is reasonable for up to a year after an aute oronary syndrome. Smoking essation Advise all patients not to smoke. (A) Inlude smoking essation ounseling and other forms of treatment as a routine omponent of diabetes are. Coronary heart disease (CHD) sreening and treatment Sreening In asymptomati patients, routine sreening for oronary artery disease (CAD) is not reommended, as it does not improveoutomesaslongascvdrisk fators are treated. (A) In patients with known CVD, onsider ACE inhibitor therapy (C) and use aspirin and statin therapy (A) (if not ontraindiated) to redue the risk of ardiovasular events. In patients with a prior myoardial infartion, b-blokers should be ontinued for at least 2 years after the event. Longer-term use of b-blokers in the absene of hypertension is reasonable if well tolerated, but data are laking. Avoid TZD treatment in patients with symptomati heart failure. (C) Metformin may be used in patients with stable ongestive heart failure (CHF) if renal funtion is normal. It should be avoided in unstable or hospitalized patients with CHF. (C) Nephropathy sreening and treatment General reommendations To redue the risk or slow the progression of nephropathy, optimize gluose ontrol. (A) To redue the risk or slow the progression of nephropathy, optimize blood pressure ontrol. (A) Sreening Perform an annual test to assess urine albumin exretion (UAE) in type 1 diabeti patients with diabetes duration of $5 years and in all type 2 diabeti patients starting at diagnosis. Measure serum reatinine at least annually in all adults with diabetes regardless of the degree of UAE. The serum reatinine should be used to estimate glomerular filtration rate (GFR) and stage the level of hroni kidney disease (CKD), if present. In the treatment of the nonpregnant patient with miro- or maroalbuminuria, either ACE inhibitors or ARBs should be used. (A) If one lass is not tolerated, the other should be substituted. Redution of protein intake to g z kg body wt 21 z day 21 in individuals with diabetes and the earlier stages of CKD and to 0.8 g z kg body wt 21 z day 21 in the later stages of CKD may improve measures of renal funtion (UAE rate, GFR) and is reommended. When ACE inhibitors, ARBs, or diuretis are used, monitor serum reatinine and potassium levels for the development of inreased reatinine and hyperkalemia. Continued monitoring of UAE to assess both response to therapy and progression of disease is reasonable. When estimated GFR (egfr) is,60 ml z min/1.73 m 2, evaluate and manage potential ompliations of CKD. Exeutive Summary Consider referral to a physiian experiened in the are of kidney disease for unertainty about the etiology of kidney disease, diffiult management issues, or advaned kidney disease. Retinopathy sreening and treatment General reommendations To redue the risk or slow the progression of retinopathy, optimize glyemi ontrol. (A) To redue the risk or slow the progression of retinopathy, optimize blood pressure ontrol. (A) Sreening Adults and hildren aged 10 years or older with type 1 diabetes should have an initial dilated and omprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. Patients with type 2 diabetes should have an initial dilated and omprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes. Subsequent examinations for type 1 and type 2 diabeti patients should be repeated annually by an ophthalmologist or optometrist. Less-frequent exams (every 2 3 years) may be onsidered following one or more normal eye exams. Examinations will be required more frequently if retinopathy is progressing. High-quality fundus photographs an detet most linially signifiant diabeti are.diabetesjournals.org DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 S7

6 Exeutive Summary retinopathy. Interpretation of the images should be performed by a trained eye are provider. While retinal photography may serve as a sreening tool for retinopathy, it is not a substitute for a omprehensive eye exam, whih should be performed at least initially and at intervals thereafter as reommended by an eye are professional. Women with preexisting diabetes who are planning pregnany or who have beome pregnant should have a omprehensive eye examination and should be ounseled on the risk of development and/or progression of diabeti retinopathy. Eye examination should our in the first trimester with lose follow-up throughout pregnany and for 1 year postpartum. Promptly refer patients with any level of maular edema, severe nonproliferative diabeti retinopathy (NPDR), or any PDR to an ophthalmologist who is knowledgeable and experiened in the management and treatment of diabeti retinopathy. (A) Laser photooagulation therapy is indiated to redue the risk of vision loss in patients with high-risk PDR, linially signifiant maular edema, and some ases of severe NPDR. (A) The presene of retinopathy is not a ontraindiation to aspirin therapy for ardioprotetion, as this therapy does not inrease the risk of retinal hemorrhage. (A) Neuropathy sreening and treatement All patients should be sreened for distal symmetri polyneuropathy (DPN) starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter, using simple linial tests. Eletrophysiologial testing is rarely needed, exept in situations where the linial features are atypial. Sreening for signs and symptoms of ardiovasular autonomi neuropathy should be instituted at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes. Speial testing is rarely needed and may not affet management or outomes. Mediations for the relief of speifi symptoms related to painful DPN and autonomi neuropathy are reommended, as they improve the quality of life of the patient. Foot are For all patients with diabetes, perform an annual omprehensive foot examination to identify risk fators preditive of ulers and amputations. The foot examination should inlude inspetion, assessment of foot pulses, and testing for loss of protetive sensation (10-g monofilament plus testing any one of the following: vibration using 128-Hz tuning fork, pinprik sensation, ankle reflexes, or vibration pereption threshold). Provide general foot self-are eduation to all patients with diabetes. A multidisiplinary approah is reommended for individuals with foot ulers and high-risk feet, espeially those with a history of prior uler or amputation. Refer patients who smoke, have loss of protetive sensation and strutural abnormalities, or have history of prior lower-extremity ompliations to foot are speialists for ongoing preventive are and life-long surveillane. (C) Initial sreening for peripheral arterial disease (PAD) should inlude a history for laudiation and an assessment of the pedal pulses. Consider obtaining an ankle-brahial index (ABI), as many patients with PAD are asymptomati. (C) Refer patients with signifiant laudiation or a positive ABI for further vasular assessment and onsider exerise, mediations, and surgial options. (C) Assessment of ommon omorbid onditions For patients with risk fators, signs or symptoms, onsider assessment and treatment for ommon diabetes-assoiated onditions (see Table 15 of the Standards of Medial Care in Diabetesd 2012 ). Children and adolesents Glyemi ontrol Consider age when setting glyemi goals in hildren and adolesents with type 1 diabetes. Sreening and management of hroni ompliations in hildren and adolesents with type 1 diabetes Nephropathy Annual sreening for miroalbuminuria, with a random spot urine sample for albumin-to-reatinine ratio (ACR), should be onsidered one the hild is 10 years of age and has had diabetes for 5 years. with an ACE inhibitor, titrated to normalization of albumin exretion, should be onsidered when elevated ACR is subsequently onfirmed on two additional speimens from different days. Hypertension Initial treatment of high-normal blood pressure (systoli or diastoli blood pressure onsistently above the 90th perentile for age, sex, and height) inludes dietary intervention and exerise, aimed at weight ontrol and inreased physial ativity, if appropriate. If target blood pressure is not reahed with 3 6 months of lifestyle intervention, pharmaologi treatment should be onsidered. Pharmaologi treatment of hypertension (systoli or diastoli blood pressure onsistently above the 95th perentile for age, sex, and height or onsistently.130/80 mmhg, if 95% exeeds that value) should be onsidered as soon as the diagnosis is onfirmed. ACE inhibitors should be onsidered for the initial treatment of hypertension, following appropriate reprodutive ounseling due to the potential teratogeni effets. The goal of treatment is a blood pressure onsistently,130/80 or below the 90th perentile for age, sex, and height, whihever is lower. Dyslipidemia Sreening If there is a family history of hyperholesterolemia or a ardiovasular event before age 55 years, or if family history is unknown, then onsider obtaining a fasting lipid profile on hildren.2 years of age soon after diagnosis (after gluose ontrol has been established). If family history is not of onern, then onsider the first lipid sreening at puberty ($10 years). For hildren diagnosed with diabetes at or after puberty, onsider obtaining afastinglipidprofile soon after diagnosis (after gluose ontrol has been established). For both age-groups, if lipids are abnormal, annual monitoring is reasonable. If LDL holesterol values are within the aepted risk levels (,100 mg/dl [2.6 mmol/l]), a lipid profile repeated every 5 years is reasonable. S8 DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 are.diabetesjournals.org

7 Initial therapy may onsist of optimization of gluose ontrol and MNT using a Step 2 Amerian Heart Assoiation Diet aimed at a derease in the amount of saturated fat in the diet. After the age of 10 years, the addition of a statin in patients who, after MNT and lifestyle hanges, have LDL holesterol.160 mg/dl (4.1 mmol/l), or LDL holesterol. 30 mg/dl (3.4 mmol/l) and one or more CVD risk fators, is reasonable. The goal of therapy is an LDL holesterol value,100 mg/dl (2.6 mmol/l). Retinopathy The first ophthalmologi examination should be obtained one the hild is $10 years of age and has had diabetes for 3 5 years. After the initial examination, annual routine follow-up is generally reommended. Less-frequent examinations may be aeptable on the advie of an eye are professional. Celia disease Consider sreening hildren with type 1 diabetes for elia disease by measuring tissue transglutaminase or antiendomysial antibodies, with doumentation of normal total serum IgA levels, soon after the diagnosis of diabetes. Testing should be onsidered in hildren with growth failure, failure to gain weight, weight loss, diarrhea, flatulene, abdominal pain, or signs of malabsorption, or in hildren with frequent unexplained hypoglyemia or deterioration in glyemi ontrol. Consider referral to a gastroenterologist for evaluation with endosopy and biopsy for onfirmation of elia disease in asymptomati hildren with positive antibodies. Children with biopsy-onfirmed elia disease should be plaed on a glutenfree diet and have onsultation with a dietitian experiened in managing both diabetes and elia disease. Hypothyroidism Consider sreening hildren with type 1 diabetes for thyroid disease using thyroid peroxidase and thyroglobulin antibodies soon after diagnosis. Measuring TSH onentrations soon after diagnosis of type 1 diabetes, after metaboli ontrol has been established, is reasonable. If normal, onsider reheking every 1 2 years, espeially if the patient develops symptoms of thyroid dysfuntion, thyromegaly, or an abnormal growth rate. Transition from pediatri to adult are As teens transition into emerging adulthood, health are providers and families must reognize their many vulnerabilities and prepare the developing teen, beginning in early to mid adolesene and at least one year prior to the transition. Both pediatriians and adult health are providers should assist in providing support and links to resoures for the teen and emerging adult. Preoneption are A1C levels should be as lose to normal as possible (,7%) in an individual patient before oneption is attempted. Starting at puberty, preoneption ounseling should be inorporated in the routine diabetes lini visit for all women of hildbearing potential. (C) Women with diabetes who are ontemplating pregnany should be evaluated and, if indiated, treated for diabeti retinopathy, nephropathy, neuropathy, and CVD. Mediations used by suh women should be evaluated prior to oneption, sine drugs ommonly used to treat diabetes and its ompliations may be ontraindiated or not reommended in pregnany, inluding statins, ACE inhibitors, ARBs, and most noninsulin therapies. Sine many pregnanies are unplanned, onsider the potential risks and benefits of mediations that are ontraindiated in pregnany in all women of hildbearing potential, and ounsel women using suh mediations aordingly. Older adults Older adults who are funtional, ognitively intat, and have signifiant life expetany should reeive diabetes are using goals developed for younger adults. Glyemi goals for older adults not meeting the above riteria may be relaxed using individual riteria, but hyperglyemia leading to symptoms or risk of aute hyperglyemi ompliations should be avoided in all patients. Other ardiovasular risk fators should be treated in older adults with onsideration of the time frame of benefit and the individual patient. of hypertension is indiated in virtually all older adults, and lipid and aspirin therapy Exeutive Summary may benefit those with life expetany at least equal to the time frame of primary or seondary prevention trials. Sreening for diabetes ompliations should be individualized in older adults, but partiular attention should be paid to ompliations that would lead to funtional impairment. Cysti fibrosis related diabetes (CFRD) Annual sreening for CFRD with OGTT should begin by age 10 years in all patients with CF who do not have CFRD. Use of A1C as a sreening test for CFRD is not reommended. During a period of stable health the diagnosis of CFRD an be made in CF patients aording to usual diagnosti riteria. Patients with CFRD should be treated with insulin to attain individualized glyemi goals. (A) Annual monitoring for ompliations of diabetes is reommended, beginning 5 years after the diagnosis of CFRD. Diabetes are in the hospital All patients with diabetes admitted to the hospital should have their diabetes learly identified in the medial reord. All patients with diabetes should have an order for blood gluose monitoring, with results available to all members of the health are team. Goals for blood gluose levels: Critially ill patients: Insulin therapy should be initiated for treatment of persistent hyperglyemia starting at a threshold of no greater than 180 mg/dl (10 mmol/l). One insulin therapy is started, a gluose range of mg/dl (7.8 to 10 mmol/l) is reommended for the majority of ritially ill patients. (A) More stringent goals, suh as mg/dl ( mmol/l) may be appropriate for seleted patients, as long as this an be ahieved without signifiant hypoglyemia. (C) Critially ill patients require an intravenous insulin protool that has demonstrated effiay and safety in ahieving the desired gluose range without inreasing risk for severe hypoglyemia. Non ritially ill patients: There is no lear evidene for speifi blood gluose goals. If treated with insulin, premeal blood gluose targets generally,140 mg/dl (7.8 mmol/l) are.diabetesjournals.org DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 S9

8 Exeutive Summary with random blood gluose,180 mg/dl (10.0 mmol/l) are reasonable, provided these targets an be safely ahieved. More stringent targets maybeappropriateinstablepatients with previous tight glyemi ontrol. Less stringent targets may be appropriate in those with severe omorbidites. Sheduled subutaneous insulin with basal, nutritional, and orretion omponents is the preferred method for ahieving and maintaining gluose ontrol in nonritially ill patients. Gluose monitoring should be initiated in any patient not known to be diabeti who reeives therapy assoiated with high-risk for hyperglyemia, inluding high-dose gluoortioid therapy, initiation of enteral or parenteral nutrition, or other mediations suh as otreotide or immunosuppressive mediations. If hyperglyemia is doumented and persistent, onsider treating suh patients to the same glyemi goals as patients with known diabetes. A hypoglyemia management protool should be adopted and implemented by eah hospital or hospital system. A plan for preventing and treating hypoglyemia should be established for eah patient. Episodes of hypoglyemia in the hospital should be doumented in the medial reord and traked. Consider obtaining an A1C on patients with diabetes admitted to the hospital if the result of testing in the previous 2 3 months is not available. Patients with hyperglyemia in the hospital who do not have a prior diagnosis of diabetes should have appropriate plans for follow-up testing and are doumented at disharge. Strategies for improving are Care should be aligned with omponents of the Chroni Care Model to ensure produtive interations between a prepared proative pratie teamandaninformedativatedpatient. (A) When feasible, are systems should support team-based are, ommunity involvement, patient registries, and embedded deision support tools to meet patient needs. deisions should be timely and based on evidene-based guidelines that are tailored to individual patient preferenes, prognoses, and omorbidities. A patient entered ommuniation style should be employed that inorporates patient preferenes, assesses literay and numeray, and addresses ultural barriers to are. S10 DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012 are.diabetesjournals.org