Diabetes Summary of Medical Guidelines

Transcription

1 Diabetes Summary of Medical Guidelines Key concepts in setting glycemic controls: goals should be individualized; certain populations (children, pregnant women, and elderly) require special considerations; less intensive glycemic goals may be indicated in patients with severe or frequent hypoglycemia; more intensive glycemic goals may further reduce microvascular complications at the cost of increasing hypoglycemia; postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals. Risk Complete exam Glycemic control Goal: A1C <7.0% Weight Foot examination Blood pressure 1 Adult Eye exam Dilated and comprehensive by an ophthalmologist or optometrist who is knowledgeable and experienced in diagnosing the presence of diabetic retinopathy and is aware of its management. Lipid profile goals 2 : < 100 mg/dl LDL > 50 mg/dl HDL < 150 mg/dl Triglycerides Aspirin therapy mg/day Urine albumin: Random spot collection is preferred method Normal albumin excretion by spot collection: <30 μg/mg creatinine Serum creatinine: Measure at least annually in all adults regardless of the degree of urine albumin excretion To test for diabetes or to assess risk of future diabetes, A1C, FPG, or 2-h 75-g OGTT are appropriate. A1C = 5.7% - 6.4%: increased risk for diabetes (indicates prediabetes) A1C 6.5% indicates the presence of diabetes. (A1C is not recommended for diagnosis in pregnancy, certain anemias and hemoglobinopathies.) OR FPG 100 mg/dl (5.6 mmol/l) to 125 mg/dl (6.9 mmol/l) (IFG): increased risk for diabetes OR 2-h plasma glucose in the 75-g OGTT 140 mg/dl (7.8 mmol/l) to 199 mg/dl (11.0 mmol/l) (IGT): increased risk for diabetes Test should be repeated for diagnosis, or confirmed using a different test. To classify the patient, detect complications, develop a management plan, and provide a basis for continuing care Quarterly, then 2x/year when stable; more stringent goals (<6.0%) may further reduce complications at the cost of increased risk of hypoglycemia and may be considered in individual patients. Less stringent goals may be appropriate in specific populations like the frail elderly, those with advanced atherosclerosis, and those at risk for severe hypoglycemia. A1C goals should be individualized based upon age, life expectancy, co-morbid conditions, known CVD or microvascular complications and hypoglycemic unawareness. Weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes. Individuals who have prediabetes or diabetes should receive individualized medical nutrition therapy as needed to achieve treatment goals. At-risk BMI may vary with ethnicity. Comprehensive exam annually. If high risk (neuropathy, smoker, PVD, prior ulcer or amputation, severe CVD) a foot exam at each provider office visit is recommended. Patients at risk should understand the importance of foot monitoring on a daily basis. People with diabetes and hypertension should be treated to a systolic blood pressure goal of <140 mmhg. Patients with diabetes should be treated to a diastolic blood pressure <80 mmhg. Patients with a blood pressure >120/80 mmhg should be advised on lifestyle changes to reduce blood pressure. Patients with confirmed blood pressure 140/80 mmhg should have prompt pharmacological therapy in addition to lifestyle therapy, Pharmacological therapy should include either an ACE inhibitor or ARB. Within 5 years after onset of diabetes once patient is age 10 years or older, then annually; less frequent exams (q2 years) may be considered when eye exam normal. Shortly after diagnosis, then annually; less frequent exams (q2 years) may be considered when eye exam normal. Annual testing Every 2 years if low risk (LDL <100, HDL >50, triglycerides <150 mg/dl) Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients: With overt CVD (Goal: < 70 mg/dl LDL) Without overt CVD (Goal: < 100 mg/dl LDL) Without CVD but over age 40 years and have one or more other CVD risk factors (Goal: < 70 mg/dl LDL) For all with type 1 or type 2 with increased cardiovascular risk for primary prevention, including most men > age 50 and women > age 60 who have at least one additional major risk factor; as secondary prevention for all with history of CVD. Urine albumin: Should begin after five years duration, then annually Urine albumin: At diagnosis and annually ACE-I or ARB recommended for treatment of persistent albuminuria at levels mg/24 h and levels 300 mg/24 h. Other drugs, such as diuretics, calcium channel blockers, and b-blockers, should be used as additional therapy to further lower blood pressure in patients already treated with ACE inhibitors or ARBs.

2 Adult Self-monitored blood glucose (SMBG) Goals for plasma values: Preprandial glucose mg/dl Peak post-prandial glucose <180 mg/dl Smoking cessation Physical activity Self-care education Self-management goals Diagnosis of gestational diabetes mellitus (GDM) Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria In pregnant women not known to have diabetes, screen for GDM at weeks of gestation. Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower A1C in selected adults (age 25 years) with type 1 diabetes. A CGM device equipped with an automatic low glucose suspend feature may reduce severe hypoglycemia for those with a history of nocturnal hypoglycemia.cgm can be an option in type 2 diabetes when treatment goals are not met, or can be used diagnostically to analyze glucose patterns. CGM should probably be instituted by a diabetes specialist, and it need not be used by the patient all of the time. Patients on multiple-dose insulin or insulin pump therapy: SMBG at least prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. As needed to maintain glycemic control; may need to check postprandially for glucose Aid patient in nicotine cessation each visit, if indicated Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50 70% of maximum heart rate), spread over at least 3 days/week with no more than two consecutive days without exercise. In the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week. At least once, update as needed People with diabetes should receive DSME according to national standards and diabetes self-management support when their diabetes is diagnosed and as needed thereafter. Effective self-management and quality of life are the key outcomes of DSME and should be measured and monitored as part of care. Women found to have diabetes at their initial prenatal visit using standard criteria (A1C 6.5%, FPG 126mg/dl, two-hour plasma glucose during OGTT 200mg/dl, random plasma glucose 200mg/dl, or symptoms of hyperglycemia) should receive a diagnosis of overt, not gestational, diabetes. The diagnosis of GDM is made when any of the plasma glucose values are exceeded. One-step (IADPSG consensus) 2-h 75-g OGTT Fasting: 92 mg/dl 1 hour: 180 mg/dl 2 hour: 153 mg/dl Two-step (NIH consensus) 1-h 50-g (nonfasting) screen followed by a 3-h 100-g OGTT for those who screen positive Fasting 1 h 2 h 3 h Carpenter/Coustan 95 mg/dl 180 mg/dl 155 mg/dl 140 mg/dl NDDG 105 mg/dl 190 mg/dl 165 mg/dl 145 mg/dl Screen women with GDM for persistent diabetes 6-12 weeks postpartum using OGTT and nonpregnancy diagnostic criteria. Women with GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years. Preconception and family planning counseling As needed. Common comorbidities for which increased risk is associated with diabetes: - Hearing impairment - Obstructive sleep apnea - Fatty liver disease - Low testosterone in men Assessment of common comorbid conditions - Periodontal disease - Certain cancers - Fractures - Cognitive impairment - Depression Routinely screen for psychosocial problems such as depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment. Medical Nutrition Therapy (MNT) Nutrition therapy is recommended for all people with type 1 and type 2 diabetes as an effective component of the overall treatment plan. Any person with diabetes, whether insulin treated or noninsulin treated, should be eligible for any employment for which he/she is otherwise qualified. Employment, driving The ADA position statement on diabetes and driving (441) recommends against blanket restrictions based on the diagnosis of diabetes and urges individual assessment by a health care professional knowledgeable in diabetes if restrictions on licensure are being considered. Influenza immunization Annually after 6 months of age Given once for patients aged 2 or older and before the age of 65, and revaccination once after age 65, as long as the two vaccinations are given Pneumonia immunization more than five years apart. 1 The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults (JNC 8) shows moderate evidence that a more relaxed goal (140/90 mmhg) may be appropriate. 2 The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults (ATP4) recommends stain treatment to reduce LDL-C by a percentage. Individuals with diabetes aged 40 to 75 years old with LDL-cholesterol levels between 70 and 189 mg/dl and without evidence of atherosclerotic cardiovascular disease, moderate-intensity statin to 30% to 49% reduction in LDL, unless 10 year risk is also >7.5%, then high-intensity statin to 50% reduction in LDL.

3 Diabetes Summary of Medical Guidelines Risk Glycemic control Weight Pediatric 3/4ths of all cases of type 1 diabetes are diagnosed <18 y. Children differ from adults: changes in insulin sensitivity with sexual maturity and physical growth; ability to provide self-care; supervision in child care and school; unique neurologic vulnerability to hypoglycemia and DKA. Ideally, care should be provided by a multidisciplinary team Consider age when setting glycemic goals Most children < 7 y have a form of hypoglycemic unawarenenss Current data have not confirmed that young children are at risk for cognitive impairment after episodes of severe hypoglycemia. Glycemic goals: the long-term health benefits of lower A1C should be balanced against the risks of hypoglycemia and the developmental burdens of intensive regimens. Postprandial blood glucose values should be measured when there is a discrepancy between preprandial blood glucose values and A1C levels and to help assess glycemia in those on basal/bolus regimens. Plasma blood glucose goal range (mg/dl) Values by age (years) Toddlers and preschoolers (0 6) School age (6 12) Adolescents -young adults (13 19) Before meals Bedtime/ overnight A1C <8.5% <8% <7.5% Dietary intervention and exercise, aimed at weight control and increased physical activity, if appropriate, especially to control high bp. The incidence of type 2 diabetes in adolescents is increasing, especially in ethnic minority populations. Distinction between type 1 and type 2 diabetes in children can be difficult, but is critical; treatment regimens, educational approaches, and dietary counsel will differ markedly between the two Same as adults. Less stringent treatment goals may be appropriate for very young children. Whether the cut-off point for AIC to diagnose children with Type 2 diabetes would be the same as in adults is uncertain. Additional problems that may need to be addressed include polycystic ovarian disease; comorbidities associated with pediatric obesity: sleep apnea, hepatic steatosis, orthopedic complications, and psychosocial concerns. Foot examination* Comprehensive exam annually (Not specified as different from adult) Comprehensive exam annually (Not specified as different from adult) Blood pressure <130/80 mmhg or below the 90th percentile for age, sex, and height, whichever is lower; confirm on at least 3 separate days; use the appropriate size cuff, with child seated and relaxed. See levels and methods at d.pdf Eye exam: by professionals with expertise in diabetic retinopathy, understanding of risk in the pediatric population, and experience in counseling on early prevention/intervention High-normal bp (systolic or diastolic consistently above the 90th percentile for age, sex, and height): Initial treatment dietary intervention and exercise for weight control and increased physical activity If target blood pressure is not reached with 3 6 months of lifestyle intervention, pharmacologic treatment should be considered. Hypertension (systolic or diastolic blood pressure consistently above the 95th percentile for age, sex, and height or consistently >130/80 mmhg, if 95% exceeds that value): Consider pharmacologic treatment when diagnosis is confirmed. Consider ACE inhibitors for initial treatment, followed by appropriate reproductive counseling 1st exam: child is 10 y or at the start of puberty, whichever is earlier, and has had diabetes for 3 5 y. Annual routine follow-up generally recommended. Perform bp measurement at diagnosis. hypertension in youth are similar to those for type 1. Perform dilated eye examination at diagnosis. retinopathy in youth are similar to those for type 1.

4 Lipid profile goals: < 100 mg/dl LDL-c Pediatric Urine albumin Annual screening by random spot urine sample for albumin-to-creatinine ratio (ACR) Self-monitored blood glucose Hypothyroidism screening Celiac disease screening Monogenic diabetes syndromes Screening: Family history of hypercholesterolemia, CV event < 55 y, or unknown: consider fasting lipid profile on children >2 y soon after diagnosis (after glucose control established). No family history concern: consider 1st lipid screening at puberty ( 10 y). Diagnosis at or after puberty: consider fasting lipid profile soon after diagnosis (after glucose control established). Abnormal lipids - annual monitoring. LDL-c acceptable - repeat every 5 y. Treatment Initial : optimization of glucose control and MNT Add statin: after MNT and lifestyle changes, with LDL cholesterol >160 mg/dl ; or LDL-c >130 mg/dl + one or more CVD risk factors in patients > 10 y Screen once child is 10 y or at the start of puberty, whichever is earlier, and has had diabetes for 5 y. Confirm elevated ACR on 2 additional specimens from different days. Treat with an ACE inhibitor; titrate to normalization of albumin Perform fasting lipid profile at diagnosis. dyslipidemia in youth are similar to those for type 1. Perform urine albumin assessment at diagnosis. albumin excretion in youth are similar to those for type 1. excretion. Although the evidence for A1C-lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device. CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. Consider screening children with type 1 diabetes for antithyroid peroxidase and antithyroglobulin antibodies at diagnosis. TSH should be checked soon after diagnosis, and rechecked every 1-2 years or with symptoms of thyroid dysfunction, thyromegaly, an abnormal growth rate, or unusual glycemic variation. Consider screening by measuring IgA antitissue transglutaminase or antiendomysial antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes. Consider testing in children with positive family history of celiac disease, growth failure, failure to gain weight, weight loss, diarrhea, flatulence, abdominal pain, or signs of malabsorption, or in children with frequent unexplained hypoglycemia or deterioration in glycemic control. Consider referral to a gastroenterologist for evaluation with possible endoscopy and biopsy for confirmation of celiac disease in asymptomatic children with positive antibodies. Children with biopsy-confirmed celiac disease should be placed on a gluten-free diet and have consultation with a dietitian experienced in managing both diabetes and celiac disease. Consider genetic testing on children in the following settings: 1) diagnosis in the first six months of life, 2) with strong family history of diabetes but without typical features of type 2 diabetes (nonobese, low-risk ethnic group), 3) with mild fasting hyperglycemia ( mg/dl), especially if young and nonobese, 4) with diabetes but with negative autoantibodies without signs of obesity or insulin resistance. N/A N/A N/A Physical activity Self-care education As is the case for all children, children with diabetes or prediabetes should be encouraged to engage in at least 60 min/day of physical activity. Family involvement is an important component of optimal diabetes management throughout childhood and into adolescence. School and day care: close communication with and cooperation of school or daycare personnel is essential

5 Self-management goals Pediatric MNT and psychological support should be provided at diagnosis, and regularly thereafter, by individuals experienced with the nutritional and behavioral needs of the growing child and family. Coordinate planning for seamless transition of all youth from pediatric to adult health care. Resources available at and The Endocrine Society at Influenza immunization Pneumonia immunization Annually after 6 months of age Administer to all diabetic patients 2 years of age. * The significance of foot examinations among school-aged children and adolescents is unclear, but these examinations are inexpensive, fast, and can be a good time for education of proper foot care; therefore, they should not be excluded. (ADA consensus statement Meeting Quality Standards for Self-Management Education in Pediatric Type 2 Diabetes (from 2007) ; Available at

6 Diabetes Summary of Medical Guidelines National Standards for Diabetes Self-Management Education and Support Diabetes Self-Management Education (DSME): A process incorporating the needs, goals, and life experiences of the person, guided by evidence-based standards. The overall objectives of DSME are to support informed decision making, self-care behaviors, problem solving, and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life. Diabetes Self-Management Support (DSMS): Activities that assist the person with prediabetes or diabetes in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis beyond or outside of formal self-management training. The type of support provided can be behavioral, educational, psychosocial, or clinical. STANDARD 1: Internal structure The provider(s) of DSME will document an organizational structure, mission statement, and goals. For those providers working within a larger organization, that organization will recognize and support quality DSME as an integral component of diabetes care. STANDARD 2: External input The provider(s) of DSME will seek ongoing input from external stakeholders and experts in order to promote program quality. STANDARD 3: Access The provider(s) of DSME will determine who to serve, how best to deliver diabetes education to that population, and what resources can provide ongoing support for that population. STANDARD 4: Program coordination A coordinator will be designated to oversee the DSME program. The coordinator will have oversight responsibility for the planning, implementation, and evaluation of education services. STANDARD 5: Instructional staff One or more instructors will provide DSME and, when applicable, DSMS. At least one of the instructors responsible for designing and planning DSME and DSMS will be a registered nurse, registered dietitian, or pharmacist with training and experience pertinent to DSME, or another professional with certification in diabetes care and education, such as a certified diabetes educator (CDE) or board certified in advanced diabetes management (BC-ADM). Other health workers can contribute to DSME and provide DSMS with appropriate training in diabetes and with supervision and support. Literature favors the registered nurse, registered dietitian, and pharmacist serving both as the key primary instructors for diabetes education and as members of the multidisciplinary team responsible for designing the curriculum and assisting in the delivery of DSME STANDARD 6: Curriculum A written curriculum reflecting current evidence and practice guidelines, with criteria for evaluating outcomes, will serve as the framework for the provision of DSME. The needs of the individual participant will determine which parts of the curriculum will be provided to that individual. STANDARD 7: Individualization The diabetes self-management, education, and support needs of each participant will be assessed by one or more instructors. The participant and instructor(s) will then together develop an individualized education and support plan focused on behavior change. STANDARD 8: Ongoing support The participant and instructor(s) will together develop a personalized follow-up plan for ongoing self-management support. The participant s outcomes and goals and the plan for ongoing self-management support will be communicated to other members of the health care team. STANDARD 9: Patient progress The provider(s) of DSME and DSMS will monitor whether participants are achieving their personal diabetes self-management goals and other outcome(s) as a way to evaluate the effectiveness of the educational intervention(s), using appropriate measurement techniques. STANDARD 10: Quality improvement The provider(s) of DSME will measure the effectiveness of the education and support and look for ways to improve any identified gaps in services or service quality using a systematic review of process and outcome data. Source: Standards of Medical Care in Diabetes Available online: National Standards for Diabetes Self-Management Education and Support Available online: