Executive Summary: Standards of Medical Care in Diabetesd2014

Transcription

1 Diabetes Care Volume 37, Supplement 1, January 2014 S5 Exeutive Summary: Standards of Medial Care in Diabetesd2014 EXECUTIVE SUMMARY CURRENT CRITERIA FOR THE DIAGNOSIS OF DIABETES A1C $6.5%. The test should be performed in a laboratory using a method that is NGSP ertified and standardized to the DCCT assay. Or Fasting plasma gluose (FPG) $126 mg/dl (7.0 mmol/l). Fasting is defined as no alori intake for at least 8 h. Or Two-hour 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, result should be onfirmed by repeat testing. TESTING FOR DIABETES IN ASYMPTOMATIC PATIENTS Testing to detet type 2 diabetes and prediabetes 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. In those without these risk fators, testing should begin at age 45 years. B If tests are normal, repeat testing at least at 3-year intervals is reasonable. E Totestfordiabetesorprediabetes,the A1C, FPG, or 2-h 75-g OGTT are appropriate. B In those identified with prediabetes, identify and, if appropriate, treat other ardiovasular disease (CVD) risk fators. B SCREENING FOR TYPE 2 DIABETES IN CHILDREN Testing to detet type 2 diabetes and prediabetes should be onsidered in hildren and adolesents who are overweight and who have two or more additional risk fators for diabetes. E SCREENING FOR TYPE 1 DIABETES Inform type 1 diabeti patients of the opportunity to have their relatives sreened for type 1 diabetes risk in the setting of a linial researh study. E DETECTION AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS Sreen for undiagnosed type 2 diabetes at the first prenatal visit in thosewithriskfators,usingstandard diagnosti riteria. B Sreen for gestational diabetes mellitus (GDM) at weeks of gestation in pregnant women not previously known to have diabetes. A Sreen women with GDM for persistent diabetes at 6 12 weeks postpartum, using the OGTT and nonpregnany diagnosti riteria. E Women with a history of GDM should have lifelong sreening for the development of diabetes or prediabetes at least every 3 years. B Women with a history of GDM found to have prediabetes should reeive lifestyle interventions or metformin to prevent diabetes. A Further researh is needed to establish a uniform approah to diagnosing GDM. E PREVENTION/DELAY OF TYPE 2 DIABETES Patients with impaired gluose tolerane (IGT) A, impaired fasting gluose (IFG) E, or an A1C % E shouldbereferredtoaneffetive ongoing support program targeting weight loss of 7% of body weight and inreasing physial ativity to at least 150 min/week of moderate ativity suh as walking. Follow-up ounseling appears to be important for suess. B Basedontheost-effetivenessof diabetes prevention, suh programs should be overed by third-party payers. B Metformin therapy for prevention of type 2 diabetes may be onsidered in those with IGT A,IFGE, or an A1C % E, espeially for those with BMI.35 kg/m 2,aged,60 years, and women with prior GDM. A At least annual monitoring for the development of diabetes in those with prediabetes is suggested. E Sreening for and treatment of modifiable risk fators for CVD is suggested. B GLUCOSE MONITORING Patients on multiple-dose insulin (MDI) or insulin pump therapy should do self-monitoring of blood gluose (SMBG) prior to meals and snaks, oasionally postprandially, at bedtime, prior to exerise, when they suspet low blood gluose, after treating low blood gluose until they are normoglyemi, and prior to ritial tasks suh as driving. B When presribed as part of a broader eduational ontext, SMBG results may be helpful to guide treatment deisions and/or patient selfmanagement for patients using less DOI: /d14-S by the Amerian Diabetes Assoiation. See for details.

2 S6 Exeutive Summary Diabetes Care Volume 37, Supplement 1, January 2014 frequent insulin injetions or noninsulin therapies. E When presribing SMBG, ensure that patients reeive ongoing instrution and regular evaluation of SMBG tehnique and SMBG results, as well as their ability to use SMBG data to adjust therapy. E When used properly, ontinuous gluose monitoring (CGM) in onjuntion with intensive insulin regimens is a useful tool to lower A1C in seleted adults (aged $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. E A1C Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glyemi ontrol). E Perform the A1C test quarterly in patients whose therapy has hanged or who are not meeting glyemi goals. E Use of point-of-are (POC) testing for A1C provides the opportunity for more timely treatment hanges. E GLYCEMIC 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%. B 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 in those with long-standing diabetes in whom the general goal is diffiult to attain despite diabetes selfmanagement eduation (DSME), appropriate gluose monitoring, and effetive doses of multiple gluoselowering agents inluding insulin. B PHARMACOLOGICAL AND OVERALL APPROACHES TO TREATMENT Insulin Therapy for Type 1 Diabetes Most people with type 1 diabetes should be treated with MDI injetions (three to four injetions per day of basal and prandial insulin) or ontinuous subutaneous insulin infusion (CSII). A Most people with type 1 diabetes should be eduated in how to math prandial insulin dose to arbohydrate intake, premeal blood gluose, and antiipated ativity. E Most people with type 1 diabetes should use insulin analogs to redue hypoglyemia risk. A Sreening Consider sreening those with type 1 diabetes for other autoimmune diseases (thyroid, vitamin B 12 defiieny, elia) as appropriate. B Pharmaologial Therapy for Hyperglyemia in Type 2 Diabetes Metformin, if not ontraindiated and if tolerated, is the preferred initial pharmaologial agent for type 2 diabetes. 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. E If noninsulin monotherapy at maximum tolerated dose does not ahieve or maintain the A1C target over 3 months, add a seond oral agent, a gluagon-like peptide 1 (GLP- 1) reeptor agonist, or insulin. A A patient-entered approah should be used to guide hoie of pharmaologial agents. Considerations inlude effiay, ost, potential side effets, effets on weight, omorbidities, hypoglyemia risk, and patient preferenes. E Due to the progressive nature of type 2 diabetes, insulin therapy is eventually indiated for many patients with type 2 diabetes. B MEDICAL NUTRITION THERAPY General Reommendations Nutrition therapy is reommended for all people with type 1 and type 2 diabetes as an effetive omponent of the overall treatment plan. A Individuals who have prediabetes or diabetes should reeive individualized medial nutrition therapy (MNT) as needed to ahieve treatment goals, preferably provided by a registered dietitian familiar with the omponents of diabetes MNT. A Beause diabetes nutrition therapy anresultinostsavingsb and improved outomes suh as redution in A1C A, nutrition therapy should be adequately reimbursed by insurane and other payers. E Energy Balane, Overweight, and Obesity For overweight or obese adults with type 2 diabetes or at risk for diabetes, reduing energy intake while maintaining a healthful eating pattern is reommended to promote weight loss. A Modest weight loss may provide linial benefits (improved glyemia, blood pressure, and/or lipids) in some individuals with diabetes, espeially those early in the disease proess. To ahieve modest weight loss, intensive lifestyle interventions (ounseling about nutrition therapy, physial ativity, and behavior hange) with ongoing support are reommended. A Eating Patterns and Maronutrient Distribution Evidene suggests that there is not an ideal perentage of alories from arbohydrate, protein, and fat for all people with diabetes B; therefore, maronutrient distribution should be based on individualized assessment of urrent eating patterns, preferenes, and metaboli goals. E A variety of eating patterns (ombinations of different foods or food groups) are aeptable for the management of diabetes. Personal

3 are.diabetesjournals.org Exeutive Summary S7 preferene (e.g., tradition, ulture, religion, health beliefs and goals, eonomis) and metaboli goals should be onsidered when reommending one eating pattern over another. E Carbohydrate Amount and Quality Monitoring arbohydrate intake, whether by arbohydrate ounting or experiene-based estimation, remains a key strategy in ahieving glyemi ontrol. B For good health, arbohydrate intake from vegetables, fruits, whole grains, legumes, and dairy produts should be advised over intake from other arbohydrate soures, espeially those that ontain added fats, sugars, or sodium. B Substituting low-glyemi load foods for higher-glyemi load foods may modestly improve glyemi ontrol. C People with diabetes should onsume at least the amount of fiber and whole grains reommended for the general publi. C While substituting suroseontaining foods for isoalori amounts of other arbohydrates may have similar blood gluose effets, onsumption should be minimized to avoid displaing nutrient-dense food hoies. A People with diabetes and those at risk for diabetes should limit or avoid intake of sugar-sweetened beverages (from any alori sweetener inluding high-frutose orn syrup and surose) to redue risk for weight gain and worsening of ardiometaboli risk profile. B Dietary Fat Quantity and Quality Evidene is inonlusive for an ideal amount of total fat intake for people with diabetes; therefore, goals should be individualized. C Fat quality appears to be far more important than quantity. B In people with type 2 diabetes, a Mediterranean-style, MUFA-rih eating pattern may benefit glyemi ontrol and CVD risk fators and an therefore be reommended as an effetive alternative to a lower-fat, higherarbohydrate eating pattern. B As reommended for the general publi, an inrease in foods ontaining long-hain n-3 fatty aids (EPA and DHA) (from fatty fish) and n-3 linoleni aid (ALA) is reommended for individuals with diabetes beause of their benefiial effets on lipoproteins, prevention of heart disease, and assoiations with positive health outomes in observational studies. B The amount of dietary saturated fat, holesterol, and trans fat reommended for people with diabetes is the same as that reommended for the general population. C Supplements for Diabetes Management There is no lear evidene of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying defiienies. C 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 Evidene does not support reommending n-3 (EPA and DHA) supplements for people with diabetes for the prevention or treatment of ardiovasular events. A There is insuffiient evidene to support the routine use of mironutrients suh as hromium, magnesium, and vitamin D to improve glyemi ontrol in people with diabetes. C There is insuffiient evidene to support the use of innamon or other herbs/supplements for the treatment of diabetes. C It is reasonable for individualized meal planning to inlude optimization of food hoies to meet reommended daily allowane/dietary referene intake for all mironutrients. E Alohol If adults with diabetes hoose to drink alohol, they should be advised to do so in moderation (one drink per day or less for adult women and two drinks per day or less for adult men). E Alohol onsumption may plae people with diabetes at inreased risk for delayed hypoglyemia, espeially if taking insulin or insulin seretagogues. Eduation and awareness regarding the reognition and management of delayed hypoglyemia is warranted. C Sodium The reommendation for the general population to redue sodium to,2,300 mg/day is also appropriate for people with diabetes. B For individuals with both diabetes and hypertension, further redution in sodium intake should be individualized. B Primary Prevention of Type 2 Diabetes Among individuals at high risk for developing type 2 diabetes, strutured programs that emphasize lifestyle hanges that inlude moderate weight loss (7% of body weight) and regular physial ativity (150 min/week), with dietary strategies inluding redued alories and redued intake of dietary fat, an redue the risk for developing diabetes and are therefore reommended. A Individuals at high risk for type 2 diabetes should be enouraged to ahieve the U.S. Department of Agriulture (USDA) reommendation for dietary fiber (14 gfiber/1,000 kal) and foods ontaining whole grains (one-half of grain intake). B DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT People with diabetes should reeive DSME and diabetes self-management support (DSMS) aording to National Standards for Diabetes Self- Management Eduation and Support when their diabetes is diagnosed and as needed thereafter. B Effetive self-management and quality of life are the key outomes of DSME and DSMS and should be measured and monitored as part of are. C DSME and DSMS should address psyhosoial issues, sine emotional well-being is assoiated with positive diabetes outomes. C DSME and DSMS programs are appropriate venues for people with prediabetes to reeive eduation and support to develop and maintain behaviors that an prevent or delay the onset of diabetes. C

4 S8 Exeutive Summary Diabetes Care Volume 37, Supplement 1, January 2014 Beause DSME and DSMS an result in ost-savings and improved outomes B, DSME and DSMS should be adequately reimbursed by thirdparty payers. E PHYSICAL ACTIVITY As is the ase for all hildren, hildren with diabetes or prediabetes should be enouraged to engage in at least 60 min of physial ativity eah day. B Adults 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/week with no more than 2 onseutive days without exerise. A In the absene of ontraindiations, adults with type 2 diabetes should be enouraged to perform resistane training at least twie per week. A PSYCHOSOCIAL ASSESSMENT AND CARE It is reasonable to inlude assessment of the patient s psyhologial and soial situation as an ongoing part of the medial management of diabetes. B Psyhosoial sreening and follow-up may inlude, but are 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. E Routinely sreen for psyhosoial problems suh as depression and diabetes-related distress, anxiety, eating disorders, and ognitive impairment. B HYPOGLYCEMIA Individuals at risk for hypoglyemia should be asked about symptomati and asymptomati hypoglyemia at eah enounter. C 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. After 15 min of treatment, if SMBG shows ontinued hypoglyemia, the treatment should be repeated. One SMBG returns to normal, the individual should onsume a meal or snak to prevent reurrene of hypoglyemia. E Gluagon should be presribed for all individuals at signifiant risk of severe hypoglyemia, and aregivers or family members of these individuals should be instruted on its administration. Gluagon administration is not limited to health are professionals. E Hypoglyemia unawareness or one or more episodes of severe hypoglyemia should trigger re-evaluation of the treatment regimen. E Insulin-treated patients with hypoglyemia unawareness or an episode 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. A Ongoing assessment of ognitive funtion is suggested with inreased vigilane for hypoglyemia by the liniian, patient, and aregivers if low ognition and/or delining ognition is found. B BARIATRIC SURGERY Bariatri surgery may be onsidered for adults with BMI.35 kg/m 2 and type 2 diabetes, espeially if diabetes or assoiated omorbidities are diffiult to ontrol with lifestyle and pharmaologial therapy. B Patients with type 2 diabetes who have undergone bariatri surgery need lifelong lifestyle support and medial monitoring. B Although small trials have shown glyemi benefit of bariatri surgery in patients with type 2 diabetes and BMI 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. E The long-term benefits, osteffetiveness, and risks of bariatri surgery in individuals with type 2 diabetes should be studied in welldesigned ontrolled trials with optimal medial and lifestyle therapy as the omparator. E IMMUNIZATION Annually provide an influenza vaine to all diabeti patients $6 months of age. C Administer pneumooal polysaharide vaine to all diabeti patients $2 years of age. A one-time revaination is reommended for individuals.65 years of age who have been immunized.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 unvainated adults with diabetes who are aged years. C Consider administering hepatitis B vaination to unvainated adults with diabetes who are aged $60 years. C HYPERTENSION/BLOOD PRESSURE CONTROL Sreening and Diagnosis Blood pressure should be measured at every routine visit. Patients found to have elevated blood pressure should have blood pressure onfirmed on a separate day. B Goals People with diabetes and hypertension should be treated to a systoli blood pressure (SBP) goal of,140 mmhg. B Lower systoli targets, suh as,130 mmhg, may be appropriate for ertain individuals, suh as younger patients, if it an be ahieved without undue treatment burden. C Patients with diabetes should be treated to a diastoli blood pressure (DBP),80 mmhg. B Patients with blood pressure.120/80 mmhg should be advised on lifestyle hanges to redue blood pressure. B Patients with onfirmed blood pressure higher than 140/80 mmhg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmaologial therapy to ahieve blood pressure goals. B Lifestyle therapy for elevated blood pressure onsists of weight loss, if

5 are.diabetesjournals.org Exeutive Summary S9 overweight; Dietary Approahes to Stop Hypertension (DASH)-style dietary pattern inluding reduing sodium and inreasing potassium intake; moderation of alohol intake; and inreased physial ativity. B Pharmaologial therapy for patients with diabetes and hypertension should omprise a regimen that inludes either an ACE inhibitor or an angiotensin reeptor bloker (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. B Administer one or more antihypertensive mediations at bedtime. A If ACE inhibitors, ARBs, or diuretis are used, serum reatinine/estimated glomerular filtration rate (egfr) and serum potassium levels should be monitored. E In pregnant patients with diabetes and hroni hypertension, blood pressure target goals of /65 79 mmhg are suggested in the interest of long-term maternal health and minimizing impaired fetal growth. ACE inhibitors and ARBs are ontraindiated during pregnany. E DYSLIPIDEMIA/LIPID MANAGEMENT Sreening In most adult patients with diabetes, measure fasting lipid profile at least annually. B 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 2 years. E Reommendations and Goals Lifestyle modifiation fousing on the redution of saturated fat, trans fat, and holesterol intake; inrease of n-3 fatty aids, visous fiberandplant 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 (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). 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 above 100 mg/dl or in those with multiple CVD risk fators. C In individuals without overt CVD, the goal is LDL holesterol,100 mg/dl (2.6 mmol/l). B In individuals with overt CVD, a lower LDL holesterol goal of,70 mg/dl (1.8 mmol/l), with a high dose of a statin, is an option. B If drug-treated patients do not reah the above targets on maximum tolerated statin therapy, a redution in LDL holesterol of ;30 40% from baseline is an alternative therapeuti goal. B Triglyeride 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. C However, LDL holesterol targeted statin therapy remains the preferred strategy. A Combination therapy has been shown not to provide additional ardiovasular benefit above statin therapy alone and is not generally reommended. A Statin therapy is ontraindiated in pregnany. B 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 aged.50 years or women aged.60 years 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%, suh as in men aged,50 years and women aged,60 years 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. E 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. B Dual antiplatelet therapy is reasonable for up to a year after an aute oronary syndrome. B SMOKING CESSATION Advise all patients not to smoke or use tobao produts. A Inlude smoking essation ounseling and other forms of treatment as a routine omponent of diabetes are. B CARDIOVASCULAR DISEASE Sreening In asymptomati patients, routine sreening for oronary artery disease (CAD) is not reommended beause it does not improve outomes as long as CVD risk 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 (MI), b-blokers should be ontinued for at least 2 years after the event. B In patients with symptomati heart failure, avoid thiazolidinedione treatment. C In patients with stable ongestive heart failure (CHF), metformin may be used if renal funtion is normal but should be avoided in unstable or hospitalized patients with CHF. B

6 S10 Exeutive Summary Diabetes Care Volume 37, Supplement 1, January 2014 NEPHROPATHY General Reommendations Optimize gluose ontrol to redue the risk or slow the progression of nephropathy. A Optimize blood pressure ontrol to redue the risk or slow the progression of nephropathy. A Sreening Perform an annual test to quantitate urine albumin exretion in type 1 diabeti patients with diabetes duration of $5yearsandinalltype2 diabeti patients starting at diagnosis. B An ACE inhibitor or ARB for the primary prevention of diabeti kidney disease is not reommended in diabeti patients with normal blood pressure and albumin exretion,30 mg/24 h. B Either ACE inhibitors or ARBs (but not both in ombination) are reommended for the treatment of the nonpregnant patient with modestly elevated ( mg/24 h) C or higher levels (.300 mg/24 h) of urinary albumin exretion. A For people with diabetes and diabeti kidney disease (albuminuria.30 mg/24 h), reduing the amount of dietary protein below usual intake is not reommended beause it does not alter glyemi measures, ardiovasular risk measures, or the ourse of GFR deline. A When ACE inhibitors, ARBs, or diuretis are used, monitor serum reatinine and potassium levels for the development of inreased reatinine or hanges in potassium. E Continued monitoring of urine albumin exretion to assess both response to therapy and progression of disease is reasonable. E When egfr is,60 ml/min/1.73 m 2, evaluate and manage potential ompliations of hroni kidney disease (CKD). E 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. B RETINOPATHY General Reommendations Optimize glyemi ontrol to redue the risk or slow the progression of retinopathy. A Optimize blood pressure ontrol to redue the risk or slow the progression of retinopathy. A Sreening Adults 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. B 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. B If there is no evidene of retinopathy for one or more eye exams, then exams every 2 years may be onsidered. If diabeti retinopathy is present, subsequent examinations for type 1 and type 2 diabeti patients should be repeated annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight threatening, then examinations will be required more frequently. B High-quality fundus photographs an detet most linially signifiant diabeti 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. E Women with preexisting diabetes who are planning pregnany or who have beome pregnant should have a omprehensive eye examination and 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. B Promptly refer patients with any level of maular edema, severe nonproliferative diabeti retinopathy (NPDR), or any proliferative diabeti retinopathy (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 in some ases severe NPDR. A Anti-vasular endothelial growth fator (VEGF) therapy is indiated for diabeti maular edema. 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 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. B Eletrophysiologial testing or referral to a neurologist is rarely needed, exept in situations where the linial features are atypial. E Sreening for signs and symptoms of ardiovasular autonomi neuropathy (CAN) 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. E Mediations for the relief of speifi symptoms related to painful DPN and autonomi neuropathy are reommended beause they may redue pain B and improve quality of life. E FOOT CARE 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 (LOPS) (10-g monofilament plus testing any one of the following: vibration using

7 are.diabetesjournals.org Exeutive Summary S Hz tuning fork, pinprik sensation, ankle reflexes, or vibration pereption threshold). B Provide general foot self-are eduation to all patients with diabetes. B A multidisiplinary approah is reommended for individuals with foot ulers and high-risk feet, espeially those with a history of prior uler or amputation. B Refer patients who smoke, have LOPS and strutural abnormalities, or have history of prior lowerextremity ompliations to foot are speialists for ongoing preventive are and lifelong 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 COMMON COMORBID CONDITIONS Consider assessing for and addressing ommon omorbid onditions that may ompliate the management of diabetes. B CHILDREN AND ADOLESCENTS Type 1 Diabetes Glyemi Control Consider age when setting glyemi goals in hildren and adolesents with type 1 diabetes. E Sreening and Management of Compliations Nephropathy Sreening Annual sreening for albumin levels, with a random spot urine sample for albumin-to-reatinine ratio (ACR), should be onsidered for the hild at the start of puberty or at age $10 years, whihever is earlier, one the youth has had diabetes for 5 years. B 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. This should be obtained over a 6-month interval following efforts to improve glyemi ontrol and normalize blood pressure for age. E Hypertension Sreening Blood pressure should be measured at eah routine visit. Children found to have high-normal blood pressure or hypertension should have blood pressure onfirmed on a separate day. B Initial treatment of high-normal blood pressure (SBP or DBP 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, pharmaologial treatment should be onsidered. E Pharmaologial treatment of hypertension (SBP or DBP 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. E ACE inhibitors should be onsidered for the initial pharmaologial treatment of hypertension, following appropriate reprodutive ounseling due to its potential teratogeni effets. E The goal of treatment is blood pressure onsistently,130/80 or below the 90th perentile for age, sex, and height, whihever is lower. E 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 in hildren.2 years of age soon after the diagnosis (after gluose ontrol has been established). If family history is not of onern, then onsider the first lipid sreeningat puberty ($10 years). For hildren diagnosed with diabetes at or after puberty, onsider obtaining a fasting lipid profile soon after the diagnosis (after gluose ontrol has been established). E 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. E Initial therapy may onsist of optimization of gluose ontrol and MNT using a Step 2 Amerian Heart Assoiation (AHA) diet aimed at a derease in the amount of saturated fat in the diet. E 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.130 mg/dl (3.4 mmol/l) and one or more CVD risk fators is reasonable. E The goal of therapy is an LDL holesterol value,100 mg/dl (2.6 mmol/l). E Retinopathy An initial dilated and omprehensive eye examination should be onsidered for the hild at the start of puberty or at age $10 years, whihever is earlier, one the youth has had diabetes for 3 5 years. B 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. E Celia Disease Consider sreening hildren with type 1 diabetes for elia disease by measuring IgA antitissue transglutaminase or antiendomysial antibodies, with doumentation of normal total serum IgA levels, soon after the diagnosis of diabetes. E Testing should be onsidered in hildren with a positive family history of elia disease, 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. E

8 S12 Exeutive Summary Diabetes Care Volume 37, Supplement 1, January 2014 Consider referral to a gastroenterologist for evaluation with possible endosopy and biopsy for onfirmation of elia disease in asymptomati hildren with positive antibodies. E Children with biopsy-onfirmed elia disease should be plaed on a gluten-free diet and have onsultation with a dietitian experiened in managing both diabetes and elia disease. B Hypothyroidism Consider sreening hildren with type 1 diabetes for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis. E Measuring thyroid-stimulating hormone (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, an abnormal growth rate, or unusual glyemi variation. E TRANSITION FROM PEDIATRIC TO ADULT CARE As teens transition into emerging adulthood, health are providers and families must reognize their many vulnerabilities B and prepare the developing teen, beginning in early to mid adolesene and at least 1 year prior to the transition. E Both pediatriians and adult health are providers should assist in providing support and links to resoures for the teen and emerging adult. B PRECONCEPTION CARE A1C levels should be as lose to normal as possible (,7%) in an individual patient before oneption is attempted. B Starting at puberty, preoneption ounseling should be inorporated in the routine diabetes lini visit for all women of hildbearing potential. B Women with diabetes who are ontemplating pregnany should be evaluated and, if indiated, treated for diabeti retinopathy, nephropathy, neuropathy, and CVD. B Mediationsusedbysuhwomen 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. E 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. E OLDER ADULTS Older adults who are funtional, ognitively intat, and have signifiant life expetany should reeive diabetes are with goals similar to those developed for younger adults. E Glyemi goals for some older adults might reasonably be relaxed, using individual riteria, but hyperglyemia leading to symptoms or risk of aute hyperglyemi ompliations should be avoided in all patients. E 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 may benefitthose with life expetany at least equal to the time frame of primary or seondary prevention trials. E Sreening for diabetes ompliations should be individualized in older adults, but partiular attention should be paid to ompliations that would lead to funtional impairment. E CYSTIC FIBROSIS RELATED DIABETES Annual sreening for ysti fibrosis related diabetes (CFRD) with OGTT should begin by age 10 years in all patients with ysti fibrosis who do not have CFRD. B A1C as a sreening test for CFRD is not reommended. B During a period of stable health, the diagnosis of CFRD an be made in ysti fibrosis patients aording to usual gluose riteria. E 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. E DIABETES CARE IN THE HOSPITAL Diabetes disharge planning should start at hospital admission, and lear diabetes management instrutions should be provided at disharge. E The sole use of sliding sale insulin in the inpatient hospital setting is disouraged. E All patients with diabetes admitted to the hospital should have their diabetes learly identified in the medial reord. E All patients with diabetes should have an order for blood gluose monitoring, with results available to all members of the health are team. E 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 ( 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. E Non ritially ill patients: Thereis no lear evidene for speifi blood gluose goals. If treated with insulin, the premeal blood gluose targets generally,140 mg/dl (7.8 mmol/l) with random blood gluose,180 mg/dl (10.0 mmol/l) are reasonable, provided these targets an be safely ahieved. More stringent targets may be appropriate in stable patients with previous tight glyemi ontrol. Less stringent targets may be appropriate in those with severe omorbidities. E Sheduled subutaneous insulin with basal, nutritional, and

9 are.diabetesjournals.org Exeutive Summary S13 orretional omponents is the preferred method for ahieving and maintaining gluose ontrol in non ritially ill patients. C Gluose monitoring should be initiated in any patient not known to be diabeti who reeives therapy assoiated with high risk for hyperglyemia, inluding highdose gluoortioid therapy, initiation of enteral or parenteral nutrition, or other mediations suh as otreotide or immunosuppressive mediations. B If hyperglyemia is doumented and persistent, onsider treating suh patients to the same glyemi goals as in patients with known diabetes. E 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. E Consider obtaining an A1C in patients with diabetes admitted to the hospital if the result of testing in the previous 2 3 months is not available. E Consider obtaining an A1C in patients with risk fators for undiagnosed diabetes who exhibit hyperglyemia in the hospital. E 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. E STRATEGIES FOR IMPROVING DIABETES CARE Care should be aligned with omponents of the Chroni Care Model (CCM) to ensure produtive interations between a prepared proative pratie team and an informed ativated patient. A When feasible, are systems should support team-based are, ommunity involvement, patient registries, and embedded deision support tools to meet patient needs. B deisions should be timely and based on evidene-based guidelines that are tailored to individual patient preferenes, prognoses, and omorbidities. B A patient-entered ommuniation style should be used that inorporates patient preferenes, assesses literay and numeray, and addresses ultural barriers to are. B