Standards of Medical Care in Diabetes—2012

Standards of Medical Care in Diabetes—2012
“Standards of Medical Care in Diabetes—2012” comprises all of the current and key clinical recommendations of the American Diabetes Association (ADA) These standards of care are intended to provide clinicians, patients, researchers, payers, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided; specifically titled sections of the standards address children with diabetes, pregnant women, and people with prediabetes These standards are not intended to preclude clinical judgment or more extensive evaluation and management of the patient by other specialists as needed; for more detailed information about management of diabetes, refer to references The recommendations included are screening, diagnostic, and therapeutic actions that are known or believed to affect health outcomes of patients with diabetes favorably; a large number of these interventions have been shown to be cost-effective The slides are organized to correspond with sections within the “Standards of Medical Care in Diabetes—2012” While not every section in the document is represented, these slides do incorporate the most salient points from the Position Statement These standards of care are revised annually by the ADA’s multidisciplinary Professional Practice Committee, incorporating new evidence; subsequently, they are reviewed and approved by the Executive Committee of ADA’s Board of Directors Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S11. Available online at

Table of Contents Section Slide No.
ADA Evidence Grading System of Clinical Recommendations 3 I. Classification and Diagnosis 4-11 II. Testing for Diabetes in Asymptomatic Patients 12-15 III. Detection and Diagnosis of Gestational Diabetes Mellitus (GDM) 16-19 IV. Prevention/Delay of Type 2 Diabetes 20-21 V. Diabetes Care 22-67 VI. Prevention and Management of Diabetes Complications 68-112 VII. Assessment of Common Comorbid Conditions VIII. Diabetes Care in Specific Populations IX. Diabetes Care in Specific Settings X. Strategies for Improving Diabetes Care The slide deck, mirroring “Standards of Medical Care in Diabetes—2012,” is divided into ten separate sections, I.–X. Each of the ten sections includes text and tables from “Standards of Medical Care in Diabetes—2012” The title slide at the beginning of each of the ten sections includes the number of slides in that section and a list of the slide titles

ADA Evidence Grading System for Clinical Recommendations
Level of Evidence Description A Clear or supportive evidence from adequately powered well-conducted, generalizable, randomized controlled trials Compelling nonexperimental evidence B Supportive evidence from well-conducted cohort studies or case-control study C Supportive evidence from poorly controlled or uncontrolled studies Conflicting evidence with the weight of evidence supporting the recommendation E Expert consensus or clinical experience The American Diabetes Association has developed a grading system for clinical recommendations (Table 1) This grading system was used to clarify and codify evidence that forms the basis for each of the recommendations in the “Standards of Medical Care in Diabetes—2012” The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E This slide summarizes the description for each of these levels of evidence ADA. Diabetes Care 2012;35(suppl 1):S12. Table 1. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S11-S12. Table 1.

I. Classification and Diagnosis
“Standards of Medical Care in Diabetes—2012” comprises ten sections Section I. Classification and Diagnosis includes seven slides: Classification of Diabetes Criteria for the Diagnosis of Diabetes (5 slides) Prediabetes: IFG, IGT, Increased A1C I. Classification and Diagnosis

Classification of Diabetes
Type 1 diabetes β-cell destruction Type 2 diabetes Progressive insulin secretory defect Other specific types of diabetes Genetic defects in β-cell function, insulin action Diseases of the exocrine pancreas Drug- or chemical-induced Gestational diabetes mellitus The classification of diabetes includes four clinical classes Type 1 diabetes (results from β-cell destruction, usually leading to absolute insulin deficiency) Type 2 diabetes (results from a progressive insulin secretory defect on the background of insulin resistance) Other specific types of diabetes due to other causes; e.g., genetic defects in β-cell function, genetic defects in insulin action, diseases of the exocrine pancreas (such as cystic fibrosis), and drug- or chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation) Gestational diabetes mellitus (GDM; diabetes diagnosed during pregnancy that is not clearly overt diabetes) Some patients cannot be clearly classified as having type 1 or type 2 diabetes Clinical presentation and disease progression vary considerably in both types of diabetes Occasionally, patients who otherwise have type 2 diabetes may present with ketoacidosis Similarly, patients with type 1 diabetes may have a late onset and slow (but relentless) progression despite having features of autoimmune disease Such difficulties in diagnosis may occur in children, adolescents, and adults The true diagnosis may become more obvious over time ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S11. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S11.

Criteria for the Diagnosis of Diabetes
A1C ≥6.5% OR Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT A random plasma glucose ≥200 mg/dL (11.1 mmol/L) Table 2, current diagnostic criteria for the diagnosis of diabetes, is divided into five slides On this slide, all four criteria are included: A1C ≥6.5% OR Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) 2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT A random plasma glucose ≥200 mg/dL (11.1 mmol/L), in patients with classic symptoms of hyperglycemia or hyperglycemic crisis The subsequent four slides examine each of the four criteria in greater detail ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S12. Table 2. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S12. Table 2.

A1C ≥6.5% The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay* A1C In 2009, an International Expert Committee that included representatives of the American Diabetes Association (ADA), the International Diabetes Federation (IDF), and the European Association for the Study of Diabetes (EASD) recommended the use of the A1C test to diagnose diabetes, with a threshold of ≥6.5%1, and ADA adopted this criterion in 20102 The diagnostic test should be performed using a method certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized or traceable to the Diabetes Control and Complications Trial (DCCT) reference assay3 Point-of-care A1C assays, for which proficiency testing is not mandated, are not sufficiently accurate at this time to use for diagnostic purposes3 The A1C has several advantages to the FPG and OGTT, including greater convenience (since fasting is not required), evidence to suggest greater preanalytical stability, and less day-to-day perturbations during periods of stress and illness These advantages must be balanced by greater cost, the limited availability of A1C testing in certain regions of the developing world, and the incomplete correlation between A1C and average glucose in certain individuals In addition, HbA1C levels may vary with patients’ race/ethnicity4,5 *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S12. Table 2. References International Expert Committee: International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009;32: American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2012;35(suppl 1):S64-S71. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;54(suppl 1):S11-S12; Table 2. Ziemer DC, Kolm P, Weintraub WS, et al. Glucose-independent, black-white differences in hemoglobin A1c levels: a cross-sectional analysis of 2 studies. Ann Intern Med 2010;152: Kumar PR, Bhansali A, Ravikiran M, et al. Utility of glycated hemoglobin in diagnosing type 2 diabetes mellitus: a community-based study. J Clin Endocrinol Metab 2010;95:

Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) Fasting is defined as no caloric intake for at least 8 h* Fasting Plasma Glucose (FGP) The established glucose criteria for the diagnosis of diabetes (FPG and 2-hour plasma glucose [next slide]) remain valid as well1 Just as there is less than 100% concordance between the FPG and 2-h PG tests, there is not perfect concordance between A1C and either glucose-based test Analyses of National Health and Nutrition Examination Survey (NHANES) data indicate that, assuming universal screening of the undiagnosed, the A1C cut point of ≥6.5% identifies one-third fewer cases of undiagnosed diabetes than a fasting glucose cut point of ≥ 126 mg/dL (7.0 mmol/L)2 However, in practice, a large portion of the diabetic population remains unaware of their condition Thus, the lower sensitivity of A1C at the designated cut point may well be offset by the test’s greater practicality, and wider application of a more convenient test (A1C) may actually increase the number of diagnoses made. *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S12. Table 2. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S12. Table 2. Cowie CC, Rust KF, Byrd-Holt DD, et al. Prevalence of diabetes and high risk for diabetes using A1C criteria in the U.S. population in Diabetes Care 2010;33:

2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water* 2-hour plasma glucose (2-h PG) The 2-hour plasma glucose test should be performed as described by the World Health Organization (WHO), using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water The established glucose criteria for the diagnosis of diabetes (FPG, previous slide, and 2-h PG) remain valid *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S12. Table 2. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S12. Table 2.

In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L) Random Plasma Glucose As with most diagnostic tests, a test result diagnostic of diabetes should be repeated to rule out laboratory error, unless the diagnosis is clear on clinical grounds, such as a patient with a hyperglycemic crisis or classic symptoms of hyperglycemia and a random plasma glucose ≥200 mg/dL It is preferable that the same test be repeated for confirmation, since there will be a greater likelihood of concurrence in this case For example, if the A1C is 7.0% and a repeat result is 6.8%, the diagnosis of diabetes is confirmed; however, if two different tests (such as A1C and FPG) are both above the diagnostic thresholds, the diagnosis of diabetes is also confirmed On the other hand, if two different tests are available in an individual and the results are discordant, the test whose result is above the diagnostic cut point should be repeated, and the diagnosis is made on the basis of the confirmed test That is, if a patient meets the diabetes criterion of the A1C (two results ≥ 6.5%) but not the FPG (<126 mg/dL or 7.0 mmol/L), or vice versa, that person should be considered to have diabetes ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S12. Table 2. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S12. Table 2.

Prediabetes: IFG, IGT, Increased A1C
Categories of increased risk for diabetes (prediabetes)* FPG 100–125 mg/dL (5.6–6.9 mmol/L): IFG OR 2-h plasma glucose in the 75-g OGTT 140–199 mg/dL (7.8–11.0 mmol/L): IGT A1C 5.7–6.4% In 1997 and 203, The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus1,2 recognized an intermediate group of individuals whose glucose levels, although not meeting criteria for diabetes, are nevertheless too high to be considered normal This group was defined as having impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) IFG: fasting plasma glucose (FPG) of 100–125 mg/dL (5.6–5.9 mmol/L)* IGT: 2-hour plasma glucose (2-h PG) on the 75-g oral glucose tolerance test (OGTT) of 140–199 mg/dL (7.8–11.0 mmol/L) Individuals with IFG and/or IGT have been referred to as having prediabetes, indicating a relatively high risk for future development of diabetes IFG and IGT should not be viewed as clinical entities in their own right but rather risk factors for diabetes as well as cardiovascular disease (CVD) IFG and IGT are associated with obesity (especially abdominal or visceral obesity), dyslipidemia with high triglycerides and/or low HDL cholesterol, and hypertension Individuals with an A1C of 5.7–6.4% should be informed of their increased risk for diabetes as well as CVD and counseled about effective strategies to lower their risks (see Section IV. Prevention/Delay of Type 2 Diabetes) *The World Health Organization (WHO) and a number of other diabetes organizations define the cutoff for IFG at 110 mg/dL (6.1 mmol/L) *For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range. ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S13. Table 3. References Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20: Genuth S, Alberti KG, Bennett P, et al., for the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S13. Table 3.

II. Testing for Diabetes in Asymptomatic Patients
Section II. Testing for Diabetes in Asymptomatic Patients includes three slides: Recommendations: Testing for Diabetes in Asymptomatic Patients Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (2 slides) II. Testing for Diabetes in Asymptomatic Patients

Recommendations: Testing for Diabetes in Asymptomatic Patients
Consider testing overweight/obese adults (BMI ≥25 kg/m2) with one or more additional risk factors In those without risk factors, begin testing at age 45 years (B) If tests are normal Repeat testing at least at 3-year intervals (E) Use A1C, FPG, or 2-h 75-g OGTT (B) In those with increased risk for future diabetes Identify and, if appropriate, treat other CVD risk factors (B) Recommendations for testing for diabetes in asymptomatic patients are summarized on this slide; testing should be considered in adults of any age with BMI ≥25 kg/m2 and one or more of the known risk factors for diabetes For many illnesses, there is major distinction between screening and diagnostic testing; however, for diabetes, the same tests would be used for “screening” as for diagnosis A1C, fasting plasma glucose (FPG), or 2-hour oral glucose tolerance test (2-h OGTT) are appropriate to test for diabetes The same assays used for testing for diabetes will also detect individuals with prediabetes In adults, prediabetes and diabetes meet established criteria for conditions in which early detection is appropriate; both conditions are common, increasing in prevalence, and impose significant health burdens There is a long presymptomatic phase before the diagnosis of type 2 diabetes is usually made; relatively simple tests are available to detect preclinical disease Additionally, the duration of glycemic burden is a strong predictor of adverse outcomes, and effective interventions exist to prevent progression of prediabetes to diabetes (see Section IV. Prevention/Delay of Type 2 Diabetes) and to reduce risk of complications of diabetes (see Section VI. Prevention and Management of Diabetes Complications) ADA. II. Testing in Asymptomatic Patients. Diabetes Care 2012;35(suppl 1):S13. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S13-S14.

Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (1)
1. Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and who have one or more additional risk factors: Physical inactivity First-degree relative with diabetes High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) Women who delivered a baby weighing >9 lb or were diagnosed with GDM Hypertension (≥140/90 mmHg or on therapy for hypertension) HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L) Women with polycystic ovarian syndrome (PCOS) A1C ≥5.7%, IGT, or IFG on previous testing Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) History of CVD The three primary criteria for testing for diabetes in asymptomatic adult individuals (Table 4) are summarized on two slides; this slide (Slide 1 of 2) includes: Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2) and have additional risk factors1 Testing should be considered in adults of any age with BMI ≥25 kg/m2 and one or more of the known risk factors listed on this slide1 There is compelling evidence that lower BMI cut-points suggest diabetes risk in some racial and ethnic groups1 In a large multiethnic cohort study, for an equivalent incidence rate of diabetes conferred by a BMI of 30 kg/m2 in whites, the BMI cutoff value was 24 kg/m2 in South Asians, 25 mg/m2 in Chinese persons, and 26 kg/m2 in African-Americans2 *At-risk BMI may be lower in some ethnic groups. ADA. Testing in Asymptomatic Patients. Diabetes Care 2012;35(suppl 1):S14. Table 4. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S14. Table 4. Chiu M, Austin PC, Manuel DG, Shah BR, Tu JV. Deriving ethnic-specific BMI cutoff points for assessing diabetes risk. Diabetes Care 2011;34:

Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (2)
2. In the absence of criteria (risk factors on previous slide), testing for diabetes should begin at age 45 years 3. If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results (e.g., those with prediabetes should be tested yearly), and risk status The three primary criteria for testing for diabetes in asymptomatic adult individuals (Table 4) are summarized on two slides; this slide (Slide 2 of 2) includes: In the absence of criteria (risk factors on previous slide), testing diabetes should begin at age 45 years If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status Age is a major risk factor for diabetes; therefore, testing of individuals (using A1C, FPG, or 2-hour OGTT) without other risk factors should begin no later than at age 45 years The rationale for the 3-year interval is that false negatives will be repeated before substantial time elapses, and there is little likelihood that an individual will develop significant complications of diabetes within 3 years of a negative test result Given the need for follow-up and discussion of abnormal results, testing should be conducted within the health care setting Community screening outside a health care setting is not recommended because people with positive tests may not seek, or have access to, appropriate follow-up testing and care Conversely, there may be failure to ensure appropriate repeat testing for individuals who test negative Community screening may also be poorly targeted; i.e., it may fail to reach the groups most at risk and inappropriately test those at low risk (the worried well) or even those already diagnosed ADA. Testing in Asymptomatic Patients. Diabetes Care 2012;35(suppl 1):S14. Table 4. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S14. Table 4.

III. Detection and Diagnosis of Gestational diabetes mellitus (GDM)
Section III. Detection and Diagnosis of Gestational Diabetes Mellitus includes three slides: Recommendations: Detection and Diagnosis of GDM (2 slides) Screening for and Diagnosis of GDM (1 slide) III. Detection and Diagnosis of Gestational diabetes mellitus (GDM)

Recommendations: Detection and Diagnosis of GDM (1)
Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria (B) In pregnant women not previously known to have diabetes, screen for GDM at 24–28 weeks’ gestation, using a 75-g OGTT and specific diagnostic cut points (B) Recommendations for the detection and diagnosis of gestational diabetes mellitus (GDM) are summarized on two slides; this slide (Slide 1 of 2) includes: Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria (B) In pregnant women not previously known to have diabetes, screen for GDM at 24–28 weeks’ gestation, using a 75-g OGTT and the diagnostic cut points in Table 6 (see Slide 19) (B) As the ongoing epidemic of obesity and diabetes has led to more type 2 diabetes in women of childbearing age, the number of pregnant women with undiagnosed type 2 diabetes has increased1 Because of this, it is reasonable to screen women with risk factors for type 2 diabetes (see Table 4 , Slides 14 and 15,) for diabetes at their initial prenatal visit, using standard diagnostic criteria (see Table 2, Slides 6-10); women with diabetes found at this visit should receive a diagnosis of overt, not gestational, diabetes2 ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2012;35(suppl 1):S15. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S15. Lawrence JM, Contreras R, Chen W, Sacks DA. Trends in the prevalence of preexisting diabetes and gestational diabetes mellitus among a racially/ethnically diverse population of pregnant women, Diabetes Care 2008;31:

Recommendations: Detection and Diagnosis of GDM (2)
Screen women with GDM for persistent diabetes at 6–12 weeks’ postpartum, using a test other than A1C (E) Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years (B) Women with a history of GDM found to have prediabetes should receive lifestyle interventions or metformin to prevent diabetes (A) Recommendations for the detection and diagnosis of gestational diabetes mellitus (GDM)1 are summarized on two slides; this slide (Slide 2 of 2) includes: Screen women with GDM for persistent diabetes at 6–12 weeks’ postpartum, using a test other than A1C (E) Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years (B) Women with a history of GDM found to have prediabetes should receive lifestyle interventions or metformin to prevent diabetes (A) Women with a history of GDM have a greatly increased subsequent risk for diabetes2; therefore, they should be screened for diabetes 6–12 weeks postpartum, using nonpregnant OGTT criteria, and followed for the development of diabetes or prediabetes (see Section II. Testing for Diabetes in Asymptomatic Patients) Because of their prepartum treatment for hyperglycemia, use of the A1C for diagnosis of persistent diabetes at the postpartum visit is not recommended3 Lifestyle interventions or metformin should be offered to women with a history GDM who develop prediabetes (see Section IV. Prevention/Delay of Type 2 Diabetes) For information on the National Diabetes Education Program campaign to prevent type 2 diabetes in women with GDM, see ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2012;35(suppl 1):S15. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S15-S16. Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002;25: Kim C, Herman WH, Cheung NW, Gunderson EP, Richardson C. Comparison of hemoglobin A1c with fasting plasma glucose and 2-h postchallenge glucose for risk stratification among women with recent gestational diabetes mellitus. Diabetes Care 2011;34:

Screening for and Diagnosis of GDM
Perform a 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24–28 weeks’ gestation in women not previously diagnosed with overt diabetes Perform OGTT in the morning after an overnight fast of at least 8 h GDM diagnosis: when any of the following plasma glucose values are exceeded Fasting ≥92 mg/dL (5.1 mmol/L) 1 h ≥180 mg/dL (10.0 mmol/L) 2 h ≥153 mg/dL (8.5 mmol/L) GDM carries risks for the mother and neonate1 The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study,2 a large-scale (approximately 25,000 pregnant women) multinational epidemiologic study, demonstrated that risk of adverse maternal, fetal, and neonatal outcomes continuously increased as a function of maternal glycemia at 24–28 weeks, even within ranges previously considered normal for pregnancy. For most complications, there was no threshold for risk. These results have led to careful reconsideration of the diagnostic criteria for GDM After deliberations in 2008–2009, the International Association of Diabetes and Pregnancy Study Groups (IADPSG), an international consensus group with representatives from multiple obstetrical and diabetes organizations, including ADA, developed revised recommendations for diagnosing GDM. The group recommended that all women not known to have diabetes undergo a 75-g OGTT at 24–28 weeks of gestation Additionally, the group developed diagnostic cut points for the fasting, 1-h, and 2-h plasma glucose measurements that conveyed an odds ratio for adverse outcomes of at least 1.75 compared with the mean glucose levels in the HAPO study Current screening and diagnostic strategies, based on the IADPSG statement,3 are outlined in Table 6, which is summarized on this slide ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2012;35(suppl 1):S15. Table 6. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S15. Table 6. Metzger BE, Lowe LP, Dyer AR, et al, for the HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 2008;358: Metzger BE, Gabbe SG, Persson B, et al, for the International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:

IV. Prevention/Delay of Type 2 Diabetes
Section IV. Prevention/Delay of Type 2 Diabetes includes one slide: Recommendations: Prevention/Delay of Type 2 Diabetes IV. Prevention/Delay of Type 2 Diabetes

Recommendations: Prevention/Delay of Type 2 Diabetes
Refer patients with IGT (A), IFG (E), or A1C 5.7–6.4% (E) to ongoing support program Targeting weight loss of 7% of body weight At least 150 min/week moderate physical activity Follow-up counseling important for success (B) Based on cost-effectiveness of diabetes prevention, third-party payers should cover such programs (E) Consider metformin for prevention of type 2 diabetes if IGT (A), IFG (E), or A1C 5.7–6.4% (E) Especially for those with BMI >35 kg/m2, age <60 years, and women with prior GDM (A) In those with prediabetes, monitor for development of diabetes annually (E) Recommendations for the prevention/delay of type 2 diabetes1 are summarized on this slide Individuals at high risk for developing type 2 diabetes (i.e., those with impaired fasting glucose [IFG], impaired glucose tolerance [IGT] or both) can be given interventions that significantly decrease rate of onset of diabetes Based on results of clinical trials and known risks of progression of prediabetes to diabetes, person with an A1C of 5.7%–6.4%, IGT or IFG should be counseled on lifestyle changes: 7% weight loss and moderate physical activity of at least 150 minutes/week Regarding drug therapy for diabetes prevention, a consensus panel believed that metformin should be the only drug considered2 Metformin may be recommended for very high-risk individuals (those with a history of GDM, the very obese, and/or those with more severe or progressive hyperglycemia) Of note, in the Diabetes Prevention Program (DPP), metformin was not significantly better than placebo in those over age 60 years For other drugs, issues of cost, side effects, and lack of persistence of effect in some studies3 require consideration ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2012;35(suppl 1):S16. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S16. Nathan DM, Davidson MB, DeFronzo RA, et al., for the American Diabetes Association. Impaired fasting glucose and impaired glucose tolerance: implications for care. Diabetes Care 2007;30: DREAM Trial Investigators. Incidence of diabetes following ramipril or rosiglitazone withdrawal. Diabetes Care 2011;34:

Section V. Diabetes Care includes 45 slides (1 slide unless otherwise noted):
Diabetes Care: Initial Evaluation Components of the Comprehensive Diabetes Evaluation (7 slides) Diabetes Care: Management Diabetes Care: Glycemic Control (3 slides) Recommendations: Glucose Monitoring Recommendations: A1C Correlation of A1C with Average Glucose (Ag) Recommendations: Glycemic Goals in Adults (3 slides) Intensive Glycemic Control and Cardiovascular Outcomes: ACCORD Intensive Glycemic Control and Cardiovascular Outcomes : ADVANCE Intensive Glycemic Control and Cardiovascular Outcomes : VADT Glycemic Recommendations for Nonpregnant Adults with Diabetes (3 slides) Recommended Therapy for Type 1 Diabetes: Three Components Recommendations: Therapy for Type 2 Diabetes (2 slides) Noninsulin Therapies for Hyperglycemia in Type 2 Diabetes (10 slides) Recommendations: Medical Nutrition Therapy Look AHEAD (Action for Health in Diabetes): 1-Year Results Recommendations: Diabetes Self-Management Education (DSME) Recommendations: Physical Activity Recommendations: Psychosocial Assessment and Care Recommendations: Hypoglycemia Recommendations: Bariatric Surgery Recommendations: Immunization V. Diabetes Care

Diabetes Care: Initial Evaluation
A complete medical evaluation should be performed to Classify the diabetes Detect presence of diabetes complications Review previous treatment, glycemic control in patients with established diabetes Assist in formulating a management plan Provide a basis for continuing care Perform laboratory tests necessary to evaluate each patient’s medical condition Initial evaluation of the patient with diabetes consists of a complete medical evaluation, which is performed to classify the diabetes, detect the presence of diabetes complications, review previous treatment and glycemic control in patients with established diabetes, assist in formulating a management plan, and provide a basis for continuing care Laboratory tests appropriate to the evaluation of each patient’s medical condition should be performed A focus on the components of comprehensive care (Table 7, see Slides 24-30), will assist the health care team to ensure optimal management of the patient with diabetes ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S16. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S16.

Components of the Comprehensive Diabetes Evaluation (1)
Medical history (1) Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding) Eating patterns, physical activity habits, nutritional status, and weight history; growth and development in children and adolescents Diabetes education history Review of previous treatment regimens and response to therapy (A1C records) A focus on the components of comprehensive care (as outlined on this and the next 6 slides) will help ensure optimal management of the patient with diabetes Slide 1 of 7 (Part 1 of 3) The first component of the comprehensive diabetes evaluation is medical history Age, characteristics of diabetes onset, such as diabetic ketoacidosis (DKA) or an asymptomatic laboratory finding Eating patterns, physical activity habits, nutritional status, and weight history as well as growth and development in children and adolescents History of diabetes education Review of previous treatment regimens and response to therapy (i.e., A1C records) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S17. Table 7. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S17. Table 7.

Medical history (2) Current treatment of diabetes, including medications and medication adherence, meal plan, physical activity patterns, and readiness for behavior change Results of glucose monitoring and patient’s use of data DKA frequency, severity, and cause Hypoglycemic episodes Hypoglycemia awareness Any severe hypoglycemia: frequency and cause Slide 2 of 7 (Part 2 of 3) During a patient’s comprehensive diabetes evaluation, his or her current treatment of diabetes should be established, including medications and medication adherence, meal plan, and patterns of physical activity Results of glucose monitoring and patient’s use of data should also be determined This should include frequency, severity, and cause of diabetic ketoacidosis; hypoglycemic episodes and awareness of hypoglycemia; and frequency and cause of any severe hypoglycemia ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S17. Table 7. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S17. Table 7.

Medical history (3) History of diabetes-related complications Microvascular: retinopathy, nephropathy, neuropathy Sensory neuropathy, including history of foot lesions Autonomic neuropathy, including sexual dysfunction and gastroparesis Macrovascular: CHD, cerebrovascular disease, PAD Other: psychosocial problems*, dental disease* Slide 3 of 7 (Part 3 of 3) A history of diabetes-related complications is an important component of the comprehensive diabetes evaluation, as noted on this slide Microvascular disease may be signaled by retinopathy, nephropathy, or neuropathy Sensory neuropathy can include a history of lesions on the feet Sexual dysfunction and gastroparesis may be symptomatic of autonomic neuropathy Macrovascular-related complications include coronary heart disease (CHD), cerebrovascular disease, or peripheral artery disease (PAD) Other complications can include psychosocial problems or dental disease; patients should be appropriately referred when necessary *See appropriate referrals for these categories. ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S17. Table 7. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S17. Table 7.

Physical examination (1) Height, weight, BMI Blood pressure determination, including orthostatic measurements when indicated Fundoscopic examination* Thyroid palpation Skin examination (for acanthosis nigricans and insulin injection sites) Slide 4 of 7 (Part 1 of 2) A physical examination of the patient with diabetes includes Height, weight, and body mass index (BMI) Determination of blood pressure that includes orthostatic measurements when indicated A fundoscopic examination (patients should be appropriately referred when necessary) Palpation of the thyroid An examination of the skin for acanthosis nigricans and sites of insulin injection *See appropriate referrals for these categories. ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S17. Table 7. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S17. Table 7.

Physical examination (2) Comprehensive foot examination Inspection Palpation of dorsalis pedis and posterior tibial pulses Presence/absence of patellar and Achilles reflexes Determination of proprioception, vibration, and monofilament sensation Slide 5 of 7 (Part 2 of 2) The physical examination includes a comprehensive examination of both feet During the inspection, palpation of the dorsalis pedis and posterior tibial pulses is conducted The presence or absence of patellar and Achilles reflexes should also be noted Proprioception, vibration, and monofilament sensation is also determined (See also Section VI. Prevention and Management of Diabetes Complications. Recommendations: Neuropathy Foot Care) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S17. Table 7. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S17. Table 7.

Laboratory evaluation A1C, if results not available within past 2–3 months If not performed/available within past year Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides Liver function tests Test for urine albumin excretion with spot urine albumin-to-creatinine ratio Serum creatinine and calculated GFR Thyroid-stimulating hormone in type 1 diabetes, dyslipidemia, or women over age 50 years Slide 6 of 7 This slide details the components of a laboratory evaluation If not available within the past 2-3 months, an A1C test is required If the following test results are not available or these tests were not performed during the previous year, the clinician should perform A fasting lipid profile, including total cholesterol, LDL cholesterol, and HDL-cholesterol levels as well as triglyceride level Liver function tests Urine albumin excretion test that includes a spot urine albumin/creatinine ratio A serum creatinine test that includes a calculated glomerular filtration rate (GFR) A thyroid-stimulating hormone (TSH) test in patients with type 1 diabetes, dyslipidemia, or in women older than 50 years of age ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S17. Table 7. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S17. Table 7.

Referrals Eye care professional for annual dilated eye exam Family planning for women of reproductive age Registered dietitian for MNT Diabetes self-management education Dentist for comprehensive periodontal examination Mental health professional, if needed Slide 7 of 7 Appropriate referrals for patients with diabetes include those outlined on this slide An eye care professional should be consulted for an annual dilated eye examination For women of reproductive age, family planning counseling is appropriate For those needing medical nutrition therapy (MNT), a referral to a registered dietitian is warranted Tools for diabetes self-management education (DSME) should be provided A dentist can provide a comprehensive periodontal examination Referral to a mental health professional may be needed ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S17. Table 7. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S17. Table 7.

Diabetes Care: Management
People with diabetes should receive medical care from a physician-coordinated team Physicians, nurse practitioners, physician’s assistants, nurses, dietitians, pharmacists, mental health professionals In this collaborative and integrated team approach, essential that individuals with diabetes assume an active role in their care Management plan should recognize diabetes self-management education (DSME) and on-going diabetes support People with diabetes should receive medical care from a physician-coordinated team This team may include, but is not limited to, physicians, nurse practitioners, physician’s assistants, nurses, dietitians, pharmacists, mental health professionals with expertise and a special interest in diabetes In this collaborative and integrated team approach, it is essential that individuals with diabetes assume an active role in their care The management plan should be formulated as a collaborative therapeutic alliance among the patient and family, the physician, and other members of the health care team A variety of strategies and techniques should be used to provide adequate education and development of problem-solving skills in the various aspects of diabetes management Implementation of the management plan requires that each aspect is understood and agreed to by the patient and the care providers and that the goals and treatment plan are reasonable Any plan should recognize diabetes self-management education (DSME) and on-going diabetes support as an integral component of care In developing the plan, consideration should be given to the patient’s age, school or work schedule and conditions, physical activity, eating patterns, social situation and cultural factors, and presence of complications of diabetes or other medical conditions ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S16. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S16.

Diabetes Care: Glycemic Control
Two primary techniques available for health providers and patients to assess effectiveness of management plan on glycemic control Patient self-monitoring of blood glucose (SMBG), or interstitial glucose A1C In addition to an initial evaluation and management, diabetes care requires an assessment of glycemic control Two primary techniques available for health providers and patients to assess the effectiveness of the management plan on glycemic control are summarized on this slide: Patient self-monitoring of blood glucose (SMBG) or interstitial glucose A1C Recommendations for glucose monitoring, A1C testing, correlation of A1C with average glucose, glycemic goals in adults, intensive glycemic control and cardiovascular outcomes, and glycemic recommendations for nonpregnant adults with diabetes are summarized in the following 14 slides ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S16. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S16.

Recommendations: Glucose Monitoring (1)
Self-monitoring of blood glucose (SMBG) should be carried out three or more times daily for patients using multiple insulin injections or insulin pump therapy (B) For patients using less frequent insulin injections, noninsulin therapies, or medical nutrition therapy (MNT) alone, SMBG may be useful as a guide to management (E) Recommendations for glucose monitoring are summarized on three slides Slide 1 of 3 For patients using multiple insulin injections or insulin pump therapy, self-monitoring of blood glucose (SMBG) should be conducted three or more times daily (B)1 SMBG may be used as a guide to the success of therapy if patients are using less frequent insulin injections, noninsulin therapy, or medical nutrition therapy (MNT) alone (E)1 The optimal frequency and timing of SMBG for patients with type 2 diabetes on noninsulin therapy is unclear In non–insulin-treated patients, several recent clinical trials have called into question the clinical utility and cost-effectiveness of routine SMBG2-4 ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S16. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S16. Farmer A, Wade A. Goyder E, et al. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. BMJ. 2007;335:132. O’Kane MJ, Bunting B, Copeland M, et al., for the ESMON Study Group. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ. 2008; Simon J, Gray A, Clarke P, et al., for the Diabetes Glycaemic Education and Monitoring Trial Group. Cost effectiveness of self monitoring of blood glucose in patients with non-insulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial. BMJ. 2008;336:

To achieve postprandial glucose targets, postprandial SMBG may be appropriate (E) When prescribing SMBG, ensure patients receive initial instruction in, and routine follow-up evaluation of, SMBG technique and their ability to use data to adjust therapy (E) Recommendations for glucose monitoring1 are summarized on three slides Slide 2 of 3 To achieve postprandial glucose targets, postprandial SMBG may be appropriate (E) When prescribing SMBG, ensure patients receive initial instruction in, and routine follow-up evaluation of, SMBG technique and their ability to use data to adjust therapy (E) Because the accuracy of SMBG is instrument and user dependent,2 it is important to evaluate each patient’s monitoring technique, both initially and at regular intervals thereafter In addition, optimal use of SMBG requires proper interpretation of the data Patients should be taught how to use the data to adjust food intake, exercise, or pharmacological therapy to achieve specific glycemic goals These skills should be reevaluated periodically ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S16. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S16. Sacks DB, Bruns DE, Goldstein DE, Maclaren NK, McDonald JM, Parrott M. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem 2002;48:

Continuous glucose monitoring (CGM) with intensive insulin regimens useful tool to lower A1C in selected adults (age ≥25 years) with type 1 diabetes (A) Evidence for A1C-lowering less strong in children, teens, and younger adults; however, CGM may be helpful; success correlates with adherence to device use (C) CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes (E) Recommendations for glucose monitoring1 are summarized on three slides Slide 3 of 3 Continuous glucose monitoring (CGM) with intensive insulin regimens useful tool to lower A1C in selected adults (age ≥25 years) with type 1 diabetes (A) Evidence for A1C-lowering less strong in children, teens, and younger adults; however, CGM may be helpful; success correlates with adherence to ongoing use of the device (C) CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes (E) Real-time CGM through the measurement of interstitial glucose (which correlates well with plasma glucose) is available These sensors require calibration with SMBG; the latter are still recommended for making acute treatment decision CGM devices have alarms for hypo- and hyperglycemic excursions Small studies in selected patients with type 1 diabetes have suggested that CGM use reduces the time spent in hypo- and hyperglycemic ranges and may modestly improve glycemic control A 26-week randomized trial of 322 type 1 patients showed that adults age 25 years and older using intensive insulin therapy and CGM experienced a 0.5% reduction in A1C (from ~7.6–7.1%) compared with usual intensive insulin therapy with SMBG2 ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S16-S17. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S16-S18. Tamborlane WV, Beck RW, Bode BW, et al.; Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group. Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med 2008;359:

Recommendations: A1C Perform A1C test at least twice yearly in patients meeting treatment goals (and have stable glycemic control) (E) Perform A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals (E) Use of point-of-care (POC) testing for A1C provides the opportunity for more timely treatment changes (E) A1C testing should be performed routinely in all patients with diabetes, at initial assessment and then as part of continuing care For any individual patient, the frequency of A1C testing depends on the clinical situation, treatment regimen used, and clinician judgment Recommendations for A1C testing are summarized on this slide An A1C test should be performed at least twice a year in patients who are meeting their treatment goals and have stable glycemic control (E) In patients whose therapy has changed or who are not meeting glycemic goals, the A1C test should be performed quarterly (E); this helps determine whether a patient’s glycemic targets are being reached and maintained When needed for timely decisions on when to change therapy, point-of-care testing (POC) for A1C may be used (E); availability of A1C results when a patient is seen has been reported to result in increased intensification of therapy and improvement in glycemic control The A1C test is subject to certain limitations: conditions that affect erythrocyte turnover (e.g., hemolysis, blood loss) and hemoglobin variants must be considered, particularly when the A1C result does not correlate with the patient’s clinical situation; in addition, A1C does not provide a measure of glycemic variability or hypoglycemia For patients prone to glycemic variability (especially type 1 diabetic patients, or type 2 diabetic patients with severe insulin deficiency), glycemic control is best judged by the combination of result of self-monitoring of blood glucose (SMBG) testing and A1C The A1C may also serve as a check on the accuracy of a patient’s meter and adequacy of the SMBG testing schedule ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S18. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S18.

Correlation of A1C with Average Glucose (AG)
Mean plasma glucose A1C (%) mg/dL mmol/L 6 126 7.0 7 154 8.6 8 183 10.2 9 212 11.8 10 240 13.4 11 269 14.9 12 298 16.5 Table 8, as shown on this slide, contains the correlation between A1C levels and mean plasma glucose (PG) levels based on data from the international A1C-Derived Average Glucose (ADAG) trial using frequent SMBG and continuous glucose monitoring (CGM) in 507 adults (83% Caucasian) with type 1, type 2, and no diabetes1 The ADA and the American Association of Clinical Chemistry have determined that the correlation (r = 0.92) is strong enough to justify reporting both an A1C result and an estimated average glucose (eAG) results when a clinician orders the A1C test2 A calculator for converting A1C results into eAG, in either mg/dL or mmol/L, is available at For patients in whom A1C/eAG and measured blood glucose appear discrepant, clinicians should consider the possibilities of hemoglobinopathy or altered red cell turnover, and the options of more frequent and/or different timing of SMBG or use of CGM Other measures of chronic glycemia, such as fructosamine, are available, but their linkage to average glucose and their prognostic significance are not as clear as for A1C These estimates are based on ADAG data of ~2,700 glucose measurements over 3 months per A1C measurement in 507 adults with type 1, type 2, and no diabetes. The correlation between A1C and average glucose was A calculator for converting A1C results into estimated average glucose (eAG), in either mg/dL or mmol/L, is available at ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S18. Table 8. Reference Nathan DM, Kuenen J, Borg R, et al., for the A1c-Derived Average Glucose Study Group. Translating the A1C assay into estimated average glucose values. Diabetes Care. 2008;31: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S18, Table 8.

Recommendations: Glycemic Goals in Adults (1)
Lowering A1C to below or around 7% has been shown to reduce microvascular complications and, if implemented soon after the diagnosis of diabetes, is associated with long-term reduction in macrovascular disease Therefore, a reasonable A1C goal for many nonpregnant adults is <7% (B) Glycemic control is fundamental to the management of diabetes; recommendations for glycemic goals in nonpregnant adults are reviewed on three slides Slide 1 of 3 Lowering A1C to below or around 7% has been shown to reduce microvascular complications of diabetes, and if implemented soon after the diagnosis of diabetes is associated with long-term reduction in macrovascular disease; therefore, a reasonable A1C goal for many nonpregnant adults is <7% (B) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S18-19. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S18-19.

Providers might reasonably suggest more stringent A1C goals (such as <6.5%) for selected individual patients, if this can be achieved without significant hypoglycemia or other adverse effects of treatment Appropriate patients might include those with short duration of diabetes, long life expectancy, and no significant CVD (C) Glycemic control is fundamental to the management of diabetes; recommendations for glycemic goals in nonpregnant adults are reviewed on three slides Slide 2 of 3 Providers might reasonably suggest more stringent A1C goals (such as <6.5%) for selected individual patients, if this can be achieved without significant hypoglycemia or other adverse effects of treatment Appropriate patients might include those with short duration of diabetes, long life expectancy, and no significant CVD (C) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S19. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S19.

Less stringent A1C goals (such as <8%) may be appropriate for patients with (B) History of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions Those with longstanding diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose lowering agents including insulin Glycemic control is fundamental to the management of diabetes; recommendations for glycemic goals in nonpregnant adults are reviewed on three slides Slide 3 of 3 Less-stringent A1C goals (such as <8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, and those with longstanding diabetes in whom the general goal is difficult to attain despite DSME, appropriate glucose monitoring, and effective doses of multiple glucose lowering agents including insulin (B) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S19. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S19.

Intensive Glycemic Control and Cardiovascular Outcomes: ACCORD
Primary Outcome: Nonfatal MI, nonfatal stroke, CVD death HR=0.90 ( ) The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study randomized 10,251 participants with either history of a CVD event or significant CVD risk to a strategy of intensive glycemic control (target A1C 6.0%) or standard glycemic control (A1C target %); investigators used multiple glycemic medications in both arms From a baseline median A1C of 8.1%, the intensive arm reached a median A1C of 6.4% within 12 months of randomization; the standard group reached a median A1C of 7.5% The glycemic control arm of ACCORD was halted early due to the finding of an increased rate of mortality in the intensive arm compared with the standard arm (1.41% vs. 1.14% per year; HR 1.22 [95% CI 1.01 to 1.46]); with a similar increase in cardiovascular deaths The primary outcome of ACCORD (MI, stroke, or cardiovascular death) was lower in the intensive glycemic control group, due to a reduction in nonfatal MI, but this reduction was not statistically significant when the study was terminated1 The potential cause of excess deaths in the intensive group of the ACCORD has been difficult to pinpoint. Exploratory analyses of the mortality findings of ACCORD (evaluating variables including weight gain, use of any specific drug or drug combination, and hypoglycemia) were reportedly unable to identify a clear explanation for the excess mortality in the intensive arm. The ACCORD investigators subsequently published additional analyses showing no increase in mortality in the intensive arm participants who achieved A1C levels7% or in those who lowered their A1C quickly after trial enrollment In fact, the converse was observed—those at highest risk for mortality were participants in the intensive arm with the highest A1C levels ©2008 New England Journal of Medicine. Used with permission. Gerstein HC, et al, for the Action to Control Cardiovascular Risk in Diabetes Study Group. N Engl J Med 2008;358: References Gerstein HC, Miller ME, Byington RP, et al., for the Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008;358: Riddle MC, Ambrosius WT, Brillon DJ, et al, for the Action to Control Cardiovascular Risk in Diabetes Investigators. Epidemiologic relationships between A1C and all-cause mortality during a median 3.4-year follow-up of glycemic treatment in the ACCORD trial. Diabetes Care 2010;33:983–990.

Intensive Glycemic Control and Cardiovascular Outcomes: ADVANCE
Primary Outcome: Microvascular plus macrovascular (nonfatal MI, nonfatal stroke, CVD death) HR=0.90 ( ) The ADVANCE study of intensive versus standard glycemic control in type 2 diabetes found a statistically significant reduction in albuminuria with an A1C target of 6.5% (achieved median A1C 6.3%) compared with standard therapy achieving a median A1C of 7.0% (63) ADVANCE randomized participants to intensive glycemic control (with primary therapy being the sulfonylurea gliclazide and additional medications as needed to achieve a target A1C of 6.5%) or to standard therapy (in which any medication but gliclazide could be used and the glycemic target was according to “local guidelines”) Participants in ADVANCE were slightly older than those in ACCORD and VADT and had similar high CVD risk; however, they had an average duration of diabetes that was 2 years shorter, lower baseline A1C (median 7.2%), and almost no use of insulin at enrollment Median A1C levels achieved in the intensive and standard arms were 6.3 and 7.0%, respectively, and maximal separation between the arms took several years to achieve Use of other drugs that favorably impact CVD risk (aspirin, statins, and angiotensin enzyme inhibitors) was lower in ADVANCE than in ACCORD or VADT The primary outcome of ADVANCE was a combination of microvascular events (nephropathy and retinopathy) and major adverse cardiovascular events (MI, stroke, and cardiovascular death) Intensive glycemic control significantly reduced the primary end point, although this was due to a significant reduction in the microvascular outcome, primarily development of macroalbuminuria, with no significant reduction in the macrovascular outcome There was no difference in overall or cardiovascular mortality between the intensive compared with the standard glycemic control arms ©2008 New England Journal of Medicine. Used with permission. Patel A, et al,. for the ADVANCE Collaborative Group. N Engl J Med 2008;358: Reference Patel A, MacMahon S, Chalmers J, et al., for the ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:

Intensive Glycemic Control and Cardiovascular Outcomes: VADT
Primary Outcome: Nonfatal MI, nonfatal stroke, CVD death, hospitalization for heart failure, revascularization HR=0.88 ( ) The Veterans Affairs Diabetes Trial (VADT) randomized participants with type 2 diabetes uncontrolled on insulin or maximal dose oral agents (median entry A1C 9.4%) to a strategy of intensive glycemic control (goal A1C 6.0%) or standard glycemic control, with a planned A1C separation of at least 1.5%1 Medication treatment algorithms were used to achieve the specified glycemic goals, with a goal of using similar medications in both groups; other CVD risk factors were treated aggressively and equally in both groups Median A1C levels of 6.9 and 8.4% were achieved in the intensive and standard arms, respectively, within the first year of the study; the primary outcome was a composite of CVD events; cumulative primary outcome was nonsignificantly lower in the intensive arm The evidence for a cardiovascular benefit of intensive glycemic control primarily rests on long-term follow-up of study cohorts treated early in the course of type 1 and type 2 diabetes and subset analyses of ACCORD, ADVANCE, and VADT. A recent group-level metaanalysis of the latter three trials suggests that glucose lowering has a modest (9%) but statistically significant reduction in major CVD outcomes, primarily nonfatal MI, with no significant effect on mortality A prespecified subgroup analysis suggested that major CVD outcome reduction occurred in patients without known CVD at baseline (HR 0.84 [95% CI 0.74–0.94]).2 Conversely, the mortality findings in ACCORD and subgroup analyses of VADT suggest that the potential risks of very intensive glycemic control may outweigh its benefits in some patients, such as those with very long duration of diabetes, known history of severe hypoglycemia, advanced atherosclerosis, and advanced age/frailty ©2009 New England Journal of Medicine. Used with permission. Duckworth W, et al., for the VADT Investigators. N Engl J Med 2009;360: References Duckworth W, Abraira C, Moritz T, et al., for the VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009;360: Turnbull FM, Abraira C, Anderson RJ, et al. Intensive glucose control and macrovascular outcomes in type 2 diabetes. Diabetologia 2009;52:2288–2298.

Glycemic Recommendations for Nonpregnant Adults with Diabetes (1)
A1C <7.0%* Preprandial capillary plasma glucose 70–130 mg/dL* (3.9–7.2 mmol/L) Peak postprandial capillary plasma glucose† <180 mg/dL* (<10.0 mmol/L) Recommended glycemic goals for nonpregnant adults (Table 9)1 are shown on three slides Slide 1 of 3 These recommendations are based on those for A1C values, with listed blood glucose levels that appear to correlate with achievement of an A1C of <7% The issue of preprandial versus postprandial self-monitoring of blood glucose (SMBG) is complex;2 in some epidemiological studies, elevated postchallenge two-hour oral glucose tolerance test (2-h OGTT) glucose values have been associated with increased cardiovascular risk independent of fasting plasma glucose (FPG) In diabetic subjects, some surrogate measures of vascular pathology, such as endothelial dysfunction, are negatively affected by postprandial hyperglycemia3 *Individualize goals based on these values. †Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes. ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S20. Table 9. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S20. Table 9. Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S. Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials. Ann Intern Med 2011;154: Ceriello A, Taboga C, Tonutti L, et al. Evidence for an independent and cumulative effect of postprandial hypertriglyceridemia and hyperglycemia on endothelial dysfunction and oxidative stress generation: effects of short- and long-term simvastatin treatment. Circulation 2002;106:

Goals should be individualized based on Duration of diabetes Age/life expectancy Comorbid conditions Known CVD or advanced microvascular complications Hypoglycemia unawareness Individual patient considerations Recommended glycemic goals for nonpregnant adults (Table 9) are shown on three slides Slide 2 of 3 Glycemic goals should be individualized, based on a patient’s duration of diabetes, age, life expectancy, comorbid conditions, known cardiovascular disease (CVD) or advanced microvascular complications, unawareness of hypoglycemia, and other considerations ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S20. Table 9. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S20. Table 9.

More- or less-stringent glycemic goals may be appropriate for individual patients Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals Recommended glycemic goals for nonpregnant adults (Table 9) are shown on three slides Slide 3 of 3 For individual patients, more or less stringent glycemic goals may be appropriate If A1C goals are not met despite reaching preprandial glucose goals, postprandial glucose may be targeted Postprandial hyperglycemia, like preprandial hyperglycemia, contributes to elevated A1C levels, with its relative contribution being higher at A1C levels that are closer to 7% However, outcome studies have clearly shown A1C to be the primary predictor of complications, and landmark trials such as the Diabetes Control and Complications Trial (DCCT) and the UK Prospective Diabetes Study (UKPDS) relied overwhelmingly on preprandial SMBG For individuals who have premeal glucose values within target but A1C values above target, a reasonable recommendation for postprandial testing and targets is monitoring postprandial plasma glucose 1-2 hours after the start of the meal and treatment aimed at reducing PPG values to <180 mg/dl to help lower A1C ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S20. Table 9. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S20. Table 9.

Recommended Therapy for Type 1 Diabetes: Three Components
Use of multiple-dose insulin injections (3–4 injections/day of basal and prandial insulin) or continuous subcutaneous insulin infusion (CSII) Matching prandial insulin to carbohydrate intake, premeal blood glucose, and anticipated activity For many patients (especially if hypoglycemia is a problem), use of insulin analogs Since the time of the DCCT, a number of rapid-acting and long-acting insulin analogs have been developed; these analogs are associated with less hypoglycemia with equal A1C-lowering in type 1 diabetes1,2 Therefore, recommended therapy for type 1 diabetes comprise the following components: 1) use of multiple-dose insulin injections (three to four injections per day of basal and prandial insulin) or CSII therapy; 2) matching prandial insulin to carbohydrate intake, premeal blood glucose, and anticipated activity; and 3) for many patients (especially if hypoglycemia is a problem), use of insulin analogs There are excellent reviews available that guide the initiation and management of insulin therapy to achieve desired glycemic goals2,4,5 Because of the increased frequency of other autoimmune diseases in type 1 diabetes, screening for thyroid dysfunction, vitamin B12 deficiency, or celiac disease should be considered based on signs and symptoms; periodic screening in absence of symptoms has been recommended, but the effectiveness and optimal frequency are unclear ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S21. References DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. JAMA 2003;289: Rosenstock J, Dailey G, Massi-Benedetti M, Fritsche A, Lin Z, Salzman A. Reduced hypoglycemia risk with insulin glargine: a meta-analysis comparing insulin glargine with human NPH insulin in type 2 diabetes. Diabetes Care 2005;28: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S21. Li R, Zhang P, Barker LE, Chowdhury FM, Zhang X. Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review. Diabetes Care 2010;33: Mooradian AD, Bernbaum M, Albert SG. Narrative review: a rational approach to starting insulin therapy. Ann Intern Med 2006;145:

Recommendations: Therapy for Type 2 Diabetes (1)
At the time of type 2 diabetes diagnosis, initiate metformin therapy along with lifestyle interventions, unless metformin is contraindicated (A) In newly diagnosed type 2 diabetes patients with markedly symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents, from the outset (E) Recommended therapy for type 2 diabetes1 is summarized on two slides Slide 1 of 2 Prior expert consensus statements have suggested approaches to management of hyperglycemia in individuals with type 2 diabetes2 Highlights include intervention at the time of diagnosis with metformin (unless contraindicated) in combination with lifestyle changes (MNT and exercise) (A) and continuing timely augmentation of therapy with additional agents (including early initiation of insulin therapy) as a means of achieving and maintaining recommended levels of glycemic control (i.e., A1C <7% for most patients) In newly diagnosed type 2 diabetes patients with markedly symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents, from the outset (E) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S21. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S21. Nathan DM, Buse JB, Davidson MB, et al.; American Diabetes Association; European Association for Study of Diabetes. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009;32:

Recommendations: Therapy for Type 2 Diabetes (2)
If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3–6 months, add a second oral agent, a GLP-1 receptor agonist, or insulin (E) Recommended therapy for type 2 diabetes1 is summarized on two slides Slide 2 of 2 As A1C targets are not achieved, treatment intensification is based on the addition of another agent from a different class Meta-analyses2 suggest that overall, each new class of noninsulin agents added to initial therapy lowers A1C around 0.9–1.1% The overall objective is to safely achieve and maintain glycemic control and to change interventions when therapeutic goals are not being met ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S21. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S21. Bennett WL, Maruthur NM, Singh S, et al. Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Ann Intern Med 2011;154:

Noninsulin Therapies for Hyperglycemia in Type 2 Diabetes (1)
Class Biguanides Compound Metformin Mechanism Activates AMP-kinase Action(s) Hepatic glucose production  Intestinal glucose absorption  Insulin action  Advantages No weight gain No hypoglycemia Reduction in cardiovascular events and mortality (UKPDS f/u) Disadvantages Gastrointestinal side effects (diarrhea, abdominal cramping) Lactic acidosis (rare) Vitamin B12 deficiency Contraindications: reduced kidney function Cost Low ADA and EASD have partnered on new guidance for individualization of use of medication classes and combinations in patients with type 2 diabetes These guidelines, to be published in early 2012, will be less prescriptive than prior algorithms, and will discuss advantages and disadvantages of the available medication classes as well as considerations for their use Information about currently approved classes of medications for treating hyperglycemia in type 2 diabetes is summarized in Table 10, which is reviewed in ten slides by drug class (this slide and the next nine slides); each slide includes class, generic name of compound, mechanism, advantages, disadvantages, and cost The thiazolidinediones, pioglitazone and rosiglitazone, are highlighted on two separate slides due to their differing advantages and disadvantages Slide 1 of 10 This slide focuses on the biguanides class of noninsulin therapy for the treatment of hyperglycemia in patients with type 2 diabetes; specifically, metformin ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S22. Table 10.

Class Sulfonylureas (2nd generation) Compound Glibenclamide/Glyburide Glipizide Gliclazide Glimepiride Mechanism Closes KATP channels on β-cell plasma membranes Action(s)  Insulin secretion Advantages Generally well tolerated Reduction in cardiovascular events and mortality (UKPDS f/u) Disadvantages Relatively glucose-independent stimulation of insulin secretion: Hypoglycemia, including episodes necessitating hospital admission and causing death Weight gain May blunt myocardial ischemic preconditioning Low “durability” Cost Low Slide 2 of 10 This slide focuses on the second-generation sulfonylurea class of noninsulin therapy for the treatment of hyperglycemia in patients with type 2 diabetes; specifically glibenclamide/glyburide, glipizide, gliclazide, and glimepiride ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S22. Table 10.

Class Meglitinides Compound Repaglinide Nateglinide Mechanism Closes KATP channels on β-cell plasma membranes Action(s) Insulin secretion  Advantages Accentuated effects around meal ingestion Disadvantages Hypoglycemia, weight gain May blunt myocardial ischemic preconditioning Dosing frequency Cost Medium Slide 3 of 10 This slide focuses on the meglitinides class of noninsulin therapy for the treatment of hyperglycemia in patients with type 2 diabetes; specifically, repaglinide and nateglinide ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S22. Table 10.

Noninsulin Therapies for Hyperglycemia in Type 2 Diabetes (4a)
Class Thiazolidinediones (Glitazones) Compound Pioglitazone Mechanism Activates the nuclear transcription factor PPAR- Action(s) Peripheral insulin sensitivity  Advantages No hypoglycemia HDL cholesterol  Triglycerides  Disadvantages Weight gain Edema Heart failure Bone fractures Cost High Slide 4 of 10 (4a) This slide focuses on the thiazolidinediones (glitazone) class of noninsulin therapy for the treatment of hyperglycemia in patients with type 2 diabetes; specifically, the compound pioglitazone ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S22. Table 10.

Noninsulin Therapies for Hyperglycemia in Type 2 Diabetes (4b)
Class Thiazolidinediones (Glitazones) Compound Rosiglitazone Mechanism Activates the nuclear transcription factor PPAR- Action(s) Peripheral insulin sensitivity  Advantages No hypoglycemia Disadvantages LDL cholesterol  Weight gain Edema Heart failure Bone fractures Increased cardiovascular events (mixed evidence) FDA warnings on cardiovascular safety Contraindicated in patients with heart disease Cost High Slide 5 of 10 (4b) This slide focuses on the thiazolidinediones (glitazone) class of noninsulin therapy for the treatment of hyperglycemia in patients with type 2 diabetes; specifically, the compound rosiglitazone ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S22. Table 10.

Class α-Glucosidase inhibitors Compound Acarbose Miglitol Mechanism Inhibits intestinal α-glucosidase Action(s) Intestinal carbohydrate digestion (and consecutively, absorption) slowed Advantages Nonsystemic medication Postprandial glucose  Disadvantages Gastrointestinal side effects (gas, flatulence, diarrhea) Dosing frequency Cost Medium Slide 6 of 10 This slide focuses on the α-glucosidase inhibitor class of noninsulin therapy for the treatment of hyperglycemia in patients with type 2 diabetes; specifically, acarbose and miglitol ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S22. Adapted with permission from Silvio Inzucchi, Yale University. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S22. Table 10.

Class GLP-1 receptor agonists (incretin mimetics) Compound Exenatide Liraglutide Mechanism Activates GLP-1 receptors (β-cells/endocrine pancreas; brain/autonomous nervous system Action(s) Insulin secretion  (glucose-dependent) Glucagon secretion  (glucose-dependent) Slows gastric emptying Satiety  Advantages Weight reduction Potential for improved β-cell mass/function Disadvantages Gastrointestinal side effects (nausea, vomiting, diarrhea) Cases of acute pancreatitis observed C-cell hyperplasia/medullary thyroid tumors in animals (liraglutide) Injectable Long-term safety unknown Cost High Slide 7 of 10 This slide focuses on the GLP-1 receptor agonist class of noninsulin therapy for the treatment of hyperglycemia in patients with type 2 diabetes; specifically, the incretin mimetics, exenatide and liraglutide ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S23. Adapted with permission from Silvio Inzucchi, Yale University. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S23. Table 10.

Class DPP-4 inhibitors (incretin enhancers) Compound Sitagliptin Vildagliptin Saxagliptin Linagliptin Mechanism Inhibits DPP-4 activity, prolongs survival of endogenously released incretin hormones Action(s) Active GLP-1 concentration  Active GIP concentration  Insulin secretion  Glucagon secretion  Advantages No hypoglycemia Weight “neutrality” Disadvantages Occasional reports of urticaria/angioedema Cases of pancreatitis observed Long-term safety unknown Cost High Slide 8 of 10 This slide focuses on the DPP-4 inhibitor class of noninsulin therapy for the treatment of hyperglycemia in patients with type 2 diabetes; specifically, the incretin enhancers, sitagliptin, vildagliptin, saxagliptin, and linagliptin ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S23. Adapted with permission from Silvio Inzucchi, Yale University. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S23. Table 10.

Class Bile acid sequestrants Compound Colesevelam Mechanism Binds bile acids/cholesterol Action(s) Unknown Advantages No hypoglycemia LDL cholesterol  Disadvantages Constipation Triglycerides  May interfere with absorption of other medications Cost High Slide 9 of 10 This slide focuses on the bile acid sequestrant class of noninsulin therapy for the treatment of hyperglycemia in patients with type 2 diabetes; specifically, colesevelam ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S23. Adapted with permission from Silvio Inzucchi, Yale University. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S23. Table 10.

Class Dopamine-2 agonists Compound Bromocriptine Mechanism Activates dopaminergic receptors Action(s) Alters hypothalamic regulation of metabolism Insulin sensitivity  Advantages No hypoglycemia Disadvantages Dizziness/syncope Nausea Fatigue Rhinitis Long-term safety unknown Cost Medium Slide 10 of 10 This slide focuses on the dopamine-2 agonist class of noninsulin therapy for the treatment of hyperglycemia in patients with type 2 diabetes; specifically, bromocriptine ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S23. Adapted with permission from Silvio Inzucchi, Yale University. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S23. Table 10.

Recommendations: Medical Nutrition Therapy (MNT)
Individuals who have prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT (A) Because MNT can result in cost-savings and improved outcomes (B), MNT should be adequately covered by insurance and other payers (E) The general recommendations for medical nutrition therapy (MNT)1 are included on this slide Individuals who have prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT (A) Because it can result in cost savings and improved outcomes (B), MNT should be covered by insurance and other payers (E) Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists; the best mix of carbohydrates, protein, and fat appears to vary depending on individual circumstances MNT is an integral component of diabetes prevention, management, and self-management education In addition to its role in preventing and controlling diabetes, ADA recognizes the importance of nutrition as an essential component of an overall healthy lifestyle A full review of the evidence regarding nutrition in preventing and controlling diabetes and its complications and additional nutrition related recommendations can be found in the ADA position statement “Nutrition Recommendations and Interventions for Diabetes,” published in 2007 and updated in 20082 ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S21. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S21, S23. Bantle JP, Wylie-Rosett J, Albright AL, et al.; American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care 2008;31(suppl 1):S61-S78.

Look AHEAD (Action for Health in Diabetes): One-Year Results
Intensive lifestyle intervention resulted in1 Average 8.6% weight loss Significant reduction of A1C Reduction in several CVD risk factors Benefits sustained at 4 years2 Final results of Look AHEAD to provide insight into effects of long-term weight loss on important clinical outcomes Look AHEAD (Action for HEAlth in Diabetes) is a large clinical trial designed to determine whether long-term weight loss will improve glycemia and prevent cardiovascular events in subjects with type 2 diabetes1 One-year results of the intensive lifestyle intervention in this trial show an average of 8.6% weight loss, significant reduction of A1C, and reduction in several cardiovascular disease (CVD) risk factors, with benefits sustained at 4 years2 When completed, the Look AHEAD study should provide insight into the effects of long-term weight loss on important clinical outcomes 1. Look AHEAD Research Group. Diabetes Care. 2007;30: ; 2. Look AHEAD Research Group. Arch Intern Med. 2010;170:1566–1575. References Pi-Sunyer X, Blackburn G, Brancati FL, et al, for the Look AHEAD Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the Look AHEAD trial. Diabetes Care. 2007;30: Wing RR, Egan C, Bahnson JL, et al, for the Look AHEAD Research Group. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med 2010;170:1566–1575.

Recommendations: Diabetes Self-Management Education (DSME)
People with diabetes should receive DSME according to national standards and diabetes self-management support at diagnosis and as needed thereafter (B) Effective self-management, quality of life are key outcomes of DSME; should be measured, monitored as part of care (C) DSME should address psychosocial issues, since emotional well-being is associated with positive outcomes (C) Because DSME can result in cost-savings and improved outcomes (B), DSME should be reimbursed by third-party payers (E) Diabetes self-management education (DSME) is an essential element of diabetes care; national standards for DSME1 are based on evidence for its benefits Education helps people with diabetes initiate effective self-management and cope with diabetes when they are first diagnosed Ongoing DSME and diabetes self-management support (DSMS) also help people with diabetes maintain effective self-management throughout a lifetime of diabetes as they face new challenges and as treatment advances become available DSME helps patients optimize metabolic control, prevent and manage complications, and maximize quality of life in a cost-effective manner2 Recommendations for DSME are summarized on this slide3 People with diabetes should receive DSME according to national standards when their diabetes is diagnosed and as needed thereafter (B) Effective self-management and quality of life are the key outcomes of DSME and should be measured and monitored as part of care (C) DSME should address psychosocial issues, since emotional well-being is associated with positive diabetes outcomes (C) Because DSME can result in cost-savings and improved outcomes (B), DSME should be reimbursed by third-party payers (E) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S24. References Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes Care 2007;30: Mulcahy K, Maryniuk M, Peeples M, et al. Diabetes self-management education core outcomes measures. Diabetes Educ 2003;29: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S24.

Recommendations: Physical Activity
Advise people with diabetes 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 per week with no more than 2 consecutive days without exercise (A) In absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training at least twice per week (A) Exercise is an important part of the diabetes management plan Regular exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well being1 Regular exercise may also prevent type 2 diabetes in high-risk individuals2-4 A joint position statement by ADA and the American College of Sports Medicine summarizes the evidence for the benefits of exercise in people with type 2 diabetes5 Recommendations for physical activity for people with diabetes1 are summarized on this slide People with diabetes should be advised to perform at least 150 minutes per week of moderate-intensity aerobic physical activity (50-70% of maximum heart rate) (A) In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training three times per week (A) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S25. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S25. Knowler WC, Barrett-Connor E, Fowler SE, et al, for the Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346: Tuomilehto J, Lindström J, Eriksson JG, et al.; Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344: Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997;20: Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes. The American Collegoe of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care 2010;33:

Recommendations: Psychosocial Assessment and Care
Ongoing part of medical management of diabetes (E) Psychosocial screening/follow-up: attitudes about diabetes, medical management/outcomes expectations, affect/mood, quality of life, resources, psychiatric history (E) When self-management is poor, screen for psychosocial problems: depression, diabetes-related anxiety, eating disorders, cognitive impairment (C) Psychological and social problems can impair the ability of the individual1-4 or the family to carry out diabetes care tasks and therefore compromise health status Opportunities exist for the clinician to assess psychosocial status in a timely and efficient manner so that referral for appropriate services can be accomplished Recommendations for psychosocial assessment and care5 are summarized on this slide Assessment of psychological and social situation should be included as an on-going part of the medical management of diabetes (E) Psychosocial screening and follow-up should include, but is not limited to, attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional), and psychiatric history (E) Screen for psychosocial problems such as depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment when self-management is poor (C) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S26. References Anderson RJ, Grigsby AB, Freedland KE, et al. Anxiety and poor glycemic control: a meta-analytic review of the literature. Int J Psychiatry Med 2002;32: Delahanty LM, Grant RW, Wittenberg E, et al. Association of diabetes-related emotional distress with diabetes treatment in primary care patients with Type 2 diabetes. Diabet Med 2007;24:48-54. American Diabetes Association: Psychosocial factors affecting adherence, quality of life, and well-being: Helping Patients cope. In Medical Management of Type 1 Diabetes. 5 ed. Francine R. Kaufman, Ed. Alexandria, VA, American Diabetes Association, 2008, p Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a metaanalysis. Diabetes Care 2001;24: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S26.

Recommendations: Hypoglycemia
Glucose (15–20 g) preferred treatment for conscious individual with hypoglycemia (E) Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemia and caregivers/family members instructed in administration (E) Those with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should raise glycemic targets to reduce risk of future episodes (B) Hypoglycemia is the leading limiting factor in the glycemic management of patients with type 1 and insulin-treated type 2 diabetes1 Recommendations for treating hypoglycemia2 are summarized on this slide Glucose (15-20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used If, after 15 minutes of treatment, SMBG shows continued hypoglycemia, the treatment should be repeated; once SMBG glucose returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia (E) Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemia, and caregivers or family members of these individuals should be instructed in its administration; glucagon administration is not limited to health care professionals (E) Individuals with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks to reverse hypoglycemia unawareness (at least partially) and reduce risk of future episodes (B) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S27. References Cryer PE. Hypoglycaemia: the limiting factor in the glycaemic management of Type I and Type II diabetes. Diabetologia 2002;45: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S26.

Recommendations: Bariatric Surgery
Consider bariatric surgery for adults with BMI >35 kg/m2 and type 2 diabetes (B) After surgery, life-long lifestyle support and medical monitoring is necessary (B) Insufficient evidence to recommend surgery in patients with BMI <35 kg/m2 outside of a research protocol (E) Well-designed, randomized controlled trials comparing optimal medical/lifestyle therapy needed to determine long-term benefits, cost-effectiveness, risks (E) Recommendations for patients for whom bariatric surgery may be an option as an effective weight loss treatment for severe obesity are summarized on this slide Bariatric surgery should be considered for adults with a body mass index (BMI) >35 kg/m2 and type 2 diabetes, especially if the diabetes or associated comorbidities are difficult to control with lifestyle and pharmacologic therapy (B) Patients with type 2 diabetes who have undergone bariatric surgery need life-long lifestyle support and medical monitoring (E) Although small trials have shown glycemic benefit of bariatric surgery in patients with type 2 diabetes and BMI of kg/m2, there is currently insufficient evidence to recommend, in general, surgery in patients with BMI <35 kg/m2 outside of a research protocol (E) The long-term benefits, cost-effectiveness, and risks of bariatric surgery in individuals with type 2 diabetes should be studied in well-designed, randomized controlled trials with optimal medical and lifestyle therapy as the comparator (E) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S27. Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2012;35(suppl 1):S27.

Recommendations: Immunization
Provide influenza vaccine annually to all diabetic patients ≥6 months of age (C) Administer pneumococcal polysaccharide vaccine to all diabetic patients ≥2 years (C) One-time revaccination recommended for those >64 years previously immunized at <65 years if administered >5 years ago Other indications for repeat vaccination: nephrotic syndrome, chronic renal disease, immunocompromised states Administer hepatitis B vaccination per CDC recommendations (C) Influenza and pneumonia are common, preventable infectious diseases associated with high mortality and morbidity in the elderly and in people with chronic disease1 Although studies reporting the morbidity and mortality of influenza and pneumococcal pneumonia specifically in people with diabetes are limited, observational studies of patients with a variety of chronic illnesses, including diabetes, show that these conditions are associated with an increase in hospitalizations for influenza and its complications1 Safe and effective vaccines are available that can greatly reduce the risk of serious complications from these diseases1 Recommendations for the immunization of people with diabetes2 are summarized on this slide Annually provide an influenza vaccine to all diabetes patients ≥6 months of age (C) Administer pneumococcal polysaccharide vaccine to all diabetes patients ≥2 years of age; a one-time revaccination is recommended for individuals >64 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago; other indications for repeat vaccination include nephrotic syndrome, chronic renal disease, and other immunocompromised states, such as after transplantation (C) Administer hepatitis B vaccination to adults with diabetes as per Centers for Disease Control and Prevention (CDC) recommendations (C) ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S28. References Smith SA, Poland GA. Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care 2000;23: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S28.

VI. Prevention and management of diabetes complications
Section VI. Prevention and Management of Diabetes Complications includes 45 slides (1 slide unless otherwise noted): Cardiovascular Disease (CVD) in Individuals with Diabetes Recommendations: Hypertension/Blood Pressure Control (7 slides) Recommendations: Dyslipidemia/Lipid Management (6 slides) Recommendations: Glycemic, Blood Pressure, Lipid Control in Adults Recommendations: Antiplatelet Agents (3 slides) Recommendations: Smoking Cessation Recommendations: Coronary Heart Disease Screening Recommendations: Coronary Heart Disease Treatment (2 slides) Recommendations: Nephropathy Recommendations: Nephropathy Screening Recommendations: Nephropathy Treatment (3 slides) Definitions of Abnormalities in Albumin Excretion Stages of Chronic Kidney Disease Management of CKD in Diabetes (2 slides) Recommendations: Retinopathy Recommendations: Retinopathy Screening (4 slides) Recommendations: Retinopathy Treatment (2 slides) Recommendations: Neuropathy Screening/Treatment (2 slides) Recommendations: Neuropathy Foot Care (4 slides) VI. Prevention and management of diabetes complications

Cardiovascular Disease (CVD) in Individuals with Diabetes
CVD is the major cause of morbidity, mortality for those with diabetes Common conditions coexisting with type 2 diabetes (e.g., hypertension, dyslipidemia) are clear risk factors for CVD Diabetes itself confers independent risk Benefits observed when individual cardiovascular risk factors are controlled to prevent/slow CVD in people with diabetes For those with diabetes, cardiovascular disease (CVD) is the major cause of morbidity and mortality and the largest contributor to the direct and indirect costs of diabetes1 Common conditions that coexist with type 2 diabetes, such as hypertension and dyslipidemia, are clear risk factors for CVD, and diabetes itself confers independent risk1 Numerous studies have shown the efficacy of controlling individual cardiovascular risk factors in preventing of slowing CVD in people with diabetes1 Large benefits are seen when multiple risk factors are addressed globally2,3 There is evidence that measures of 10-year coronary heart disease (CHD) risk among U.S. adults with diabetes have improved significantly over the past decade4 ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S28. References Buse JB, Ginsberg HN, Bakris GL, et al., for the American Heart Association, American Diabetes Association. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care 2007;30: Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S28. Ford ES. Trends in the risk for coronary heart disease among adults with diagnosed diabetes in the U.S.: findings from the National Health and Nutrition Examination Survey, Diabetes Care 2011;34:

Recommendations: Hypertension/Blood Pressure Control
Screening and diagnosis Measure blood pressure at every routine diabetes visit (C) If patients have systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg (C) Confirm blood pressure on a separate day Repeat systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg confirms a diagnosis of hypertension Hypertension is a common comorbidity of diabetes that affects the majority of patients, with prevalence depending on type of diabetes, age, obesity, and ethnicity Hypertension is a major risk factor for both CVD and microvascular complications In type 1 diabetes, hypertension is often the result of underlying nephropathy, while in type 2 diabetes it usually coexists with other cardiometabolic risk factors This slide and the following six slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 1 of 7 – Screening and Diagnosis Blood pressure should be measured at every routine diabetes visit (C) Patients found to have systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg should have blood pressure confirmed on a separate day (C) Repeat systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg confirms a diagnosis of hypertension (C) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S28-S29. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S28-S29.

Goals A goal systolic blood pressure <130 mmHg is appropriate for most patients with diabetes (C) Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate (B) Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg (B) This set of seven slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 2 of 7 – Goals A goal systolic blood pressure <130 mmHg is appropriate for most patients with diabetes (C) Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate (B) Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S29. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S29.

Treatment (1) Patients with a systolic blood pressure 130–139 mmHg or a diastolic blood pressure 80–89 mmHg (E) May be given lifestyle therapy alone for a maximum of 3 months If targets are not achieved, patients should be treated with the addition of pharmacological agents This set of seven slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 3 of 7 – Treatment (Slide 1 of 5) Patients with a systolic blood pressure mmHg or a diastolic blood pressure mmHg may be given lifestyle therapy alone for a maximum of 3 months, and then if targets are not achieved, patients should be treated with the addition of pharmacological agents (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S29. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S29.

Treatment (2) Patients with more severe hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) at diagnosis or follow-up (A) Should receive pharmacologic therapy in addition to lifestyle therapy This set of seven slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 4 of 7 – Treatment (Slide 2 of 5) Patients with more severe hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) at diagnosis or follow-up should receive pharmacologic therapy in addition to lifestyle therapy (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S29. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S29.

Treatment (3) Lifestyle therapy for hypertension (B) Weight loss if overweight DASH-style dietary pattern including reducing sodium, increasing potassium intake Moderation of alcohol intake Increased physical activity This set of seven slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 5 of 7 – Treatment (Slide 3 of 5) Lifestyle therapy for hypertension consists of weight loss if overweight, DASH-style dietary pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S27. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;34(suppl 1):S27.

Treatment (4) Pharmacologic therapy for patients with diabetes and hypertension A regimen that includes either an ACE inhibitor or angiotensin II receptor blocker If one class is not tolerated, the other should be substituted Multiple drug therapy (two or more agents at maximal doses) is generally required to achieve blood pressure targets (B) This set of seven slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 6 of 7 – Treatment (Slide 4 of 5) Pharmacologic therapy for patients with diabetes and hypertension should be paired with a regimen that included either an ACE inhibitor or an angiotensin II receptor blocker (ARB); if one class is not tolerated, the other should be substituted Multiple drug therapy (two or more agents at maximal doses) is generally required to achieve blood pressure targets (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S29. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S29.

Treatment (5) If ACE inhibitors, ARBs, or diuretics are used, kidney function, serum potassium levels should be monitored (E) In pregnant patients with diabetes and chronic hypertension, blood pressure target goals of 110–129/65–79 mmHg are suggested in interest of long-term maternal health and minimizing impaired fetal growth; ACE inhibitors, ARBs, contraindicated during pregnancy (E) This set of seven slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 7 of 7 – Treatment (Slide 5 of 5) If ACE inhibitors, angiotensin II receptor blockers (ARBs), or diuretics are used, kidney function and serum potassium levels should be closely monitored (E) In pregnant women with diabetes and chronic 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 angiotensin II receptor blockers (ARBs) are contraindicated during pregnancy (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S29. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S29.

Recommendations: Dyslipidemia/Lipid Management
Screening In most adult patients, measure fasting lipid profile at least annually (E) In adults with low-risk lipid values (LDL cholesterol <100 mg/dL, HDL cholesterol >50 mg/dL, and triglycerides <150 mg/dL), lipid assessments may be repeated every 2 years (E) Patients with type 2 diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of CVD Low levels of HDL cholesterol, often associated with elevated triglyceride levels, are the most prevalent pattern of dyslipidemia in persons with type 2 diabetes This set of six slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 1 of 6 – Screening In most adult patients, measure fasting lipid profile at least annually In adults with low-risk lipid values (LDL cholesterol <100 mg/dl, HDL cholesterol >50 mg/dl, and triglycerides <150 mg/dl), lipid assessments may be repeated every 2 years (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S29. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S29.

Treatment recommendations and goals (1) To improve lipid profile in patients with diabetes, recommend lifestyle modification (A), focusing on Reduction of saturated fat, trans fat, cholesterol intake Increased n-3 fatty acids, viscous fiber, plant stanols/sterols Weight loss (if indicated) Increased physical activity This set of six slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 2 of 6 – Treatment Recommendations and Goals (Slide 1 of 5) Lifestyle modification focusing on the reduction of saturated fat, trans fat, and cholesterol intake; increase of n-3 fatty acids, viscous fiber, and plant stanols/sterols; weight loss (if indicated) and increased physical activity should be recommended to improve the lipid profile in patients with diabetes (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S30. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S30.

Treatment recommendations and goals (2) Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels with overt CVD (A) without CVD >40 years of age who have one or more other CVD risk factors (A) For patients at lower risk (e.g., without overt CVD, <40 years of age) (E) Consider statin therapy in addition to lifestyle therapy if LDL cholesterol remains >100 mg/dL In those with multiple CVD risk factors This set of six slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 3 of 6 – Treatment Recommendations and Goals (Slide 2 of 5) Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients With overt CVD (A) Without CVD who are over the age of 40 years and have one or more other CVD risk factors (A) For patients at lower risk (e.g., without overt CVD and younger than age 40 years), statin therapy should be considered in addition to lifestyle therapy if LDL cholesterol remains >100 mg/dL or in those with multiple CVD risk factors (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S30-31. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S23-S31.

Treatment recommendations and goals (3) In individuals without overt CVD Primary goal is an LDL cholesterol <100 mg/dL (2.6 mmol/L) (A) In individuals with overt CVD Lower LDL cholesterol goal of <70 mg/dL (1.8 mmol/L), using a high dose of a statin, is an option (B) This set of six slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 4 of 6 – Treatment Recommendations and Goals (Slide 3 of 5) In individuals without overt CVD, the primary goal is an LDL cholesterol <100 mg/dl (2.6 mmol/l) (A) In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a high dose of a statin, is an option (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S31. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S31.

Treatment recommendations and goals (4) If targets not reached on maximal tolerated statin therapy Alternative therapeutic goal: reduce LDL cholesterol ~30–40% from baseline (A) Triglyceride levels <150 mg/dL (1.7 mmol/L), HDL cholesterol >40 mg/dL (1.0 mmol/L) in men and >50 mg/dL (1.3 mmol/L) in women, are desirable However, LDL cholesterol–targeted statin therapy remains the preferred strategy (C) This set of six slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 5 of 6 – Treatment Recommendations and Goals (Slide 4 of 5) If drug-treated patients do not reach the targets outlined on the previous slide (Slide 3 of 5) on maximal tolerated statin therapy, a reduction in LDL cholesterol of ~30-40% from baseline is an alternative therapeutic goal (A) Triglyceride levels <150 mg/dl (1.7 mmol/l) and HDL cholesterol >40 mg/dl (1.0 mm/l) in men and >50 mg/dl (1.3 mmol/l) in women, are desirable; however, LDL cholesterol-targeting statin therapy remains the preferred strategy (C) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S31. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S31.

Treatment recommendations and goals (5) If targets are not reached on maximally tolerated doses of statins (E) Combination therapy using statins and other lipid lowering agents may be considered to achieve lipid targets Has not been evaluated in outcome studies for either CVD outcomes or safety Statin therapy is contraindicated in pregnancy (B) This set of six slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 6 of 6 – Treatment Recommendations and Goals (Slide 5 of 5) If targets are not reached on maximally tolerated doses of statins, combination therapy using statins and other lipid-lowering agents may be considered to achieve lipid targets but has not been evaluated in outcome studies for either CVD outcomes or safety (E) Statin therapy is contraindicated in pregnancy (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S31. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S31.

Recommendations: Glycemic, Blood Pressure, Lipid Control in Adults
A1C <7.0%* Blood pressure <130/80 mmHg† Lipids LDL cholesterol <100 mg/dL (<2.6 mmol/L)‡ This slide represents a summary of common treatment goals for A1C, blood pressure, and LDL cholesterol for most adults with diabetes *More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on: duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations. †Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate. ‡In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dL (1.8 mmol/L), using a high dose of statin, is an option. ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S32. Table 11. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S31. Table 11.

Recommendations: Antiplatelet Agents (1)
Consider aspirin therapy (75–162 mg/day) (C) As a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk >10%) Includes most men >50 years of age or women >60 years of age who have at least one additional major risk factor Family history of CVD Hypertension Smoking Dyslipidemia Albuminuria In 2010, a position statement of the ADA, AHA, and the American College of Cardiology Foundation (ACCF) updated prior joint recommendations for primary prevention1 Recommendations for the use of antiplatelet agents2 are summarized in three slides Slide 1 of 3 Low-dose (75–162 mg/day) aspirin use for primary prevention is reasonable for adults with diabetes and no previous history of vascular disease who are at increased CVD risk (10-year risk of CVD events >10%) and who are not at increased risk for bleeding This generally includes most men over age 50 years and women over age 60 years who also have one or more of the following major risk factors: smoking, hypertension, dyslipidemia, family history of premature CVD, or albuminuria ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S32. References Pignone M, Alberts MJ, Colwell JA, et al.; American Diabetes Association; American Heart Association; American College of Cardiology Foundation. Aspirin for primary prevention of cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Diabetes Care 2010;33: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S32.

Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk, since potential adverse effects from bleeding likely offset potential benefits (C) 10-year CVD risk <5%: men <50 and women <60 years of age with no major additional CVD risk factors In patients in these age groups with multiple other risk factors (10-year risk 5–10%), clinical judgment is required (E) However, aspirin is no longer recommended for those at low CVD risk (women under age 60 years and men under age 50 years with no major CVD risk factors; 10-year CVD risk <5%), as the low benefit is likely to be outweighed by the risks of significant bleeding Clinical judgment should be used for those at intermediate risk (younger patients with one or more risk factors, or older patients with no risk factors; those with 10-year CVD risk of 5–10%) until further research is available. Use of aspirin in patients under the age of 21 years is contraindicated due to the associated risk of Reye’s syndrome Recommendations for the use of antiplatelet agents are summarized in three slides Slide 2 of 3 Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (10-year CVD risk <5%, such as in men <50 and women <60 years of age with no major additional CVD risk factors), since the potential adverse effects from bleeding likely offset the potential benefits (C) In patients in these age groups with multiple other risk factors (e.g., 10-year risk 5%-10%) clinical judgment is required (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S32. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S32.

Use aspirin therapy (75–162 mg/day) Secondary prevention strategy in those with diabetes with a history of CVD (A) For patients with CVD and documented aspirin allergy Clopidogrel (75 mg/day) should be used (B) Combination therapy with ASA (75–162 mg/day) and clopidogrel (75 mg/day) Reasonable for up to a year after an acute coronary syndrome (B) Recommendations for the use of antiplatelet agents1 are summarized in three slides Slide 3 of 3 Use aspirin therapy ( mg/day) as a secondary prevention strategy in those with diabetes with a history of CVD (A) For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used (B) Combination therapy with ASA ( mg/day) and clopidogrel (75 mg/day) is reasonable for up to a year after an acute coronary syndrome (B) Clopidogrel has been demonstrated to reduce CVD events in diabetic individuals2 It is recommended as adjunctive therapy in the first year after an acute coronary syndrome or as alternative therapy in aspirin-intolerant patients ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S32. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2011;35(suppl 1):S32. Bhatt DL, Marso SP, Hirsch AT, Ringleb PA, Hacke W, Topol EJ. Amplified benefit of clopidogrel versus aspirin in patients with diabetes mellitus. Am J Cardiol 2002;90:

Recommendations: Smoking Cessation
Advise all patients not to smoke (A) Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care (B) A large body of evidence from epidemiological, case-control, and cohort studies provides convincing documentation of the causal link between cigarette smoking and health risks Much of the work documenting the impact of smoking on health did not separately discuss results on subsets of individuals with diabetes, but suggests that the identified risks are at least equivalent to those found in the general population Smoking may have a role in the development of type 2 diabetes and other studies of individuals with diabetes consistently demonstrate that smokers have a heightened risk of CVD, premature death, and increased rate of microvascular complications of diabetes The routine and thorough assessment of tobacco use is important as a means of preventing smoking or encouraging cessation A number of large randomized clinical trials have demonstrated the efficacy and cost-effectiveness of brief counseling in smoking cessation, including the use of quit lines, in the reduction of tobacco use. For the patient motivated to quit, the addition of pharmacological therapy to counseling is more effective than either treatment alone Special considerations should include assessment of level of nicotine dependence, which is associated with difficulty in quitting and relapse1 Recommendations for smoking cessation2 are summarized on this slide Advise all patients not to smoke (A) Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S33. References Ranney L, Melvin C, Lux L, McClain E, Lohr KN. Systematic review: smoking cessation intervention strategies for adults and adults in special populations. Ann Intern Med 2006;145: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S33.

Recommendations: Coronary Heart Disease Screening
In asymptomatic patients, routine screening for CAD is not recommended, as it does not improve outcomes as long as CVD risk factors are treated (A) Screening for CAD is reviewed in a recently updated consensus statement1 To identify the presence of CAD in diabetic patients without clear or suggestive symptoms, a risk factor-based approach to the initial diagnostic evaluation and subsequent follow-up has intuitive appeal However, recent studies concluded that using this approach fails to identify which patients with type 2 diabetes will have silent ischemia on screening tests2,3 Recommendations for CHD screening4 is summarized on this slide In asymptomatic patients, routine screening for CAD is not recommended, as it does not improve outcomes as long as CVD risk factors are treated (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S32. References Bax JJ, Young LH, Frye RL, Bonow RO, Steinberg HO, Barrett EJ; ADA. Screening for coronary artery disease in patients with diabetes. Diabetes Care 2007;30: Wackers FJ, Young LH, Inzucchi SE, et al.; Detection of Ischemia in Asymptomatic Diabetics Investigators. Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care 2004;27: Scognamiglio R, Negut C, Ramondo A, Tiengo A, Avogaro A. Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus. J Am Coll Cardiol 2006;47:65-71. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S32.

Recommendations: Coronary Heart Disease Treatment (1)
To reduce risk of cardiovascular events in patients with known CVD, use ACE inhibitor* (C) Aspirin* (A) Statin therapy* (A) In patients with a prior MI Beta-blockers should be continued for at least 2 years after the event (B) In patients with known CVD, ACE inhibitor (C), aspirin (A), and statin therapy (A) (if not contraindicated) should be used to reduce the risk of cardiovascular events1 In patients with a prior MI, β-blockers should be continued for at least 2 years after the event (B)1 In all patients with diabetes, cardiovascular risk factors should be assessed at least annually These risk factors include dyslipidemia, hypertension, smoking, a positive family history of premature coronary disease, and the presence of micro- or macroalbuminuria Abnormal risk factors should be treated as described elsewhere in the guidelines Patients at increased CHD risk should receive aspirin and a statin, and ACE inhibitor or ARB therapy if hypertensive, unless there are contraindications to a particular drug class While clear benefit exists for ACE inhibitor and ARB therapy in patients with nephropathy or hypertension, the benefits in patients with CVD in the absence of these conditions is less clear, especially when LDL cholesterol is concomitantly controlled2,3 *If not contraindicated. ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S33. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S33. Braunwald E, Domanski MJ, Fowler SE, et al.; PEACE Trial Investigators. Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med 2004;351: Yusuf S, Teo K, Anderson C, et al.; Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease (TRANSCEND) Investigators. Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial. Lancet 2008;372:

Recommendations: Coronary Heart Disease Treatment (2)
Longer-term use of beta-blockers in the absence of hypertension Reasonable if well tolerated, but data are lacking (E) Avoid TZD treatment In patients with symptomatic heart failure (C) Metformin use in patients with stable CHF Indicated if renal function is normal Should be avoided in unstable or hospitalized patients with CHF (C) Longer-term use of β-blockers in the absence of hypertension is reasonable if well tolerated, but data are lacking (E) Avoid thiazolidinedione (TZD) treatment in patients with symptomatic heart failure (C) Metformin may be used in patients with stable CHF if renal function is normal; it should be avoided in unstable or hospitalized patients with CHF (C) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S33. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S33.

Recommendations: Nephropathy
To reduce risk or slow the progression of nephropathy Optimize glucose control (A) Optimize blood pressure control (A) Diabetic nephropathy occurs in 20-40% of patients with diabetes and is the single leading cause of end-stage renal disease (ESRD) Persistent albuminuria in the range of mg/24 h (microalbuminuria) has been shown to be the earliest stage of diabetic nephropathy in type 1 diabetes and a marker for development of nephropathy in type 2 diabetes Microalbuminuria is also a well-established marker of increased CVD risk1,2 General recommendations for the care of patients with diabetes and nephropathy3 are summarized on this slide To reduce the risk or slow the progression of nephropathy, optimize glucose control (A) To reduce the risk or slow the progression of nephropathy, optimize blood pressure control (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S34. References Garg JP, Bakris GL. Microalbuminuria: marker of vascular dysfunction, risk factor for cardiovascular disease. Vasc Med 2002;7:35-43. Klausen K, Borch-Johnsen K, Feldt-Rasmussen B, et al. Very low levels of microalbuminuria are associated with increased risk of coronary heart disease and death independently of renal function, hypertension, and diabetes. Circulation 2004;110:32-35. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S34.

Recommendations: Nephropathy Screening
Assess urine albumin excretion annually (B) In type 1 diabetic patients with diabetes duration of ≥5 years In all type 2 diabetic patients at diagnosis Measure serum creatinine at least annually (E) In all adults with diabetes regardless of degree of urine albumin excretion Serum creatinine should be used to estimate GFR and stage level of chronic kidney disease, if present Perform an annual test to assess urine albumin excretion in type 1 diabetic patients with diabetes duration of 5 years and in all type 2 diabetic patients, starting at diagnosis (E) Measure serum creatinine at least annually in all adults with diabetes regardless of the degree of urine albumin excretion The serum creatinine should be used to estimate GFR and stage the level of chronic kidney disease (CKD), if present (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S34. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S34.

Recommendations: Nephropathy Treatment (1)
Nonpregnant patient with micro- or macroalbuminuria Use either ACE inhibitors or ARBs (A) If one class is not tolerated, the other should be substituted (E) Reduction of protein intake may improve measures of renal function (urine albumin excretion rate, GFR) (B) To 0.8–1.0 g x kg body wt–1 x day–1 in those with diabetes, earlier stages of CKD To 0.8 g x kg body wt–1 x day–1 in later stages of CKD Recommendations for the treatment of nephropathy in patients with diabetes are summarized in three slides Slide 1 of 3 In the Reduction of protein intake may improve measures of renal function (urine albumin excretion rate, GFR) (B) To 0.8 –1.0 g x kg body wt–1 x day–1 in those with diabetes, earlier stages of CKD To 0.8 g x kg body wt–1 x day–1 in later stages of CKD treatment of the nonpregnant patient with micro- or macroalbuminuria, either ACE inhibitors or angiotensin II receptor blockers (ARBs) should be used (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S34. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S34.

When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine and potassium levels for the development of increased creatinine and hyperkalemia (E) Continued monitoring of urine albumin excretion to assess both response to therapy and progression of disease is reasonable (E) When estimated GFR is <60 mL x min/1.73 m2, evaluate and manage potential complications of CKD (E) Recommendations for the treatment of nephropathy in patients with diabetes are summarized in three slides Slide 2 of 3 When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine and potassium levels for the development of increased creatinine and hyperkalemia (E) Continued monitoring of urine albumin excretion to assess both response to therapy and progression of disease is reasonable (E) When estimated GFR is <60 mL x min/1.73 m2, evaluate and manage potential complications of CKD (E) ADA. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S34. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S34.

Consider referral to a physician experienced in care of kidney disease (B) Uncertainty about etiology of kidney disease Difficult management issues Advanced kidney disease Recommendations for the treatment of nephropathy in patients with diabetes are summarized in three slides Slide 3 of 3 Consider referral to a physician experienced in the care of kidney disease when there is uncertainty about the etiology of kidney disease (active urine sediment, absence of retinopathy, or rapid decline in GFR), difficult management issues, or advanced kidney disease (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S34. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S34.

Definitions of Abnormalities in Albumin Excretion
Category Spot collection (µg/mg creatinine) Normal <30 Microalbuminuria 30-299 Macroalbuminuria (clinical) ≥300 This table defines abnormalities of albumin excretion Because of variability in urinary albumin excretion, two of three specimens collected within a 3- to 6-month period should be abnormal before considering a patient to have crossed one of these diagnostic thresholds Exercise within 24 h, infection, fever, CHF, marked hyperglycemia, and marked hypertension may elevate urinary albumin excretion over baseline values ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S34. Table 12. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S34-S35. Table 12.

Stages of Chronic Kidney Disease
Description GFR (mL/min per 1.73 m2 body surface area) 1 Kidney damage* with normal or increased GFR ≥90 2 Kidney damage* with mildly decreased GFR 60–89 3 Moderately decreased GFR 30–59 4 Severely decreased GFR 15–29 5 Kidney failure <15 or dialysis The National Kidney Foundation classification of the stages of chronic kidney disease (Table 13;1 adapted from Levey et al2) is primarily based on GFR levels and therefore differs from other systems, in which staging is based primarily on urinary albumin excretion3 Studies have found decreased GFR in the absence of increased urine albumin excretion in a substantial percentage of adults with diabetes4 GFR calculators are available at 3. GFR = glomerular filtration rate *Kidney damage defined as abnormalities on pathologic, urine, blood, or imaging tests. ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S35. Table 13. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S35. Table 13. Levey AS, Coresh J, Balk E, et al.; National Kidney Foundation. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003;139:137–147. Kramer H, Molitch ME. Screening for kidney disease in adults with diabetes. Diabetes Care 2005;28: Kramer HJ, Nguyen QD, Curhan G, Hsu CY. Renal insufficiency in the absence of albuminuria and retinopathy among adults with type 2 diabetes mellitus. JAMA 2003;289:

Management of CKD in Diabetes (1)
GFR (mL/min/ 1.73 m2) Recommended All patients Yearly measurement of creatinine, urinary albumin excretion, potassium 45-60 Referral to nephrology if possibility for nondiabetic kidney disease exists Consider dose adjustment of medications Monitor eGFR every 6 months Monitor electrolytes, bicarbonate, hemoglobin, calcium, phosphorus, parathyroid hormone at least yearly Assure vitamin D sufficiency Consider bone density testing Referral for dietary counselling Management of chronic kidney disease (CKD) is summarized in two slides1,2 Slide 1 of 2 Complications of kidney disease correlate with level of kidney function When the eGFR is <60 ml/min/1.73 m2, screening for complications of CKD is indicated, as summarized on this slide (Table 14) Consider referral to a physician experienced in the care of kidney disease when there is uncertainty about the etiology of kidney disease (heavy proteinuria, active urine sediment, absence of retinopathy, rapid decline in GFR, resistant hypertension), difficult management issues, or advanced kidney disease. The threshold for referral may vary depending on the frequency with which a provider encounters diabetic patients with significant kidney disease Early vaccination against hepatitis B is indicated in patients likely to progress to end-stage kidney disease ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S35. Table 14; Adapted from References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S35. Table 14. Adapted from

Management of CKD in Diabetes (2)
GFR (ml/min/ 1.73 m2) Recommended 30-44 Monitor eGFR every 3 months Monitor electrolytes, bicarbonate, calcium, phosphorus, parathyroid hormone, hemoglobin, albumin, weight every 3–6 months Consider need for dose adjustment of medications <30 Referral to nephrologists Management of chronic kidney disease (CKD) is summarized in two slides1,2 Slide 2 of 2 When the eGFR is <60 ml/min/1.73 m2, screening for complications of CKD is indicated, as summarized on this slide (Table 14) Consultation with a nephrologist when stage 4 CKD develops has been found to reduce cost, improve quality of care, and keep people off dialysis longer3 However, nonrenal specialists should not delay educating their patients about the progressive nature of diabetic kidney disease; the renal preservation benefits of aggressive treatment of blood pressure, blood glucose, and hyperlipidemia; and the potential need for renal replacement therapy ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S35. Table 14; Adapted from References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S35. Table 14. Adapted from Levinsky NG. Specialist evaluation in chronic kidney disease: too little, too late. Ann Intern Med 2002;137:542–543.

Recommendations: Retinopathy
To reduce risk or slow progression of retinopathy Optimize glycemic control (A) Optimize blood pressure control (A) Diabetic retinopathy is a highly specific vascular complication of both type 1 and type 2 diabetes, with prevalence strongly related to duration of diabetes Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20–74 years Glaucoma, cataracts, and other disorders of the eye occur earlier and more frequently in people with diabetes In addition to duration of diabetes, other factors that increase the risk of, or are associated with, retinopathy include chronic hyperglycemia1, the presence of nephropathy2, and hypertension3 Recommendations for the care of patients with diabetes with respect to retinopathy4 are summarized on this slide To reduce the risk or slow the progression of retinopathy, optimize glycemic control (A) To reduce the risk or slow the progression of retinopathy, optimize blood pressure control (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S35. References Klein R. Hyperglycemia and microvascular and macrovascular disease in diabetes. Diabetes Care 1995;18: Estacio RO, McFarling E, Biggerstaff S, Jeffers BW, Johnson D, Schrier RW. Overt albuminuria predicts diabetic retinopathy in Hispanics with NIDDM. Am J Kidney Dis 1998;31: Leske MC, Wu SY, Hennis A, et al., for the Barbados Eye Study Group. Hyperglycemia, blood pressure, and the 9-year incidence of diabetic retinopathy: the Barbados Eye Studies. Ophthalmology 2005;112: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S35.

Recommendations: Retinopathy Screening (1)
Initial dilated and comprehensive eye examination by an ophthalmologist or optometrist Adults and children aged 10 years or older with type 1 diabetes Within 5 years after diabetes onset (B) Patients with type 2 diabetes Shortly after diagnosis of diabetes (B) Results of eye examinations should be documented and transmitted to the referring health care professional Recommendations for the screening of nephropathy in patients with diabetes are summarized in four slides Slide 1 of 4 Adults and children aged 10 years or older with type 1 diabetes should have an initial dilated and comprehensive 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 comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S35. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S35.

Subsequent examinations for type 1 and type 2 diabetic patients Should be repeated annually by an ophthalmologist or optometrist Less frequent exams (every 2–3 years) May be considered following one or more normal eye exams More frequent examinations required if retinopathy is progressing (B) Recommendations for the screening of nephropathy in patients with diabetes are summarized in four slides Slide 2 of 4 Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist Less frequent exams (every 2-3 years) may be considered following one or more normal eye exams, if recommended by the eye care professional Examinations will be required more frequently if retinopathy is progressing (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S35-S36. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S35-S36.

High-quality fundus photographs Can detect most clinically significant diabetic retinopathy (E) Interpretation of the images Performed by a trained eye care provider (E) While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam Perform comprehensive eye exam at least initially and at intervals thereafter as recommended by an eye care professional (E) Recommendations for the screening of nephropathy in patients with diabetes are summarized in four slides Slide 3 of 4 High-quality fundus photographs can detect most clinically significant diabetic retinopathy. Interpretation of the images should be performed by a trained eye care provider While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S36. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S36.

Women with preexisting diabetes who are planning pregnancy or who have become pregnant (B) Comprehensive eye examination Counseled on risk of development and/or progression of diabetic retinopathy Eye examination should occur in the first trimester (B) Close follow-up throughout pregnancy For 1 year postpartum Recommendations for the screening of nephropathy in patients with diabetes are summarized in four slides Slide 4 of 4 Women with preexisting diabetes who are planning pregnancy or who have become pregnant should have a comprehensive eye examination and be counseled on the risk of development and/or progression of diabetic retinopathy Eye examination should occur in the first trimester with close follow-up throughout pregnancy and for 1 year postpartum (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S36. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S36.

Recommendations: Retinopathy Treatment (1)
Promptly refer patients with any level of macular edema, severe NPDR, or any PDR To an ophthalmologist knowledgeable and experienced in management, treatment of diabetic retinopathy (A) Laser photocoagulation therapy is indicated (A) To reduce risk of vision loss in patients with High-risk PDR Clinically significant macular edema Some cases of severe NPDR Recommendations for the treatment of nephropathy in patients with diabetes are summarized in two slides Slide 1 of 2 Promptly refer patients with any level of macular edema, severe non-proliferative diabetic retinopathy (NPDR), or any peripheral diabetic retinopathy (PDR) to an ophthalmologist who is knowledgeable and experienced in the management and treatment of diabetic retinopathy (A) Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with high-risk PDR, clinically significant macular edema, and in some cases of severe NPDR (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S36. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S36.

Recommendations: Retinopathy Treatment (2)
Presence of retinopathy Not a contraindication to aspirin therapy for cardioprotection, as this therapy does not increase the risk of retinal hemorrhage (A) Recommendations for the treatment of nephropathy in patients with diabetes are summarized in two slides Slide 2 of 2 The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as this therapy does not increase the risk of retinal hemorrhage (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S36. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S36.

Recommendations: Neuropathy Screening, Treatment (1)
All patients should be screened for distal symmetric polyneuropathy (DPN) (B) At diagnosis of type 2 diabetes with 5 years after diagnosis of type 1 diabetes At least annually thereafter using simple clinical tests Electrophysiological testing rarely needed Except in situations where clinical features are atypical (E) The diabetic neuropathies are heterogeneous with diverse clinical manifestations; they may be focal or diffuse Most common among the neuropathies are chronic sensorimotor diabetic peripheral neuropathy (DPN) and autonomic neuropathy; although DPN is a diagnosis of exclusion, complex investigations to exclude other conditions are rarely needed Early recognition and appropriate management of neuropathy in the patient with diabetes is important for a number of reasons: 1) nondiabetic neuropathies may be present in patients with diabetes and may be treatable; 2) a number of treatment options exist for symptomatic diabetic neuropathy; 3) up to 50% of DPN may be asymptomatic and patients are at risk of insensate injury to their feet; 4) autonomic neuropathy and particularly cardiovascular autonomic neuropathy is associated with substantial morbidity, mortality Specific treatment for the underlying nerve damage is not currently available, other than improved glycemic control, which may slow progression but not reverse neuronal loss; effective symptomatic treatments are available for some manifestations of DPN and autonomic neuropathy Recommendations for the screening and treatment of neuropathy in patients with diabetes are summarized in two slides Slide 1 of 2 All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter using simple clinical tests (B) Electrophysiological testing is rarely needed, except in situations where the clinical features are atypical (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S36. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S36-S37.

Recommendations: Neuropathy Screening, Treatment (2)
Screening for signs and symptoms of cardiovascular autonomic neuropathy Should be instituted at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes Special testing rarely needed; may not affect management or outcomes (E) Medications for relief of specific symptoms related to DPN, autonomic neuropathy are recommended Improve quality of life of the patient (E) Recommendations for the screening and treatment of neuropathy in patients with diabetes are summarized in two slides Slide 2 of 2 Screening for signs and symptoms of cardiovascular autonomic neuropathy should be instituted at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes; special testing is rarely needed and may not affect management or outcomes (E) Medications for the relief of specific symptoms related to DPN and autonomic neuropathy are recommended, as they improve the quality of life of the patient (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S36. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S36.

Recommendations: Foot Care (1)
For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations Inspection Assessment of foot pulses Test for loss of protective sensation: 10-g monofilament plus testing any one of Vibration using 128-Hz tuning fork Pinprick sensation Ankle reflexes Vibration perception threshold (B) Amputation and foot ulceration, consequences of diabetic neuropathy and/or peripheral artery disease (PAD), are common and major causes of morbidity and disability in people with diabetes; early recognition and management of risk factors can prevent or delay adverse outcomes Risk of ulcers or amputations is increased in people who have the following risk factors: Previous amputation Past foot ulcer history Peripheral neuropathy Foot deformity Peripheral vascular disease Visual impairment Diabetic nephropathy (especially patients on dialysis) Poor glycemic control Cigarette smoking Recommendations for foot care in patients with diabetes are summarized in four slides Slide 1 of 4 For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation (LOPS) (10-g monofilament plus testing any one of: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold) (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S37. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S37-S38.

Upper panel To perform the 10-g monofilament test, place the device perpendicular to the skin, with pressure applied until the monofilament buckles Hold in place for 1 second and then release Lower panel The monofilament test should be performed at the highlighted sites while the patient’s eyes are closed Recommendations for foot care in patients with diabetes are summarized in four slides Slide 2 of 4 This slide illustrates how to perform the 10-g monofilament test1,2 Boulton AJM, et al. Diabetes Care. 2008;31: References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S37. Boulton AJ, Armstrong DG, Albert SF, et al., for the American Diabetes Association, American Association of Clinical Endocrinologists. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care 2008;31:

Provide general foot self-care education (B) Use multidisciplinary approach Individuals with foot ulcers, high-risk feet; especially prior ulcer or amputation (B) Refer patients to foot care specialists for ongoing preventive care, life-long surveillance (C) Smokers Loss of protective sensation or structural abnormalities History of prior lower-extremity complications Recommendations for foot care in patients with diabetes are summarized in four slides Slide 3 of 4 Provide general foot self-care education to all patients with diabetes (B) A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet, especially those with a history of prior ulcer or amputation (B) Refer patients who smoke, have LOPS and structural abnormalities, or have history of prior lower-extremity complications to foot care specialists for ongoing preventive care and life-long surveillance (C) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S37. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S37.

Initial screening for peripheral arterial disease (PAD) Include a history for claudication, assessment of pedal pulses Consider obtaining an ankle-brachial index (ABI); many patients with PAD are asymptomatic (C) Refer patients with significant claudication or a positive ABI for further vascular assessment Consider exercise, medications, surgical options (C) Recommendations for foot care in patients with diabetes are summarized in four slides Slide 4 of 4 Initial screening for peripheral arterial disease (PAD) should include a history for claudication and an assessment of the pedal pulses Consider obtaining an ankle-brachial index (ABI), as many patients with PAD are asymptomatic (C) Refer patients with significant claudication or a positive ABI for further vascular assessment and consider exercise, medications, and surgical options (C) ADA. VI. Prevention, Management of Complications. Diabetes Care 2012;35(suppl 1):S37. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S37.

VII. Assessment of Common Comorbid Conditions
Section VII. Assessment of Common Comorbid Conditions includes 1 slide Recommendations: Assessment of Common Comorbid Conditions VII. Assessment of Common Comorbid Conditions

Recommendations: Assessment of Common Comorbid Conditions
For patients with risk factors, signs or symptoms, consider assessment and treatment for common diabetes-associated conditions (B) Common comorbidities for which increased risk is associated with diabetes Hearing impairment Periodontal disease Obstructive sleep apnea Certain cancers Fatty liver disease Fractures Low testosterone in men Cognitive impairment Patients who have risk factors, signs or symptoms of common diabetes-associated conditions should be assessed In addition to the commonly appreciated comorbidities of obesity, hypertension, and dyslipidemia, diabetes is also associated with other diseases or conditions at rates higher than those of age-matched people without diabetes A few of the more common comorbidities are described on this slide (Table 15) ADA. VII. Assessment of Common Comorbid Conditions. Diabetes Care. 2012;35(suppl 1):S38; Table 15. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S38; Table 15.

VIII. diabetes care in specific populations
Section VIII. Diabetes Care in Specific Populations includes 17 slides (1 slide unless otherwise indicated): Recommendations: Pediatric Glycemic Control (Type 1 Diabetes) Recommendations: Pediatric Nephropathy (Type 1 Diabetes) Recommendations: Pediatric Hypertension (Type 1 Diabetes) (3 slides) Recommendations: Pediatric Dyslipidemia (Type 1 Diabetes) (4 slides) Recommendations: Retinopathy (Type 1 Diabetes) Recommendations: Celiac Disease (Type 1 Diabetes) (2 slides) Recommendations: Hypothyroidism (Type 1 Diabetes) Recommendations: Transition from Pediatric to Adult Care Recommendations: Preconception Care (2 slides) Recommendations: Older Adults (2 slides) Recommendations: Cystic Fibrosis-Related Diabetes (CFRD) (2 slides) VIII. diabetes care in specific populations

Recommendations: Pediatric Glycemic Control (Type 1 Diabetes)
Consider age when setting glycemic goals in children and adolescents with type 1 diabetes (E) While current standards for diabetes management reflect the need to maintain glucose control as near to normal as safely possible, special consideration should be given to the unique risks of hypoglycemia in young children Glycemic goals may need to be modified to take into account the fact that most children <6 or 7 years of age have a form of “hypoglycemic unawareness,” including immaturity of and a relative inability to recognize and response to hypoglycemic symptoms, placing them at greater risk for severe hypoglycemia and its sequelae In addition, and unlike the case in adults, young children under the age of 5 years may be at risk for permanent cognitive impairment after episodes of severe hypoglycemia In selecting glycemic goals, the benefits on long-term health outcomes of achieving a lower A1C should be balanced against the risks of hypoglycemia and the developmental burdens of intensive regimens in children and youth Recommendations for glycemic control in children with type 1 diabetes are summarized on this slide Clinicians should consider age when setting glycemic goals in children and adolescents with type 1 diabetes (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S40. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S40.

Recommendations: Pediatric Nephropathy (Type 1 Diabetes)
Annual screening for microalbuminuria, with a random spot urine sample for albumin-to-creatinine (ACR) ratio Consider once child is 10 years of age and has had diabetes for 5 years (E) Confirmed, persistently elevated ACR on two additional urine specimens from different days Treat with an ACE inhibitor, titrated to normalization of albumin excretion, if possible (E) Recommendations Annual screening for microalbuminuria, for albumin-to-creatinine (ACR) ratio, should be considered once the child is 10 years of age and has had diabetes for 5 years (E) Confirmed, persistently elevated ACR on two additional urine specimens from different days should be treated with an ACE inhibitor, titrated to normalization of albumin excretion if possible (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S40. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S40.

Recommendations: Pediatric Hypertension (Type 1 Diabetes) (1)
Treat high-normal blood pressure (systolic or diastolic blood pressure consistently above the 90th percentile for age, sex, and height) with Dietary intervention Exercise aimed at weight control and increased physical activity, if appropriate If target blood pressure is not reached with 3–6 months of lifestyle intervention Consider pharmacologic treatment (E) Recommendations for the care of children and adolescents with hypertension are summarized in three slides Slide 1 of 3 Treatment of high-normal blood pressure (systolic or diastolic blood pressure consistently above the 90th percentile for age, sex, and height) should include dietary intervention and exercise aimed at weight control and increased physical activity, if appropriate If target blood pressure is not reached with 3–6 months of lifestyle intervention, pharmacologic treatment should be initiated (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S40. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S40.

Pharmacologic treatment of 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 Initiate treatment as soon as diagnosis is confirmed (E) Recommendations for the care of children and adolescents with hypertension are summarized in three slides Slide 2 of 3 Pharmacologic treatment of 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) should be initiated as soon as the diagnosis is confirmed (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S40. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S40.

ACE inhibitors Consider for initial treatment of hypertension, following appropriate reproductive counseling due to potential teratogenic effects (E) Goal of treatment Blood pressure consistently <130/80 mmHg or below the 90th percentile for age, sex, and height, whichever is lower (E) Recommendations for the care of children and adolescents with hypertension are summarized in three slides Slide 3 of 3 ACE inhibitors should be considered for the initial treatment of hypertension (E) The goal of treatment is a blood pressure consistently 130/80 mmHg or below the 90th percentile for age, sex, and height, whichever is lower (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S40. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;34(suppl 1):S40.

Recommendations: Pediatric Dyslipidemia (Type 1 Diabetes) (1)
Screening (1) If family history of hypercholesterolemia (total cholesterol >240 mg/dL) or a cardiovascular event before age 55 years, or if family history is unknown Perform fasting lipid profile on children >2 years of age soon after diagnosis (after glucose control has been established) People diagnosed with type 1 diabetes in childhood have a high risk of early subclinical1-3 and clinical4 CVD Recommendations for the screening and treatment of children and adolescents with type 1 diabetes for dyslipidemia are summarized in four slides5 Slide 1 of 4 If there is a family history of hypercholesterolemia (total cholesterol 240 mg/dl) or a cardiovascular event before age 55 years, or if family history is unknown, then a fasting lipid profile should be performed on children 2 years of age soon after diagnosis (after glucose control has been established) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S40-S41. References Krantz JS, Mack WJ, Hodis HN, Liu CR, Liu CH, Kaufman FR. Early onset of subclinical atherosclerosis in young persons with type 1 diabetes. J Pediatr 2004;145: Järvisalo MJ, Putto-Laurila A, Jartti L, et al. Carotid artery intima-media thickness in children with type 1 diabetes. Diabetes 2002;51: Haller MJ, Samyn M, Nichols WW, et al. Radial artery tonometry demonstrates arterial stiffness in children with type 1 diabetes. Diabetes Care 2004;27: Orchard TJ, Forrest KY, Kuller LH, Becker DJ, for the Pittsburgh Epidemiology of Diabetes Complications Study. Lipid and blood pressure treatment goals for type 1 diabetes: 10-year incidence data from the Pittsburgh Epidemiology of Diabetes Complications Study. Diabetes Care 2001;24: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S40-S41.

Screening (2) If family history is not of concern Consider first lipid screening at puberty (≥10 years) All children diagnosed with diabetes at or after puberty Perform fasting lipid profile soon after diagnosis (after glucose control has been established) (E) Recommendations for the screening and treatment of children and adolescents with type 1 diabetes for dyslipidemia are summarized in four slides Slide 2 of 4 If family history is not of concern, then the first lipid screening should be performed at puberty (10 years) All children diagnosed with diabetes at or after puberty should have a fasting lipid profile performed soon after diagnosis (after glucose control has been established) (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S41. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S41.

Screening (3) For both age-groups, if lipids are abnormal Annual monitoring is recommended If LDL cholesterol values are within accepted risk levels (<100 mg/dL [2.6 mmol/L]) Repeat lipid profile every 5 years (E) Recommendations for the screening and treatment of children and adolescents with type 1 diabetes for dyslipidemia are summarized in four slides Slide 3 of 4 For both age-groups, if lipids are abnormal, annual monitoring is recommended If LDL cholesterol values are within the accepted risk levels (100 mg/dl [2.6 mmol/l]), a lipid profile should be repeated every 5 years (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S41. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S41.

Treatment Initial therapy: optimize glucose control, MNT using Step II AHA diet aimed at decreasing dietary saturated fat (E) > age 10 years, statin reasonable in those (after MNT and lifestyle changes) with LDL cholesterol >160 mg/dL (4.1 mmol/L) or LDL cholesterol >130 mg/dL (3.4 mmol/L) and one or more CVD risk factors (E) Goal: LDL cholesterol <100 mg/dL (2.6 mmol/L) (E) Recommendations for the screening and treatment of children and adolescents with type 1 diabetes for dyslipidemia are summarized in four slides Slide 4 of 4 Initial therapy should consist of optimization of glucose control and MNT using a Step II AHA diet aimed at a decrease in the amount of saturated fat in the diet (E) After the age of 10 years, the addition of a statin is recommended in patients who, after MNT and lifestyle changes, have LDL cholesterol 160 mg/dl (4.1 mmol/l) or LDL cholesterol 130 mg/dl (3.4 mmol/l) and one or more CVD risk factors (E) The goal of therapy is an LDL cholesterol value 100 mg/dl (2.6 mmol/l) (E) MNT=medical nutrition therapy ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S41. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S41.

Recommendations: Pediatric Retinopathy (Type 1 Diabetes)
First ophthalmologic examination Obtain once child is 10 years of age; has had diabetes for 3–5 years (E) After initial examination Annual routine follow-up generally recommended Less frequent examinations may be acceptable on advice of an eye care professional (E) Although retinopathy most commonly occurs after the onset of puberty and after 5–10 years of diabetes duration,1 it has been reported in prepubertal children and with diabetes duration of only 1–2 years Referrals should be made to eye care professionals with expertise in diabetic retinopathy, an understanding of the risk for retinopathy in the pediatric population, and experience in counseling the pediatric patient and family on the importance of early prevention/intervention Recommendations for those with type 1 diabetes and pediatric retinopathy2 are summarized on this slide The first ophthalmologic examination should be obtained once the child is 10 years of age and has had diabetes for 3-5 years (E) After the initial examination, annual routine follow-up is generally recommended; less frequent examinations may be acceptable on the advice of an eye care professional (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S41. References Cho YH, Craig ME, Hing S, Gallego PH, Poon M, Chan A, Donaghue KC: Microvascular complications assessment in adolescents with 2- to 5-yr duration of type 1 diabetes from 1990 to Pediatr Diabetes 24 March 2011 [Epub ahead of print]. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;34(suppl 1):S41.

Recommendations: Pediatric Celiac Disease (Type 1 Diabetes) (1)
Children with type 1 diabetes Screen for celiac disease by measuring tissue transglutaminase or antiendomysial antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes (E) Repeat testing in children with Growth failure Failure to gain weight, weight loss Diarrhea, flatulence, abdominal pain, or signs of malabsorption Frequent unexplained hypoglycemia or deterioration in glycemic control (E) Celiac disease is an immune-mediated disorder that occurs with increased frequency in patients with type 1 diabetes (1–16% of individuals compared with 0.3–1% in the general population)1,2 Symptoms of celiac disease include diarrhea, weight loss or poor weight gain, growth failure, abdominal pain, chronic fatigue, malnutrition due to malabsorption, other gastrointestinal problems, and unexplained hypoglycemia or erratic blood glucose concentrations3 Screening for celiac disease includes measuring serum levels of tissue transglutaminase or anti-endomysial antibodies, then small bowel biopsy in antibody positive children Recommendations for the care of children with type 1 diabetes and celiac disease are summarized in two slides3 Slide 1 of 2 Children with type 1 diabetes should be screened for celiac disease by measuring tissue transglutaminase or anti-endomysial antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes (E) Testing should be repeated in children with 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 (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S41. References Holmes GK. Screening for coeliac disease in type 1 diabetes. Arch Dis Child 2002;87: Rewers M, Liu E, Simmons J, Redondo MJ, Hoffenberg EJ: Celiac disease associated with type 1 diabetes mellitus. Endocrinol Metab Clin North Am 2004;33:197–214, xi. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 20121;35(suppl 1):S41.

Recommendations: Pediatric Celiac Disease (Type 1 Diabetes) (2)
Children with positive antibodies Refer to a gastroenterologist for evaluation with endoscopy and biopsy (E) Children with biopsy-confirmed celiac disease Place on a gluten-free diet Consult with a dietitian experienced in managing both diabetes and celiac disease (E) Recommendations for the care of children with type 1 diabetes and celiac disease are summarized in two slides Slide 2 of 2 Children with positive antibodies should be referred to a gastroenterologist for evaluation with endoscopy and biopsy (E) 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 (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S41. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S41.

Recommendations: Pediatric Hypothyroidism (Type 1 Diabetes)
Children with type 1 diabetes Screen for thyroid peroxidase, thyroglobulin antibodies at diagnosis (E) Thyroid-stimulating hormone (TSH) concentrations Measure after metabolic control established If normal, recheck every 1-2 years; or If patient develops symptoms of thyroid dysfunction, thyromegaly, or an abnormal growth rate Autoimmune thyroid disease is the most common autoimmune disorder associated with diabetes, occurring in 17-30% of patients with type 1 diabetes1 About one-quarter of children with type 1 diabetes have thyroid autoantibodies at the time of diagnosis;2 presence of these autoantibodies is predictive of thyroid dysfunction, generally hypothyroidism but less commonly hyperthyroidism3 Subclinical hypothyroidism may be associated with increased risk of symptomatic hypoglycemia4 and with reduced linear growth5 Hyperthyroidism alters glucose metabolism, potentially resulting in deterioration of metabolic control6 Children with type 1 diabetes should be screened for thyroid peroxidase and thyroglobulin antibodies at diagnosis (E) TSH concentrations should be measured after metabolic control has been established. If normal, they should be re-checked every 1–2 years, or if the patient develops symptoms of thyroid dysfunction, thyromegaly, or an abnormal growth rate (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S41. References Roldán MB, Alonso M, Barrio R. Thyroid autoimmunity in children and adolescents with Type 1 diabetes mellitus. Diabetes Nutr Metab 1999;12:27–31. Triolo TM, Armstrong TK, McFann K, et al. Additional autoimmune disease found in 33% of patients at type 1 diabetes onset. Diabetes Care 2011;34: Kordonouri O, Deiss D, Danne T, Dorow A, Bassir C, Gruüters-Kieslich A. Predictivity of thyroid autoantibodies for the development of thyroid disorders in children and adolescents with Type 1 diabetes. Diabet Med 2002;19: Mohn A, Di Michele S, Di Luzio R, Tumini S, Chiarelli F. The effect of subclinical hypothyroidism on metabolic control in children and adolescents with Type 1 diabetes mellitus. Diabet Med 2002;19:70-73. Chase HP, Garg SK, Cockerham RS, Wilcox WD, Walravens PA. Thyroid hormone replacement and growth of children with subclinical hypothyroidism and diabetes. Diabet Med 1990;7: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S41.

Recommendations: Transition from Pediatric to Adult Care
As teens transition into emerging adulthood, health care providers and families must recognize their many vulnerabilities (B) and prepare the developing teen, beginning in early to mid adolescence and at least 1 year prior to the transition (E) Both pediatricians and adult health care providers should assist in providing support and links to resources for the teen and emerging adult (B) Care and close supervision of diabetes management is increasingly shifted from parents and other older adults throughout childhood and adolescence; however, the shift from pediatric to adult health care providers often occurs very abruptly as the older teen enters the next developmental stage, referred to as emerging adulthood, a critical period for young people who have diabetes Though scientific evidence continues to be limited, it is clear that early and ongoing attention be given to comprehensive coordinated planning for seamless transition of all youth from pediatric to adult health care1,2 A comprehensive discussion regarding the challenges faced during this period, including specific recommendations is found in the ADA position statement “Diabetes Care for Emerging Adults: Recommendations for the Transition from Pediatric to Adult Diabetes Care Systems”2 The National Diabetes Education Program (NDEP) has materials available to facilitate the transition process ( This slide includes recommendations for transitioning teens with diabetes into adulthood3 ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S42. References Weissberg-Benchell J, Wolpert H, Anderson BJ. Transitioning from pediatric to adult care: a new approach to the post-adolescent young person with type 1 diabetes. Diabetes Care 2007;30: American Diabetes Association. Transition in care from youth to adulthood. Diabetes Care 2011;34: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S42.

Recommendations: Preconception Care (1)
A1C levels should be as close to normal as possible (7%) in an individual patient before conception is attempted (B) Starting at puberty, incorporate preconception counseling in routine diabetes clinic visit for all women of childbearing potential (C) Women with diabetes contemplating pregnancy should be evaluated and, if indicated, treated for diabetic retinopathy, nephropathy, CVD (B) Major congenital malformations remain the leading cause of mortality and serious morbidity in infants of mothers with type 1 and type 2 diabetes Observational studies indicate that the risk of malformations increases continuously with increasing maternal glycemia during the first 6–8 weeks of gestation, as defined by first-trimester A1C concentrations There is no threshold for A1C values below which risk disappears entirely; however, malformation rates above the 1–2% background rate of nondiabetic pregnancies appear to be limited to pregnancies in which first-trimester A1C concentrations are >1% above the normal range for a nondiabetic pregnant woman Preconception care of diabetes appears to reduce the risk of congenital malformations Recommendations for the preconception care of women with diabetes are summarized in two slides Slide 1 of 2 A1C levels should be as close to normal as possible (7%) in an individual patient before conception is attempted (B) Starting at puberty, preconception counseling should be incorporated in the routine diabetes clinic visit for all women of child-bearing potential (C) Women with diabetes who are contemplating pregnancy should be evaluated and, if indicated, treated for diabetic retinopathy, nephropathy, neuropathy, and CVD (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S42. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S42.

Recommendations: Preconception Care (2)
Medications should be evaluated prior to conception, since drugs commonly used to treat diabetes and its complications may be contraindicated or not recommended in pregnancy, including statins, ACE inhibitors, ARBs, and most noninsulin therapies (E) Since many pregnancies are unplanned, consider potential risks/benefits of medications contraindicated in pregnancy in all women of childbearing potential; counsel accordingly (E) Recommendations for the preconception care of women with diabetes are summarized in two slides Slide 2 of 2 Medications used by such women should be evaluated prior to conception, since drugs commonly used to treat diabetes and its complications may be contraindicated or not recommended in pregnancy, including statins, ACE inhibitors, ARBs, and most noninsulin therapies (E) Since many pregnancies are unplanned, consider the potential risks and benefits of medications that are contraindicated in pregnancy in all women of childbearing potential, and counsel women using such medications accordingly (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S42. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S42.

Recommendations: Older Adults (1)
Functional, cognitively intact older adults with significant life expectancies should receive diabetes care using goals developed for younger adults (E) Glycemic goals for those not meeting the above criteria may be relaxed using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients (E) Diabetes is an important health condition for the aging population; at least 20% of patients over the age of 65 years have diabetes, and this number can be expected to grow rapidly in the coming decades Older individuals with diabetes have higher rates of premature death, functional disability, and coexisting illnesses such as hypertension, CHD, and stroke than those without diabetes Older adults with diabetes are also at greater risk than other older adults for several common geriatric syndromes, such as polypharmacy, depression, cognitive impairment, urinary incontinence, injurious falls, and persistent pain The American Geriatric Society’s guidelines for improving the care of the older person with diabetes1 have influenced these recommendations Recommendations for the care of diabetes in older adults2 are summarized in two slides Slide 1 of 2 Older adults who are functional, are cognitively intact, and have significant life expectancy should receive diabetes care using goals developed for younger adults (E) Glycemic goals for older adults not meeting the above criteria may be related using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoid in all patients (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S43. References Brown AF, Mangione CM, Saliba D, Sarkisian CA; California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc 2003;51 (Suppl Guidelines):S265-S280. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S43.

Recommendations: Older Adults (2)
Treat other cardiovascular risk factors with consideration of the time frame of benefit and the individual patient Treatment of hypertension is indicated in virtually all older adults; lipid, aspirin therapy may benefit those with life expectancy equal to time frame of primary/secondary prevention trials (E) Individualize screening for diabetes complications with attention to those leading to functional impairment (E) Recommendations for the care of diabetes in older adults are summarized in two slides Slide 2 of 2 Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient Treatment of hypertension is indicated in virtually all older adults and lipid and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials (E) Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S43. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S43.

Recommendations: Cystic Fibrosis-Related Diabetes (CFRD)
Annual screening for CFRD with OGTT should begin by age 10 years in all patients with cystic fibrosis who do not have CFRD (B) Use of A1C as a screening test for CFRD is not recommended (B) During a period of stable health, diagnosis of CFRD can be made in patients with cystic fibrosis according to usual diagnostic criteria (E) Cystic fibrosis-related diabetes is the most common comorbidity in persons with cystic fibrosis, occurring in about 20% of adolescents and 40–50% of adults The additional diagnosis of diabetes in this population is associated with worse nutritional status, more severe inflammatory lung disease, and greater mortality from respiratory failure Insulin insufficiency related to partial fibrotic destruction of the islet mass is the primary defect in CFRD; genetically determined function of the remaining b-cells and insulin resistance associated with infection and inflammation may also play a role Recommendations for the care of patients with cystic-fibrosis-related diabetes (CFRD) are summarized in two slides Slide 1 of 2 Annual screening for CFRD with OGTT should begin by age 10 years in all patients with cystic fibrosis who do not have CFRD (B) Use of A1C as a screening test for CFRD is not recommended (B) During a period of stable health, diagnosis of CFRD can be made in patients with cystic fibrosis according to usual diagnostic criteria ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S44. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S44.

Recommendations: Cystic Fibrosis-Related Diabetes (CFRD)
Patients with CFRD should be treated with insulin to attain individualized glycemic goals (A) Annual monitoring for complications of diabetes is recommended, beginning 5 years after the diagnosis of CFRD (E) Encouraging new data suggest early detection and aggressive insulin therapy have narrowed the gap in mortality between cystic fibrosis patients with and without diabetes, and have eliminated the difference in mortality between the sexes1 Recommendations for the clinical management of CFRD can be found in a recent ADA position statement on this topic2 Recommendations for the care of patients with cystic-fibrosis-related diabetes (CFRD)3 are summarized in two slides Slide 2 of 2 Patients with CFRD should be treated with insulin to attain individualized glycemic goals (A) Annual monitoring for complications of diabetes is recommended, beginning 5 years after the diagnosis of CFRD (E) ADA. VIII. Diabetes Care in Specific Populations. Diabetes Care. 2012;35(suppl 1):S44. References Moran A, Dunitz J, Nathan B, Saeed A, Holme B, Thomas W. Cystic fibrosis related diabetes: current trends in prevalence, incidence, and mortality. Diabetes Care 2009;32: Moran A, Brunzell C, Cohen RC, et al.; CFRD Guidelines Committee. Clinical care guidelines for cystic fibrosis-related diabetes: a position statement of the American Diabetes Association and a clinical practice guideline of the Cystic Fibrosis Foundation, endorsed by the Pediatric Endocrine Society. Diabetes Care 2010;33: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S44.

IX. diabetes care in specific settings
Section IX. Diabetes Care in Specific Settings includes seven slides: Recommendations: Diabetes Care in the Hospital (5 slides) Diabetes Care in the Hospital: NICE-SUGAR (2 slides) IX. diabetes care in specific settings

Recommendations: Diabetes Care in the Hospital (1)
All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record (E) All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team (E) Hyperglycemia in the hospital can represent previously known diabetes, previously undiagnosed diabetes, or hospital-related hyperglycemia (fasting blood glucose ≥126 mg/dL or random blood glucose ≥200 mg/dL occurring during the hospitalization that reverts to normal after hospital discharge) Hyperglycemia in the hospital is extensively reviewed in an ADA technical review1 An updated consensus statement by the American Association of Clinical Endocrinologists (AACE) and ADA2 forms the basis for the information in this section The management of hyperglycemia in the hospital has often been considered secondary in importance to the condition that prompted admission1 However, a body of literature now supports targeted glucose control in the hospital setting for potential improved clinical outcomes Recommendations for the care of patients with diabetes who are admitted to the hospital3 are summarized on six slides Slide 1 of 6 As noted on this slide, patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record (E) and an order for blood glucose monitoring, with results available to all members of the health care team (E) ADA. IX. Diabetes Care in Specific Settings. Diabetes Care. 2012;35(suppl 1):S44. References Clement S, Braithwaite SS, Magee MF, et al.; American Diabetes Association; Diabetes in Hospitals Writing Committee. Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004;27: Moghissi ES, Korytkowski MT, DiNardo M, et al.; American Association of Clinical Endocrinologists; American Diabetes Association. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009;32: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S44.

Goals for blood glucose levels Critically ill patients: mg/dL (7.8–10 mmol/L) (A) More stringent goals, such as mg/dL (6.1–7.8 mmol/L) may be appropriate for selected patients, if achievable without significant hypoglycemia (C) Critically ill patients require an IV insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia (E) Recommendations for the care of patients with diabetes who are admitted to the hospital are summarized on six slides Slide 2 of 6 Goals for blood glucose levels for critically ill patients are as follows: Critically Ill Patients Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of no greater than 180 mg/dL (10 mmol/L) Once insulin therapy is started, a glucose range of mg/dL ( mmol/L) is recommended for the majority of critically ill patients (A) More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia (C) Critically ill patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia (E) ADA. IX. Diabetes Care in Specific Settings. Diabetes Care. 2012;35(suppl 1):S44. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S44.

Goals for blood glucose levels Noncritically ill patients: No clear evidence for specific blood glucose goals If treated with insulin, premeal blood glucose targets (if safely achieved) Generally <140 mg/dL (7.8 mmol/L) with random blood glucose <180 mg/dL (10.0 mmol/L) More stringent targets may be appropriate in stable patients with previous tight glycemic control Less stringent targets may be appropriate in those with severe comorbidities (E) Recommendations for the care of patients with diabetes who are admitted to the hospital are summarized on six slides Slide 3 of 6 Goals for blood glucose levels for noncritically ill patients are as follows: Non-Critically Ill Patients There is no clear evidence for specific blood glucose goals If treated with insulin, premeal blood glucose target should generally be <140 mg/dL (7.8 mmol/L) with random blood glucose <180 mg/dL (10.0 mmol/L), provided these targets can be safely achieved More stringent targets may be appropriate in stable patients with previous tight glycemic control Less stringent targets may be appropriate in those with severe comorbidites (E) ADA. IX. Diabetes Care in Specific Settings. Diabetes Care. 2012;35(suppl 1):S44. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S44.

Scheduled subcutaneous insulin with basal, nutritional, and correction components is the preferred method for achieving and maintaining glucose control in noncritically ill patients Recommendations for the care of patients with diabetes who are admitted to the hospital are summarized on six slides Slide 4 of 6 Scheduled subcutaneous insulin with basal, nutritional, and correction components is the preferred method for achieving and maintaining glucose control in non-critically ill patients ADA. IX. Diabetes Care in Specific Settings. Diabetes Care. 2012;35(suppl 1):S44. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S44.

Initiate glucose monitoring in any patient not known to be diabetic who receives therapy associated with high-risk for hyperglycemia High-dose glucocorticoid therapy, initiation of enteral or parenteral nutrition, or other medications such as octreotide or immunosuppressive medications (B) If hyperglycemia is documented and persistent, consider treating such patients to the same glycemic goals as patients with known diabetes (E) Recommendations for the care of patients with diabetes who are admitted to the hospital are summarized on six slides Slide 5 of 6 Glucose monitoring should be initiated in any patient not known to be diabetic who receives therapy associated with high risk for hyperglycemia, including high-dose glucocorticoid therapy, initiation of enteral or parenteral nutrition, or other medications such as octreotide or immunosuppressive medications (B) If hyperglycemia is documented and persistent, treatment is necessary; such patients should be treated to the same glycemic goals as patients with known diabetes (E) ADA. IX. Diabetes Care in Specific Settings. Diabetes Care. 2012;35(suppl 1):S44. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S44.

A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system Establish a plan for treating hypoglycemia for each patient; document episodes of hypoglycemia in medical record and track (E) Obtain A1C for all patients if results within previous 2–3 months unavailable (E) Patients with hyperglycemia without a diagnosis of diabetes: document plans for follow-up testing and care at discharge (E) Recommendations for the care of patients with diabetes who are admitted to the hospital are summarized on six slides Slide 6 of 6 A plan for treating hypoglycemia should be established for each patient; episodes of hypoglycemia in the hospital should be tracked (E) All patients with diabetes admitted to the hospital should have an A1C obtained if the result of testing in the previous 2-3 months is not available (E) Patients with hyperglycemia in the hospital who do not have a diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge (E) ADA. IX. Diabetes Care in Specific Settings. Diabetes Care. 2012;35(suppl 1):S44. Reference American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S44.

Diabetes Care in the Hospital: NICE-SUGAR Study (1)
Largest randomized controlled trial to date Tested effect of tight glycemic control (target 81–108 mg/dL) on outcomes among 6,104 critically ill participants Majority (>95%) required mechanical ventilation Results of the NICE-SUGAR study1,2 are summarized on two slides Slide 1 of 2 Hyperglycemia in the hospital may result from stress; decompensation of type 1, type 2, or other forms of diabetes; and/or may be iatrogenic due to withholding of antihyperglycemic medications of administration of hyperglycemia-provoking agents such as glucocorticoids or vasopressors There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes The largest study to date, NICE-SUGAR, a multicenter, multinational randomized controlled trial, compared the effect of intensive glycemic control (target 81–108 mg/dL, mean blood glucose attained 115 mg/dL) to standard glycemic control (target 144– 180 mg/dL, mean blood glucose attained 144 mg/dL) on outcomes among 6,104 critically ill participants, almost all of whom required mechanical ventilation2 ADA. IX. Diabetes Care in Specific Settings. Diabetes Care. 2012;35(suppl 1):S45. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S45. Finfer S, Chittock Dr, Su SY, et al for the NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:

Diabetes Care in the Hospital: NICE-SUGAR Study (2)
In both surgical/medical patients, 90-day mortality significantly higher in intensively treated vs conventional group (target 144–180 mg/dL) 78 more deaths (27.5% vs 24.9%; P=0.02) 76 more deaths from cardiovascular causes (41.6% vs 35.8%; P=0.02) Severe hypoglycemia more common (6.8% vs 0.5%; P<0.001) Results of the NICE-SUGAR study1,2 are summarized on two slides Slide 2 of 2 Ninety-day mortality was significantly higher in the intensive versus the conventional group in both surgical and medical patients, as was mortality from cardiovascular causes Severe hypoglycemia was also more common in the intensively treated group (6.8% vs 0.5%; P <0.001); the precise reason for the increased mortality in the tightly controlled group is unknown In a recent meta-analysis of 26 trials (N=13,567) that included the NICE-SUGAR data, the pooled relative risk (RR) of death with intensive insulin therapy was 0.93 vs conventional therapy (95% CI 0.83–1.04)3 Approximately half of these trials reported hypoglycemia, with a pooled RR of intensive therapy of 6.0 (95% CI 4.5–8.0) The specific ICU setting influenced the findings; patients in surgical ICUs appearing to benefit from intensive insulin therapy (RR 0.63, 95% CI 0.44–0.91), while those in other medical and mixed critical care settings did not Overall, intensive insulin therapy appeared to increase risk of hypoglycemia but provided no overall benefit on mortality in the critically ill, although a possible mortality benefit to patients admitted to the surgical ICU was suggested ADA. IX. Diabetes Care in Specific Settings. Diabetes Care. 2012;35(suppl 1):S45. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S45. Finfer S, Chittock Dr, Su SY, et al for the NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360: Griesdale DE, de Souza RJ, van Dam RM, et al. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ 2009;180:821–827.

x. Strategies for improving diabetes care
Section X. Strategies for Improving Diabetes Care includes five slides: Recommendations: Strategies for Improving Diabetes Care (two slides) Objective 1: Optimize Provider and Team Behavior Objective 2: Support Patient Behavior Change Objective 3: Change the System of Care x. Strategies for improving diabetes care

Recommendations: Strategies for Improving Diabetes Care (1)
Care should be aligned with components of the Chronic Care Model to ensure productive interactions between a prepared proactive practice team and an informed activated patient (A) When feasible, care systems should support team-based care, community involvement, patient registries, and embedded decision support tools to meet patient needs (B) Recommendations: Strategies for Improving Care1 are summarized on two slides Slide 1 of 2 The Chronic Care Model (CCM) has been shown in numerous studies to be an effective framework for improving the quality of diabetes care2 The CCM includes six core elements for the provision of optimal care of patients with chronic disease 1) delivery system design (moving from a reactive to a proactive care delivery system where planned visits are coordinated through a team based approach) 2) self-management support 3) decision support (basing care on evidence-based, effective care guidelines) 4) clinical information systems (using registries that can provide patient-specific and population-based support to the care team) 5) community resources and policies (identifying or developing resources to support healthy lifestyles) 6) health systems (to create a quality-oriented culture) Redefinition of the roles of the clinic staff and promoting self-management on the part of the patient are fundamental to the successful implementation of the CCM3 ADA. X. Strategies for Improving Diabetes Care. Diabetes Care. 2012;35(suppl 1):S48. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S48. The Chronic Care Model: Improving Chronic Illness Care Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood) 2009;28:75-85.

Recommendations: Strategies for Improving Diabetes Care (2)
Treatment decisions should be timely and based on evidence-based guidelines that are tailored to individual patient preferences, prognoses, and comorbidities (B) A patient-centered communication style should be employed that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care (B) Recommendations: Strategies for Improving Care1 are summarized on two slides Slide 2 of 2 In addition to timely treatment decisions that adhere to evidence-based guidelines, such treatment should be tailored to individual patient preferences, prognoses, and comorbidities A patient-centered communication style should be used that incorporates patient preferences, assesses literary and numeracy, and addresses any cultural barriers to care ADA. X. Strategies for Improving Diabetes Care. Diabetes Care. 2012;35(suppl 1):S48. Reference 1. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S48.

Objective 1: Optimize Provider and Team Behavior
Care team should prioritize timely, appropriate intensification of lifestyle and/or pharmaceutical therapy Patients who have not achieved beneficial levels of blood pressure, lipid, or glucose control Strategies include Explicit goal setting with patients Identifying and addressing barriers to care Integrating evidence-based guidelines Incorporating care management teams NDEP maintains an online resource ( to help health care professionals design and implement more effective health care delivery systems for those with diabetes Three specific objectives that outline practical strategies to achieve each are included on this and the next two slides Objective 1 Optimize provider and team behavior: the care team should prioritize timely and appropriate intensification of lifestyle and/or pharmaceutical therapy of patients who have not achieved beneficial levels of blood pressure, lipid, or glucose control1 As outlined on this slide, the following strategies each have been shown to optimize provider and team behavior and thereby catalyze reduction in A1C, blood pressure, and LDL cholesterol2 Explicit goal setting with patients Identifying and addressing language, numeracy, or cultural barriers to care Integrating evidence-based guidelines and clinical information tools into the process of care; and Incorporating care management teams including nurses, pharmacists, and other providers ADA. X. Strategies for Improving Diabetes Care. Diabetes Care. 2012;35(suppl 1):S49. References Davidson MB. How our current medical care system fails people with diabetes: lack of timely, appropriate clinical decisions. Diabetes Care 2009;32:370–372. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S49.

Objective 2: Support Patient Behavior Change
Implement a systematic approach to support patient behavior change efforts a) Healthy lifestyle: physical activity, healthy eating, nonuse of tobacco, weight management, effective coping b) Disease self-management: medication taking and management, self-monitoring of glucose and blood pressure when clinically appropriate c) Prevention of diabetes complications: self-monitoring of foot health, active participation in screening for eye, foot, and renal complications, and immunizations Objective 2 In addition to the approaches on this slide1, support for patient behavior change includes: Delivery of high-quality DSME, which has been shown to improve patient self-management, satisfaction, and glucose control2,3 Delivery of ongoing diabetes self-management support (DSMS) to ensure that gains achieved during DSME are sustained4-6 National DSME standards call for an integrated approach that includes clinical content and skills and behavioral strategies (goal-setting, problem solving), and addresses emotional concerns in each needed curriculum content area ADA. X. Strategies for Improving Diabetes Care. Diabetes Care. 2012;35(suppl 1):S49. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S49. Duncan I, Birkmeyer C, Coughlin S, Li QE, Sherr D, Boren S. Assessing the value of diabetes education. Diabetes Educ 2009;35:752–760. Berikai P, Meyer PM, Kazlauskaite R, Savoy B, Kozik K, Fogelfeld L. Gain in patients’ knowledge of diabetes management targets is associated with better glycemic control. Diabetes Care 2007;30: Klein S, Sheard NF, Pi-Sunyer X, et al.; American Diabetes Association; North American Association for the Study of Obesity; American Society for Clinical Nutrition. Weight management through lifestyle modification for the prevention and management of type 2 diabetes: rationale and strategies: a statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition. Diabetes Care 2004;27: Norris SL, Zhang X, Avenell A, et al. Efficacy of pharmacotherapy for weight loss in adults with type 2 diabetes mellitus: a meta-analysis. Arch Intern Med 2004;164: Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes Care 2007;30:1630–1637.

Objective 3: Change the System of Care
The most successful practices have an institutional priority for providing high quality of care Basing care on evidence-based guidelines Expanding the role of teams and staff Redesigning the processes of care Implementing electronic health record tools Activating and educating patients Identifying and/or developing community resources and public policy that supports healthy lifestyles Alterations in reimbursement Objective 3 Change the system of care: additional strategies are outlined on this slide1 The most successful practices have an institutional priority for providing high quality of care2 Recent initiatives such as the Patient Centered Medical Home show promise to improve outcomes through coordinated primary care and offer new opportunities for team-based chronic disease care3 Alterations in reimbursement that reward the provision of appropriate and high quality care rather than visit-based billing,4 and that can accommodate the need to personalize care goals, may provide additional incentives to improve diabetes care5 It is clear that optimal diabetes management requires an organized, systematic approach and involvement of a coordinated team of dedicated health care professionals working in an environment where patient-centered high quality care is a priority ADA. X. Strategies for Improving Diabetes Care. Diabetes Care. 2012;35(suppl 1):S49. References American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(suppl 1):S49. Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA 2006;296: Bojadzievski T, Gabbay RA. Patient centered medical home and diabetes. Diabetes Care 2011;34: Rosenthal MB, Cutler DM, Feder J. The ACO rules—striking the balance between participation and transformative potential. N Engl J Med 2011;365:e6. Washington AE, Lipstein SH: The Patient-Centered Outcomes Research Institute: Promoting better information, decisions, and health. N Engl J Med 2011;365:e31.

Standards of Medical Care in Diabetes—2012

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