1. Standards of Care in Diabetes 2016--What's New?
Veronica Brady, FNP-BC, PhD, BC-ADM,CDE
Karmella Thomas, RD, LD,CDE

3. Terminology No longer using the term “diabetic.”
Diabetes does not define people.
People with diabetes are individuals with diabetes, not “diabetics.”
“Diabetic” will continue to be used related to complications, e.g., “diabetic retinopathy.”
The Association made one point of clarification this year which we hope clinicians, advocates, journalists, and the general public will adopt:
In alignment with our longstanding informal policy Association-wide, the Standards of Care will no longer use the term “diabetic” to refer to patients with diabetes. This decision is in alignment with the American Diabetes Association’s position that diabetes does not define people.
Those with diabetes are individuals with diabetes, not “diabetics.”
ADA will continue to use the term “diabetic” as an adjective for complications related to diabetes (e.g., diabetic retinopathy).
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Introduction. Diabetes Care 2016; 39 (Suppl. 1): S1-S2 3

4. Strategies for Improving Care
Section 1.
Strategies for Improving Care
Therapy must be tailored for patients with:
Food insecurity-lack of funds to afford appropriate food
Cognitive dysfunction-special consideration
HIV- screen for DM prior to starting therapy and annually

5. Cognitive Dysfunction
Intensive glucose control is not advised for the improvement of poor cognitive function in hyperglycemic individuals with T2DM.
In individuals with poor cognitive function or severe hypoglycemia, glycemic therapy should be tailored to avoid significant hypoglycemia.
Specific to your patients with cognitive dysfunction, the most common form of which is dementia, including Alzheimer’s, the Association offers four recommendations:
First, intensive glucose control is not advised for the improvement of poor cognitive function in hyperglycemic individuals with type 2 diabetes, [CLICK]
Second, in individuals with poor cognitive function or severe hypoglycemia, glycemic therapy should be tailored to avoid significant hypoglycemia.
[SLIDE[
American Diabetes Association Standards of Medical Care in Diabetes. Strategies for improving diabetes care. Diabetes Care 2016; 39 (Suppl. 1): S6-S12 5

6. Cognitive Dysfunction
In individuals with diabetes at high CVD risk, the cardiovascular benefits of statin therapy outweigh the risk of cognitive dysfunction.
If a second-generation antipsychotic medication is prescribed, changes in weight, glycemic control, and cholesterol levels, should be carefully monitored and the treatment regimen reassessed.
In individuals with diabetes at high cardiovascular risk, the cardiovascular benefits of statin therapy outweigh the risk of cognitive dysfunction [CLICK]
And, finally, if a second-generation antipsychotic medication is prescribed, changes in weight, glycemic control, and cholesterol levels, should be carefully monitored and the treatment regimen reassessed.
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Strategies for improving diabetes care. Diabetes Care 2016; 39 (Suppl. 1): S6-S12 6

7. Section 2. Classification and Diagnosis of Diabetes
None of the test used for diagnosis are preferred over the other.
All persons over age of 45 should be tested regardless of weight.
Adults who are obese with one or more risk factors should be tested regardless of age.

8. Criteria for the Diagnosis of Diabetes
Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) OR
2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT
A1C ≥6.5%
Random plasma glucose ≥200 mg/dL (11.1 mmol/L)
The same tests are used to screen for and diagnose diabetes and to detect people with prediabetes. These include:
Fasting plasma glucose (FPG) ≥126 mg/dL OR
2-hour plasma glucose ≥200 mg/dL during an OGTT
A1C ≥6.5%
Or in a patient with classic symptoms of hyperglycemia a random plasma glucose ≥ 200 can also be used.
The subsequent slides examine each of the criteria in greater detail.
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S15; Table 2 8

9. POC testing not recommended
A1C ≥6.5% *
Performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay –
POC testing not recommended
Greater convenience, preanalytical stability, and less day-to-day perturbations than FPG and OGTT
Consider cost, age, race/ethnicity, anemia, etc.
One way to combat both of those issues is with the A1C.
This 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 assay [CLICK]
Although point-of-care (POC) assays may be NGSP-certified, proficiency testing is not mandated for performing the test, so use of these assays for diagnostic purposes may be problematic [CLICK]
The A1C has several advantages to the FPG and OGTT, including greater convenience (fasting not required), possibly greater preanalytical stability, and less day-to-day perturbations during periods of stress and illness [CLICK]
But, 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
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
References
International Expert Committee: International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009;32:1327–1334
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S15; 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;152:770–777
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;95:2832–2835 9

10. Self Management Education Nutrition Counseling Physical Activity
Foundations of Care
Self Management Education
Nutrition
Counseling
Physical Activity
Smoking Cessation
Immunizations
Psychosocial Care
Medications
The foundations of care include eight key components: Self-management education, nutrition, counseling, physical activity, smoking cessation, immunizations, psychosocial care, and medications, which are covered in other chapters.
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35 10

11. Recommendations: Physical Activity
Children with diabetes/pre-diabetes: at least 60 min/day physical activity
Adults with diabetes: at least 150 min/wk of moderate- intensity aerobic activity over at least 3 days/week with no more than 2 consecutive days without exercise
All individuals, including those with diabetes, should reduce sedentary time, particularly by breaking up extended amounts of time (>90 min) spent sitting.
Adults with type 2 diabetes should perform resistance training at least twice weekly
Recommendations for physical activity for people with diabetes1 are summarized on this slide
• As with all children, children with diabetes or prediabetes should be encouraged to engage in at least 60 minutes of physical activity each day. [CLICK]
Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (with “moderate” defined as 50–70% of maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise. [CLICK]
All individuals, including those with diabetes, should be encouraged to reduce sedentary time, particularly by breaking up extended amounts of time (>90 min) spent sitting. [CLICK]
And finally, in the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week. [CLICK]
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S31
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;346:393–403
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;344:1343–1350
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;20:537–544
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;33:2692–2696 11

12. Section 4. Prevention or Delay of Type 2 Diabetes
Refer those with pre-diabetes to intensive diet and physical activity behavioral counseling program (lose 7% weight and increase moderate-intensity PA to at least 150 min/week
Follow up counseling and maintenance programs long term
Diabetes prevention programs should be covered by third party payers
Metformin therapy for prevention should be considered in those with pre-diabetes, especially those with BMI greater 35 kg/m2, those less than 60 years and women with prior gestational diabetes mellitus

13. Diet, physical activity, and behavioral therapy ┼
Diabetes Care Vol 39, Supp 1, Jan 2016 Table 6.1—Treatment for overweight and obesity in type 2 diabetes BMI category (kg/m2)
Treatment
23.0* or 25.0–26.9
27.0– 29.9
30.0– 34.9
35.0– 39.9
$40
Diet, physical activity, and behavioral therapy ┼
Pharmacotherapy
Bariatric surgery

14. Section 4. Prevention or Delay of Type 2 Diabetes
Annual monitoring for development of diabetes
Screening for and treatment of modifiable risk factors for CVD
DSME programs are appropriate venues for those with prediabetes to receive education and support
NEW – technology assisted tools including internet based social networks, distance learning, DVD-based content, and mobile applications can be useful for lifestyle modification to prevent diabetes

15. Some supportive apps Myfitnesspal – more specific to calorie counting
American Diabetes Association Standards of Care
Medtronic –Carb Counting with Lenny
AADE Diabetes Goal Tracker
Some are free and others range from $ $9.99

16. Section 5. Glycemic Targets
Methods for assessing glycemic control
SMBG
A1c
*CGM could be useful addition

17. Mean Glucose Levels for Specified A1C Levels
Mean Glucose
Mean Plasma Glucose*
Fasting
Premeal
Postmeal
Bedtime
A1C%
mg/dL
mmol/L 6
126
7.0
<6.5
122
118
144
136
142
139
164
153 7
154
8.6
152
176
177
167
155
189
175 8
183
10.2
8-8.5
178
179
206
222 9
212
11.8 10
240
13.4 11
269
14.9 12
298
16.5
This slide shows the correlation between A1C and mean plasma glucose levels based on data from the international A1C-Derived Average Glucose (ADAG) trial. The trial used frequent SMBG and continuous glucose monitoring in 507 adults with type 1, type 2, and no diabetes.
The Association and the American Association for 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
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 is the case for A1C
[CLICK]
You can access a calculator for converting A1C results into eAG, in either mg/dL or mmol/L, at professional.diabetes.org/eAG
[SLIDE]
professional.diabetes.org/eAG
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
References
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;31:1473–1478
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S23; Table 8 17

18. Approach to the Management of Hyperglycemia
Patient/Disease Features
A1C 7%
more stringent
less stringent
Risks associated with hypoglycemia & other drug adverse effects
low
high
Disease Duration
newly diagnosed
long-standing
Life expectancy
long
short
Important comorbidities
absent
Few/mild
severe
Established vascular complications
This slide, “Approach to Management of Hyperglycemia,” depicts the elements of decision making used to determine appropriate efforts to achieve glycemic targets1 (Adapted with permission from Inzucchi et al.)
You may have seen this before, but in case not we’ll walk through it briefly. Going down the left side you see a series of patient or disease characteristics with a corresponding A1C impact scale on the right. The small end of the triangle aligns with a more stringent A1C and the fatter end aligns with less stringent A1C. So taking the first one, the red triangle, risks associated with hypoglycemia and other drug adverse effects…. Clearly the risks are lower with a more stringent A1C and higher with a less stringent A1C.
These are grouped into two categories, the [CLICK] top set consists of factors that are usually not modifiable and [CLICK] the bottom set may be potentially modifiable.
Where possible, such decisions should be made in conjunction with the patient, reflecting his or her preferences, needs, and values
This “scale” is not designed to be applied rigidly but to be used as a broad construct to help guide clinical decisions
Those with long duration of diabetes, known history of severe hypoglycemia, advanced atherosclerosis, and advanced age/frailty may benefit from less aggressive targets
Providers should be vigilant in preventing severe hypoglycemia in patients with advanced disease and should not aggressively attempt to achieve near-normal A1C levels in patients in whom such targets cannot be safely and reasonably achieved
Severe or frequent hypoglycemia is an absolute indication for the modification of treatment regimens, including setting higher glycemic goals
[SLIDE]
absent
Few/mild
severe
Patient attitude & expected treatment efforts
highly motivated, adherent, excellent self-care capabilities
less motivated, nonadherent, poor self-care capabilities
Resources & support system
readily available
limited
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S25; Figure 1
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;154:554–559 18

19. Glycemic Recommendations for Nonpregnant Adults with Diabetes
A1C
<7.0%* (<53 mmol/mol)
Preprandial capillary plasma glucose
80–130 mg/dL* (4.4–7.2 mmol/L)
Peak postprandial capillary plasma glucose†
<180 mg/dL* (<10.0 mmol/L)
Shown here are the Association’s recommended glycemic goals for many nonpregnant adults.
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%
[SLIDE]
* Goals should be individualized.
† Postprandial glucose measurements should be made 1–2 hours after the beginning of the meal.
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S25–S26; Table 9
American Diabetes Association. Postprandial blood glucose. Diabetes Care 2001;24:775–778
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;106:1211–1218 19

20. Recommendations: Hypoglycemia
Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter.
Glucose (15–20 g) preferred treatment for conscious individual with hypoglycemia.
Prescribe glucagon for all patients at significant risk of severe hypoglycemia. Instruct caregivers in administration.
Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger treatment re- evaluation.
Moving on to hypoglycemia recommendations, hypoglycemia is the leading limiting factor in the glycemic management of patients with type 1 and insulin-treated type 2 diabetes.
Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter [CLICK]
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; after 15 min of treatment, if SMBG shows continued hypoglycemia, the treatment should be repeated. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. [CLICK]
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. A glucagon kit does require a prescription; some patients may want more than one kit, for example, one to keep at school or work and another for home. Care should be taken to ensure that glucagon kits are not expired; its worth reminding patients to check expiration dates upon receipt and perhaps jotting the date down on a calendar. [CLICK]
Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger re-evaluation of the treatment regimen
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
References
Cryer PE. Hypoglycaemia: the limiting factor in the glycaemic management of Type I and Type II diabetes. Diabetologia 2002;45:937–948
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S33–S34 20

21. Section 6. Obesity Management for Treatment of Type 2 Diabetes.
New section that includes previous recommendations about bariatric surgery
Now incorporates comprehensive assessment of weight in diabetes, including approved medications. .

22. Strong evidence that reducing obesity can delay the progression from pre-diabetes to type 2 diabetes.
Modest and sustained weight loss improves glycemic control and need for medications.
Weight loss most effective early in the course of diabetes to maintain beta cell function and insulin secretion. Weight loss also improves mobility, physical function, intimacy, and health related quality of life.

23. Current Recommendations
At each patient encounter, BMI should be calculated and documented in medical record. Assess the patient’s readiness to lose weight
Diet, PA, and behavioral therapy should be included to support a 5% weight loss
High interventions of at least 16 sessions in 6 months (2-3 visits/month) to support a calorie/day energy deficit (independent of protein, carb, fat distribution)

24. Maintenance programs should be offered for at least 1 year with monthly contact
Very low calorie diets (less than 800 kcal/day) used along with trained practitioners with close monitoring
When choosing glucose lowering medications, consider their effect on weight and minimize those associated with weight gain

25. Discontinue medications if after 3 months there is less than 5% of weight loss achieved
Bariatric surgery may be considered for adults with a BMI greater than 35 kg/m2 and diabetes
Livelong support necessary for those who have undergone surgery

26. Insufficient evidence to recommend surgery to those with a BMI less than or equal to 35 kg/m2.
Higher remission rates in those who are younger, have shorter duration of type 2 diabetes, lower A1c, higher serum insulin levels, and non-use of insulin
Remission means normal blood glucose levels without need for medications.

28. Section 7. Approaches to Glycemic Treatment
Evans, J.L & Rushakoff, R.J, 2010, Endotext.org

30. Recommendations: Pharmacological Therapy For Type 1 Diabetes
Most people with T1DM should be treated with multiple dose insulin (MDI) injections (3–4 injections /day of basal & prandial insulin) or continuous subcutaneous insulin infusion (CSII).
Individuals who have been successfully using CSII should have continued access after they turn 65 years old.
Starting off with type 1 diabetes, there are plenty of other resources out there on initiating and managing insulin therapy, so we won’t go into that here.
Most of your patients with type 1 diabetes should be treated with multiple dose injections or insulin pump therapy. There are minimal differences between the two as far as hypoglycemia is concerned. Whichever one a patient chooses, intensive management and active patient or family participation should be strongly encouraged. [CLICK]
Individuals who have been successfully using an insulin pump should have continued access after they turn 65.
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Approaches to glycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S59
References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S26
The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977–986
Nathan DM, Cleary PA, Backlund JY, et al for the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005;353:2643–2653 30

31. Recommendations: Pharmacological Therapy For T2DM (2)
If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3 months, add a second oral agent, a GLP-1 receptor agonist, or insulin.
Use a patient-centered approach to treatment.
Don’t delay insulin initiation in patients not achieving glycemic goals.
If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3 months, add a second oral agent, a glucagon-like peptide 1 (GLP-1) receptor agonist, or insulin [CLICK]
A patient centered approach should be used to guide the choice of pharmacological agents. Considerations include efficacy, cost, potential side effects, weight, comorbidities, hypoglycemia risk, and patient preference. [CLICK]
And finally, for patients with type 2 diabetes who are not achieving glycemic goals, insulin therapy should not be delayed.
The Association has a comprehensive algorithm for antihyperglycemic therapy which appears as figure 7.1 in the full recommendations. I won’t go through it here but do download it in the full recommendations.
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Approaches to glycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S59
References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S27
Holman RR, Paul SK, Bethel MA,Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577–1589
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;154:602–613 31

32. Section 10. Older Adults
Glycemic goals for some older adults might be relaxed but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients.
Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacologic interventions.
Glycemic goals for some older adults might reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients.
Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacologic interventions.
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Older adults. Diabetes Care 2016; 39 (Suppl. 1): S81-S85
References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S54-55
Kirkman M, Briscoe VJ, Clark N, et al. Diabetes in older adults. Diabetes Care 2012;35:2650–2664 32

33. Section 11. Children & Adolescents
Distinguishing between type 1 and type 2 can be challenging.
Excessive weight is common in type 1.
Diabetes-associated autoantibodies and ketosis may be present in patients with features of type 2 such as obesity and AN).
Accurate diagnosis is critical.
We covered information on screening and testing for type 2 diabetes in children & adolescents earlier, so now we’ll focus on treatment.
Given the current obesity epidemic, distinguishing between type 1 and type 2 diabetes in children can be difficult. For example, excessive weight is common in children with type 1 diabetes.
Furthermore, diabetes-associated autoantibodies and ketosis may be present in patients with features of type 2 diabetes (including obesity and acanthosis nigricans) (64). Nevertheless, accurate diagnosis is critical as treatment regimens, educational approaches, dietary advice, and outcomes differ markedly between the two diagnoses.
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Children and adolescents. Diabetes Care 2016; 39 (Suppl. 1): S86-S93 33

34. Section 12. Gestational Diabetes Mellitus (GDM)
Lifestyle change is an essential part GDM mgmt. and may suffice for many women. Add medications if needed to achieve glycemic targets.
Preferred medications in GDM are insulin and metformin; glyburide may be used but may have higher rate of neonatal hypoglycemia & macrosomia than insulin or metformin. Other agents have not been adequately studied. Most oral agents cross the placenta and all lack long-term safety data.
Recommendations for care of women with gestational diabetes include the following:
Lifestyle change is an essential part GDM mgmt. and may suffice for many women. Add medications if needed to achieve glycemic targets.
Preferred medications in GDM are insulin and metformin; glyburide may be used but may have higher rate of neonatal hypoglycemia & macrosomia than insulin or metformin. Other agents have not been adequately studied. Most oral agents cross the placenta and all lack long-term safety data.
[SLIDE]
American Diabetes Association. Management of diabetes in pregnancy. Standards of Medical Care in Diabetes Diabetes Care 2016;39(Suppl. 1):S94–S98 34

35. Glycemic Targets in Pregnancy (Preexisting Type 1 or Type 2)
The American College of Obstetricians and Gynecologists (ACOG) recommends the following targets for women with pregestational type 1 or type 2 diabetes:
Fasting ≤90 mg/dL (5.0 mmol/L)
One-hour postprandial ≤130–140mg/dL (7.2–7.8 mmol/L)
Two-hour postprandial ≤120 mg/dL (6.7 mmol/L)
In women with pregestational, or pre-existing type 1 or type 2 diabetes, the American College of Obstetricians and Gynecologists recommends the following targets:
Fasting ≤90 mg/dL
One-hour postprandial ≤130–140mg/dL
Two-hour postprandial ≤120 mg/dL
[SLIDE]
American Diabetes Association. Management of diabetes in pregnancy. Standards of Medical Care in Diabetes Diabetes Care 2016;39(Suppl. 1):S94–S98
References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S54
Kitzmiller JL, Block JM, Brown FM, et al. Managing preexisting diabetes for pregnancy: summary of evidence and consensus recommendations for care. Diabetes Care 2008;31:1060–1079
American Diabetes Association. Preconception care of women with diabetes. Diabetes Care 2004;27(Suppl. 1):S76–S78 35

36. Section 13. Diabetes Care in the Hospital
Consider getting an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months.
Start insulin therapy for persistent hyperglycemia starting at a threshold ≥180 mg/dL (10 mmol/L). Then a target glucose of 140–180 mg/dL (7.8–10 mmol/L) is recommended for the majority of critically ill and noncritically ill patients.
Recommendations for diabetes care in the hospital include:
Consider performing an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months.
Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold $180 mg/dL. Once insulin therapy is started, a target glucose range of 140–180 mg/dL is recommended for the majority of critically ill patients and noncritically ill patients.
[SLIDE]
American Diabetes Association. Diabetes care in the hospital. Standards of Medical Care in Diabetes Diabetes Care 2016;39(Suppl. 1):S94–S98
Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S56–S57 36

38. Thank you!