American Diabetes Association

American Diabetes Association

STANDARDS OF MEDICAL CARE IN DIABETES2015 ADA Evidence Grading System for Clinical Practice Recommendations Level of Evidence A Description 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 ADA. Diabetes Care 2015;38(suppl 1):S2; Table 1

Trends in the Number and Proportion of Higher and Lower Level Recommendations Higher level recommendations defined as A or B evidence grades Lower level recommendations defined as C or E evidence grades Grant R W , and Kirkman M S Dia Care 2015;38:6-8 Trends in the Proportion of Higher Level Recommendations by Category Grant R W , and Kirkman M S Dia Care 2015;38:6-8 1. 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 ADA. 1. Strategies for Improving Diabetes Care. Diabetes Care 2015;38(suppl 1):S5 Recommendations: Strategies for

Improving Diabetes Care (2) Treatment decisions should be timely, based on evidence-based guidelines 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 ADA. 1. Strategies for Improving Diabetes Care. Diabetes Care 2015;38(suppl 1):S5 Diabetes Care Concepts The American Diabetes Association highlights three themes that are woven throughout the Standards of Care in Diabetes that clinicians, policymakers, and advocates should keep in mind:

a) b) c) Patient-Centeredness: The science and art of medicine come together when the clinician is faced with making treatment recommendations for a patients who would not have met eligibility criteria for the studies on which guidelines were based. Diabetes Across the Lifespan: There is a need to improve coordination between clinical teams as patients pass through different stages of the life span or the stages of pregnancy (preconception, pregnancy, an postpartum.) Advocacy for Patients With Diabetes: Given the tremendous toll that lifestyle factors such as obesity, physical inactivity, and smoking

have on the health of patients with diabetes, ongoing and energetic efforts are needed to address and change the societal determinants at the root of these problems. ADA. 1. Strategies for Improving Diabetes Care. Diabetes Care 2015;38(suppl 1):S5 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 ADA. 1. Strategies for Improving Diabetes Care. Diabetes Care 2014;38(suppl 1):S6 Objective 2: Support Patient Behavior Change

Implement a systematic approach to support patient behavior change efforts a) b) c) Healthy lifestyle: physical activity, healthy eating, nonuse of tobacco, weight management, effective coping Disease self-management: medication taking and management, selfmonitoring of glucose and blood pressure when clinically appropriate Prevention of diabetes complications: self-monitoring of foot health, active participation in screening for eye, foot, and renal complications, and immunizations ADA. 1. Strategies for Improving Diabetes Care. Diabetes Care 2015;38(suppl 1):S6

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 ADA. 1. Strategies for Improving Diabetes Care. Diabetes Care 2015;38(suppl 1):S6 2. CLASSIFICATION AND DIAGNOSIS OF DIABETES Classification of Diabetes Type 1 diabetes -cell destruction

Type 2 diabetes Progressive insulin secretory defect Other specific types of diabetes Genetic defects in -cell function, insulin action Diseases of the exocrine pancreas Drug- or chemical-induced Gestational diabetes mellitus (GDM) ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S8 Criteria for the Diagnosis of Diabetes A1C 6.5% OR 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 OR A random plasma glucose 200 mg/dL (11.1 mmol/L) ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S9; Table 2.1 Criteria for the Diagnosis of Diabetes A1C 6.5% The test should be performed in a laboratory using a method that is NGSP certified and standardized

to the DCCT assay* *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S9; Table 2 Criteria for the Diagnosis of Diabetes Fasting plasma glucose (FPG) 126 mg/dL (7.0 mmol/L) Fasting is defined as no caloric intake for at least 8 h* *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S9; Table 2.1 Criteria for the Diagnosis of Diabetes 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* *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S9; Table 2.1 Criteria for the Diagnosis of Diabetes In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose 200 mg/dL (11.1 mmol/L)

ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S9; Table 2.1 Recommendation: Screening for Type 1 Diabetes Inform type 1 diabetes patients of the opportunity to have their relatives screened for type 1 diabetes risk in the setting of a clinical research study E ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S9; Table 2.1 Categories of Increased Risk for Diabetes (Prediabetes)* FPG 100125 mg/dL (5.66.9 mmol/L): IFG OR

2-h plasma glucose in the 75-g OGTT 140199 mg/dL (7.811.0 mmol/L): IGT OR A1C 5.76.4% *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. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S10; Table 2.3 Recommendations: Testing for Diabetes in Asymptomatic Patients Consider testing overweight/obese adults (BMI 25 kg/m2 or 23 kg/m2 in Asian Americans) with one or more additional risk

factors for type 2 diabetes; for all patients, particularly those who are overweight, testing should begin at age 45 years B If tests are normal, repeat testing at least at 3-year intervals is reasonable C To test for diabetes/prediabetes, the A1C, FPG, or 2-h 75-g OGTT are appropriate B In those with prediabetes, identify and, if appropriate, treat other CVD risk factors B ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S11 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* or 23 kg/m2 in Asian Americans) and have

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 ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S10; Table 2.2 Criteria for Testing for Diabetes in

Asymptomatic Adult Individuals (2) 2. In the absence of criteria (risk factors on previous slide), and particularly in those who are overweight or obese, 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 ADA. 2.Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S10; Table 2.2 Recommendation: Screening for Type 2 Diabetes in Children Testing to detect type 2 diabetes and

prediabetes should be considered in children and adolescents who are overweight and who have two or more additional risk factors for diabetes E ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S11 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 Screen for GDM at 2428 weeks of gestation in pregnant women not previously known to have diabetes A

Screen women with GDM for persistent diabetes at 612 weeks postpartum, using OGTT, nonpregnancy diagnostic criteria E ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S13 Recommendations: Detection and Diagnosis of GDM (2) 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

ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S13 Screening for and Diagnosis of GDM One-step Strategy Perform a 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 2428 weeks of 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)

ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S14; Table 2.5 Screening for and Diagnosis of GDM Two-step Strategy (1) Step 1: Perform 50-g GLT (nonfasting) with plasma glucose measurement at 1 h at 2428 weeks of gestation in women not previously diagnosed with overt diabetes If plasma glucose level measured at 1 h after load is 140 mg/dL* (7.8 mmol/L), proceed to step 2, 100-g OGTT *ACOG recommends 135 mg/dL in high-risk ethnic minorities with higher prevalence of GDM. ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S14; Table 2.5 Screening for and Diagnosis of GDM

Two-step Strategy (2) Step 2: 100-g OGTT is performed while patient is fasting. The diagnosis of GDM is made if 2 or more of the following plasma glucose levels are met or exceeded: Carpenter/Coustan Fasting 95 mg/dL (5.3 mmol/L) or NDDG______ 105 mg/dL (5.8 mmol/L) 1h

180 md/dL (10.0 mmol/L) 190 mg/dL (10.6 mmol/L) 2h 155 mg/dL (8.6 mmol/L) 165 mg/dL (9.2 mmol/L) 3h 140 mg/dL (7.8 mmol/L) 145 mg/dL (8.0 mmol/L)

ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S14; Table 2.5 Recommendations: Cystic Fibrosis Related Diabetes (CFRD) (1) Annual screening for CFRD with OGTT should begin by age 10 years in all patients with cystic fibrosis who do not have CFRD B A1C as a screening test for CFRD is not recommended B In patients with cystic fibrosis and IGT without confirmed diabetes, prandial insulin therapy should be considered to maintain weight. B ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S15

Recommendations: Cystic Fibrosis Related Diabetes (CFRD) (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. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S15 3. INITIAL EVALUATION AND DIABETES MANAGEMENT PLANNING Diabetes Care: Initial Evaluation

A complete medical evaluation should be performed to Classify the diabetes Detect presence of diabetes complications Review previous treatment, risk factor 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 patients medical condition Screening Recommendation Consider screening those with type 1 diabetes for other autoimmune diseases (thyroid, vitamin B12 deficiency, celiac) as appropriate B ADA. 3. Initial Evaluation and Diabetes Management Planning. Diabetes Care 2015;38(suppl 1):S17

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) ADA. 3. Initial Evaluation and Diabetes Management Planning. Diabetes Care 2015;38(suppl 1):S18

Components of the Comprehensive Diabetes Evaluation (2) Medical history (2) Current treatment of diabetes, including medications, adherence and barriers thereto, meal plan, physical activity patterns, readiness for behavior change Results of glucose monitoring, patients use of data DKA frequency, severity, cause Hypoglycemic episodes Hypoglycemic awareness Any severe hypoglycemia: frequency, cause ADA. 3. Initial Evaluation and Diabetes Management Planning. Diabetes Care 2015;38(suppl 1):S18 Components of the

Comprehensive Diabetes Evaluation (3) 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* *See appropriate referrals for these categories. ADA. 3. Initial Evaluation and Diabetes Management Planning. Diabetes Care 2015;38(suppl 1):S18 Components of the

Comprehensive Diabetes Evaluation (4) 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) ADA. 3. Initial Evaluation and Diabetes Management Planning. Diabetes Care 2015;38(suppl 1):S18 Components of the Comprehensive Diabetes Evaluation (5)

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 ADA. 3. Initial Evaluation and Diabetes Management Planning. Diabetes Care 2015;38(suppl 1):S18 Components of the Comprehensive Diabetes Evaluation (6) Laboratory evaluation

A1C, if results not available within past 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 TSH in type 1 diabetes, dyslipidemia, or women over age 50 years ADA. 3. Initial Evaluation and Diabetes Management Planning. Diabetes Care 2015;38(suppl 1):S18 Components of the Comprehensive Diabetes Evaluation (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/support Dentist for comprehensive periodontal examination Mental health professional, if needed ADA. 3. Initial Evaluation and Diabetes Management Planning. Diabetes Care 2015;38(suppl 1):S18 Diabetes Care: Management People with diabetes should receive medical care from a team that may include Physicians, nurse practitioners, physicians 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 selfmanagement education (DSME) and on-going diabetes support ADA. 3. Initial Evaluation and Diabetes Management Planning. Diabetes Care 2015;38(suppl 1):S17 Recommendation: Assessment of Common Comorbid Conditions Consider assessing for and addressing common comorbid conditions that may complicate the management of diabetes B Common comorbidities Depression

Cognitive impairment Obstructive sleep apnea Low testosterone in men Fatty liver disease Periodontal disease Cancer Hearing impairment Fractures

ADA. 3. Initial Evaluation and Diabetes Management Planning. Diabetes Care 2015;38(suppl 1):S17 4. FOUNDATIONS OF CARE: EDUCATION, NUTRITION, PHYSICAL ACTIVITY, SMOKING CESSATION, PYSCHOSOCIAL CARE, AND IMMUNIZATION Recommendations: Diabetes Self-Management Education, Support People with diabetes should receive DSME/DSMS according

to National Standards for Diabetes Self-Management Education and Support at diagnosis and as needed thereafter B Effective self-management, quality of life are key outcomes of DSME/DSMS; should be measured, monitored as part of care C DSME/DSMS should address psychosocial issues, since emotional well-being is associated with positive outcomes C ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S20 Recommendations: Diabetes Self-Management Education, Support DSME/DSMS programs are appropriate venues for people with prediabetes to receive education and support to develop and

maintain behaviors that can prevent or delay the onset of diabetes C Because DSME/DSMS can result in costsavings and improved outcomes B, DSME/DSMS should be adequately reimbursed by third-party payers E ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S20 Recommendations: Medical Nutrition Therapy (MNT) (1) Nutrition therapy is recommended for all people with type 1 and type 2 diabetes as an effective component of the overall treatment plan A 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 ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S22 Recommendations: Medical Nutrition Therapy (MNT) (2) Because diabetes nutrition therapy can result in cost savings B and improved outcomes such as reduction in A1C A, nutrition therapy should be adequately reimbursed by insurance and other payers E

ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S22 Recommendation: Macronutrient Distribution Evidence suggests there is no ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes B Therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals E ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S22 Recommendations: Physical Activity Children with diabetes/prediabetes: engage in at least

60 min/day physical activity B Adults with diabetes: at least 150 min/wk of moderateintensity aerobic activity (5070% of maximum heart rate),over at least 3 days/ wk with no more than 2 consecutive days without exercise A Evidence supports that all individuals, including those with diabetes, should be encouraged to reduce sedentary time, particularly by breaking up extended amoungs of time (>90 min) spent sitting B If not contraindicated, adults with type 2 diabetes should perform resistance training at least twice weekly A ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S24 Recommendations:

Smoking Cessation Advise all patients not to smoke or use tobacco products A Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care B ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S25 Recommendations: Psychosocial Assessment and Care Ongoing part of medical management of diabetes B Psychosocial screening/follow-up: attitudes, medical management/outcomes expectations, affect/mood, quality of life, resources, psychiatric history E Routinely screen for psychosocial problems:

depression, diabetes-related distress, anxiety, eating disorders, cognitive impairment B ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S26 Recommendations: Immunization (1) Provide routine vaccinations for children and adults with diabetes as for the general population C Provide influenza vaccine annually to all patients with diabetes 6 months of age C Administer pneumococcal polysaccharide vaccine 23 (PPSV23) to all patients with diabetes 2 years C Adults 65 years of age, if not previously vaccinated, should receive pneumococcal conjugate vaccine (PCV13), followed by PPSV23 6-12 months after initial vaccination C

Adults 65 years of age, if previously vaccinated with PPSV23, should receive a follow-up 12 months with PCV13 C ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S26 Recommendations: Immunization (2) Administer hepatitis B vaccination to unvaccinated adults with diabetes who are aged 1959 years C Consider administering hepatitis B vaccination to unvaccinated adults with diabetes who are aged 60 years C ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S26 5. PREVENTION/DELAY OF

TYPE 2 DIABETES Recommendations: Prevention/Delay of Type 2 Diabetes Refer patients with IGT A, IFG E, or A1C 5.76.4% E to ongoing support program Targeting weight loss of 7% of body weight Increasing physical activity to at least 150 min/week of moderate activity (eg, walking) Follow-up counseling appears to be important for success B Based on cost-effectiveness of diabetes prevention, such programs should be covered by third-party payers B ADA. 5. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2015;38(suppl 1):S31

Recommendations: Prevention/Delay of Type 2 Diabetes Consider metformin for prevention of type 2 diabetes if IGT A, IFG E, or A1C 5.76.4% 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 Screen for and treat modifiable risk factors for CVD B DSME/DSMS programs are approparite venues for people with prediabetes to develop and maintain behaviors that can

prevent or delay the onset of diabetes C ADA. 5. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2015;38(suppl 1):S31 6. GLYCEMIC TARGETS 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 ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S33

Recommendations: Glucose Monitoring (1) Patients on multiple-dose insulin (MDI) or insulin pump therapy should do SMBG B Prior to meals and snacks Occasionally postprandially At bedtime Prior to exercise When they suspect low blood glucose

After treating low blood glucose until they are normoglycemic Prior to critical tasks such as driving ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S33 Recommendations: Glucose Monitoring (2) When prescribed as part of a broader educational context, SMBG results may be helpful to guide treatment decisions and/or patient self-management for patients using less frequent insulin injections B or noninsulin therapies E When prescribing SMBG, ensure that patients receive ongoing instruction and regular evaluation of SMBG technique and SMBG results, as well as their ability to

use SMBG data to adjust therapy E ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S33 Recommendations: Glucose Monitoring (3) When used properly, CGM in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults (aged 25 years) with type 1 diabetes. A Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device. B CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent

hypoglycemic episodes. C Given variable adherence to CGM, assess individual readiness for continuing use of CGM prior to prescribing. E When prescribing CGM, robust diabetes education, training, and support are required for optimal CGM implementation and ongoing use. E ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S33 Recommendations: A1C Perform the A1C test at least two times a year in patients meeting treatment goals (and have stable glycemic control) E Perform the 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 ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S34 Mean Glucose Levels for Specified A1C Levels Mean Plasma Glucose* Mean Fasting Glucose Mean Premeal

Glucose Mean Postmeal Glucose Mean Bedtime Glucose A1C% mg/dL mmol/L

mg/dL mg/dL mg/dL mg/dL 6 <6.5 6.5-6.99 7 7.0-7.49 7.5-7.99 8 8-8.5

9 10 11 12 126 7.0 122 142 118 139 144 164

136 153 152 167 152 155 176 189 177 175

178 179 206 222 154 183 212 240 269 298

8.6 10.2 11.8 13.4 14.9 16.5 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 0.92. A calculator for converting A1C results into estimated average glucose (eAG), in either mg/dL or mmol/L, is available at http://professional.diabetes.org/eAG. ADA. 6. Glycemic Targets. Diabetes Care. 2015;38(suppl 1):S35; Table 6.1 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 ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S35 Recommendations: Glycemic Goals in Adults (2) 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. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S35 Recommendations: Glycemic Goals in Adults (3) 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 DSME, appropriate

glucose monitoring, and effective doses of multiple glucose lowering agents including insulin ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S35 Approach to the Management of Hyperglycemia ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S37. Figure 6.1; adapted with permission from Inzucchi SE, et al. Diabetes Care, 2015;38:140-149 Glycemic Recommendations for Nonpregnant Adults with Diabetes (1) A1C <7.0%*

Preprandial capillary plasma glucose 80130 mg/dL* (4.47.2 mmol/L) Peak postprandial <180 mg/dL* capillary plasma glucose (<10.0 mmol/L) *Goals should be individualized. Postprandial glucose measurements should be made 12 h after the beginning of the meal, generally peak levels in patients with diabetes. ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S37; Table 6.2

Glycemic Recommendations for Nonpregnant Adults with Diabetes (2) 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

ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S37; Table 6.2 Glycemic Recommendations for Nonpregnant Adults with Diabetes (3) 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 ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S37; Table 6.2 Recommendations: Hypoglycemia (1) Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter C

Glucose (1520 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 ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S38 Recommendations: Hypoglycemia (2) Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger re-evaluation of the treatment regimen E Insulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia should be advised to raise glycemic targets to strictly avoid further hypoglycemia for at least several weeks,

to partially reverse hypoglycemia unawareness, and to reduce risk of future episodes A ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S38 Recommendations: Hypoglycemia (3) Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if low cognition and/or declining cognition is found B ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S38 7. APPROACHES TO GLYCEMIC TREATMENT

Recommendations: Pharmacological Therapy For Type 1 Diabetes Most people with type 1 diabetes should: Be treated with MDI injections (34 injections per day of basal and prandial insulin) or continuous subcutaneous insulin infusion (CSII) A Be educated in how to match prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated activity E Use insulin analogs to reduce hypoglycemia risk A ADA. 7. Approaches to Glycemic Treatment. Diabetes Care 2015;38(suppl 1):S41

Recommendations: Pharmacological Therapy For Type 2 Diabetes (1) Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacological agent for type 2 diabetes A In patients with newly diagnosed type 2 diabetes and markedly symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy (with or without additional agents) E ADA. 7. Approaches to Glycemic Treatment. Diabetes Care 2015;38(suppl 1):S42 Recommendations: Therapy for Type 2 Diabetes (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 A ADA. 7. Approaches to Glycemic Treatment. Diabetes Care 2015;38(suppl 1):S41 Recommendations: Therapy for Type 2 Diabetes (3) A patient-centered approach should be used to guide choice of pharmacological agents Considerations include efficacy, cost, potential side effects, effects on weight, comorbidities, hypoglycemia risk, and patient preferences E

Due to the progressive nature of type 2 diabetes, insulin therapy is eventually indicated for many patients with type 2 diabetes B ADA. 7. Approaches to Glycemic Treatment. Diabetes Care 2015;38(suppl 1):S41 Antihyperglycemic Therapy in Type 2 Diabetes ADA. 7. Approaches to Glycemic Treatment. Diabetes Care 2015;38(suppl 1):S43. Figure 7.1; adapted with permission from Inzucchi SE, et al. Diabetes Care, 2015;38:140-149 Approach To Starting and Adjusting Insulin in Type 2 Diabetes

ADA. 7. Approaches to Glycemic Treatment. Diabetes Care 2015;38(suppl 1):S46. Figure 7.2; adapted with permission from Inzucchi SE, et al. Diabetes Care, 2015;38:140-149 Recommendations: Bariatric Surgery Bariatric surgery may be considered for adults with BMI > 35 kg/m2 and type 2 diabetes, especially if diabetes or associated comorbidities are difficult to control with lifestyle and pharmacological therapy 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

ADA. 7. Approaches to Glycemic Treatment. Diabetes Care 2015;38(suppl 1):S46 8. CARDIOVASCULAR DISEASE AND RISK MANAGEMENT Cardiovascular Disease CVD is the major cause of morbidity, mortality for those with diabetes Largest contributor to direct/indirect costs

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 ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S49 Recommendations: Hypertension/Blood Pressure Control Screening and diagnosis Blood pressure should be measured at every routine visit B Patients found to have elevated blood pressure should have blood pressure

confirmed on a separate day B ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S49 Recommendations: Hypertension/Blood Pressure Control Goals People with diabetes and hypertension should be treated to a systolic blood pressure goal of <140 mmHg A Lower systolic targets, such as <130 mmHg, may be appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden C Patients with diabetes should be treated to a diastolic blood pressure <90 mmHg A Lower diastolic targets, such as <80 mmHg, may be

appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden B ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S49 Recommendations: Hypertension/Blood Pressure Control Treatment (1) Patients with blood pressure >120/80 mmHg should be advised on lifestyle changes to reduce blood pressure B Patients with confirmed blood pressure higher than 140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve blood pressure

goals A ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S49 Recommendations: Hypertension/Blood Pressure Control Treatment (2) Lifestyle therapy for elevated blood pressure B Weight loss if overweight DASH-style dietary pattern including reducing sodium, increasing potassium intake Moderation of alcohol intake Increased physical activity ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S49

Recommendations: Hypertension/Blood Pressure Control Treatment (3) Pharmacological therapy for patients with diabetes and hypertension comprise a regimen that includes either an ACE inhibitor or angiotensin II receptor blocker B; if one class is not tolerated, substitute the other C Multiple drug therapy (two or more agents at maximal doses) generally required to achieve blood pressure targets B

ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S50 Recommendations: Hypertension/Blood Pressure Control Treatment (4) If ACE inhibitors, ARBs, or diuretics are used, serum creatinine/eGFR and potassium levels should be monitored E In pregnant patients with diabetes and chronic hypertension, blood pressure target goals of 110129/6579 mmHg are suggested in interest of long-term maternal health and minimizing impaired fetal growth; ACE inhibitors, ARBs, contraindicated during pregnancy E ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S50

Recommendations: Dyslipidemia/Lipid Management (1) Screening In adults, a screening lipid profile is reasonable E At first diagnosis At the initial medical evaluation And/or at age 40 years and periodically (e.g., every 1-2 years) thereafter ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S51 Recommendations: Dyslipidemia/Lipid Management (2) Treatment recommendations and goals To improve lipid profile in patients with diabetes,

recommend lifestyle modification A, focusing on Reduction of saturated fat, trans fat, cholesterol intake Increase of n-3 fatty acids, viscous fiber, plant stanols/sterols Weight loss (if indicated) Increased physical activity ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S51 Recommendations: Dyslipidemia/Lipid Management (3) Treatment recommendations and goals Intensify lifestyle therapy and optimize glycemic control for patients with C Triglyceride levels >150 mg/dL (1.7 mmol/L) and/or

HDL cholesterol >40 mg/dL (1.0 mmol/L) in men and >50 mg/dL (1.3 mmol/L) in women For patients with fasting triglyceride levels > 500 mg/ dL (5.7 mmol/L), evaluate for secondary causes and consider medical therapy to reduce the risk of pancreatitis C ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S52 Recommendations for Statin Treatment in People with Diabetes (4) Age Risk factors <40 years

4075 years >75 years Recommended statin dose* None None CVD risk factor(s)** Moderate or

high Overt CVD*** High None Moderate CVD risk factors High Overt CVD High None

Moderate Moderate or CVD risk factors high Overt CVD High Monitoring with lipid panel Annually or as needed to monitor for adherence

As needed to monitor adherence As needed to monitor adherence * In addition to lifestyle therapy. ** CVD risk factors include LDL cholesterol 100 mg/dL (2.6 mmol/L), high blood pressure, smoking, and overweight and obesity. *** Overt CVD includes those with previous cardiovascular events or acute coronary syndromes. ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S52, Table 8.1 Recommendations: Dyslipidemia/Lipid Management (5) Treatment recommendations and goals

In clinical practice, providers may need to adjust intensity of statin therapy based on individual patient response to medication (e.g. side effects, tolerability, LDL cholesterol levels.) E Cholesterol laboratory testing may be helpful in monitoring adherence to therapy but may not be needed once the patient is stable on therapy E ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S52 Recommendations: Dyslipidemia/Lipid Management (6) Treatment recommendations and goals Combination therapy has been shown not to provide additional cardiovascular benefit above statin therapy alone and is not

generally recommended A Statin therapy is contraindicated in pregnancy B ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S52 Recommendations: Antiplatelet Agents (1) Consider aspirin therapy (75162 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 ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S54 Recommendations: Antiplatelet Agents (2) 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 Low risk: 10-year CVD risk <5%, such as in men <50 years, women <60 years with no major additional CVD risk factors In patients in these age groups with multiple other risk factors (10-year risk 510%), clinical judgment is required E ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S54 Recommendations: Antiplatelet Agents (3) Use aspirin therapy (75162 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 Dual antiplatelet therapy is reasonable for up to a year after an acute coronary syndrome B ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S54 Recommendations: Cardiovascular Disease (1) Screening In asymptomatic patients, routine screening for CAD is not recommended because it does not improve outcomes as

long as CVD risk factors are treated A ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S55 Recommendations: Cardiovascular Disease (2) Treatment (1) To reduce risk of cardiovascular events in patients with known CVD, consider ACE inhibitor C Aspirin* A Statin therapy* A In patients with a prior MI -blockers should be continued for at least

2 years after the event B *If not contraindicated. ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S55 Recommendations: Cardiovascular Disease (3) Treatment (2) In patients with symptomatic heart failure, thiazolidinedione treatment should not be used A In patients with stable CHF, metformin B May be used if renal function is normal Should be avoided in unstable or hospitalized patients with CHF

ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S55 9. MICROVASCULAR COMPLICATIONS AND FOOT CARE Recommendations: Nephropathy To reduce the risk or slow the progression of nephropathy Optimize glucose control A Optimize blood pressure control A ADA. 9. Microvascular Complications and Foot Care. Diabetes Care 2015;38(suppl 1):S58 Recommendations: Nephropathy (1)

Screening At least once a year, quantitatively assess urine albumin excretion and estimated glomerular filtration rate B In patients with type 1 diabetes duration of 5 years In all patients with type 2 diabetes ADA. 9. Microvascular Complications and Foot Care. Diabetes Care 2015;38(suppl 1):S58 Recommendations: Nephropathy (2) Treatment (1) An ACE inhibitor or ARB is not recommended for the primary prevention of diabetic kidney disease in patients who have normal blood pressure and a

normal urine-albumin-to-creatinine ratio (UACR) (<30 mg/g) B Nonpregnant patient with modestly elevated urinary albumin excretion (30299 mg/day) C or higher levels (>300 mg/day) A Use either ACE inhibitors or ARBs (not both) ADA. 9. Microvascular Complications and Foot Care. Diabetes Care 2015;38(suppl 1):S58 Recommendations: Nephropathy (3) Treatment (2) When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine, potassium levels for increased creatinine or changes in potassium E Reasonable to continue monitoring urine albumin

excretion to assess both response to therapy and disease progression E When eGFR is <60 mL/min/1.73 m2, evaluate and manage potential complications of CKD E ADA. 9. Microvascular Complications and Foot Care. Diabetes Care 2015;38(suppl 1):S58 Recommendations: Nephropathy (4) Treatment (3) Consider referral to a physician experienced in care of kidney disease B Uncertainty about etiology; difficult management issues; advanced kidney disease Nutrition

For people with diabetes and diabetic kidney disease (albuminuria >30 mg/24 h), reducing dietary protein below usual intake not recommended A ADA. 9. Microvascular Complications and Foot Care. Diabetes Care 2015;38(suppl 1):S58 Definitions of Abnormalities in Albumin Excretion Category Normal Increased urinary albumin excretion* Spot collection (mg/g creatinine)

<30 30 *Historically, ratios between 30 and 299 have been called microalbuminuria and those 300 or greater have been called macroalbuminuria (or clinical albuminuria). ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S59; Table 9.1 Stages of Chronic Kidney Disease GFR (mL/min per 1.73 m2) Stage Description 1

Kidney damage* with normal or increased GFR 90 2 Kidney damage* with mildly decreased GFR 6089 3 Moderately decreased GFR

3059 4 Severely decreased GFR 1529 5 Kidney failure <15 or dialysis GFR = glomerular filtration rate *Kidney damage defined as abnormalities on pathologic, urine, blood, or imaging tests.

ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S59; Table 9.2 Management of CKD in Diabetes (1) GFR Recommended All patients Yearly measurement of creatinine, urinary albumin excretion, potassium 45-60 Referral to a nephrologist 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 ADA. 9.Microvascular Complications and Foot Care. Diabetes Care 2015;38(suppl 1):S60; Table 93; Adapted from http://www.kidney.org/professionals/KDOQI/guideline_diabetes/ Management of CKD in Diabetes (2) GFR 30-44

Recommended Monitor eGFR every 3 months Monitor electrolytes, bicarbonate, calcium, phosphorus, parathyroid hormone, hemoglobin, albumin weight every 36 months Consider need for dose adjustment of medications <30 Referral to a nephrologist ADA. 9.Microvascular Complications and Foot Care. Diabetes Care 2015;38(suppl 1):S60; Table 93; Adapted from http://www.kidney.org/professionals/KDOQI/guideline_diabetes/

Recommendations: Retinopathy To reduce the risk or slow the progression of retinopathy Optimize glycemic control A Optimize blood pressure control A ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S60 Recommendations: Retinopathy Screening (1) Initial dilated and comprehensive eye examination by an ophthalmologist or optometrist Adults with type 1 diabetes

Within 5 years after diabetes onset B Patients with type 2 diabetes Shortly after diagnosis of diabetes B ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S60 Recommendations: Retinopathy Screening (2) If no evidence of retinopathy for one or more eye exam Exams every 2 years may be considered B

If diabetic retinopathy if present Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist B If retinopathy is progressing, more frequent exams required B ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S61 Recommendations: Retinopathy Screening (3) High-quality fundus photographs

Can detect most clinically significant diabetic retinopathy E Interpretation of 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 recommended intervals E

ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S61 Recommendations: Retinopathy Screening (4) 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

ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S61 Recommendations: Retinopathy Treatment 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 ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S61 Recommendations: Retinopathy Treatment Anti-vascular endothelial growth factor (VEGF) therapy is indicated for diabetic macular edema A Presence of retinopathy Not a contraindication to aspirin therapy for cardioprotection, as this therapy does not increase the risk of retinal hemorrhage A

ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S61 Recommendations: Neuropathy Screening, Treatment (1) All patients should be screened for distal symmetric polyneuropathy (DPN) B At diagnosis of type 2 diabetes and 5 years after diagnosis of type 1 diabetes At least annually thereafter using simple clinical tests, such as a 10-g monofilament Screening for signs and symptoms of cardiovascular autonomic neuropathy Should be considered with more advanced disease E

ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S62 Recommendations: Neuropathy Screening, Treatment (2) Tight glycemic control is the only strategy convincingly shown To prevent or delay the development of DPN or CAN in patients with type 1 diabetes A To slow the progression of neuropathy in some patients with type 2 diabetes B Assess and treat patients To reduce pain related to DPN B

To reduce symptoms of automatic neuropathy E To improve the quality of life E ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S62 Recommendations: Foot Care (1) For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations B Inspection Assessment of foot pulses ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S63 Recommendations: Foot Care (2)

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 patients eyes are closed Boulton AJM, et al. Diabetes Care 2008;31:16791685

Recommendations: Foot Care (3) Provide general foot self-care education B Use multidisciplinary approach Individuals with foot ulcers, high-risk feet (e.g., dialysis patients and those with Charcot foot, prior ulcers, 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 ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S63

Recommendations: Foot Care (4) Initial screening for peripheral arterial disease (PAD) C Include a history for claudication, assessment of pedal pulses Refer patients with significant claudication or a positive ABI for further vascular assessment C Consider exercise, medications, surgical options ADA. 9. Microvascular Complications and Food Care. Diabetes Care 2015;38(suppl 1):S63 10. OLDER ADULTS 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 some older adults might reasonably be related, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients E ADA. 10.Older Adults. Diabetes Care 2015;38(suppl 1):S67 Recommendations: Older Adults (2) Treat other cardiovascular risk factors with consideration of 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 Older adults with diabetes should be considered a high-priority population for depression screening and treatment B ADA. 10.Older Adults. Diabetes Care 2015;38(suppl 1):S67 11. CHILDREN AND ADOLESCENTS

Recommendations: Pediatric Glycemic Control (Type 1 Diabetes) An A1C goal of < 7.5% is recommended across all pediatric age groups E ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S70 Recommendations: Pediatric Glycemic Control (Type 1 Diabetes) Plasma blood glucose goal range Before meals 90130 mg/dL (5.07.2 mmol/L)

Bedtime/ overnight 90150 mg/dL (5.08.3 mmol/L) A1C <7.5% Rationale A lower goal (<7.0%) is reasonable if it

can be achieved without excessive hypoglycemia Goals should be individualized, and lower goals may be reasonable based on benefit-risk assessment. Blood glucose goals should be modified in children with frequent hypoglycemia or hypoglycemia unawareness. Postprandial blood glucose values should be measured when there is a discrepancy between preprandial blood glucose values and A1C levels and to help assess glycemia in those on basal bolus regimens. ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S71; Table 11.1 Recommendations: Autoimmune Conditions (Type 1 Diabetes)

Screening Assess for the presence of additional autoimmune conditions at diagnosis and if symptoms develop E ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S71 Recommendations: Pediatric Celiac Disease (Type 1 Diabetes) (1)

Screen for by measuring IgA antitissue transglutaminase or antiendomysial antibodies; document normal total serum IgA levels soon after diabetes diagnosis E Consider testing in children with Positive family history of celiac disease Growth failure Failure to gain weight, weight loss Diarrhea, flatulence, abdominal pain, signs of malabsorption Frequent unexplained hypoglycemia or deterioration in glycemic control E ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S71 Recommendations: Pediatric Celiac Disease (Type 1 Diabetes) (2)

Asymptomatic children with positive antibodies Consider referral to a gastroenterologist for evaluation with possible endoscopy and biopsy for confirmation of celiac disease 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 B ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S71 Recommendations: Pediatric Hypothyroidism (Type 1 Diabetes) Children with type 1 diabetes

Screen for antithyroid peroxidase, antithyroglobulin antibodies soon after diagnosis E Thyroid-stimulating hormone (TSH) concentrations Measure after metabolic control established If normal, consider rechecking every 12 years, especially if patient develops symptoms of thyroid dysfunction, thyromegaly, an abnormal growth rate, or unusual glycemic variation E ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S71 Recommendations: Pediatric Hypertension (Type 1 Diabetes) (1)

Screening Measure blood pressure at each routine visit; confirm high-normal blood pressure or hypertension on three separate days B ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S71 Recommendations: Pediatric Hypertension (Type 1 Diabetes) (2) Treatment (1) Initial treatment of high-normal blood pressure (SBP or DBP consistently above 90th percentile for age, sex, and height) Dietary intervention and exercise, aimed at weight control; increased physical activity, if appropriate

If target blood pressure is not reached with 36 months of lifestyle intervention, consider pharmacologic treatment E ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S72 Recommendations: Pediatric Hypertension (Type 1 Diabetes) (3) Treatment (2) Pharmacologic treatment of hypertension SBP or DBP consistently above the 95th percentile for age, sex, and height Consider treatment as soon as diagnosis is confirmed E

ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S72 Recommendations: Pediatric Hypertension (Type 1 Diabetes) (4) Treatment (3) ACE inhibitors Consider for initial treatment of hypertension, following appropriate reproductive counseling due to potential teratogenic effects E Goal of treatment Blood pressure consistently below the 90th percentile for age, sex, and height E ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S72

Recommendations: Pediatric Dyslipidemia (Type 1 Diabetes) Screening Obtain a fasting lipid profile in children >2 years of age soon after diagnosis (after glucose control has been established) E ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S72 Recommendations: Pediatric Dyslipidemia (Type 1 Diabetes) Screening If lipids are abnormal Annual monitoring is reasonable E

If LDL cholesterol values are within accepted risk levels (<100 mg/dL [2.6 mmol/L]) Repeat lipid profile every 5 years E ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S72 Recommendations: Pediatric Dyslipidemia (Type 1 Diabetes) Treatment Initial therapy: optimize glucose control, MNT using Step 2 AHA diet aimed at decreasing dietary saturated fat B After the age of 10 years, statin treatment is reasonable in those (after MNT and lifestyle changes) with E 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

Goal: LDL cholesterol <100 mg/dL (2.6 mmol/L) E MNT=medical nutrition therapy ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S72 Recommendations: Pediatric Nephropathy (Type 1 Diabetes) Screening At least annual screening for albumin levels; random spot urine sample for albumin-to-creatinine (UACR) ratio at start of puberty or age 10 years, whichever is earlier, once youth has had diabetes for 5 years B

Measure creatinine clearance/estimated glomerular filtration rate at initial evaluation and then based on age, diabetes duration and treatment E Treatment ACE inhibitor when elevated UACR (>30 mg/g) confirmed on two of three additional urine samples from different days over 6-month interval B ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S72 Recommendations: Pediatric Retinopathy (Type 1 Diabetes) Initial dilated and comprehensive eye examination should be considered Start of puberty or age 10 years, whichever is earlier, once the youth has had diabetes for 35 years B

After initial examination Annual routine follow-up generally recommended Less frequent examinations may be acceptable on advice of an eye care professional E ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S73 Recommendations: Pediatric Neuropathy (Type 1 Diabetes) Consider an annual comprehensive foot exam for the child at the start of puberty or at age > 10 years, whichever is earlier, once the youth has had type 1 diabetes for 5 years E

ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S73 Recommendations: Pediatric DSME/DSMS(Type 1 Diabetes) Youth with type 1 diabetes and parents/caregivers (for patients aged <18 years) should receive diabetes self-management education and support at diagnosis and routinely thereafter that is B Culturally sensitive Developmentally appropriate Individualized ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S73 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 ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S73 Recommendations: Pediatric Psychosocial Issues At diagnosis and during routine follow-up care, assess psychosocial issues and family

stresses that could impact adherence with diabetes management E Provide appropriate referrals to trained mental health professions, preferably experienced in childhood diabetes Encourage family involvement in diabetes management tasks B Recognize that premature transfer of diabetes care to the child can result in nonadherence and deterioration of glycemic control ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S74 Pediatric Type 2 Diabetes

Given the obesity epidemic, distinguishing between type 1 and type 2 diabetes in children is difficult, but critical for determining the optimal treatment regimen Due to the significant comorbidities associated with type 2 diabetes, these tests are recommended at diagnosis: Blood pressure measurement fasting lipid panel Albumin excretion assessment Dilated eye examination

Thereafter, screening and treatment guidelines for in youth with type 2 diabetes are similar to those with type 1 diabetes. ADA. 11. Children and Adolescents. Diabetes Care 2015;38(suppl 1):S74 12. MANAGEMENT OF DIABETES IN PREGNANCY Recommendations: Diabetes in Pregnancy (1) Provide preconception counseling that addresses the importance of tight control in reducing the risk of congenital anomalies with an emphasis on achieving A1C < 7%, if this can be achieved without

hypoglycemia. B Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. B GDM should be managed first with diet and exercise, and medications should be added if needed. A ADA. 12. Management of Diabetes in Pregnancy. Diabetes Care 2015;38(suppl 1):S77 Recommendations: Diabetes in Pregnancy (2) Women with pregestational diabetes should have a baseline ophthalmology exam in the first trimester and then be monitored every trimester as indicated by degree of retinopathy. B

Due to alterations in red blood cell turnover that lower the normal A1C level in pregnancy, the A1C target in pregnancy is < 6% if this can be achieved without significant hypoglycemia. B Medications widely used in pregnancy include insulin, metformin, and glyburide; most oral agents cross the placenta or lack long-term safety data. B ADA. 12. Management of Diabetes in Pregnancy. Diabetes Care 2015;38(suppl 1):S77 Glycemic Targets in Pregnancy (GDM) The goals for glycemic control for GDM are based on recommendations from the Fifth International Workshop-Conference on Gestational Diabetes Mellitus (GDM) and have the following targets for maternal capillary glucose concentrations:

Preprandial <95 mg/dL (5.3 mmol/L) and either One-hour postmeal <140 mg/dL (7.8 mmol/L) or Two-hour postmeal <120 mg/dL (6.7 mmol/L) ADA. 12. Management of Diabetes in Pregnancy. Diabetes Care 2015;38(suppl 1):S78 Glycemic Targets in Pregnancy (Preexisting Type 1 or Type 2) For women with preexisting type 1 diabetes or type 2 diabetes who become pregnant, the following are recommended as optimal glycemic goals if they can be achieved without excessive hypoglycemia: Premeal, bedtime, and overnight glucose 6099 mg/dL (3.35.4 mmol/L) Peak postprandial glucose 100129 mg/dL (5.47.1 mmol/L)

A1C < 6.0% The ADA recommends setting targets based on clinical experience, individualizing care as needed ADA. 12. Management of Diabetes in Pregnancy. Diabetes Care 2015;38(suppl 1):S78 13. DIABETES CARE IN THE HOSPITAL, NURSING HOME, AND SKILLED NURSING FACILITY Recommendations: Diabetes Care in the Hospital Diabetes discharge planning should start at hospital admission, and clear diabetes management instructions should be provided at discharge E

The sole use of sliding scale insulin in the inpatient hospital setting is discouraged A ADA. 13. Diabetes Care in the Hospital, Nursing Home, and Skilled Nursing Facility. Diabetes Care 2015;38(suppl 1):S80 Recommendations: Diabetes Care in the Hospital All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record E ADA. 13. Diabetes Care in the Hospital, Nursing Home, and Skilled Nursing Facility. Diabetes Care 2015;38(suppl 1):S80 Recommendations:

Diabetes Care in the Hospital Goals for blood glucose levels Critically ill patients Initiate insulin therapy for persistent hyperglycemia starting no greater than 180 mg/dL (10 mmol/L); once started, glucose range of 140 180 mg/dL (7.810 mmol/L) is recommended A More stringent goals, 110140 mg/dL (6.17.8 mmol/L) may be appropriate for selected patients if achievable without significant hypoglycemia C Critically ill patients require an IV insulin protocol with demonstrated efficacy, safety in achieving desired glucose range without increasing risk for severe hypoglycemia E ADA. 13. Diabetes Care in the Hospital, Nursing Home, and Skilled Nursing Facility. Diabetes Care 2015;38(suppl 1):S80

Recommendations: Diabetes Care in the Hospital Goals for blood glucose levels Non-Critically ill patients If treated with insulin, generally premeal blood glucose targets of <140 mg/dL (7.8 mmol/L) with random blood glucose <180 mg/dL (10.0 mmol/L) are reasonable, provided these targets can be safely achieved. C More stringent targets may be appropriate in stable patients with previous tight glycemic control. Less stringent targets may be appropriate in those with severe

A basal plus correction insulin regimen is the preferred treatment for patients with poor oral intake or who are taking nothing by mouth (NPO). An insulin regimen with basal, nutritional, and correction components is the preferred treatment for patients with good nutritional intake. A ADA. 13. Diabetes Care in the Hospital, Nursing Home, and Skilled Nursing Facility. Diabetes Care 2015;38(suppl 1):S80 Recommendations: Diabetes Care in the Hospital A hypoglycemia management protocol should be adopted

and implemented by each hospital or hospital system E Consider obtaining an A1C in patients With diabetes admitted to the hospital if testing result in previous 23 mo unavailable E With risk factors for undiagnosed diabetes who exhibit hyperglycemia in the hospital E Patients with hyperglycemia without a prior diagnosis: document plans for follow-up testing and care at discharge E ADA. 13. Diabetes Care in the Hospital, Nursing Home, and Skilled Nursing Facility. Diabetes Care 2015;38(suppl 1):S80

Diabetes Care in the Hospital: NICE-SUGAR Study (1) Largest randomized controlled trial to date Tested effect of tight glycemic control (target 81108 mg/dL) on outcomes among 6,104 critically ill participants Majority (>95%) required mechanical ventilation ADA. 13. Diabetes Care in the Hospital, Nursing Home, and Skilled Nursing Facility. Diabetes Care 2015;38(suppl 1):S80 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 144180 mg/dL) Severe hypoglycemia more common (6.8% vs. 0.5%; P < 0.001) Findings strongly suggest may not be necessary to target blood glucose levels <140 mg/dL; highly stringent target of <110 mg/dL may actually be dangerous ADA. 13. Diabetes Care in the Hospital, Nursing Home, and Skilled Nursing Facility. Diabetes Care 2015;38(suppl 1):S80 14. DIABETES ADVOCACY Advocacy Position Statements

The ADA publishes evidence-based, peer-reviewed statements on topics such as Diabetes and employment Diabetes and driving Diabetes management in certain settings such as schools, child care programs, and correctional institutions. In addition to ADAs clinical position statements, these

advocacy position statements can help describe the intersection of diabetes medicine and the law to Schools Employers Licensing agencies Policy makers Others ADA. 14 Diabetes Advocacy. Diabetes Care 2015;38(suppl 1):S86

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