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Insulin therapy is the agent of choice for the management of hyperglycemia, PTDM, and preexisting diabetes and diabetes in the hospital setting.
After discharge, patients with preexisting diabetes could go back on their pretransplant regimen if they were in good control before transplantation. Those with previously poor control or with persistent hyperglycemia should continue insulin with frequent home self-monitoring of blood glucose to determine when insulin dose reductions may be needed and when it may be appropriate to switch to noninsulin agents.
No studies to date have established which noninsulin agents are safest or most efficacious in PTDM. Drug dose adjustments may be required because of decreases in the glomerular filtration rate, a relatively common complication in transplant patients. A small short-term pilot study reported that metformin was safe to use in renal transplant recipients 97 , but its safety has not been determined in other types of organ transplant.
Thiazolidinediones have been used successfully in patients with liver and kidney transplants, but side effects include fluid retention, heart failure, and osteopenia 98 , Dipeptidyl peptidase 4 inhibitors do not interact with immunosuppressant drugs and have demonstrated safety in small clinical trials , Well-designed intervention trials examining the efficacy and safety of these and other antihyperglycemic agents in patients with PTDM are needed.
For a comprehensive list of causes, see Genetic Diagnosis of Endocrine Disorders Most common causes of monogenic diabetes Neonatal diabetes occurs much less often after 6 months of age, whereas autoimmune type 1 diabetes rarely occurs before 6 months of age. Neonatal diabetes can either be transient or permanent. Transient diabetes is most often due to overexpression of genes on chromosome 6q24, is recurrent in about half of cases, and may be treatable with medications other than insulin. Permanent neonatal diabetes is most commonly due to autosomal dominant mutations in the genes encoding the Kir6.
Correct diagnosis has critical implications because most patients with K ATP -related neonatal diabetes will exhibit improved glycemic control when treated with high-dose oral sulfonylureas instead of insulin. Insulin gene INS mutations are the second most common cause of permanent neonatal diabetes, and, while intensive insulin management is currently the preferred treatment strategy, there are important genetic counseling considerations, as most of the mutations that cause diabetes are dominantly inherited.
MODY is frequently characterized by onset of hyperglycemia at an early age classically before age 25 years, although diagnosis may occur at older ages. MODY is characterized by impaired insulin secretion with minimal or no defects in insulin action in the absence of coexistent obesity.
It is inherited in an autosomal dominant pattern with abnormalities in at least 13 genes on different chromosomes identified to date. For individuals with MODY, the treatment implications are considerable and warrant genetic testing , Clinically, patients with GCK-MODY exhibit mild, stable, fasting hyperglycemia and do not require antihyperglycemic therapy except sometimes during pregnancy. Additionally, diagnosis can lead to identification of other affected family members.
Genetic screening is increasingly available and cost-effective , In most cases, the presence of autoantibodies for type 1 diabetes precludes further testing for monogenic diabetes, but the presence of autoantibodies in patients with monogenic diabetes has been reported Individuals in whom monogenic diabetes is suspected should be referred to a specialist for further evaluation if available, and consultation is available from several centers.
Readily available commercial genetic testing following the criteria listed below now enables a cost-effective , often cost-saving, genetic diagnosis that is increasingly supported by health insurance. It is critical to correctly diagnose one of the monogenic forms of diabetes because these patients may be incorrectly diagnosed with type 1 or type 2 diabetes, leading to suboptimal, even potentially harmful, treatment regimens and delays in diagnosing other family members The correct diagnosis is especially critical for those with GCK-MODY mutations where multiple studies have shown that no complications ensue in the absence of glucose-lowering therapy Genetic counseling is recommended to ensure that affected individuals understand the patterns of inheritance and the importance of a correct diagnosis.
The diagnosis of monogenic diabetes should be considered in children and adults diagnosed with diabetes in early adulthood with the following findings:. Diabetes without typical features of type 1 or type 2 diabetes negative diabetes-associated autoantibodies, nonobese, lacking other metabolic features especially with strong family history of diabetes. Pancreatic diabetes includes both structural and functional loss of glucose-normalizing insulin secretion in the context of exocrine pancreatic dysfunction and is commonly misdiagnosed as type 2 diabetes.
The diverse set of etiologies includes pancreatitis acute and chronic , trauma or pancreatectomy, neoplasia, cystic fibrosis addressed elsewhere in this chapter , hemochromatosis, fibrocalculous pancreatopathy, rare genetic disorders , and idiopathic forms 1.
A distinguishing feature is concurrent pancreatic exocrine insufficiency according to the monoclonal fecal elastase 1 test or direct function tests , pathological pancreatic imaging endoscopic ultrasound, MRI, computed tomography and absence of type 1 diabetesï¿½associated autoimmunity ï¿½ There is loss of both insulin and glucagon secretion and often higher-than-expected insulin requirements.
Risk for microvascular complications is similar to other forms of diabetes. In the context of pancreatectomy, islet autotransplantation can be done to retain insulin secretion , In some cases, this can lead to insulin independence. In others, it may decrease insulin requirements For many years, GDM was defined as any degree of glucose intolerance that was first recognized during pregnancy 49 , regardless of the degree of hyperglycemia.
This definition facilitated a uniform strategy for detection and classification of GDM, but this definition has serious limitations First, the best available evidence reveals that many, perhaps most, cases of GDM represent preexisting hyperglycemia that is detected by routine screening in pregnancy, as routine screening is not widely performed in nonpregnant women of reproductive age. It is the severity of hyperglycemia that is clinically important with regard to both short- and long-term maternal and fetal risks.
A compelling argument for further work in this area is the fact that hyperglycemia that would be diagnostic of diabetes outside of pregnancy and is present at the time of conception is associated with an increased risk of congenital malformations that is not seen with lower glucose levels , The ongoing epidemic of obesity and diabetes has led to more type 2 diabetes in women of reproductive age, with an increase in the number of pregnant women with undiagnosed type 2 diabetes in early pregnancy ï¿½ Because of the number of pregnant women with undiagnosed type 2 diabetes, it is reasonable to test women with risk factors for type 2 diabetes Table 2.
Women found to have diabetes by the standard diagnostic criteria used outside of pregnancy should be classified as having diabetes complicating pregnancy most often type 2 diabetes, rarely type 1 diabetes or monogenic diabetes and managed accordingly. Women who meet the lower glycemic criteria for GDM should be diagnosed with that condition and managed accordingly.
As effective prevention interventions are available , , women diagnosed with GDM should receive lifelong screening for prediabetes to allow interventions to reduce diabetes risk and for type 2 diabetes to allow treatment at the earliest possible time GDM carries risks for the mother, fetus, and neonate.
The Hyperglycemia and Adverse Pregnancy Outcome HAPO study , a large-scale multinational cohort study completed by more than 23, pregnant women, demonstrated that risk of adverse maternal, fetal, and neonatal outcomes continuously increased as a function of maternal glycemia at 24ï¿½28 weeks of gestation, even within ranges previously considered normal for pregnancy.
For most complications, there was no threshold for risk. These results have led to careful reconsideration of the diagnostic criteria for GDM. GDM diagnosis Table 2. American College of Obstetricians and Gynecologists notes that one elevated value can be used for diagnosis Many regional studies have investigated the impact of adopting IADPSG criteria on prevalence and have seen a roughly one- to threefold increase A recent follow-up study of women participating in a blinded study of pregnancy OGTTs found that 11 years after their pregnancies, women who would have been diagnosed with GDM by the one-step approach, as compared with those without, were at 3.
The ADA recommends the IADPSG diagnostic criteria with the intent of optimizing gestational outcomes because these criteria were the only ones based on pregnancy outcomes rather than end points such as prediction of subsequent maternal diabetes. The expected benefits of using IADPSG to the offspring are inferred from intervention trials that focused on women with lower levels of hyperglycemia than identified using older GDM diagnostic criteria.
Those trials found modest benefits including reduced rates of large-for-gestational-age births and preeclampsia , Additional well-designed clinical studies are needed to determine the optimal intensity of monitoring and treatment of women with GDM diagnosed by the one-step strategy , The member panel had representatives from obstetrics and gynecology, maternal-fetal medicine, pediatrics, diabetes research, biostatistics, and other related fields. The panel recommended a two-step approach to screening that used a 1-h g glucose load test GLT followed by a 3-h g OGTT for those who screened positive.
A systematic review for the U. As for other screening tests, choice of a cutoff is based upon the trade-off between sensitivity and specificity. Key factors cited by the NIH panel in their decision-making process were the lack of clinical trial data demonstrating the benefits of the one-step strategy and the potential negative consequences of identifying a large group of women with GDM, including medicalization of pregnancy with increased health care utilization and costs.
Moreover, screening with a g GLT does not require fasting and is therefore easier to accomplish for many women. Treatment of higher-threshold maternal hyperglycemia, as identified by the two-step approach, reduces rates of neonatal macrosomia, large-for-gestational-age births , and shoulder dystocia, without increasing small-for-gestational-age births. ACOG currently supports the two-step approach but notes that one elevated value, as opposed to two, may be used for the diagnosis of GDM If this approach is implemented, the incidence of GDM by the two-step strategy will likely increase markedly.
A secondary analysis of data from a randomized clinical trial of identification and treatment of mild GDM demonstrated that treatment was similarly beneficial in patients meeting only the lower thresholds per Carpenter-Coustan and in those meeting only the higher thresholds per National Diabetes Data Group If the two-step approach is used, it would appear advantageous to use the Carpenter-Coustan lower diagnostic thresholds as shown in step 2 in Table 2.
The conflicting recommendations from expert groups underscore the fact that there are data to support each strategy. A cost-benefit estimation comparing the two strategies concluded that the one-step approach is cost-effective only if patients with GDM receive postdelivery counseling and care to prevent type 2 diabetes The decision of which strategy to implement must therefore be made based on the relative values placed on factors that have yet to be measured e.
Data comparing population-wide outcomes with one-step versus two-step approaches have been inconsistent to date , There remains strong consensus that establishing a uniform approach to diagnosing GDM will benefit patients, caregivers, and policy makers.
Longer-term outcome studies are currently underway. Suggested citation: American Diabetes Association. Classification and diagnosis of diabetes: Standards of Medical Care in Diabetesï¿½ Diabetes Care ;43 Suppl. Sign In or Create an Account. Search Dropdown Menu. Advanced Search. User Tools Dropdown. Sign In. Skip Nav Destination Article Navigation.
Close navigation menu Article navigation. Previous Article Next Article. Article Navigation. Position Statements December 16 This Site. Google Scholar. Get Permissions. Diabetes can be classified into the following general categories:. Stage 1. Stage 2. Stage 3. View Large. Fasting is defined as no caloric intake for at least 8 h.
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. Women who were diagnosed with GDM should have lifelong testing at least every 3 years. For all other patients, testing should begin at age 45 years. GDM, gestational diabetes mellitus. Figure 2. View large Download slide. Clinical features. One-step strategy Perform a g OGTT, with plasma glucose measurement when patient is fasting and at 1 and 2 h, at 24ï¿½28 weeks of gestation in women not previously diagnosed with diabetes.
The OGTT should be performed in the morning after an overnight fast of at least 8 h. American Diabetes Association. Search ADS. Type 1 diabetes defined by severe insulin deficiency occurs after 30 years of age and is commonly treated as type 2 diabetes. Practical classification guidelines for diabetes in patients treated with insulin: a cross-sectional study of the accuracy of diabetes diagnosis.
Trends in hospital admission for diabetic ketoacidosis in adults with type 1 and type 2 diabetes in England, ï¿½ a retrospective cohort study. Diabetic ketoacidosis in type 1 and type 2 diabetes mellitus: clinical and biochemical differences. Differentiation of diabetes by pathophysiology, natural history, and prognosis.
International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. Not performing an OGTT results in significant underdiagnosis of pre diabetes in a high risk adult Caucasian population. Prevalence of diabetes and high risk for diabetes using A1C criteria in the U.
Glycated hemoglobin A 1c as screening for diabetes mellitus in HIV-infected individuals. Evaluation and management of youth-onset type 2 diabetes: a position statement by the American Diabetes Association. Association of sickle cell trait with hemoglobin A1c in African Americans. Impact of common genetic determinants of hemoglobin A1c on type 2 diabetes risk and diagnosis in ancestrally diverse populations: a transethnic genome-wide meta-analysis.
Glucose-independent, black-white differences in hemoglobin A1c levels: a cross-sectional analysis of 2 studies. Utility of glycated hemoglobin in diagnosing type 2 diabetes mellitus: a community-based study. Are there clinical implications of racial differences in HbA 1c? Yes, to not consider can do great harm! Differences in A1C by race and ethnicity among patients with impaired glucose tolerance in the Diabetes Prevention Program. Racial differences in the relationship of glucose concentrations and hemoglobin A1c levels.
Racial differences in glycemic markers: a cross-sectional analysis of community-based data. Racial and ethnic differences in mean plasma glucose, hemoglobin A1c, and 1,5-anhydroglucitol in over patients with type 2 diabetes. No racial differences in the association of glycated hemoglobin with kidney disease and cardiovascular outcomes.
A difference, to be a difference, must make a difference. Hemoglobin A 1c versus oral glucose tolerance test in postpartum diabetes screening. Is early postpartum HbA1c an appropriate risk predictor after pregnancy with gestational diabetes mellitus? The usefulness of HbA1c in postpartum reclassification of gestational diabetes.
Role of glycated proteins in the diagnosis and management of diabetes: research gaps and future directions. Prognostic implications of single-sample confirmatory testing for undiagnosed diabetes: a prospective cohort study. Adult-onset autoimmune diabetes: current knowledge and implications for management. Prevalence of type 1 and type 2 diabetes among children and adolescents from to Seroconversion to multiple islet autoantibodies and risk of progression to diabetes in children.
The prediction of type 1 diabetes by multiple autoantibody levels and their incorporation into an autoantibody risk score in relatives of type 1 diabetic patients.
Pancreatic islet autoantibodies as predictors of type 1 diabetes in the Diabetes Prevention Trial-Type 1. Predicting progression to type 1 diabetes from ages 3 to 6 in islet autoantibody positive TEDDY children. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults.
Identifying adults at high risk for diabetes and cardiovascular disease using hemoglobin A1c National Health and Nutrition Examination Survey Diabetes Prevention Program Research Group. HbA 1c as a predictor of diabetes and as an outcome in the diabetes prevention program: a randomized clinical trial. Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Effect of early intensive multifactorial therapy on 5-year cardiovascular outcomes in individuals with type 2 diabetes detected by screening ADDITION-Europe : a cluster-randomised trial.
Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States. Age at initiation and frequency of screening to detect type 2 diabetes: a cost-effectiveness analysis. BMI cut points to identify at-risk Asian Americans for type 2 diabetes screening. WHO Expert Consultation.
Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Prevalence of and trends in diabetes among adults in the United States, Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States, Accessed 31 October New-onset treatment-dependent diabetes mellitus and hyperlipidemia associated with atypical antipsychotic use in older adults without schizophrenia or bipolar disorder.
The efficacy and cost of alternative strategies for systematic screening for type 2 diabetes in the U. Identification of unrecognized diabetes and pre-diabetes in a dental setting. Diabetes screening with hemoglobin A 1c versus fasting plasma glucose in a multiethnic middle-school cohort. Hemoglobin A1c measurement for the diagnosis of type 2 diabetes in children. Using hemoglobin A1c for prediabetes and diabetes diagnosis in adolescents: can adult recommendations be upheld for pediatric use?
Cost-effectiveness of screening strategies for identifying pediatric diabetes mellitus and dysglycemia. Cystic fibrosis-related diabetes screening in adults: a gap analysis and evaluation of accuracy of glycated hemoglobin levels.
Response to the Letter to the Editor from Dr. Sensitivity and specificity of different methods for cystic fibrosis-related diabetes screening: is the oral glucose tolerance test still the standard? Cystic fibrosis-related diabetes: current trends in prevalence, incidence, and mortality.
Clinical care guidelines for cystic fibrosis-related diabetes: a position statement of the American Diabetes Association and a clinical practice guideline of the Cystic Fibrosis Foundation, endorsed by the Pediatric Endocrine Society.
Management of cystic fibrosis-related diabetes in children and adolescents. Post-transplant diabetes mellitus: causes, treatment, and impact on outcomes. Proceedings from an international consensus meeting on posttransplantation diabetes mellitus: recommendations and future directions.
Novel views on new-onset diabetes after transplantation: development, prevention and treatment. The association between glycemic control and clinical outcomes after kidney transplantation. Early peri-operative hyperglycaemia and renal allograft rejection in patients without diabetes. Diabetes care after transplant: definitions, risk factors, and clinical management.
The use of oral glucose tolerance tests to risk stratify for new-onset diabetes after transplantation: an underdiagnosed phenomenon. Early peri-operative glycaemic control and allograft rejection in patients with diabetes mellitus: a pilot study.
Effectiveness and long-term safety of thiazolidinediones and metformin in renal transplant recipients. The pharmacokinetics of pioglitazone in patients with impaired renal function. Pioglitazone in the management of diabetes mellitus after transplantation.
Short-term efficacy and safety of sitagliptin treatment in long-term stable renal recipients with new-onset diabetes after transplantation. Sitagliptin therapy in kidney transplant recipients with new-onset diabetes after transplantation.
A clinical guide to monogenic diabetes. In Genetic Diagnosis of Endocrine Disorders. Philadelphia, PA, Elsevier, De Franco. The effect of early, comprehensive genomic testing on clinical care in neonatal diabetes: an international cohort study. Maturity-onset diabetes of the young MODY : how many cases are we missing? Systematic population screening, using biomarkers and genetic testing, identifies 2. Arlington, American Diabetes Association, Accessed 26 September Positivity for islet cell autoantibodies in patients with monogenic diabetes is associated with later diabetes onset and higher HbA1c level.
Cost-effectiveness of MODY genetic testing: translating genomic advances into practical health applications. Population-based assessment of a biomarker-based screening pathway to aid diagnosis of monogenic diabetes in young-onset patients. The diagnosis and management of monogenic diabetes in children and adolescents. Neonatal diabetes: an expanding list of genes allows for improved diagnosis and treatment.
Le Bodic. Is pancreatic diabetes type 3c diabetes underdiagnosed and misdiagnosed? Incidence, demographics, and clinical characteristics of diabetes of the exocrine pancreas type 3c : a retrospective cohort study.
The nutritional management of type 3c pancreatogenic diabetes in chronic pancreatitis. Glycemic predictors of insulin independence after total pancreatectomy with islet autotransplantation.
Glycemic thresholds for spontaneous abortion and congenital malformations in insulin-dependent diabetes mellitus. Congenital malformations in offspring of women with hyperglycemia first detected during pregnancy.
Trends in incidence of diabetes in pregnancy and serious perinatal outcomes: a large, population-based study in Ontario, Canada, Trends and racial and ethnic disparities in the prevalence of pregestational type 1 and type 2 diabetes in Northern California: Trends in the incidence of diabetes, its clinical sequelae, and associated costs in pregnancy. Early pregnancy diabetes screening and diagnosis: prevalence, rates of abnormal test results, and associated factors.
Issues with the diagnosis and classification of hyperglycemia in early pregnancy. Abnormal glucose tolerance post-gestational diabetes mellitus as defined by the International Association of Diabetes and Pregnancy Study Groups criteria.
Gestational diabetes and the incidence of type 2 diabetes: a systematic review. When caring for hospitalized patients with diabetes, consult with a specialized diabetes or glucose management team when possible. Initial orders should state the type of diabetes. Because inpatient treatment and discharge planning are more effective if based on preadmission glycemia, an A1C should be measured on all patients with diabetes or hyperglycemia.
Hypoglycemia in the hospital is classified the same as in any setting. In patients who are eating, glucose monitoring should be performed before meals; in those not eating, glucose monitoring is advised every 4ï¿½6 h.
Testing every 30 min to every 2 h is required for intravenous insulin infusion. Several inpatient studies have shown that CGM use did not improve glucose control but detected a greater number of hypoglycemic events than point-of-care glucose testing. However, there are insufficient data on clinical outcomes, safety, and cost-effectiveness to recommend using CGM in hospitalized patients.
In most instances in the hospital setting, insulin is the preferred treatment for glycemic control. In certain circumstances, it may be appropriate to continue home regimens including oral glucose-lowering medications. If oral medications are held in the hospital, there should be a protocol for resuming them 1ï¿½2 days before discharge.
In the critical care setting, continuous intravenous insulin infusion is the best method for achieving glycemic targets. Outside of critical care units, scheduled insulin regimens as described above are recommended. For patients who are eating, insulin injections should align with meals. In such instances, point-of-care glucose testing should be performed immediately before meals. An insulin regimen with basal and correction components is necessary for all hospitalized patients with type 1 diabetes, with the addition of prandial insulin if patients are eating.
A transition protocol from insulin infusion to subcutaneous insulin is recommended. The safety and efficacy of noninsulin glucose-lowering therapies in the hospital setting is an area of active research.
Patients with or without diabetes may experience hypoglycemia in the hospital setting. While hypoglycemia is associated with increased mortality, it may be a marker of underlying disease rather than the cause of fatality. Recently, several groups have developed algorithms to predict episodes of hypoglycemia among inpatients.
Models such as these are potentially important and, once validated for general use, could provide a valuable tool to reduce rates of hypoglycemia in hospitalized patients.
The goals of MNT in the hospital are to provide adequate calories to meet metabolic demands, optimize glycemic control, and address personal food preferences, and facilitate creation of a discharge plan. The ADA does not endorse any single meal plan. Diabetes self-management in the hospital may be appropriate for selected patients. Sufficient cognitive and physical skills, adequate oral intake, proficiency in carbohydrate estimation, and knowledge of sick-day management are some of the requirements.
Self-administered insulin with a stable MDI regimen or insulin pump therapy may be considered. A protocol should exist for these situations. Transition from the acute care setting presents risk for all patients. A structured discharge plan may reduce length of hospital stay and readmission rates and increase patient satisfaction. Discharge planning should begin at admission and be updated as patient needs change.
An outpatient follow-up visit 1 month after discharge is recommended. An earlier appointment in 1ï¿½2 weeks is preferred, and frequent contact may be needed. Hill, MA, Matthew P. Diabetes Care ;43 Suppl.
The complete Standards supplement, including all supporting references, is available at professional. Clin Diabetes. Copyright and License information Disclaimer. Readers may use this work as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.
Readers may link to the version of record of this work on professional. Requests to reuse or repurpose; adapt or modify; or post, display, or distribute this work may be sent to gro. A ï¿½Clear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered. Recommendations 1. This model emphasizes person-centered team care, integrated long-term treatment approaches to diabetes and comorbidities, and ongoing collaborative communication and goal setting between all team members.
Delivery system design moving from a reactive to a proactive care delivery system where planned visits are coordinated through a team-based approach. Clinical information systems using registries that can provide patient-specific and population-based support to the care team. Community resources and policies identifying or developing resources to support healthy lifestyles. Strategies for System-Level Improvement 1. Care teams. Tailoring Treatment for Social Context Recommendations 1. Gestational diabetes mellitus GDM; diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation.
Specific types of diabetes due to other causes, e. Screening and Diagnostic Tests for Prediabetes and Type 2 Diabetes The diagnostic criteria for diabetes and prediabetes are shown in Table 2.
TABLE 2. Prediabetes Diabetes A1C 5. Open in a separate window. Recommendations 2. Women who were diagnosed with GDM should have lifelong testing at least every 3 years. For all other patients, testing should begin at age 45 years. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.
See Table 2. If tests are normal, repeat testing at a minimum of 3-year intervals, or more frequently if BMI is increasing, is recommended. Reports of type 2 diabetes before age 10 years exist, and this can be considered with numerous risk factors.
Lifestyle Interventions Recommendations 3. Pharmacologic Interventions Recommendation 3. Prevention of CVD Recommendation 3. Comprehensive Medical Evaluation Recommendations 4.
Review previous treatment and risk factor control in patients with established diabetes. Immunizations Children and adults with diabetes should receive vaccinations according to age-specific recommendations. Assessment of Comorbidities Besides assessing diabetes-related complications, clinicians and their patients need to be aware of common comorbidities that may complicate diabetes management.
Autoimmune Diseases Recommendations 4. Cancer Patients with diabetes should be encouraged to undergo recommended age- and sex-appropriate cancer screenings and to reduce their modifiable cancer risk factors obesity, physical inactivity, and smoking. Medical Nutrition Therapy Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes.
Physical Activity Recommendations 5. B Prolonged sitting should be interrupted every 30 min for blood glucose benefits. Yoga and tai chi may be included based on individual preferences to increase flexibility, muscular strength, and balance. Psychosocial Issues Recommendations 5.
Including caregivers and family members in this assessment is recommended. Refer for treatment if anxiety is present. A1C Testing. Recommendations 6. A1C Goals Recommendations 6. TABLE 6. Postprandial glucose measurements should be made 1ï¿½2 h after the beginning of the meal, generally peak levels in patients with diabetes.
Hypoglycemia Table 6. Fifteen minutes after 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. Caregivers, school personnel, or family members of these individuals should know where it is and when and how to administer it.
Glucagon administration is not limited to health care professionals, particularly with the availability of intranasal and stable soluble glucagon available in autoinjector pens.
Recommendation 7. Nonprofit websites can offer advice for providers and patients to determine the suitability of various options. SMBG Recommendations 7. CGM Table 7. TABLE 7. Intermittently scanned CGM CGM systems that measure glucose levels continuously but only display glucose values when swiped by a reader or a smart phone that reveals the glucose levels.
These devices are generally initiated in a clinic, using a reader that is owned by the clinic. They are removed after a period of time generally 10ï¿½14 days and analyzed by the patient and provider to assess glycemic patterns and trends. Recommendations 7. Assessment Recommendations 8.
B If deterioration of medical status is associated with significant weight gain or loss, inpatient evaluation should be considered, specifically focused on the association between medication use, food intake, and glycemic status. Greater benefits in control of diabetes and CV factors may be gained from even greater weight loss.
To maintain weight loss, such programs must incorporate long-term comprehensive weight-maintenance counseling. Pharmacotherapy Recommendations 8. Potential benefits must be weighed against potential risks of medications.
Metabolic Surgery Recommendations 8. Pharmacologic Therapy for Type 2 Diabetes Figure 9. TABLE 9. Recommendations 9. Considerations include CV comorbidities, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences Figure 9. Recommendations Individualization of Treatment Targets Patients and clinicians should engage in a shared decision-making process to determine individual blood pressure targets.
Treatment Strategies Figure Lifestyle Intervention. Recommendation Pharmacologic Interventions. B If one class is not tolerated, the other should be substituted. Resistant Hypertension. Lipid Management Lifestyle Intervention. Secondary Prevention A Ezetimibe may be preferred due to lower cost. Treatment of Other Lipoprotein Fractions or Targets. Diabetes Risk With Statin Use Several studies have reported a modestly increased risk of incident diabetes with statin use, which may be limited to those with diabetes risk factors.
Lipid-Lowering Agents and Cognitive Function A concern that statins or other lipid-lowering agents might cause cognitive dysfunction or dementia is not currently supported by evidence and should not deter their use in individuals with diabetes at high risk for ASCVD. Antiplatelet Agents Recommendations Risk Reduction Aspirin has been shown to be effective in reducing CV morbidity and mortality in high-risk patients with previous myocardial infarction or stroke secondary prevention and is strongly recommended.
CVD Recommendations. Screening Treatment A For patients on dialysis, higher levels of dietary protein intake should be considered, since malnutrition is a major problem in some dialysis patients. Diabetic Retinopathy Recommendations If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight-threatening, then examinations will be required more frequently.
Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated. Neuropathy Recommendations Screening All patients should have annual g monofilament testing to identify feet at risk for ulceration and amputation. Neuropathic Pain Pregabalin and duloxetine have received regulatory approval by the FDA in treating diabetic neuropathic pain.
Foot Care Recommendations Treatment People with neuropathy or evidence of increased plantar pressures e. Neurocognitive Function Recommendation Hypoglycemia Recommendation It should be assessed and managed by adjusting glycemic targets and pharmacologic regimens. Treatment Goals Recommendations Particular attention should be paid to complications that would lead to functional impairment.
Lipid-lowering therapy and aspirin therapy may benefit those with life expectancies at least equal to the time frame of primary prevention or secondary intervention trials.
Lifestyle Management Recommendation Pharmacologic Therapy Recommendations End-of-Life Care Recommendations Strict glucose and blood pressure control may not be necessary E , and reduction of therapy may be appropriate.
Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. Type 1 Diabetes Type 1 diabetes is the most common form of diabetes in youth.
Type 2 Diabetes Management. Recommendations Glycemic Targets Pharmacologic Management Preconception Counseling Recommendations Preconception Care Recommendations Dilated eye examinations should occur ideally before pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy and as recommended by the eye care provider.
Management of GDM Recommendations Insulin should be added if needed to achieve glycemic targets. Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data. Pregnancy and Drug Considerations Recommendations Postpartum Care Recommendations Hospital Care Delivery Standards Recommendations Considerations on Admission Initial orders should state the type of diabetes.
Glycemic Targets in Hospitalized Patients Recommendations Bedside Blood Glucose Monitoring In patients who are eating, glucose monitoring should be performed before meals; in those not eating, glucose monitoring is advised every 4ï¿½6 h. A An insulin regimen with basal, prandial, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake.
Insulin Therapy In the critical care setting, continuous intravenous insulin infusion is the best method for achieving glycemic targets.
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