Diabetes Checklist (as per ADA guidelines 2015)

Diabetes diagnosis
1. HbA1c 6.5
2. FPG 126 after 8hrs fasting
3. 2hr PG 200 after 75g glucose
4. symptomatic patient RPG 200

Pre-diabetes diagnosis
FPG 100-125
2hr PG 140-199
HbA1c 5.7-6.4

Screening
asymptomatic adults 45yrs + BMI 25 + one or more risk
factors (FH, HTN, HLD, GDM, PCOS etc)
asian americans 45yrs + BMI 23 + one or more risk factors
screen every 3 yrs

Checklist for starting pre-diabetes/diabetes screening

patient is not a known diabetic and does not have symptoms
suggestive of diabetes
Age 45, if yes
check for BMI, if 25 (or 23 for asian americans), if yes
check for risk factors for diabetes (FH, ethnicity, HTN, HDL,
past h/o GDM, PCOS), if yes
check if patient has had diabetes screening in the last 3 yrs, if
no
Start screening for diabetes every 3 yrs (most convenient test is
HbA1c)

Diabetes new diagnosis workup

1. History
routine history + history for
depression
obstructive sleep apnea
fatty liver disease
cancer
fractures
cognitive impairment
low testosterone in men
periodontal diseases
hearing impairment
2. Labs
HbA1c (if not done in last 3 months)
If not done in the last 1 year
Fasting lipid profile, including total, LDL, and HDL
cholesterol and triglycerides
Liver function tests
Test for urine albumin excretion with spot urine albuminto-creatinine ratio
Serum creatinine and calculated glomerular filtration rate
TSH in type 1 diabetes, dyslipidemia, or women over age
50 years
3. Referrals
Eye care professional for annual dilated eye exam
Family planning for women of reproductive age
Registered dietitian for medical nutrition therapy
DSME/DSMS (diabetes self management education &
support)
Dentist for comprehensive periodontal examination
Mental health professional, if needed
4. Glycemic target

Set up a glycemic target in every recently diagnosed patient

HbA1c 7 in most patients (reasonable risk benefit
between diabetes complications and drug adverse effects)
HbA1c 6.5 (younger patient, less comorbidities, fewer
medications, long life expectancy)
HbA1c 8 (older patient, multiple comorbidities, multiple
medications, short life expectancy)
Note: If you are able to achieve strict glucose control in a patient
with lifestyle modifications and minimal medications alone
without problems with hypoglycemia, you dont need to hold
back the medications to bring up the HbA1c. These
recommendations only state that you dont need to go overboard
with medications in order to achieve a favorable lab result. Just
give what you think the patient can handle safely.

Diabetes follow up monitoring and care

5. Immunizations
all routine vaccinations +
annual influenza vaccine
if duration of diabetes 2yrs, Give PPSV23 (diabetics dont
need revaccination after 5 yrs)
if age 65yrs, and not received PPSV23 yet, give PCV13
followed by PPSV23 (6-12m later, if delayed give ASAP)
if age 65yrs and has already received PPSV23, give PCV13
only (12m later, if delayed give ASAP)
6. BP Monitoring
BP monitoring at every visit
BP goals for most patients 140/90
BP goal of 130/80 (younger patients, less comorbidities)
Lifestyle modifications + pharmacologic therapy

 Dont go overboard with BP medications. Risk of Rx ADRs

should be lower than risk of high BP.
ACEi, ARBs, Thiazides and CCBs
Monitor Creat/GFR and potassium levels.
7. Lipid monitoring
Lipid profile at diagnosis and every 1-2 years afterwards
Diabetics with active ASCVD or ASCVD equivalent conditions
high intensity statins (dont start HIS after 75, but if patient
already taking them safely then dont cut back)
Diabetics 40-75 + 10yr ASCVD risk >7.5% - high intensity
statins
Diabetics 40-75 + 10yr ASCVD risk 5-7.4% or no risk factors moderate intensity statins
Diabetics >75yrs with CVD risk factors, moderate intensity
statins
Combining statins with fibrates/niacin etc has not shown to be
beneficial.
8. Anti-platelet agents
Aspirin (75-162mg daily) diabetic males >50 and women >60,
who have diabetes + 1 major risk factor for CVD (FM, HTN,
smoking, HLD, albuminuria)
Aspirin should be avoided in diabetic males >50 or females
>60, whose 10yrs CVD risk is <5%
9. CAD monitoring
Diabetics + known CVD use aspirin, high dose statins
(40-75), ACEi
If there is a prior MI, BBs continued for 2yrs
Thiazolidenediones avoided in pt with symptomatic heart
failure
Metformin should be avoided in CHF and renal failure

10. Diabetic kidney disease

Screen every year, quantitative urinary albumin (alb/creat
ratio), estimated GFR. For all type 2 DM and type 1 DM after
5yrs of disease
Rx Glycemic control + ACEi/ARBs are recommended for
those with urinary albumin excretion >300 mg/day (monitor creat,
potassium and urinary alb/creat ratio)
When GFR is below 60, evaluate for CKD
11. Diabetic retinopathy
Screen first dilated comprehensive eye exam soon after
diagnosis (within 5yrs of Dx in type 1DM)
Repeat exams every 2 yearly (1yrly if pathology detected)
RxGlycemic control + Laser photocoagulation therapy is
indicated to reduce the risk of vision loss in patients with highrisk proliferative diabetic retinopathy (PDR), clinically significant
macular edema, and, in some cases, severe non proliferative
diabetic retinopathy NPDR.
Antivascular endothelial growth factor (VEGF) therapy is
indicated for diabetic macular edema.
12. Diabetic neuropathy
Diabetic peripheral neuropathy (DPN) and diabetic autonomic
neuropathy (DAN). DAN has 3 major components
cardiovascular, gastrointestinal and genitourinary.
Screening All patients screened for neuropathy soon after
diagnosis in type 2 and within 5 yrs of Dx in type1. Using a 10g
monofilament test.
Rx Tight glycemic control is the only strategy convincingly
shown to prevent or delay the development of DPN and DAN in
patients with type 1 diabetes and to slow the progression of
neuropathy in some patients with type 2 diabetes.
Rx - Assess and treat patients to reduce pain related to DPN and
symptoms of autonomic neuropathy (and to improve quality of

life.
13. Foot care
Screening - Annual comprehensive foot examination to identify
risk factors for ulcers and amputations.
Patients with insensate feet, foot deformities and ulcers should
have their feet examined at every visit.
14. PAD monitoring
Screening - Initial screening for peripheral arterial disease
(PAD) should include a history for claudication and an
assessment of the pedal pulses.
Patients with significant claudication, foot ulcers, foot
deformities and previous amputation should be referred for
specialist care and need more stringent monitoring.