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Section
ADA Evidence Grading System of Clinical Recommendations I. II. III. I,. ,. ,I. ,II. ,III. I1. 1. Classification and Diagnosis esting for Dia!etes in Asym"tomatic #atients Detection and Diagnosis of Gestational Dia!etes &ellit's (GD&) #revention-Delay of y"e $ Dia!etes Dia!etes Care #revention and &anagement of Dia!etes Com"lications Assessment of Common Comor!id Conditions Dia!etes Care in S"ecific #o"'lations Dia!etes Care in S"ecific Settings Strategies for Im"roving Dia!etes Care
Slide No.
3 4-11 1$-1% 1*-1+ $.-$1 $$-*/ *0-11$ 113-114 11%-13% 13*-144 14%-1%.
y"e $ dia!etes
#rogressive ins'lin secretory defect
AIn t9e a!sence of 'ne3'ivocal 9y"erglycemia5 res'lt s9o'ld !e confirmed !y re"eat testing. ADA. I. Classification and Diagnosis. Diabetes Care $.1$:3%(s'""l 1);S1$. a!le $.
AIn t9e a!sence of 'ne3'ivocal 9y"erglycemia5 res'lt s9o'ld !e confirmed !y re"eat testing. ADA. I. Classification and Diagnosis. Diabetes Care $.1$:3%(s'""l 1);S1$. a!le $.
AIn t9e a!sence of 'ne3'ivocal 9y"erglycemia5 res'lt s9o'ld !e confirmed !y re"eat testing. ADA. I. Classification and Diagnosis. Diabetes Care $.1$:3%(s'""l 1);S1$. a!le $.
A1C %./E*.4?
A@or all t9ree tests5 risB is contin'o's5 e7tending !elo4 t9e lo4er limit of a range and !ecoming dis"ro"ortionately greater at 9ig9er ends of t9e range.
Fse A1C5 @#G5 or $-9 /%-g =G (8) In t9ose 4it9 increased risB for f't're dia!etes
Identify and5 if a""ro"riate5 treat ot9er C,D risB factors (8)
DD2 c9olesterol level H3% mg-d2 (..+. mmol-2) and-or a triglyceride level G$%. mg-d2 ($.0$ mmol-2) Comen 4it9 "olycystic ovarian syndrome (#C=S) A1C >%./?5 IG 5 or I@G on "revio's testing =t9er clinical conditions associated 4it9 ins'lin resistance (e.g.5 severe o!esity5 acant9osis nigricans) Distory of C,D
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.1$:3%(s'""l 1);S1%.
@ollo4-'" co'nseling im"ortant for s'ccess (8) 8ased on cost-effectiveness of dia!etes "revention5 t9ird-"arty "ayers s9o'ld cover s'c9 "rograms (E) Consider metformin for "revention of ty"e $ dia!etes if IG (A)5 I@G (E)5 or A1C %./E*.4? (E)
Es"ecially for t9ose 4it9 8&I G3% Bg-m$5 age H*. years5 and 4omen 4it9 "rior GD& (A)
E &acrovasc'lar; CDD5 cere!rovasc'lar disease5 #AD E =t9er; "syc9osocial "ro!lemsA5 dental diseaseA
ASee a""ro"riate referrals for t9ese categories. ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1/. a!le /.
ASee a""ro"riate referrals for t9ese categories. ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1/. a!le /.
&anagement "lan s9o'ld recogni6e dia!etes self-management ed'cation (DS&E) and on-going dia!etes s'""ort
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S1*.
Re o%%endations) A1C
#erform A1C test at least t4ice yearly in "atients meeting treatment goals (and 9ave sta!le glycemic control) (E) #erform A1C test 3'arterly in "atients 49ose t9era"y 9as c9anged or 49o are not meeting glycemic goals (E) Fse of "oint-of-care (#=C) testing for A1C "rovides t9e o""ort'nity for more timely treatment c9anges (E)
9ese estimates are !ased on ADAG data of L$5/.. gl'cose meas'rements over 3 mont9s "er A1C meas'rement in %./ ad'lts 4it9 ty"e 15 ty"e $5 and no dia!etes. 9e correlation !et4een A1C and average gl'cose 4as ..+$. A calc'lator for converting A1C res'lts into estimated average gl'cose (eAG)5 in eit9er mg-d2 or mmol-25 is availa!le at 9tt";--"rofessional.dia!etes.org-Gl'coseCalc'lator.as"7. ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S10. a!le 0.
Intensive !l$ e%i Cont"ol and Ca"diovas -la" O-t o%es) ACCORD
*rimar+ ,utcome# -on"atal MI. non"atal stroke. /01 death
234%'5% (%'6&78'%9!
Gerstein DC5 et al5 for t9e Action to Control Cardiovasc'lar RisB in Dia!etes St'dy Gro'". N Engl J Med $..0:3%0;$%4%-$%%+.
Intensive !l$ e%i Cont"ol and Ca"diovas -la" O-t o%es) AD2ANCE
*rimar+ ,utcome# Microvascular )lus macrovascular (non"atal MI. non"atal stroke. /01 death!
234%'5% (%'&27%'5&!
#atel A5 et al5. for t9e AD,ANCE Colla!orative Gro'". N Engl J Med $..0:3%0;$%*.-$%/$.
Intensive !l$ e%i Cont"ol and Ca"diovas -la" O-t o%es) 2ADT
*rimar+ ,utcome# -on"atal MI. non"atal stroke. /01 death. hos)itali:ation "or heart "ailure. revasculari:ation
234%'&& (%'6978'%5!
AIndivid'ali6e goals !ased on t9ese val'es. ;#ost"randial gl'cose meas'rements s9o'ld !e made 1E$ 9 after t9e !eginning of t9e meal5 generally "eaB levels in "atients 4it9 dia!etes. ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$.. a!le +.
Advantages
Disadvantages Gastrointestinal side effects (diarr9ea5 a!dominal cram"ing) 2actic acidosis (rare) ,itamin 81$ deficiency Contraindications; red'ced Bidney f'nction Cost 2o4
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.
Closes JA
Ins'lin secretion Generally 4ell tolerated Red'ction in cardiovasc'lar events and mortality (FJ#DS f-') Relatively gl'cose-inde"endent stim'lation of ins'lin secretion; Dy"oglycemia5 incl'ding e"isodes necessitating 9os"ital admission and ca'sing deat9 Ceig9t gain &ay !l'nt myocardial isc9emic "reconditioning 2o4 Od'ra!ilityP 2o4
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.
Disadvantages
Cost
Ins'lin secretion Accent'ated effects aro'nd meal ingestion Dy"oglycemia5 4eig9t gain &ay !l'nt myocardial isc9emic "reconditioning Dosing fre3'ency &edi'm
Cost
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.
Disadvantages
Cost
Dig9
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.
Cost
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.
Cost
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$$. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.
Advantages Disadvantages
Gastrointestinal side effects (na'sea5 vomiting5 diarr9ea) Cases of ac'te "ancreatitis o!served C-cell 9y"er"lasia-med'llary t9yroid t'mors in animals (liragl'tide) InKecta!le 2ong-term safety 'nBno4n Dig9
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$3. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.
Cost
&ec9anism Action(s)
In9i!its D##-4 activity5 "rolongs s'rvival of endogeno'sly released incretin 9ormones Active G2#-1 concentration Active GI# concentration Ins'lin secretion Gl'cagon secretion No 9y"oglycemia Ceig9t One'tralityP =ccasional re"orts of 'rticaria-angioedema Cases of "ancreatitis o!served 2ong-term safety 'nBno4n Dig9
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$3. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.
Advantages Disadvantages
Cost
Cost
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$3. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.
Cost
&edi'm
ADA. ,. Dia!etes Care. Diabetes Care $.1$:3%(s'""l 1);S$3. Ada"ted 4it9 "ermission from Silvio In6'cc9i5 Nale Fniversity.
8enefits s'stained at 4 years$ @inal res'lts of 2ooB ADEAD to "rovide insig9t into effects of long-term 4eig9t loss on im"ortant clinical o'tcomes
1. 2ooB ADEAD Researc9 Gro'". Diabetes Care. $../:3.;13/4-1303: $. 2ooB ADEAD Researc9 Gro'". Arch Intern Med. 2%8%<86%#85==8565.
Re o%%endations) I%%-ni>ation
#rovide infl'en6a vaccine ann'ally to all dia!etic "atients >* mont9s of age (C) Administer "ne'mococcal "olysacc9aride vaccine to all dia!etic "atients >$ years (C)
=ne-time revaccination recommended for t9ose G*4 years "revio'sly imm'ni6ed at H*% years if administered G% years ago =t9er indications for re"eat vaccination; ne"9rotic syndrome5 c9ronic renal disease5 imm'nocom"romised states
&'lti"le dr'g t9era"y (t4o or more agents at ma7imal doses) is generally re3'ired to ac9ieve !lood "ress're targets (8)
@or "atients at lo4er risB (e.g.5 4it9o't overt C,D5 H4. years of age) (E)
Consider statin t9era"y in addition to lifestyle t9era"y if 2D2 c9olesterol remains G1.. mg-d2 In t9ose 4it9 m'lti"le C,D risB factors
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3.-31.
riglyceride levels H1%. mg-d2 (1./ mmol-2)5 DD2 c9olesterol G4. mg-d2 (1.. mmol-2) in men and G%. mg-d2 (1.3 mmol-2) in 4omen5 are desira!le
Do4ever5 2D2 c9olesterolEtargeted statin t9era"y remains t9e "referred strategy (C)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S31.
A&ore or less stringent glycemic goals may !e a""ro"riate for individ'al "atients. Goals s9o'ld !e individ'ali6ed !ased on; d'ration of dia!etes5 age-life e7"ectancy5 comor!id conditions5 Bno4n C,D or advanced microvasc'lar com"lications5 9y"oglycemia 'na4areness5 and individ'al "atient considerations. M8ased on "atient c9aracteristics and res"onse to t9era"y5 9ig9er or lo4er systolic !lood "ress're targets may !e a""ro"riate. RIn individ'als 4it9 overt C,D5 a lo4er 2D2 c9olesterol goal of H/. mg-d2 (1.0 mmol-2)5 'sing a 9ig9 dose of statin5 is an o"tion. ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3$. a!le 11.
In "atients in t9ese age gro'"s 4it9 m'lti"le ot9er risB factors (1.-year risB %E1.?)5 clinical K'dgment is re3'ired (E)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3$.
Com!ination t9era"y 4it9 ASA (/%E1*$ mg-day) and clo"idogrel (/% mg-day)
Reasona!le for '" to a year after an ac'te coronary syndrome (8)
AIf not contraindicated. ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S33.
Avoid SD treatment
In "atients 4it9 sym"tomatic 9eart fail're (C)
Re o%%endations) Ne,'"o,at'$
o red'ce risB or slo4 t9e "rogression of ne"9ro"at9y
="timi6e gl'cose control (A) ="timi6e !lood "ress're control (A)
Red'ction of "rotein intaBe may im"rove meas'res of renal f'nction ('rine al!'min e7cretion rate5 G@R) (8)
o ..0E1.. g 7 Bg !ody 4tE1 7 dayE1 in t9ose 4it9 dia!etes5 earlier stages of CJD o ..0 g 7 Bg !ody 4tE1 7 dayE1 in later stages of CJD
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S34.
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S34. a!le 1$.
Stage 1 $ 3 4 %
Descri"tion Jidney damageA 4it9 normal or increased G@R Jidney damageA 4it9 mildly decreased G@R &oderately decreased G@R Severely decreased G@R Jidney fail're
?@3 4 glomerular "iltration rate >idne+ damage de"ined as abnormalities on )athologic. urine. blood. or imaging tests' ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3%. a!le 13.
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3%. a!le 14: Ada"ted from 9tt";--444.Bidney.org-"rofessionals-JD=UI-g'idelineVdia!etes-.
Re o%%endations) Retino,at'$
o red'ce risB or slo4 "rogression of retino"at9y
="timi6e glycemic control (A) ="timi6e !lood "ress're control (A)
C9ile retinal "9otogra"9y may serve as a screening tool for retino"at9y5 it is not a s'!stit'te for a com"re9ensive eye e7am
#erform com"re9ensive eye e7am at least initially and at intervals t9ereafter as recommended !y an eye care "rofessional (E)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3*.
&edications for relief of s"ecific sym"toms related to D#N5 a'tonomic ne'ro"at9y are recommended
Im"rove 3'ality of life of t9e "atient (E)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3*.
Refer "atients to foot care s"ecialists for ongoing "reventive care5 life-long s'rveillance (C)
SmoBers 2oss of "rotective sensation or str'ct'ral a!normalities Distory of "rior lo4er-e7tremity com"lications
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3/.
Refer "atients 4it9 significant cla'dication or a "ositive A8I for f'rt9er vasc'lar assessment
Consider e7ercise5 medications5 s'rgical o"tions (C)
ADA. ,I. #revention5 &anagement of Com"lications. Diabetes Care $.1$:3%(s'""l 1);S3/.
ADA. ,II. Assessment of Common Comor!id Conditions. Diabetes Care. $.1$:3%(s'""l 1);S30: a!le 1%.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4..
Confirmed5 "ersistently elevated ACR on t4o additional 'rine s"ecimens from different days
reat 4it9 an ACE in9i!itor5 titrated to normali6ation of al!'min e7cretion5 if "ossi!le (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4..
If target !lood "ress're is not reac9ed 4it9 3E* mont9s of lifestyle intervention
Consider "9armacologic treatment (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4..
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4..
Goal of treatment
8lood "ress're consistently H13.-0. mmDg or !elo4 t9e +.t9 "ercentile for age5 se75 and 9eig9t5 49ic9ever is lo4er (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4..
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S4.-S41.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.
If 2D2 c9olesterol val'es are 4it9in acce"ted risB levels (H1.. mg-d2 X$.* mmol-2Y)
Re"eat li"id "rofile every % years (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S41.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S43.
D'ring a "eriod of sta!le 9ealt95 diagnosis of C@RD can !e made in "atients 4it9 cystic fi!rosis according to 's'al diagnostic criteria (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S44.
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1$:3%(s'""l 1);S44.
ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S44.
&ore stringent targets may !e a""ro"riate in sta!le "atients 4it9 "revio's tig9t glycemic control 2ess stringent targets may !e a""ro"riate in t9ose 4it9 severe comor!idities (E)
ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S44.
ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S44.
If 9y"erglycemia is doc'mented and "ersistent5 consider treating s'c9 "atients to t9e same glycemic goals as "atients 4it9 Bno4n dia!etes (E)
ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S44.
=!tain A1C for all "atients if res'lts 4it9in "revio's $E3 mont9s 'navaila!le (E) #atients 4it9 9y"erglycemia 4it9o't a diagnosis of dia!etes; doc'ment "lans for follo4-'" testing and care at disc9arge (E)
ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S44.
ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S4%.
ADA. I1. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1$:3%(s'""l 1);S4%.
ADA. 1. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1$:3%(s'""l 1);S40.
ADA. 1. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1$:3%(s'""l 1);S40.
Strategies incl'de
E7"licit goal setting 4it9 "atients Identifying and addressing !arriers to care Integrating evidence-!ased g'idelines Incor"orating care management teams
ADA. 1. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1$:3%(s'""l 1);S4+.