ADA Standards of Medical Care 2013 FINAL 21 Dec 2012

STANDARDS OF MEDICAL CARE
STANDARDS OF MEDICAL CARE

IN DIABETES2013
IN DIABETES2013
Table of Contents
Table of Contents
Section Section Slide No. Slide No.
ADA Evidence Grading System of
Clinical Recommendations
3
I. Classification and Diagnosis 4-11
II. esting for Dia!etes in Asym"tomatic #atients 1$-1%
III. Detection and Diagnosis of
Gestational Dia!etes &ellit's (GD&)
1*-1+
I,. #revention-Delay of y"e $ Dia!etes $.-$$
,. Dia!etes Care $3-*4
,I. #revention and &anagement of
Dia!etes Com"lications
*%-1./
,II. Assessment of Common Comor!id Conditions 1.+-11.
,III. Dia!etes Care in S"ecific #o"'lations 111-131
I0. Dia!etes Care in S"ecific Settings 13$-14.
0. Strategies for Im"roving Dia!etes Care 141-14*
ADA Evien!e "#ain$ S%ste& fo#
ADA Evien!e "#ain$ S%ste& fo#
Clini!al Re!o&&enations
Clini!al Re!o&&enations
1evel of 1evel of
Evidence Evidence Descri"tion Descri"tion
A Clear or s'""ortive evidence from ade2'ately
"o3ered 3ell-cond'cted4 generali5a!le4
randomi5ed controlled trials
Com"elling none6"erimental evidence
7 S'""ortive evidence from 3ell-cond'cted co8ort
st'dies or case-control st'dy
C S'""ortive evidence from "oorly controlled or
'ncontrolled st'dies
Conflicting evidence 3it8 t8e 3eig8t of evidence
s'""orting t8e recommendation
E E6"ert consens's or clinical e6"erience
ADA. Diabetes Care $.1393*(s'""l 1):S1$9 a!le 1.
I' CLASSIFICATION AND
DIA"NOSIS
Classifi!ation of Diabetes
Classifi!ation of Diabetes
y"e 1 dia!etes
;-cell destr'ction
y"e $ dia!etes
#rogressive ins'lin secretory defect
<t8er s"ecific ty"es of dia!etes
Genetic defects in ;-cell f'nction4 ins'lin action
Diseases of t8e e6ocrine "ancreas
Dr'g- or c8emical-ind'ced
Gestational dia!etes mellit's (GD&)

ADA. I. Classification and Diagnosis. Diabetes Care $.1393*(s'""l 1):S11.
C#ite#ia fo# t(e Dia$nosis of Diabetes
A1C =*.%>
OR
?asting "lasma gl'cose (?#G)
=1$* mg-d1 (@.. mmol-1)
OR
$-8 "lasma gl'cose =$.. mg-d1
(11.1 mmol-1) d'ring an <G
OR
A random "lasma gl'cose =$.. mg-d1
(11.1 mmol-1)
ADA. I. Classification and Diagnosis. Diabetes Care $.1393*(s'""l 1):S139 a!le $.
A1C =*.%>
8e test s8o'ld !e "erformed in a
la!oratory 'sing a met8od t8at is
NGS# certified and standardi5ed
to t8e DCC assay
A
AIn t8e a!sence of 'ne2'ivocal 8y"erglycemia4 res'lt s8o'ld !e confirmed !y re"eat testing.
?asting "lasma gl'cose (?#G)
=1$* mg-d1 (@.. mmol-1)
?asting is defined as no caloric intaBe
for at least / 8
A
$-8 "lasma gl'cose =$.. mg-d1
(11.1 mmol-1) d'ring an <G
8e test s8o'ld !e "erformed as
descri!ed !y t8e CD<4 'sing a
gl'cose load containing t8e e2'ivalent
of @% g an8ydro's gl'cose
dissolved in 3ater
A
In a "atient 3it8 classic sym"toms of
8y"erglycemia or 8y"erglycemic crisis4
a random "lasma gl'cose =$.. mg-d1
(11.1 mmol-1)
)#eiabetes* IF"+ I"T+ In!#ease A1C
)#eiabetes* IF"+ I"T+ In!#ease A1C
Categories of increased risB for dia!etes
("redia!etes)
A
?#G 1..E1$% mg-d1 (%.*E*.+ mmol-1): I?G
OR
$-8 "lasma gl'cose in t8e @%-g <G
14.E1++ mg-d1 (@./E11.. mmol-1): IG
OR
A1C %.@E*.4>
A?or all t8ree tests4 risB is contin'o's4 e6tending !elo3 t8e lo3er limit of a range and !ecoming
dis"ro"ortionately greater at 8ig8er ends of t8e range.
ADA. I. Classification and Diagnosis. Diabetes Care $.1393*(s'""l 1):S139 a!le 3.
II' TESTIN" FOR DIABETES IN
II' TESTIN" FOR DIABETES IN
AS,M)TOMATIC )ATIENTS
AS,M)TOMATIC )ATIENTS
Re!o&&enations* Testin$ fo#
Re!o&&enations* Testin$ fo#
Diabetes in As%&-to&ati! )atients
Diabetes in As%&-to&ati! )atients
Consider testing over3eig8t-o!ese ad'lts

(7&I =$% Bg-m
$
) and 38o 8ave one or more
additional risB factors
In t8ose 3it8o't risB factors4 !egin testing at age

4% years (7)
If tests are normal
Re"eat testing at least at 3-year intervals (E)
Fse A1C4 ?#G4 or $-8 @%-g <G (7)
In t8ose 3it8 "redia!etes
Identify and4 if a""ro"riate4 treat ot8er C,D risB

factors (7)
ADA. II. esting for Dia!etes in Asym"tomatic #atients. Diabetes Care $.1393*(s'""l 1):S13.
C#ite#ia fo# Testin$ fo# Diabetes in
As%&-to&ati! A.lt Inivi.als /10
#8ysical inactivity
?irst-degree relative 3it8
dia!etes
Dig8-risB race-et8nicity (e.g.4
African American4 1atino4
Native American4 Asian
American4 #acific Islander)
Comen 38o delivered a !a!y
3eig8ing G+ l! or 3ere
diagnosed 3it8 GD&
Dy"ertension (=14.-+.
mmDg or on t8era"y for
8y"ertension)
DD1 c8olesterol level
H3% mg-d1 (..+. mmol-1)
and-or a triglyceride level
G$%. mg-d1 ($./$ mmol-1)
Comen 3it8 "olycystic ovary
syndrome (#C<S)
A1C =%.@>4 IG4 or I?G on
"revio's testing
<t8er clinical conditions
associated 3it8 ins'lin
resistance (e.g.4 severe
o!esity4 acant8osis nigricans)
Distory of C,D
AAt-risB 7&I may !e lo3er in some et8nic gro'"s.
1. Testing should be considered in all adults who are overweight
(BMI 25 kg/m
2
! and have additional risk "actors#
ADA. esting for Dia!etes in Asym"tomatic #atients. Diabetes Care $.1393*(s'""l 1):S149 a!le 4.
2' In t8e a!sence of criteria (risB factors on
"revio's slide)4 testing for dia!etes s8o'ld !egin
at age 4% years
3' If res'lts are normal4 testing s8o'ld !e re"eated
at least at 3-year intervals4 3it8 consideration of
more fre2'ent testing de"ending on initial
res'lts (e.g.4 t8ose 3it8 "redia!etes s8o'ld !e
tested yearly)4 and risB stat's
ADA. esting for Dia!etes in Asym"tomatic #atients. Diabetes Care $.1393*(s'""l 1):S149 a!le 4.
III' DETECTION AND
III' DETECTION AND
DIA"NOSIS OF
DIA"NOSIS OF
"ESTATIONAL DIABETES
"ESTATIONAL DIABETES
MELLIT1S /"DM0
MELLIT1S /"DM0
Re!o&&enations*
Re!o&&enations*
Dete!tion an Dia$nosis of "DM /10
Screen for 'ndiagnosed ty"e $ dia!etes

at t8e first "renatal visit in t8ose 3it8
risB factors4 'sing standard diagnostic
criteria (7)
In "regnant 3omen not "revio'sly

Bno3n to 8ave dia!etes4 screen for GD&
at $4E$/ 3eeBsI gestation4 'sing a
@%-g <G and s"ecific diagnostic
c't "oints (7)
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.1393*(s'""l 1):S1%.
Re!o&&enations*
Re!o&&enations*
Screen 3omen 3it8 GD& for "ersistent dia!etes

at *E1$ 3eeBs "ost"art'm4 'sing <G4
non"regnancy diagnostic criteria (E)
Comen 3it8 a 8istory of GD& s8o'ld

8ave lifelong screening for t8e develo"ment of
dia!etes or "redia!etes
at least every 3 years (7)
Comen 3it8 a 8istory of GD& fo'nd to 8ave

"redia!etes s8o'ld receive lifestyle interventions
or metformin to "revent dia!etes (A)
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.1393*(s'""l 1):S1%.
S!#eenin$ fo# an Dia$nosis of "DM
S!#eenin$ fo# an Dia$nosis of "DM
#erform a @%-g <G4 3it8 "lasma gl'cose

meas'rement fasting and at 1 and $ 84 at
$4E$/ 3eeBs of gestation in 3omen not
"revio'sly diagnosed 3it8 overt dia!etes
#erform <G in t8e morning after an

overnig8t fast of at least / 8
GD& diagnosis: 38en any of t8e follo3ing

"lasma gl'cose val'es are e6ceeded
E ?asting =+$ mg-d1 (%.1 mmol-1)
E 1 8 =1/. mg-d1 (1... mmol-1)
E $ 8 =1%3 mg-d1 (/.% mmol-1)
ADA. III. Detection and Diagnosis of GD&. Diabetes Care $.1393*(s'""l 1):S1%9 a!le *.
I2' )RE2ENTION3DELA, OF
I2' )RE2ENTION3DELA, OF
T,)E 2 DIABETES
T,)E 2 DIABETES
Re!o&&enations*
Re!o&&enations*
)#evention3Dela% of T%-e 2 Diabetes
Refer "atients 3it8 IG (A)4 I?G (E)4 or A1C

%.@E*.4> (E) to ongoing s'""ort "rogram
argeting 3eig8t loss of @> of !ody 3eig8t
At least 1%. min-3eeB moderate "8ysical activity
?ollo3-'" co'nseling im"ortant for s'ccess (7)
7ased on cost-effectiveness of dia!etes

"revention4 t8ird-"arty "ayers s8o'ld cover
s'c8 "rograms (E)
ADA. I,. #revention-Delay of y"e $ Dia!etes. Diabetes Care $.1393*(s'""l 1):S1*.
Re!o&&enations*
Re!o&&enations*
Consider metformin for "revention of ty"e $

dia!etes if IG (A)4 I?G (E)4 or A1C %.@E*.4> (E)
Es"ecially for t8ose 3it8 7&I G3% Bg-m
$
4
age H*. years4 and 3omen 3it8 "rior GD& (A)
In t8ose 3it8 "redia!etes4 monitor for

develo"ment of dia!etes ann'ally (E)
Screen for and treat modifia!le risB factors for

C,D (7)
ADA. I,. #revention-Delay of y"e $ Dia!etes. Diabetes Care $.1393*(s'""l 1):S1*.
2' DIABETES CARE
A com"lete medical eval'ation s8o'ld !e "erformed to
E Classify t8e dia!etes
E Detect "resence of dia!etes com"lications
E Revie3 "revio's treatment4 risB factor control in "atients 3it8
esta!lis8ed dia!etes
E Assist in form'lating a management "lan
E #rovide a !asis for contin'ing care
#erform la!oratory tests necessary to eval'ate eac8 "atientIs
medical condition
Diabetes Ca#e* Initial Eval.ation
Diabetes Ca#e* Initial Eval.ation
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1*.
Co&-onents of t(e Co&-#e(ensive
Diabetes Eval.ation /10
&edical 8istory (1)
Age and c8aracteristics of onset of dia!etes

(e.g.4 DJA4 asym"tomatic la!oratory finding)
Eating "atterns4 "8ysical activity 8a!its4

n'tritional stat's4 and 3eig8t 8istory9 gro3t8
and develo"ment in c8ildren and adolescents
Dia!etes ed'cation 8istory
Revie3 of "revio's treatment regimens and

res"onse to t8era"y (A1C records)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@9 a!le @.
&edical 8istory ($)
C'rrent treatment of dia!etes4 incl'ding

medications4 medication ad8erence and !arriers
t8ereto4 meal "lan4 "8ysical activity "atterns4
and readiness for !e8avior c8ange
Res'lts of gl'cose monitoring and "atientIs

'se of data
DJA fre2'ency4 severity4 and ca'se
Dy"oglycemic e"isodes
E Dy"oglycemia a3areness
E Any severe 8y"oglycemia: fre2'ency and ca'se
&edical 8istory (3)
Distory of dia!etes-related com"lications

E &icrovasc'lar: retino"at8y4 ne"8ro"at8y4 ne'ro"at8y
Sensory ne'ro"at8y4 incl'ding 8istory of foot lesions
A'tonomic ne'ro"at8y4 incl'ding se6'al dysf'nction and
gastro"aresis
E &acrovasc'lar: CDD4 cere!rovasc'lar disease4 #AD
E <t8er: "syc8osocial "ro!lems
A
4 dental disease
A
ASee a""ro"riate referrals for t8ese categories.
#8ysical e6amination (1)
Deig8t4 3eig8t4 7&I
7lood "ress're determination4 incl'ding

ort8ostatic meas'rements 38en indicated
?'ndosco"ic e6amination
A
8yroid "al"ation
SBin e6amination (for acant8osis nigricans and

ins'lin inKection sites)
ASee a""ro"riate referrals for t8ese categories.
#8ysical e6amination ($)
Com"re8ensive foot e6amination

EIns"ection
E #al"ation of dorsalis "edis and "osterior ti!ial "'lses
E #resence-a!sence of "atellar and Ac8illes refle6es
E Determination of "ro"rioce"tion4 vi!ration4 and
monofilament sensation
1a!oratory eval'ation
A1C4 if res'lts not availa!le 3it8in "ast

$E3 mont8s
If not "erformed-availa!le 3it8in "ast year

E ?asting li"id "rofile4 incl'ding total4 1D14 and DD1
c8olesterol and triglycerides
E 1iver f'nction tests
E est for 'rine al!'min e6cretion 3it8 s"ot 'rine
al!'min-to-creatinine ratio
E Ser'm creatinine and calc'lated G?R
E 8yroid-stim'lating 8ormone in ty"e 1 dia!etes4
dysli"idemia4 or 3omen over age %. years
Referrals
Eye care "rofessional for ann'al dilated eye e6am
?amily "lanning for 3omen of re"rod'ctive age
Registered dietitian for &N
Dia!etes self-management ed'cation
Dentist for com"re8ensive "eriodontal

e6amination
&ental 8ealt8 "rofessional4 if needed

ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@.
Diabetes Ca#e* Mana$e&ent
Diabetes Ca#e* Mana$e&ent
#eo"le 3it8 dia!etes s8o'ld receive medical care from a
team t8at may incl'de
#8ysicians4 n'rse "ractitioners4 "8ysicianIs assistants4 n'rses4
dietitians4 "8armacists4 mental 8ealt8 "rofessionals
In t8is colla!orative and integrated team a""roac84 essential t8at
individ'als 3it8 dia!etes ass'me an active role in t8eir care
&anagement "lan s8o'ld recogni5e dia!etes self-
management ed'cation (DS&E) and on-going dia!etes
s'""ort
Diabetes Ca#e* "l%!e&i! Cont#ol
Diabetes Ca#e* "l%!e&i! Cont#ol
3o "rimary tec8ni2'es availa!le for 8ealt8

"roviders and "atients to assess effectiveness
of management "lan on glycemic control
#atient self-monitoring of !lood gl'cose (S&7G)4

or interstitial gl'cose
A1C
Re!o&&enations*
Re!o&&enations*
"l.!ose Monito#in$ /10
#atients on m'lti"le-dose ins'lin (&DI) or

ins'lin "'m" t8era"y s8o'ld do S&7G (7)
At least "rior to meals and snacBs
<ccasionally "ost"randially
At !edtime
#rior to e6ercise
C8en t8ey s's"ect lo3 !lood gl'cose
After treating lo3 !lood gl'cose 'ntil t8ey are

normoglycemic
#rior to critical tasBs s'c8 as driving

Re!o&&enations*
Re!o&&enations*
C8en "rescri!ed as "art of a !roader ed'cational
conte6t4 S&7G res'lts may !e 8el"f'l to g'ide
treatment decisions and-or "atient self-management
for "atients 'sing less fre2'ent ins'lin inKections or
nonins'lin t8era"ies (E)
C8en "rescri!ing S&7G4 ens're t8at "atients

receive ongoing instr'ction and reg'lar eval'ation of
S&7G tec8ni2'e and S&7G res'lts4 as 3ell as t8eir
a!ility to 'se S&7G data to adK'st t8era"y (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1*.
Re!o&&enations*
Re!o&&enations*
Contin'o's gl'cose monitoring (CG&) 3it8

intensive ins'lin regimens 'sef'l tool to lo3er
A1C in selected ad'lts (age =$% years) 3it8 ty"e
1 dia!etes (A)
Evidence for A1C-lo3ering less strong in

c8ildren4 teens4 and yo'nger ad'lts9 8o3ever4
CG& may !e 8el"f'l9 s'ccess correlates 3it8
ad8erence to device 'se (C)
CG& may !e a s'""lemental tool to S&7G in

t8ose 3it8 8y"oglycemia 'na3areness and-or
fre2'ent 8y"oglycemic e"isodes (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1@-S1/.
Re!o&&enations* A1C
Re!o&&enations* A1C
#erform A1C test at least t3ice yearly in

"atients meeting treatment goals (and
8ave sta!le glycemic control) (E)
#erform A1C test 2'arterly in "atients

38ose t8era"y 8as c8anged or 38o are
not meeting glycemic goals (E)
Fse of "oint-of-care (#<C) testing for A1C

"rovides t8e o""ort'nity for more timely
treatment c8anges (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1$93%(s'""l 1):S1/.
Co##elation of A1C 8it(
Co##elation of A1C 8it(
Ave#a$e "l.!ose /A"0
Ave#a$e "l.!ose /A"0
&ean "lasma gl'cose
A1C (>) mg-d1 mmol-1
* 1$* @..
@ 1%4 /.*
/ 1/3 1..$
+ $1$ 11./
1. $4. 13.4
11 $*+ 14.+
1$ $+/ 1*.%
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1+9 a!le /.
8ese estimates are !ased on ADAG data of L$4@.. gl'cose meas'rements over 3 mont8s "er A1C
meas'rement in %.@ ad'lts 3it8 ty"e 14 ty"e $4 and no dia!etes. 8e correlation !et3een A1C and
average gl'cose 3as ..+$. A calc'lator for converting A1C res'lts into estimated average gl'cose (eAG)4
in eit8er mg-d1 or mmol-14 is availa!le at 8tt":--"rofessional.dia!etes.org-eAG.
1o3ering A1C to !elo3 or aro'nd @> 8as !een

s8o3n to red'ce microvasc'lar com"lications
and4 if im"lemented soon after t8e diagnosis of
dia!etes4 is associated 3it8 long-term red'ction
in macrovasc'lar disease (7)
8erefore4 a reasona!le A1C goal for many

non"regnant ad'lts is H@> (7)
Re!o&&enations*
Re!o&&enations*
"l%!e&i! "oals in A.lts /10
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S1+.
#roviders mig8t reasona!ly s'ggest more stringent

A1C goals (s'c8 as H*.%>) for selected individ'al
"atients4 if t8is can !e ac8ieved 3it8o't significant
8y"oglycemia or ot8er adverse effects of treatment (C)
A""ro"riate "atients mig8t incl'de t8ose 3it8 s8ort
d'ration of dia!etes4 long life e6"ectancy4 and no
significant C,D (C)
Re!o&&enations*
Re!o&&enations*
Re!o&&enations*
Re!o&&enations*
1ess stringent A1C goals (s'c8 as H/>)

may !e a""ro"riate for "atients 3it8 (7)
EDistory of severe 8y"oglycemia4 limited life
e6"ectancy4 advanced microvasc'lar or
macrovasc'lar com"lications4 e6tensive
comor!id conditions
E8ose 3it8 longstanding dia!etes in 38om t8e
general goal is diffic'lt to attain des"ite dia!etes
self-management ed'cation4 a""ro"riate gl'cose
monitoring4 and effective doses of m'lti"le
gl'cose lo3ering agents incl'ding ins'lin
Intensive "l%!e&i! Cont#ol an
Ca#iovas!.la# O.t!o&es* ACCORD
Ca#iovas!.la# O.t!o&es* ACCORD
Gerstein DC4 et al4 for t8e Action to Control Cardiovasc'lar RisB in Dia!etes St'dy Gro'".
N Engl J Med $../93%/:$%4%-$%%+.
$2%%& New England Journal of Medicine' (sed with )ermission'
*rimar+ ,utcome# -on"atal MI. non"atal stroke. /01 death
234%'5% (%'6&78'%9!
Ca#iovas!.la# O.t!o&es* AD2ANCE
Ca#iovas!.la# O.t!o&es* AD2ANCE
$2%%& New England Journal of Medicine' (sed with )ermission'
*rimar+ ,utcome# Microvascular )lus macrovascular
(non"atal MI. non"atal stroke. /01 death!
#atel A4 et al4. for t8e AD,ANCE Colla!orative Gro'". N Engl J Med $../93%/:$%*.-$%@$.
234%'5% (%'&27%'5&!
Ca#iovas!.la# O.t!o&es* 2ADT
Ca#iovas!.la# O.t!o&es* 2ADT
D'cB3ort8 C4 et al.4 for t8e ,AD Investigators. N Engl J Med $..+93*.:1$+-13+.
*rimar+ ,utcome# -on"atal MI. non"atal stroke. /01 death.
hos)itali:ation "or heart "ailure. revasculari:ation
234%'&& (%'6978'%5!
$2%%5 New England Journal of Medicine' (sed with )ermission'
"l%!e&i! Re!o&&enations fo#
Non-#e$nant A.lts 8it( Diabetes /10
A1C H@..>
A
#re"randial ca"illary
"lasma gl'cose
@.E13. mg-d1
A

(3.+E@.$ mmol-1)
#eaB "ost"randial
ca"illary "lasma gl'cose
M
H1/. mg-d1
A

(H1... mmol-1)
AIndivid'ali5e goals !ased on t8ese val'es.
;#ost"randial gl'cose meas'rements s8o'ld !e made 1E$ 8 after t8e !eginning of t8e meal4 generally
"eaB levels in "atients 3it8 dia!etes.
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$19 a!le +.
Goals s8o'ld !e individ'ali5ed !ased on

ED'ration of dia!etes
EAge-life e6"ectancy
EComor!id conditions
EJno3n C,D or advanced microvasc'lar
com"lications
EDy"oglycemia 'na3areness
EIndivid'al "atient considerations
&ore or less stringent glycemic goals may

!e a""ro"riate for individ'al "atients
#ost"randial gl'cose may !e targeted if

A1C goals are not met des"ite reac8ing
"re"randial gl'cose goals
Re!o&&enations* Ins.lin T(e#a-%
fo# T%-e 1 Diabetes /10
&ost "eo"le 3it8 ty"e 1 dia!etes
S8o'ld !e treated 3it8 &DI inKections (3E4

inKections "er day of !asal and "randial ins'lin)
or contin'o's s'!c'taneo's ins'lin inf'sion
(CSII) (A)
S8o'ld !e ed'cated in 8o3 to matc8 "randial

ins'lin dose to car!o8ydrate intaBe4 "remeal
!lood gl'cose4 and antici"ated activity (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$1.
&ost "eo"le 3it8 ty"e 1 dia!etes s8o'ld

'se ins'lin analogs to red'ce
8y"oglycemia risB (A)
Consider screening t8ose 3it8 ty"e 1

dia!etes for ot8er a'toimm'ne diseases
(t8yroid4 vitamin 71$ deficiency4 celiac) as
a""ro"riate (7)
&etformin4 if not contraindicated and

if tolerated4 is t8e "referred initial
"8armacological agent for ty"e $ dia!etes
(A)
In ne3ly diagnosed ty"e $ dia!etic

"atients 3it8 marBedly sym"tomatic
and-or elevated !lood gl'cose levels or
A1C4 consider ins'lin t8era"y4 3it8 or
3it8o't additional agents4 from t8e
o'tset (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$$.
Re!o&&enations* T(e#a-%
Re!o&&enations* T(e#a-%
Re!o&&enations*
Re!o&&enations*
T(e#a-% fo# T%-e 2 Diabetes /20
If nonins'lin monot8era"y at ma6imal

tolerated dose does not ac8ieve or
maintain t8e A1C target over 3E* mont8s4
add a second oral agent4 a G1#-1 rece"tor
agonist4 or ins'lin (A)
Re!o&&enations*
Re!o&&enations*
A "atient-centered a""roac8 s8o'ld !e

'sed to g'ide c8oice of "8armacological
agents9 considerations incl'de efficacy4
cost4 "otential side effects4 effects on
3eig8t4 comor!idities4 8y"oglycemia risB4
and "atient "references (E)
D'e to t8e "rogressive nat're of ty"e $

dia!etes4 ins'lin t8era"y is event'ally
indicated for many "atients 3it8 ty"e $
dia!etes (7)
Re!o&&enations*
Re!o&&enations*
Mei!al N.t#ition T(e#a-% /MNT0
Mei!al N.t#ition T(e#a-% /MNT0
Individ'als 38o 8ave "redia!etes or

dia!etes s8o'ld receive individ'ali5ed &N
as needed to ac8ieve treatment goals4
"refera!ly "rovided !y a registered
dietitian familiar 3it8 t8e com"onents of
dia!etes &N (A)
7eca'se &N can res'lt in cost-savings

and im"roved o'tcomes (7)4 &N s8o'ld
!e ade2'ately covered !y ins'rance and
ot8er "ayers (E)
Loo9 A:EAD /A!tion fo# :ealt( in
Loo9 A:EAD /A!tion fo# :ealt( in
Diabetes0* T#ial :alte Ea#l%
Diabetes0* T#ial :alte Ea#l%
14 $. 1ooB ADEAD Researc8 Gro'". Diabetes Care. $..@93.:13@4-13/3 and Arch Intern Med.
$.1.91@.:1%**E1%@%9 8tt":--333.ni8.gov-ne3s-8ealt8-oct$.1$-niddB-1+.8tm.
Intensive lifestyle intervention res'lted in

1
Average /.*> 3eig8t loss
Significant red'ction of A1C
Red'ction in several C,D risB factors
7enefits s'stained at 4 years

$
Do3ever4 trial 8alted after 11 years of

follo3-'" !eca'se t8ere 3as no significant
difference in "rimary cardiovasc'lar
o'tcome !et3een 3eig8t loss4 standard
care gro'"
Re!o&&enations* Diabetes
Self;Mana$e&ent E.!ation+ S.--o#t
#eo"le 3it8 dia!etes s8o'ld receive DS&E

according to National Standards for Dia!etes
Self-&anagement Ed'cation and S'""ort at
diagnosis and as needed t8ereafter (7)
Effective self-management4 2'ality of life are

Bey o'tcomes of DS&E9 s8o'ld !e meas'red4
monitored as "art of care (C)
DS&E s8o'ld address "syc8osocial iss'es4

since emotional 3ell-!eing is associated 3it8
"ositive o'tcomes (C)
DS&E and DS&S "rograms are a""ro"riate

ven'es for "eo"le 3it8 "redia!etes to receive
ed'cation and s'""ort to develo" and
maintain !e8aviors t8at can "revent or delay
t8e onset of dia!etes (C)
7eca'se DS&E can res'lt in cost-savings and

im"roved o'tcomes (7)4 DS&E s8o'ld !e
reim!'rsed !y t8ird-"arty "ayers (E)
Re!o&&enations* )(%si!al A!tivit%
Re!o&&enations* )(%si!al A!tivit%
Advise "eo"le 3it8 dia!etes to "erform at

least 1%. min-3eeB of moderate-intensity
aero!ic "8ysical activity (%.E@.> of
ma6im'm 8eart rate)4 s"read over at least
3 days "er 3eeB 3it8 no more t8an
$ consec'tive days 3it8o't e6ercise (A)
In a!sence of contraindications4 ad'lts

3it8 ty"e $ dia!etes s8o'ld !e enco'raged
to "erform resistance training at least
t3ice "er 3eeB (A)
Re!o&&enations*
Re!o&&enations*
)s%!(oso!ial Assess&ent an Ca#e
)s%!(oso!ial Assess&ent an Ca#e
<ngoing "art of medical management of

dia!etes (E)
#syc8osocial screening-follo3-'": attit'des

a!o't dia!etes4 medical
management-o'tcomes e6"ectations4
affect-mood4 2'ality of life4 reso'rces4
"syc8iatric 8istory (E)
C8en self-management is "oor4 screen for

"syc8osocial "ro!lems: de"ression4 dia!etes-
related an6iety4 eating disorders4 cognitive
im"airment (7)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$%-S$*.
Re!o&&enations* :%-o$l%!e&ia /10
Individ'als at risB for 8y"oglycemia s8o'ld

!e asBed a!o't sym"tomatic and
asym"tomatic 8y"oglycemia at eac8
enco'nter (C)
Gl'cose (1%E$. g) "referred treatment for

conscio's individ'al 3it8 8y"oglycemia (E)
Gl'cagon s8o'ld !e "rescri!ed for all

individ'als at significant risB of severe
8y"oglycemia and caregivers-family
mem!ers instr'cted in administration (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$*.
Dy"oglycemia 'na3areness or one or more

e"isodes of severe 8y"oglycemia s8o'ld
trigger re-eval'ation of t8e treatment
regimen (E)
Ins'lin-treated "atients 3it8 8y"oglycemia

'na3areness or an e"isode of severe
8y"oglycemia
Advised to raise glycemic targets to strictly avoid

f'rt8er 8y"oglycemia for at least several 3eeBs4
to "artially reverse 8y"oglycemia 'na3areness4
and to red'ce risB of f't're e"isodes (A)
<ngoing assessment of cognitive f'nction

is s'ggested 3it8 increased vigilance for
8y"oglycemia !y t8e clinician4 "atient4 and
caregivers if lo3 cognition and-or declining
cognition is fo'nd (7)
Re!o&&enations* Ba#iat#i! S.#$e#%
Re!o&&enations* Ba#iat#i! S.#$e#%
Consider !ariatric s'rgery for ad'lts 3it8 7&I

=3% Bg-m
$
and ty"e $ dia!etes (7)
After s'rgery4 life-long lifestyle s'""ort and

medical monitoring is necessary (7)
Ins'fficient evidence to recommend s'rgery in

"atients 3it8 7&I H3% Bg-m
$
o'tside of a
researc8 "rotocol (E)
Cell-designed4 randomi5ed controlled trials

com"aring o"timal medical-lifestyle t8era"y
needed to determine long-term !enefits4 cost-
effectiveness4 risBs (E)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$@.
Re!o&&enations* I&&.ni<ation /10
#rovide infl'en5a vaccine ann'ally to all

dia!etic "atients =* mont8s of age (C)
Administer "ne'mococcal "olysacc8aride

vaccine to all dia!etic "atients =$ years (C)
<ne-time revaccination recommended for t8ose

G*4 years "revio'sly imm'ni5ed at H*% years
if administered G% years ago
<t8er indications for re"eat vaccination:

ne"8rotic syndrome4 c8ronic renal disease4
imm'nocom"romised states
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$/.
Administer 8e"atitis 7 vaccination to

'nvaccinated ad'lts 3it8 dia!etes 38o are
aged 1+ t8ro'g8 %+ years (C)
Consider administering 8e"atitis 7

vaccination to 'nvaccinated ad'lts 3it8
dia!etes 38o are aged =*. years (C)
ADA. ,. Dia!etes Care. Diabetes Care $.1393*(s'""l 1):S$/.
2I' )RE2ENTION AND
MANA"EMENT OF
DIABETES COM)LICATIONS
C,D is t8e maKor ca'se of mor!idity4 mortality for t8ose 3it8
dia!etes
Common conditions coe6isting 3it8 ty"e $ dia!etes (e.g.4
8y"ertension4 dysli"idemia) are clear risB factors for C,D
Dia!etes itself confers inde"endent risB
7enefits o!served 38en individ'al cardiovasc'lar risB factors
are controlled to "revent-slo3 C,D in "eo"le 3it8 dia!etes
Ca#iovas!.la# Disease /C2D0 in
Ca#iovas!.la# Disease /C2D0 in
Inivi.als 8it( Diabetes
Inivi.als 8it( Diabetes
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S$/-$+.
Re!o&&enations*
Re!o&&enations*
:%-e#tension3Bloo )#ess.#e Cont#ol
Screening and diagnosis
7lood "ress're s8o'ld !e meas'red at

every ro'tine visit
#atients fo'nd to 8ave elevated !lood

"ress're s8o'ld 8ave !lood "ress're
confirmed on a se"arate day (7)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S$/-S$+.
Re!o&&enations*
Re!o&&enations*
Goals
#eo"le 3it8 dia!etes and 8y"ertension s8o'ld !e treated to a
systolic !lood "ress're goal of H14. mmDg (7)
1o3er systolic targets4 s'c8 as H13. mmDg4 may !e
a""ro"riate for certain individ'als4 s'c8 as yo'nger "atients4
if it can !e ac8ieved 3it8o't 'nd'e treatment !'rden (C)
#atients 3it8 dia!etes s8o'ld !e treated to a diastolic !lood
"ress're H/. mmDg (7)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S$+.
Re!o&&enations*
Re!o&&enations*
reatment (1)
#atients 3it8 a !lood "ress're (7#) G1$.-/. mmDg

s8o'ld !e advised on lifestyle c8anges to red'ce 7# (7)
#atients 3it8 confirmed 7# =14.-/. mmDg s8o'ld4 in

addition to lifestyle t8era"y4 8ave "rom"t initiation and
timely s'!se2'ent titration of "8armacological t8era"y
to ac8ieve 7# goals (7)
Re!o&&enations*
Re!o&&enations*
reatment ($)
1ifestyle t8era"y for elevated 7# (7)

Ceig8t loss if over3eig8t
DASD-style dietary "attern incl'ding red'cing sodi'm4
increasing "otassi'm intaBe
&oderation of alco8ol intaBe
Increased "8ysical activity

Re!o&&enations*
Re!o&&enations*
reatment (3)
#8armacological t8era"y for "atients 3it8 dia!etes and
8y"ertension (C)
A regimen t8at incl'des eit8er an ACE in8i!itor or angiotensin II
rece"tor !locBer9 if one class is not tolerated4 s'!stit'te t8e ot8er
&'lti"le dr'g t8era"y (t3o or more agents at ma6imal doses)
generally re2'ired to ac8ieve 7# targets (7)
Administer one or more anti8y"ertensive medications at
!edtime (A)
Re!o&&enations*
Re!o&&enations*
reatment (4)
If ACE in8i!itors4 AR7s4 or di'retics are 'sed4 Bidney
f'nction4 ser'm "otassi'm levels s8o'ld !e monitored (E)
In "regnant "atients 3it8 dia!etes and c8ronic
8y"ertension4 !lood "ress're target goals of 11.E1$+-*%E
@+ mmDg are s'ggested in interest of long-term maternal
8ealt8 and minimi5ing im"aired fetal gro3t89 ACE
in8i!itors4 AR7s4 contraindicated d'ring "regnancy (E)
Re!o&&enations*
Re!o&&enations*
D%sli-ie&ia3Li-i Mana$e&ent /10
Screening
In most ad'lt "atients4 meas're fasting li"id

"rofile at least ann'ally (7)
In ad'lts 3it8 lo3-risB li"id val'es

(1D1 c8olesterol H1.. mg-d14 DD1 c8olesterol
G%. mg-d14 and triglycerides H1%. mg-d1)4 li"id
assessments may !e re"eated every $ years (E)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S31.
Re!o&&enations*
Re!o&&enations*
reatment recommendations and goals (1)
o im"rove li"id "rofile in "atients 3it8 dia!etes4

recommend lifestyle modification (A)4 foc'sing on
Red'ction of sat'rated fat4 trans fat4 c8olesterol intaBe
Increased n-3 fatty acids4 visco's fi!er4
"lant stanols-sterols
Ceig8t loss (if indicated)
Increased "8ysical activity
Re!o&&enations*
Re!o&&enations*
reatment recommendations and goals ($)
Statin t8era"y s8o'ld !e added to lifestyle t8era"y4 regardless of
!aseline li"id levels
3it8 overt C,D (A)
3it8o't C,D G4. years of age 38o 8ave one or more ot8er C,D risB factors (A)
?or "atients at lo3er risB (e.g.4 3it8o't overt C,D4 H4. years of age)
(C)
Consider statin t8era"y in addition to lifestyle t8era"y if 1D1 c8olesterol remains
G1.. mg-d1
In t8ose 3it8 m'lti"le C,D risB factors
Re!o&&enations*
Re!o&&enations*
In individ'als 3it8o't overt C,D

#rimary goal is an 1D1 c8olesterol
H1.. mg-d1 ($.* mmol-1) (7)
In individ'als 3it8 overt C,D

1o3er 1D1 c8olesterol goal of H@. mg-d1
(1./ mmol-1)4 'sing a 8ig8 dose of a statin4
is an o"tion (7)
Re!o&&enations*
Re!o&&enations*
If targets not reac8ed on ma6imal tolerated statin t8era"y
Alternative t8era"e'tic goal: red'ce 1D1 c8olesterol L3.E4.> from !aseline (7)
riglyceride levels H1%. mg-d1
(1.@ mmol-1)4 DD1 c8olesterol G4. mg-d1 (1.. mmol-1) in men and
G%. mg-d1
(1.3 mmol-1) in 3omen4 are desira!le (C)
Do3ever4 1D1 c8olesterolEtargeted statin t8era"y remains t8e "referred strategy
(A)
Re!o&&enations*
Re!o&&enations*
reatment recommendations and goals (%)
Com!ination t8era"y 8as !een s8o3n not to

"rovide additional cardiovasc'lar !enefit a!ove
statin t8era"y alone and is not generally
recommended (A)
Statin t8era"y is contraindicated in "regnancy (7)

Re!o&&enations* "l%!e&i!+ Bloo
Re!o&&enations* "l%!e&i!+ Bloo
)#ess.#e+ Li-i Cont#ol in A.lts
)#ess.#e+ Li-i Cont#ol in A.lts
A1C H@..>
A
7lood "ress're H14.-/. mmDg
M
1i"ids: 1D1
c8olesterol
H1.. mg-d1 (H$.* mmol-1)
N
Statin t8era"y for t8ose 3it8
8istory of &I or age G4.O or
ot8er risB factors
A&ore or less stringent glycemic goals may !e a""ro"riate for individ'al "atients. Goals s8o'ld !e
individ'ali5ed !ased on: d'ration of dia!etes4 age-life e6"ectancy4 comor!id conditions4 Bno3n C,D or
advanced microvasc'lar com"lications4 8y"oglycemia 'na3areness4 and individ'al "atient
considerations.
M7ased on "atient c8aracteristics and res"onse to t8era"y4 8ig8er or lo3er systolic !lood "ress're targets
may !e a""ro"riate.
NIn individ'als 3it8 overt C,D4 a lo3er 1D1 c8olesterol goal of H@. mg-d1 (1./ mmol-1)4 'sing a 8ig8
dose of statin4 is an o"tion.
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S339 a!le 1..
Re!o&&enations*
Re!o&&enations*
Anti-latelet A$ents /10
Consider as"irin t8era"y (@%E1*$ mg-day) (C)
As a "rimary "revention strategy in t8ose 3it8 ty"e 1 or ty"e $
dia!etes at increased cardiovasc'lar risB (1.-year risB G1.>)
Incl'des most men G%. years of age or 3omen G*. years of age
38o 8ave at least one additional maKor risB factor
?amily 8istory of C,D
Dy"ertension
SmoBing
Dysli"idemia
Al!'min'ria
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3$-S33.
Re!o&&enations*
Re!o&&enations*
As"irin s8o'ld not !e recommended for C,D "revention for
ad'lts 3it8 dia!etes at lo3 C,D risB4 since "otential adverse
effects from !leeding liBely offset "otential !enefits (C)
1.-year C,D risB H%>: men H%. and 3omen H*. years of age
3it8 no maKor additional C,D risB factors
In "atients in t8ese age gro'"s 3it8 m'lti"le ot8er risB
factors (1.-year risB
%E1.>)4 clinical K'dgment is re2'ired (E)
Re!o&&enations*
Re!o&&enations*
Fse as"irin t8era"y (@%E1*$ mg-day)
Secondary "revention strategy in t8ose 3it8 dia!etes 3it8 a
8istory of C,D (A)
?or "atients 3it8 C,D and doc'mented as"irin allergy
Clo"idogrel (@% mg-day) s8o'ld !e 'sed (7)
Com!ination t8era"y 3it8 as"irin (@%E1*$ mg-day) and
clo"idogrel (@% mg-day)
Reasona!le for '" to a year after an ac'te coronary syndrome (7)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S33-S34.
Re!o&&enations*
Re!o&&enations*
S&o9in$ Cessation
S&o9in$ Cessation
Advise all "atients not to smoBe or 'se

to!acco "rod'cts (A)
Incl'de smoBing cessation co'nseling and

ot8er forms of treatment as a ro'tine
com"onent of dia!etes care (7)
Re!o&&enations*
Re!o&&enations*
Co#ona#% :ea#t Disease S!#eenin$
Co#ona#% :ea#t Disease S!#eenin$
In asym"tomatic "atients4 ro'tine

screening for CAD is not recommended4 as
it does not im"rove o'tcomes as long as
C,D risB factors are treated (A)
Re!o&&enations*
Re!o&&enations*
Co#ona#% :ea#t Disease T#eat&ent /10
o red'ce risB of cardiovasc'lar events in "atients 3it8
Bno3n C,D4 consider
ACE in8i!itor (C)
As"irin
A
(A)
Statin t8era"y
A
(A)
In "atients 3it8 a "rior &I

;-!locBers s8o'ld !e contin'ed for at least
$ years after t8e event (7)
AIf not contraindicated.
Re!o&&enations*
Re!o&&enations*
Avoid t8ia5olidinedione treatment in

"atients 3it8 sym"tomatic 8eart fail're (C)
&etformin 'se in "atients 3it8 sta!le CD?
Indicated if renal f'nction is normal (C)
S8o'ld !e avoided in 'nsta!le or 8os"itali5ed

"atients 3it8 CD? (C)
Re!o&&enations* Ne-(#o-at(%
Re!o&&enations* Ne-(#o-at(%
o red'ce t8e risB or slo3 t8e "rogression

of ne"8ro"at8y
<"timi5e gl'cose control (A)
<"timi5e !lood "ress're control (A)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S34-S3%.
Re!o&&enations*
Re!o&&enations*
Ne-(#o-at(% S!#eenin$
Ne-(#o-at(% S!#eenin$
Assess 'rine al!'min e6cretion ann'ally (7)

In ty"e 1 dia!etic "atients 3it8 dia!etes d'ration of =% years
In all ty"e $ dia!etic "atients at diagnosis
&eas're ser'm creatinine at least ann'ally (E)

In all ad'lts 3it8 dia!etes regardless of degree of 'rine
al!'min e6cretion
Ser'm creatinine s8o'ld !e 'sed to estimate G?R and stage
level of c8ronic Bidney disease4 if "resent
Re!o&&enations*
Re!o&&enations*
Ne-(#o-at(% T#eat&ent /10
Non"regnant "atient 3it8 modestly elevated (3.-$++ mg-day) (C)
or 8ig8er levels (=3.. mg-day) (A) of 'rinary al!'min e6cretion
Fse eit8er ACE in8i!itors or AR7s
Red'ction of "rotein intaBe may im"rove meas'res of renal
f'nction ('rine al!'min e6cretion rate4 G?R) (7)
o ../E1.. g-Bg !ody 3t "er day in t8ose
3it8 dia!etes4 earlier stages of CJD
o ../ g-Bg !ody 3t "er day in later stages
of CJD
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S34-S3%.
Re!o&&enations*
Re!o&&enations*
C8en ACE in8i!itors4 AR7s4 or di'retics are 'sed4 monitor
ser'm creatinine and "otassi'm levels for t8e develo"ment of
increased creatinine or c8anges in "otassi'm (E)
Reasona!le to contin'e monitoring 'rine al!'min e6cretion to
assess !ot8 res"onse to t8era"y and disease "rogression (E)
C8en estimated G?R is H*. m1-min-
1.@3 m
$
4 eval'ate and manage "otential com"lications of CJD
(E)
ADA. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%.
Re!o&&enations*
Re!o&&enations*
Consider referral to a "8ysician

e6"erienced in care of Bidney disease (7)
Fncertainty a!o't etiology of Bidney disease
Diffic'lt management iss'es
Advanced Bidney disease

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%.
Definitions of Abno#&alities in
Definitions of Abno#&alities in
Alb.&in E=!#etion
Alb.&in E=!#etion
Category
S"ot collection
(Pg-mg
creatinine)
Normal H3.
Increased 'rinary
al!'min e6cretionA =3.
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%9 a!le 11.
ADistorically4 ratios !et3een 3. and $++ 8ave !een called microal!'min'ria and t8ose 3.. or greater
8ave !een called macroal!'min'ria (or clinical al!'min'ria).
Sta$es of C(#oni! >ine% Disease
Sta$es of C(#oni! >ine% Disease
Stage Descri"tion
G?R (m1-min
"er 1.@3 m
$

!ody s'rface
area)
1 Jidney damage
A
3it8 normal or
increased G?R
=+.
$ Jidney damage
A
3it8 mildly
decreased G?R
*.E/+
3 &oderately decreased G?R 3.E%+
4 Severely decreased G?R 1%E$+
% Jidney fail're H1% or dialysis
<idne+ damage de"ined as abnormalities on )athologic. urine. blood. or imaging tests'
=>3 4 glomerular "iltration rate
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%-S3*9 a!le 1$.
Mana$e&ent of C>D in Diabetes /10
G?R Recommended
All "atients Qearly meas'rement of creatinine4 'rinary
al!'min e6cretion4 "otassi'm
4%-*. Referral to ne"8rology if "ossi!ility for
nondia!etic Bidney disease e6ists
Consider dose adK'stment of medications
&onitor eG?R every * mont8s
&onitor electrolytes4 !icar!onate4 8emoglo!in4
calci'm4 "8os"8or's4 "arat8yroid 8ormone at
least yearly
Ass're vitamin D s'fficiency
Consider !one density testing
Referral for dietary co'nselling
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3@9 a!le 139
Ada"ted from 8tt":--333.Bidney.org-"rofessionals-JD<RI-g'idelineSdia!etes-.
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3@9 a!le 139
Ada"ted from 8tt":--333.Bidney.org-"rofessionals-JD<RI-g'idelineSdia!etes-.
G?R Recommended
3.-44 &onitor eG?R every 3 mont8s
&onitor electrolytes4 !icar!onate4
calci'm4 "8os"8or's4 "arat8yroid
8ormone4 8emoglo!in4 al!'min
3eig8t every 3E* mont8s
Consider need for dose adK'stment of
medications
H3. Referral to ne"8rologist
Re!o&&enations* Retino-at(%
Re!o&&enations* Retino-at(%
o red'ce t8e risB or slo3 t8e "rogression

of retino"at8y
<"timi5e glycemic control (A)
<"timi5e !lood "ress're control (A)

ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3*.
Re!o&&enations*
Re!o&&enations*
Retino-at(% S!#eenin$ /10
Initial dilated and com"re8ensive eye

e6amination !y an o"8t8almologist or o"tometrist
Ad'lts and c8ildren aged 1. years or older

3it8 ty"e 1 dia!etes
Cit8in % years after dia!etes onset (7)
#atients 3it8 ty"e $ dia!etes

S8ortly after diagnosis of dia!etes (7)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%.
Re!o&&enations*
Re!o&&enations*
S'!se2'ent e6aminations for ty"e 1 and ty"e $ dia!etic

"atients (7)
S8o'ld !e re"eated ann'ally !y an o"8t8almologist or
o"tometrist
1ess fre2'ent e6ams (every $E3 years) (7)

&ay !e considered follo3ing one or more normal eye e6ams
&ore fre2'ent e6aminations re2'ired if retino"at8y is

"rogressing (7)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3%-S3*.
Re!o&&enations*
Re!o&&enations*
Dig8-2'ality f'nd's "8otogra"8s
Can detect most clinically significant
dia!etic retino"at8y (E)
Inter"retation of t8e images
#erformed !y a trained eye care "rovider (E)
C8ile retinal "8otogra"8y may serve as a screening tool for
retino"at8y4 it is not a s'!stit'te for a com"re8ensive eye e6am
#erform com"re8ensive eye e6am at least initially and at intervals
t8ereafter as recommended !y an eye care "rofessional (E)
Re!o&&enations*
Re!o&&enations*
Comen 3it8 "ree6isting dia!etes 38o are "lanning

"regnancy or 38o 8ave !ecome "regnant (7)
Com"re8ensive eye e6amination
Co'nseled on risB of develo"ment and-or "rogression of
dia!etic retino"at8y
Eye e6amination s8o'ld occ'r in t8e first trimester (7)

Close follo3-'" t8ro'g8o't "regnancy
?or 1 year "ost"art'm
Re!o&&enations*
Re!o&&enations*
Retino-at(% T#eat&ent /10
#rom"tly refer "atients 3it8 any level of mac'lar edema4
severe N#DR4 or any #DR
o an o"8t8almologist Bno3ledgea!le and e6"erienced in
management4 treatment of dia!etic retino"at8y (A)
1aser "8otocoag'lation t8era"y is indicated (A)
o red'ce risB of vision loss in "atients 3it8
Dig8-risB #DR
Clinically significant mac'lar edema
Some cases of severe N#DR
Re!o&&enations*
Re!o&&enations*
Anti-vasc'lar endot8elial gro3t8 factor (,EG?)

t8era"y is indicated for dia!etic mac'lar
edema (A)
#resence of retino"at8y
Not a contraindication to as"irin t8era"y for

cardio"rotection4 as t8is t8era"y does not increase
t8e risB of retinal 8emorr8age (A)
Re!o&&enations*
Re!o&&enations*
Ne.#o-at(% S!#eenin$+ T#eat&ent /10
All "atients s8o'ld !e screened for distal symmetric

"olyne'ro"at8y (D#N) (7)
At diagnosis of ty"e $ dia!etes and % years after diagnosis
of ty"e 1 dia!etes
At least ann'ally t8ereafter 'sing sim"le clinical tests
Electro"8ysiological testing rarely needed

E6ce"t in sit'ations 38ere clinical feat'res are aty"ical (E)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3@.
Re!o&&enations*
Re!o&&enations*
Screening for signs and sym"toms of cardiovasc'lar
a'tonomic ne'ro"at8y
S8o'ld !e instit'ted at diagnosis of ty"e $ dia!etes and % years after
t8e diagnosis of ty"e 1 dia!etes
S"ecial testing rarely needed9 may not affect management or
o'tcomes (E)
&edications for relief of s"ecific sym"toms related to D#N4
a'tonomic ne'ro"at8y are recommended
Im"rove 2'ality of life of t8e "atient (E)
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3@.
Re!o&&enations* Foot Ca#e /10
?or all "atients 3it8 dia!etes4 "erform an ann'al com"re8ensive foot
e6amination to identify risB factors "redictive of 'lcers and
am"'tations (7)
Ins"ection
Assessment of foot "'lses
est for loss of "rotective sensation: 1.-g monofilament "l's testing any one of
,i!ration 'sing 1$/-D5 t'ning forB
#in"ricB sensation
AnBle refle6es
,i!ration "erce"tion t8res8old
ADA. ,I. #revention4 &anagement of Com"lications. Diabetes Care $.1393*(s'""l 1):S3/.
1--e# -anel
o "erform t8e 1.-g
monofilament test4 "lace
t8e device "er"endic'lar to
t8e sBin4 3it8 "ress're
a""lied 'ntil t8e
monofilament !'cBles
Dold in "lace for 1 second
and t8en release
Lo8e# -anel
8e monofilament test
s8o'ld !e "erformed at t8e
8ig8lig8ted sites 38ile t8e
"atientIs eyes are closed
7o'lton AT&4 et al. Diabetes Care. $../931:1*@+-1*/%.
#rovide general foot self-care ed'cation (7)
Fse m'ltidisci"linary a""roac8
Individ'als 3it8 foot 'lcers4 8ig8-risB feet9 es"ecially "rior 'lcer or
am"'tation (7)
Refer "atients to foot care s"ecialists for ongoing "reventive care4
life-long s'rveillance (C)
SmoBers
1oss of "rotective sensation or str'ct'ral a!normalities
Distory of "rior lo3er-e6tremity com"lications
Initial screening for "eri"8eral arterial disease (#AD) (C)
Incl'de a 8istory for cla'dication4 assessment of "edal "'lses
Consider o!taining an anBle-!rac8ial inde6 (A7I)9 many
"atients 3it8 #AD are asym"tomatic
Refer "atients 3it8 significant cla'dication or a "ositive

A7I for f'rt8er vasc'lar assessment (C)
Consider e6ercise4 medications4 s'rgical o"tions
2II' ASSESSMENT OF COMMON
COMORBID CONDITIONS
Re!o&&enations* Assess&ent of
Re!o&&enations* Assess&ent of
Co&&on Co&o#bi Conitions
Co&&on Co&o#bi Conitions
?or "atients 3it8 risB factors4 signs or

sym"toms4 consider assessment and
treatment for common dia!etes-associated
conditions (7)
Common comor!idities for 38ic8 increased

risB is associated 3it8 dia!etes
ADA. ,II. Assessment of Common Comor!id Conditions. Diabetes Care. $.1393*(s'""l 1):S3+9 a!le 14.
Dearing im"airment Certain cancers
<!str'ctive slee" a"nea ?ract'res
?atty liver disease Cognitive im"airment
1o3 testosterone in men De"ression
#eriodontal disease
2III' DIABETES CARE IN
S)ECIFIC )O)1LATIONS
Re!o&&enations* )eiat#i!
"l%!e&i! Cont#ol /T%-e 1 Diabetes0
"l%!e&i! Cont#ol /T%-e 1 Diabetes0
As is t8e case for all c8ildren4 c8ildren 3it8

dia!etes or "redia!etes s8o'ld !e
enco'raged to engage in at least *.
min'tes of "8ysical activity eac8 day (7)
Consider age 38en setting glycemic goals

in c8ildren and adolescents 3it8 ty"e 1
dia!etes (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4.-S41.
Ne-(#o-at(% /T%-e 1 Diabetes0
Ne-(#o-at(% /T%-e 1 Diabetes0
Ann'al screening for microal!'min'ria4

3it8 a random s"ot 'rine sam"le for
al!'min-to-creatinine (ACR) ratio (7)
Consider once c8ild is 1. years of age and

8as 8ad dia!etes for % years
Confirmed4 elevated ACR on t3o additional

'rine s"ecimens from different days
reat 3it8 an ACE in8i!itor4 titrated to

normali5ation of al!'min e6cretion (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S41.
:%-e#tension /T%-e 1 Diabetes0 /10
&eas're !lood "ress're (7#) at eac8 ro'tine

visit9 confirm 8ig8-normal 7# or 8y"ertension
on a se"arate day (7)
reat 8ig8-normal 7# (systolic or diastolic

consistently a!ove +.
t8
"ercentile for age4 se64
and 8eig8t) 3it8
Dietary intervention9 e6ercise aimed at 3eig8t

control and increased "8ysical activity
If target 7# is not reac8ed 3it8 3E* mont8s of

lifestyle intervention4 consider "8armacologic
treatment (E)
#8armacologic treatment of 8y"ertension
Systolic or diastolic !lood "ress're consistently

a!ove t8e +%
t8
"ercentile for age4 se64 and
8eig8t
Or
Consistently G13.-/. mmDg4 if +%> e6ceeds

t8at val'e
Initiate treatment as soon as diagnosis

is confirmed (E)
ACE in8i!itors
Consider for initial treatment of 8y"ertension4

follo3ing a""ro"riate re"rod'ctive co'nseling
d'e to "otential teratogenic effects (E)
Goal of treatment
7lood "ress're consistently H13.-/. mmDg or

!elo3 t8e +.
t8
"ercentile for age4 se64 and
8eig8t4 38ic8ever is lo3er (E)
D%sli-ie&ia /T%-e 1 Diabetes0 /10
Screening (1)
If family 8istory of 8y"erc8olesterolemia or a

cardiovasc'lar event !efore age %% years4 or if
family 8istory is 'nBno3n
#erform fasting li"id "rofile on c8ildren

G$ years of age soon after diagnosis (after gl'cose
control 8as !een esta!lis8ed)
Screening ($)
If family 8istory is not of concern

Consider first li"id screening at "'!erty
(=1. years) (E)
All c8ildren diagnosed 3it8 dia!etes at or after "'!erty
#erform fasting li"id "rofile soon after diagnosis (after
gl'cose control 8as !een esta!lis8ed) (E)
Screening (3)
?or !ot8 age-gro'"s4 if li"ids are a!normal

Ann'al monitoring is reasona!le
If 1D1 c8olesterol val'es are 3it8in acce"ted risB

levels (H1.. mg-d1
U$.* mmol-1V)
Re"eat li"id "rofile every % years (E)
reatment
Initial t8era"y: o"timi5e gl'cose control4 &N 'sing Ste" $ ADA diet
aimed at decreasing dietary sat'rated fat (E)
G age 1. years4 statin reasona!le in t8ose (after &N and lifestyle
c8anges) 3it8
1D1 c8olesterol G1*. mg-d1 (4.1 mmol-1) or
1D1 c8olesterol G13. mg-d1 (3.4 mmol-1) and one or more C,D risB factors (E)
Goal: 1D1 c8olesterol H1.. mg-d1
($.* mmol-1) (E)
&NWmedical n'trition t8era"y
?irst o"8t8almologic e6amination
<!tain once c8ild is =1. years of age9 8as 8ad

dia!etes for 3E% years (7)
After initial e6amination

Ann'al ro'tine follo3-'" generally recommended
1ess fre2'ent e6aminations may !e acce"ta!le on
advice of an eye care "rofessional (E)
Retino-at(% /T%-e 1 Diabetes0
Retino-at(% /T%-e 1 Diabetes0
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4$.
Celia! Disease /T%-e 1 Diabetes0 /10
C8ildren 3it8 ty"e 1 dia!etes
Screen for celiac disease !y meas'ring tiss'e transgl'taminase or
antiendomysial anti!odies4 3it8 doc'mentation of normal total ser'm IgA
levels4 soon after t8e diagnosis of dia!etes (E)
Re"eat testing in c8ildren 3it8
Gro3t8 fail're
?ail're to gain 3eig8t4 3eig8t loss
Diarr8ea4 flat'lence4 a!dominal "ain4 or signs of mala!sor"tion
?re2'ent 'ne6"lained 8y"oglycemia or deterioration in glycemic control (E)
Asym"tomatic c8ildren 3it8 "ositive anti!odies

Refer to a gastroenterologist for eval'ation 3it8
"ossi!le endosco"y and !io"sy (E)
C8ildren 3it8 !io"sy-confirmed celiac disease

#lace on a gl'ten-free diet
Cons'lt 3it8 a dietitian e6"erienced in managing

!ot8 dia!etes and celiac disease (7)
:%-ot(%#oiis& /T%-e 1 Diabetes0
:%-ot(%#oiis& /T%-e 1 Diabetes0
C8ildren 3it8 ty"e 1 dia!etes

Screen for t8yroid "ero6idase4 t8yroglo!'lin anti!odies
soon after diagnosis (E)
8yroid-stim'lating 8ormone (SD) concentrations

&eas're after meta!olic control esta!lis8ed
If normal4 rec8ecB every 1E$ years9 or
If "atient develo"s sym"toms of t8yroid dysf'nction4
t8yromegaly4 or an a!normal gro3t8 rate (E)
Re!o&&enations* T#ansition f#o&
Re!o&&enations* T#ansition f#o&
)eiat#i! to A.lt Ca#e
)eiat#i! to A.lt Ca#e
As teens transition into emerging ad'lt8ood4 8ealt8 care
"roviders and families m'st recogni5e t8eir many
v'lnera!ilities (7) and "re"are t8e develo"ing teen4
!eginning in early to mid adolescence and at least 1 year
"rior to t8e transition (E)
7ot8 "ediatricians and ad'lt 8ealt8 care "roviders s8o'ld
assist in "roviding s'""ort and linBs to reso'rces for t8e
teen and emerging ad'lt (7)
Re!o&&enations*
Re!o&&enations*
)#e!on!e-tion Ca#e /10
A1C levels s8o'ld !e as close to normal as "ossi!le (@>)

in an individ'al "atient !efore conce"tion is attem"ted (7)
Starting at "'!erty4 incor"orate "reconce"tion co'nseling
in ro'tine dia!etes clinic visit for all 3omen of
c8ild!earing "otential (C)
Comen 3it8 dia!etes contem"lating "regnancy s8o'ld !e

eval'ated and4 if indicated4 treated for dia!etic
retino"at8y4 ne"8ro"at8y4 ne'ro"at8y4 C,D (7)
&edications s8o'ld !e eval'ated "rior to conce"tion4 since
dr'gs commonly 'sed to treat dia!etes and its com"lications
may !e contraindicated or not recommended in "regnancy4
incl'ding statins4 ACE in8i!itors4 AR7s4 and most nonins'lin
t8era"ies (E)
Since many "regnancies are 'n"lanned4 consider "otential
risBs-!enefits of medications contraindicated in "regnancy in
all 3omen of c8ild!earing "otential9 co'nsel accordingly (E)
Re!o&&enations*
Re!o&&enations*
Re!o&&enations* Ole# A.lts /10
?'nctional4 cognitively intact older ad'lts 3it8

significant life e6"ectancies s8o'ld receive dia!etes
care 'sing goals develo"ed for yo'nger ad'lts (E)
Glycemic goals for t8ose not meeting t8e a!ove criteria

may !e rela6ed 'sing individ'al criteria4 !'t
8y"erglycemia leading to sym"toms or risB of ac'te
8y"erglycemic com"lications s8o'ld !e avoided in all
"atients (E)
reat ot8er cardiovasc'lar risB factors 3it8 consideration

of t8e time frame of !enefit and t8e individ'al "atient (E)
reatment of 8y"ertension is indicated in virt'ally all older
ad'lts9 li"id4 as"irin t8era"y may !enefit t8ose 3it8 life
e6"ectancy e2'al to time frame of "rimary-secondary
"revention trials (E)
Individ'ali5e screening for dia!etes com"lications 3it8
attention to t8ose leading to f'nctional im"airment (E)
Re!o&&enations* C%sti! Fib#osis;
Relate Diabetes /CFRD0 /10
Ann'al screening for C?RD 3it8 <G s8o'ld !egin !y

age 1. years in all "atients 3it8 cystic fi!rosis 38o do
not 8ave C?RD (7)
Fse of A1C as a screening test for C?RD is not recommended
(7)
D'ring a "eriod of sta!le 8ealt84 diagnosis of C?RD can

!e made in "atients 3it8 cystic fi!rosis according to
's'al gl'cose criteria (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4%.
#atients 3it8 C?RD s8o'ld !e treated 3it8

ins'lin to attain individ'ali5ed glycemic
goals (A)
Ann'al monitoring for com"lications of

dia!etes is recommended4 !eginning %
years after t8e diagnosis of C?RD (E)
ADA. ,III. Dia!etes Care in S"ecific #o"'lations. Diabetes Care. $.1393*(s'""l 1):S4%.
I?' DIABETES CARE IN
S)ECIFIC SETTIN"S
Re!o&&enations*
Re!o&&enations*
Diabetes Ca#e in t(e :os-ital /10
All "atients 3it8 dia!etes admitted to t8e

8os"ital s8o'ld 8ave t8eir dia!etes clearly
identified in t8e medical record (E)
All "atients 3it8 dia!etes s8o'ld 8ave an order

for !lood gl'cose monitoring4 3it8 res'lts
availa!le to all mem!ers of t8e 8ealt8 care team
(E)
ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4%.
Re!o&&enations*
Re!o&&enations*
Goals for !lood gl'cose levels
Critically ill "atients: Initiate ins'lin t8era"y for treatment of "ersistent
8y"erglycemia starting at a t8res8old of no greater t8an 14.-1/.
mg-d1 (@./E1. mmol-1) (A)
&ore stringent goals4 s'c8 as 11.-14. mg-d1 (*.1E@./ mmol-1) may
!e a""ro"riate for selected "atients4 if ac8ieva!le 3it8o't significant
8y"oglycemia (C)
Critically ill "atients re2'ire an I, ins'lin "rotocol 3it8 demonstrated
efficacy4 safety in ac8ieving desired gl'cose range 3it8o't increasing
risB for severe 8y"oglycemia (E)
ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4%.
Re!o&&enations*
Re!o&&enations*
Goals for !lood gl'cose levels
Noncritically ill "atients: No clear evidence for s"ecific !lood gl'cose
goals
If treated 3it8 ins'lin4 "remeal !lood gl'cose targets (if safely ac8ieved)
Generally H14. mg-d1 (@./ mmol-1) 3it8 random !lood gl'cose H1/. mg-d1 (1...
mmol-1)
&ore stringent targets may !e a""ro"riate in sta!le "atients 3it8
"revio's tig8t glycemic control
1ess stringent targets may !e a""ro"riate in t8ose 3it8 severe
comor!idities (E)
ADA. I0. Dia!etes Care in S"ecific Settings. Diabetes Care. $.1393*(s'""l 1):S4*.
Re!o&&enations*
Re!o&&enations*
Sc8ed'led s'!c'taneo's ins'lin 3it8 !asal4

n'tritional4 and correction com"onents is
t8e "referred met8od for ac8ieving and
maintaining gl'cose control in non-critically
ill "atients (C)
Re!o&&enations*
Re!o&&enations*
Initiate gl'cose monitoring in any "atient not Bno3n to !e
dia!etic 38o receives t8era"y associated 3it8 8ig8-risB for
8y"erglycemia
Dig8-dose gl'cocorticoid t8era"y4 initiation of enteral or "arenteral
n'trition4 or ot8er medications s'c8 as octreotide or
imm'nos'""ressive medications (7)
If 8y"erglycemia is doc'mented and "ersistent4 consider
treating s'c8 "atients to t8e same glycemic goals as "atients
3it8 Bno3n dia!etes (E)
Re!o&&enations*
Re!o&&enations*
A 8y"oglycemia management "rotocol s8o'ld !e ado"ted

and im"lemented !y eac8 8os"ital or 8os"ital system (E)
<!tain A1C for all "atients (E)
If res'lts 3it8in "revio's $E3 mont8s 'navaila!le
Cit8 dia!etes risB factors 38o e68i!it 8y"erglycemia
#atients 3it8 8y"erglycemia 3it8o't a diagnosis of
dia!etes: doc'ment "lans for follo3-'" testing and care
at disc8arge (E)
Diabetes Ca#e in t(e :os-ital*
NICE;S1"AR St.% /10
NICE;S1"AR St.% /10
1argest randomi5ed controlled trial to date
ested effect of tig8t glycemic control

(target /1E1./ mg-d1) on o'tcomes
among *41.4 critically ill "artici"ants
&aKority (G+%>) re2'ired mec8anical

ventilation
NICE;S1"AR St.% /20
NICE;S1"AR St.% /20
In !ot8 s'rgical-medical "atients4 +.-day mortality

significantly 8ig8er in intensively treated vs conventional
gro'" (target 144E1/. mg-d1)
Severe 8y"oglycemia more common
(*./> vs ..%>9 PH....1)
?indings strongly s'ggest may not !e necessary to target !lood
gl'cose levels
H14. mg-d19 8ig8ly stringent target of
H11. mg-d1 may !e dangero's
?' STRATE"IES FOR
IM)RO2IN"
DIABETES CARE
Re!o&&enations* St#ate$ies fo#
I&-#ovin$ Diabetes Ca#e /10
ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1393*(s'""l 1):S4+-S%..
Care s8o'ld !e aligned 3it8 com"onents of t8e C8ronic

Care &odel to ens're "rod'ctive interactions !et3een a
"re"ared "roactive "ractice team and an informed
activated "atient (A)
C8en feasi!le4 care systems s8o'ld s'""ort team-

!ased care4 comm'nity involvement4 "atient registries4
and em!edded decision s'""ort tools to meet "atient
needs (7)
ADA. 0. Strategies for Im"roving Dia!etes Care. Diabetes Care. $.1393*(s'""l 1):S%..
reatment decisions s8o'ld !e timely

and !ased on evidence-!ased g'idelines t8at are
tailored to individ'al "atient "references4 "rognoses4
and comor!idities (7)
A "atient-centered comm'nication style s8o'ld !e

em"loyed t8at incor"orates "atient "references4
assesses literacy and n'meracy4 and addresses c'lt'ral
!arriers to care (7)
Ob@e!tive 1*
Ob@e!tive 1*
O-ti&i<e )#ovie# an Tea& Be(avio#
O-ti&i<e )#ovie# an Tea& Be(avio#
Care team s8o'ld "rioriti5e timely4 a""ro"riate intensification
of lifestyle and-or "8armace'tical t8era"y
#atients 38o 8ave not ac8ieved !eneficial levels of !lood "ress're4
li"id4 or gl'cose control
Strategies incl'de
E6"licit goal setting 3it8 "atients
Identifying and addressing !arriers to care
Integrating evidence-!ased g'idelines
Incor"orating care management teams
Ob@e!tive 2*
Ob@e!tive 2*
S.--o#t )atient Be(avio# C(an$e
S.--o#t )atient Be(avio# C(an$e
Im"lement a systematic a""roac8 to s'""ort "atient !e8avior
c8ange efforts
a) Dealt8y lifestyle: "8ysical activity4 8ealt8y eating4 non'se of to!acco4
3eig8t management4 effective co"ing
!) Disease self-management: medication taBing and management4 self-
monitoring of gl'cose and !lood "ress're 38en clinically a""ro"riate
c) #revention of dia!etes com"lications:
self-monitoring of foot 8ealt84 active "artici"ation in screening for eye4
foot4 and renal com"lications4 and imm'ni5ations
Ob@e!tive 3*
Ob@e!tive 3*
C(an$e t(e S%ste& of Ca#e
C(an$e t(e S%ste& of Ca#e
8e most s'ccessf'l "ractices 8ave an instit'tional "riority for
"roviding 8ig8 2'ality of care
7asing care on evidence-!ased g'idelines
E6"anding t8e role of teams and staff
Redesigning t8e "rocesses of care
Im"lementing electronic 8ealt8 record tools
Activating and ed'cating "atients
Identifying and-or develo"ing comm'nity reso'rces and "'!lic "olicy t8at
s'""orts 8ealt8y lifestyles
Alterations in reim!'rsement

ADA Standards of Medical Care 2013 FINAL 21 Dec 2012

Enviado por

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ADA Standards of Medical Care 2013 FINAL 21 Dec 2012

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STANDARDS OF MEDICAL CARE

STANDARDS OF MEDICAL CARE

#rogressive ins'lin secretory defect

<t8er s"ecific ty"es of dia!etes

Genetic defects in ;-cell f'nction4 ins'lin action

Diseases of t8e e6ocrine "ancreas

Gestational dia!etes mellit's (GD&)

Consider testing over3eig8t-o!ese ad'lts

In t8ose 3it8o't risB factors4 !egin testing at age

If tests are normal

Re"eat testing at least at 3-year intervals (E)

Fse A1C4 ?#G4 or $-8 @%-g <G (7)

In t8ose 3it8 "redia!etes

Identify and4 if a""ro"riate4 treat ot8er C,D risB

Screen for 'ndiagnosed ty"e $ dia!etes

In "regnant 3omen not "revio'sly

Screen 3omen 3it8 GD& for "ersistent dia!etes

Comen 3it8 a 8istory of GD& s8o'ld

Comen 3it8 a 8istory of GD& fo'nd to 8ave

#erform a @%-g <G4 3it8 "lasma gl'cose

#erform <G in t8e morning after an

GD& diagnosis: 38en any of t8e follo3ing

Refer "atients 3it8 IG (A)4 I?G (E)4 or A1C

?ollo3-'" co'nseling im"ortant for s'ccess (7)

7ased on cost-effectiveness of dia!etes

Consider metformin for "revention of ty"e $

In t8ose 3it8 "redia!etes4 monitor for

Screen for and treat modifia!le risB factors for

Age and c8aracteristics of onset of dia!etes

Eating "atterns4 "8ysical activity 8a!its4

Dia!etes ed'cation 8istory

Revie3 of "revio's treatment regimens and

C'rrent treatment of dia!etes4 incl'ding

Res'lts of gl'cose monitoring and "atientIs

DJA fre2'ency4 severity4 and ca'se

Distory of dia!etes-related com"lications

Deig8t4 3eig8t4 7&I

7lood "ress're determination4 incl'ding

SBin e6amination (for acant8osis nigricans and

Com"re8ensive foot e6amination

A1C4 if res'lts not availa!le 3it8in "ast

If not "erformed-availa!le 3it8in "ast year

Eye care "rofessional for ann'al dilated eye e6am

?amily "lanning for 3omen of re"rod'ctive age

Registered dietitian for &N

Dia!etes self-management ed'cation

Dentist for com"re8ensive "eriodontal

&ental 8ealt8 "rofessional4 if needed

3o "rimary tec8ni2'es availa!le for 8ealt8

#atient self-monitoring of !lood gl'cose (S&7G)4

#atients on m'lti"le-dose ins'lin (&DI) or

At least "rior to meals and snacBs

C8en t8ey s's"ect lo3 !lood gl'cose

After treating lo3 !lood gl'cose 'ntil t8ey are

#rior to critical tasBs s'c8 as driving

C8en "rescri!ing S&7G4 ens're t8at "atients

Contin'o's gl'cose monitoring (CG&) 3it8

Evidence for A1C-lo3ering less strong in

CG& may !e a s'""lemental tool to S&7G in

#erform A1C test at least t3ice yearly in

#erform A1C test 2'arterly in "atients

Fse of "oint-of-care (#<C) testing for A1C

1o3ering A1C to !elo3 or aro'nd @> 8as !een