ADA Standards of Medical Care 2014 FINAL 8 Jan 2014 LOCKED

STANDARDS OF MEDICAL CARE
STANDARDS OF MEDICAL CARE

IN DIABETES2014
IN DIABETES2014
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*-$$
I+. #revention,Delay of y"e $ Dia!etes $3-$-
+. Dia!etes Care $.-..
+I. #revention and &anagement of
Dia!etes Com"lications
.%-11/
+II. Assessment of Common Comor!id Conditions 111-11$
+III. Dia!etes Care in S"ecific #o"'lations 113-134
I0. Dia!etes Care in S"ecific Settings 13--144
0. Strategies for Im"roving Dia!etes Care 14--1-/
ADA Evien!e "#ain$ S%ste& fo#
ADA Evien!e "#ain$ S%ste& fo#
Clini!al '#a!ti!e Re!o&&enations
Clini!al '#a!ti!e 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. Dia!etes Care $/1493%(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. Dia!etes Care $/1493%(s'""l 1):S14
C#ite#ia fo# t)e Dia$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. Dia!etes Care $/1493%(s'""l 1):S1-9 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
@
@In 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 intaAe
for at least * 8
@
$-8 "lasma gl'cose =$// mg,d1
(11.1 mmol,1) d'ring an <G
8e test s8o'ld !e "erformed as
descri!ed !y t8e BC<4 'sing a
gl'cose load containing t8e e2'ivalent
of %- g an8ydro's gl'cose
dissolved in 3ater
@
In a "atient 3it8 classic sym"toms of
8y"erglycemia or 8y"erglycemic crisis4
a random "lasma gl'cose =$// mg,d1
(11.1 mmol,1)
?#G 1//D1$- mg,d1 (-..D..E mmol,1): I?G
OR
$-8 "lasma gl'cose in t8e %--g <G
14/D1EE mg,d1 (%.*D11./ mmol,1): IG
OR
A1C -.%D..4>
@?or all t8ree tests4 risA 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. Dia!etes Care $/1493%(s'""l 1):S1.9 a!le 3
Cate$o#ies of In!#ease Ris* fo# Diabetes
Cate$o#ies of In!#ease Ris* fo# Diabetes
+'#eiabetes,-
+'#eiabetes,-
II( TESTIN" FOR DIABETES IN
II( TESTIN" FOR DIABETES IN
AS.M'TOMATIC 'ATIENTS
AS.M'TOMATIC 'ATIENTS
Re!o&&enations/ Testin$ fo#
Re!o&&enations/ Testin$ fo#
Diabetes in As%&0to&ati! 'atients
Diabetes in As%&0to&ati! 'atients
est over3eig8t,o!ese ad'lts (7&I =$-

Ag,m
$
) 3it8 one or more additional risA
factors9 in t8ose 3it8o't risA factors4
!egin testing at age 4- years B
If tests are normal4 re"eat testing at least

at 3-year intervals is reasona!le E
o test for dia!etes,"redia!etes4 t8e A1C4

?#G4 or $-8 %--g <G are a""ro"riate B
In t8ose 3it8 "redia!etes4 identify and4 if

a""ro"riate4 treat ot8er C+D risA factors B
ADA. II. esting for Dia!etes in Asym"tomatic #atients. Dia!etes Care $/1493%(s'""l 1):S1.
C#ite#ia fo# Testin$ fo# Diabetes in
As%&0to&ati! A1lt Inivi1als +1,
#8ysical inactivity
?irst-degree relative 3it8
dia!etes
Cig8-risA race,et8nicity
(e.g.4 African American4 1atino4
Native American4 Asian
American4 #acific Islander)
Bomen 38o delivered a !a!y
3eig8ing FE l! or 3ere
diagnosed 3it8 GD&
Cy"ertension (=14/,E/
mmCg or on t8era"y for
8y"ertension)
CD1 c8olesterol level
G3- mg,d1 (/.E/ mmol,1)
and,or a triglyceride level
F$-/ mg,d1 ($.*$ mmol,1)
Bomen 3it8 "olycystic ovarian
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)
Cistory of C+D
@At-risA 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. Dia!etes Care $/1493%(s'""l 1):S1%9 a!le 4
2( In t8e a!sence of criteria (risA factors on
"revio's slide)4 testing for dia!etes s8o'ld !egin
at age 4- years
2( 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 risA stat's
ADA. esting for Dia!etes in Asym"tomatic #atients. Dia!etes Care $/1493%(s'""l 1):S1%9 a!le 4
esting to detect ty"e $ dia!etes and

"redia!etes s8o'ld !e considered in
c8ildren and adolescents 38o are
over3eig8t and 38o 8ave t3o or more
additional risA factors for dia!etes E
Re!o&&enation/ S!#eenin$ fo#
T%0e 2 Diabetes in C)il#en
T%0e 2 Diabetes in C)il#en
ADA. II. esting for Dia!etes in Asym"tomatic #atients. Dia!etes Care $/1493%(s'""l 1):S1%DS1*
Inform ty"e 1 dia!etes "atients of t8e

o""ort'nity to 8ave t8eir relatives
screened for ty"e 1 dia!etes risA in t8e
setting of a clinical researc8 st'dy E
T%0e 1 Diabetes
T%0e 1 Diabetes
ADA. II. esting for Dia!etes in Asym"tomatic #atients. Dia!etes Care $/1493%(s'""l 1):S1*
III( DETECTION AND
III( DETECTION AND
DIA"NOSIS OF
DIA"NOSIS OF
"ESTATIONAL DIABETES
"ESTATIONAL DIABETES
MELLIT3S +"DM,
MELLIT3S +"DM,
Re!o&&enations/
Re!o&&enations/
Dete!tion an Dia$nosis of "DM +1,
Screen for 'ndiagnosed ty"e $ dia!etes

at t8e first "renatal visit in t8ose 3it8
risA factors4 'sing standard diagnostic
criteria B
Screen for GD& at $4D$* 3eeAs of

gestation in "regnant 3omen not
"revio'sly Ano3n to 8ave dia!etes A
Screen 3omen 3it8 GD& for "ersistent

dia!etes at .D1$ 3eeAs "ost"art'm4 'sing
<G4 non"regnancy diagnostic criteria E
ADA. III. Detection and Diagnosis of GD&. Dia!etes Care $/1493%(s'""l 1):S1*
Re!o&&enations/
Re!o&&enations/
Bomen 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 B
Bomen 3it8 a 8istory of GD& fo'nd to

8ave "redia!etes s8o'ld receive lifestyle
interventions or metformin to "revent
dia!etes A
?'rt8er researc8 is needed to esta!lis8 a

'niform a""roac8 to diagnosing GD& E
ADA. III. Detection and Diagnosis of GD&. Dia!etes Care $/1493%(s'""l 1):S1*
S!#eenin$ fo# an Dia$nosis of "DM
4One5ste06 +IAD'S" Consens1s,
4One5ste06 +IAD'S" Consens1s,
#erform a %--g <G4 3it8 "lasma gl'cose

meas'rement fasting and at 1 and $ 84 at
$4D$* 3eeAs 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
D ?asting: =E$ mg,d1 (-.1 mmol,1)
D 1 8: =1*/ mg,d1 (1/./ mmol,1)
D $ 8: =1-3 mg,d1 (*.- mmol,1)
ADA. III. Detection and Diagnosis of GD&. Dia!etes Care $/1493%(s'""l 1):S1E9 a!le .
4T7o5ste06 +NI8 Consens1s,
4T7o5ste06 +NI8 Consens1s,
#erform -/-g G1 (nonfasting) 3it8 "lasma

gl'cose meas'rement at 1 8 (Ste" 1) at
$4D$* 3eeAs of gestation in 3omen not
"revio'sly diagnosed 3it8 overt dia!etes
If "lasma gl'cose level meas'red at 1 8

after load is =14/ mg,d1@ (%.* mmol,1)4
"roceed to 1//-g <G (Ste" $) 38en
"atient is fasting
GD& diagnosis: "lasma gl'cose meas'red

3 8 after t8e test is =14/ mg,d1
@
(%.* mmol,1)
ADA. III. Detection and Diagnosis of GD&. Dia!etes Care $/1493%(s'""l 1):S1E9 a!le .
@AC<G recommends 13- mg,d1 in 8ig8-risA et8nic minorities 3it8 8ig8er "revalence of GD&.
I9( 'RE9ENTION:DELA. OF
I9( 'RE9ENTION:DELA. OF
T.'E 2 DIABETES
T.'E 2 DIABETES
Re!o&&enations/
Re!o&&enations/
'#evention:Dela% of T%0e 2 Diabetes
Refer "atients 3it8 IG A4 I?G E4 or A1C

-.%D..4> E to ongoing s'""ort "rogram
argeting 3eig8t loss of %> of !ody 3eig8t
Increasing "8ysical activity to at least 1-/

min,3eeA of moderate activity (eg4 3alAing)
?ollo3-'" co'nseling a""ears to !e

im"ortant for s'ccess B
7ased on cost-effectiveness of dia!etes

"revention4 s'c8 "rograms s8o'ld !e
covered !y t8ird-"arty "ayers B
ADA. I+. #revention,Delay of y"e $ Dia!etes. Dia!etes Care $/1493%(s'""l 1):S$/
Re!o&&enations/
Re!o&&enations/
Consider metformin for "revention of ty"e

$ dia!etes if IG A4 I?G E4 or
A1C -.%D..4> E
Es"ecially for t8ose 3it8 7&I F3- Ag,m

$
4
age G./ 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 risA

factors for C+D B
ADA. I+. #revention,Delay of y"e $ Dia!etes. Dia!etes Care $/1493%(s'""l 1):S$/
9( DIABETES CARE
A com"lete medical eval'ation s8o'ld !e

"erformed to
Classify t8e dia!etes

Detect "resence of dia!etes com"lications
Revie3 "revio's treatment4 risA factor control in
"atients 3it8 esta!lis8ed dia!etes
Assist in form'lating a management "lan
#rovide a !asis for contin'ing care
#erform la!oratory tests necessary to

eval'ate eac8 "atientHs medical condition
Diabetes Ca#e/ Initial Eval1ation
Diabetes Ca#e/ Initial Eval1ation
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$1
&edical 8istory (1)
Age and c8aracteristics of onset of

dia!etes (e.g.4 DIA4 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)
Co&0onents of t)e Co&0#e)ensive
Diabetes Eval1ation +1,
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$19 a!le %
&edical 8istory ($)
C'rrent treatment of dia!etes4 incl'ding

medications4 ad8erence and !arriers
t8ereto4 meal "lan4 "8ysical activity
"atterns4 readiness for !e8avior c8ange
Res'lts of gl'cose monitoring4 "atientHs

'se of data
DIA fre2'ency4 severity4 ca'se
Cy"oglycemic e"isodes
Cy"oglycemic a3areness
Any severe 8y"oglycemia: fre2'ency4 ca'se

@See a""ro"riate referrals for t8ese categories.
&edical 8istory (3)
Cistory of dia!etes-related com"lications
&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
&acrovasc'lar: CCD4 cere!rovasc'lar disease4

#AD
<t8er: "syc8osocial "ro!lems4@ dental

disease@
@See a""ro"riate referrals for t8ese categories.
#8ysical e6amination (1)
Ceig8t4 3eig8t4 7&I
7lood "ress're determination4 incl'ding

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

and ins'lin inJection sites)
Diabetes Eval1ation +;,
Diabetes Eval1ation +;,
#8ysical e6amination ($)
Com"re8ensive foot e6amination
Ins"ection
#al"ation of dorsalis "edis and "osterior

ti!ial "'lses
#resence,a!sence of "atellar and Ac8illes

refle6es
Determination of "ro"rioce"tion4 vi!ration4

and monofilament sensation
Diabetes Eval1ation +<,
Diabetes Eval1ation +<,
1a!oratory eval'ation
A1C4 if res'lts not availa!le 3it8in "ast

$D3 mont8s
If not "erformed,availa!le 3it8in "ast year
?asting li"id "rofile4 incl'ding total4 1D14 and

CD1 c8olesterol and triglycerides
1iver f'nction tests
est for 'rine al!'min e6cretion 3it8 s"ot 'rine

al!'min-to-creatinine ratio
Ser'm creatinine and calc'lated G?R
SC in ty"e 1 dia!etes4 dysli"idemia4 or

3omen over age -/ years
Diabetes Eval1ation +=,
Diabetes Eval1ation +=,
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

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 "8ysicianHs

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/
"l1!ose Monito#in$ +1,
#atients on m'lti"le-dose ins'lin (&DI) or

ins'lin "'m" t8era"y s8o'ld do S&7G B
#rior to meals and snacAs
<ccasionally "ost"randially
At !edtime
#rior to e6ercise
B8en t8ey s's"ect lo3 !lood gl'cose
After treating lo3 !lood gl'cose 'ntil t8ey are

normoglycemic
#rior to critical tasAs s'c8 as driving

B8en "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
inJections or nonins'lin t8era"ies E
B8en "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 adJ'st t8era"y E
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
Alt8o'g8 evidence for A1C-lo3ering less

strong in c8ildren4 teens4 and yo'nger
ad'lts4 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
Re!o&&enations/
Re!o&&enations/
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$1DS$$
Re!o&&enations/ A1C
Re!o&&enations/ A1C
#erform t8e A1C test at least t3o times a

year in "atients meeting treatment goals
(and 8ave sta!le glycemic control) E
#erform t8e A1C test 2'arterly in "atients

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

"rovides t8e o""ort'nity for more timely
treatment c8anges E
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$$DS$3
Co##elation of A1C 7it)
Co##elation of A1C 7it)
Ave#a$e "l1!ose
Ave#a$e "l1!ose
&ean "lasma gl'cose
A1C (>) mg,d1 mmol,1
. 1$. %./
% 1-4 *..
* 1*3 1/.$
E $1$ 11.*
1/ $4/ 13.4
11 $.E 14.E
1$ $E* 1..-
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$39 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 $4 and no dia!etes. 8e correlation !et3een A1C and
average gl'cose 3as /.E$. 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
8erefore4 a reasona!le A1C goal for many

non"regnant ad'lts is G%> B
Re!o&&enations/
Re!o&&enations/
"l%!e&i! "oals in A1lts +1,
#roviders mig8t reasona!ly s'ggest more

stringent A1C goals (s'c8 as G..->) for
selected individ'al "atients4 if t8is can !e
ac8ieved 3it8o't significant 8y"oglycemia
or ot8er adverse effects of treatment
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 G*>)

may !e a""ro"riate for "atients 3it8 B
Cistory of severe 8y"oglycemia4 limited life

e6"ectancy4 advanced microvasc'lar or
macrovasc'lar com"lications4 e6tensive
comor!id conditions
8ose 3it8 longstanding dia!etes in 38om t8e

general goal is diffic'lt to attain des"ite DS&E4
a""ro"riate gl'cose monitoring4 and effective
doses of m'lti"le gl'cose lo3ering agents
incl'ding ins'lin
A00#oa!) to Mana$e&ent of
A00#oa!) to Mana$e&ent of
8%0e#$l%!e&ia
8%0e#$l%!e&ia
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$-. ?ig're 19 ada"ted 3it8 "ermission
from Ismail-7eigi ?4 et al. Ann Intern &ed $/1191-4:--4---E
"l%!e&i! Re!o&&enations fo#
Non0#e$nant A1lts 7it) Diabetes +1,
A1C G%./>
@
#re"randial ca"illary
"lasma gl'cose
%/D13/ mg,d1
@

(3.ED%.$ mmol,1)
#eaA "ost"randial
ca"illary "lasma gl'cose
M
G1*/ mg,d1
@

(G1/./ mmol,1)
@Goals s8o'ld !e individ'ali5ed !ased on t8ese val'es.
$#ost"randial gl'cose meas'rements s8o'ld !e made 1D$ 8 after t8e !eginning of t8e meal4 generally
"eaA levels in "atients 3it8 dia!etes.
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$.9 a!le E
Goals s8o'ld !e individ'ali5ed !ased on
D'ration of dia!etes
Age,life e6"ectancy
Comor!id conditions
Ino3n C+D or advanced microvasc'lar

com"lications
Cy"oglycemia 'na3areness
Individ'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/ Ins1lin T)e#a0%
fo# T%0e 1 Diabetes +1,
&ost "eo"le 3it8 ty"e 1 dia!etes s8o'ld
7e treated 3it8 &DI inJections (3D4

inJections "er day of !asal and "randial
ins'lin) or contin'o's s'!c'taneo's ins'lin
inf'sion (CSII) A
7e ed'cated in 8o3 to matc8 "randial ins'lin

dose to car!o8ydrate intaAe4 "remeal !lood
gl'cose4 and antici"ated activity E
Kse ins'lin analogs to red'ce 8y"oglycemia

risA A
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$.
Screening
Consider screening t8ose 3it8 ty"e 1

dia!etes for ot8er a'toimm'ne diseases
(t8yroid4 vitamin 71$ deficiency4 celiac) as
a""ro"riate B
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$.
&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 marAedly 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. Dia!etes Care $/1493%(s'""l 1):S$%
Re!o&&enations/ T)e#a0%
Re!o&&enations/ T)e#a0%
Re!o&&enations/
Re!o&&enations/
T)e#a0% fo# T%0e 2 Diabetes +2,
If nonins'lin monot8era"y at ma6imal

tolerated dose does not ac8ieve or
maintain t8e A1C target over 3 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
agents
Considerations incl'de efficacy4 cost4 "otential

side effects4 effects on 3eig8t4 comor!idities4
8y"oglycemia risA4 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 B
Anti)%0e#$l%!e&i! T)e#a0% in
Anti)%0e#$l%!e&i! T)e#a0% in
T%0e 2 Diabetes
T%0e 2 Diabetes
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$%. ?ig're $9
ada"ted 3it8 "ermission from In5'cc8i SE4 et al. Dia!etes Care $/1$93-:13.4D13.E
Re!o&&enations/
Re!o&&enations/
Mei!al N1t#ition T)e#a0% +MNT, +1,
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$*
N'trition t8era"y is recommended for all

"eo"le 3it8 ty"e 1 and ty"e $ dia!etes as
an effective com"onent of t8e overall
treatment "lan A
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
Re!o&&enations/
Re!o&&enations/
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S$*
7eca'se dia!etes n'trition t8era"y can

res'lt in cost savings B and im"roved
o'tcomes s'c8 as red'ction in A1C A4
n'trition t8era"y s8o'ld !e ade2'ately
reim!'rsed !y ins'rance and ot8er
"ayers E
#eo"le 3it8 dia!etes s8o'ld receive

DS&E,DS&S according to National
Standards for Dia!etes Self-&anagement
Ed'cation and S'""ort at diagnosis and as
needed t8ereafter B
Effective self-management4 2'ality of life

are Aey o'tcomes of DS&E,DS&S9 s8o'ld
!e meas'red4 monitored as "art of care C
DS&E,DS&S s8o'ld address "syc8osocial

iss'es4 since emotional 3ell-!eing is
associated 3it8 "ositive o'tcomes C
Re!o&&enations/ Diabetes
Self5Mana$e&ent E1!ation> S100o#t
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S3/
DS&E,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,DS&S can res'lt in cost-

savings and im"roved o'tcomes B4
DS&E,DS&S s8o'ld !e ade2'ately
reim!'rsed !y t8ird-"arty "ayers E
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S3/
C8ildren 3it8 dia!etes,"redia!etes:

engage in at least ./ min,day "8ysical
activity B
Ad'lts 3it8 dia!etes: at least 1-/ min,3A

of moderate-intensity aero!ic activity
(-/D%/> of ma6im'm 8eart rate)4over at
least 3 days,3A 3it8 no more t8an $
consec'tive days 3it8o't e6ercise A
If not contraindicated4 ad'lts 3it8 ty"e $

dia!etes s8o'ld "erform resistance
training at least t3ice 3eeAly A
Re!o&&enations/ ')%si!al A!tivit%
Re!o&&enations/ ')%si!al A!tivit%
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S31
<ngoing "art of medical management of

dia!etes B
#syc8osocial screening,follo3-'":
attit'des4 medical management,o'tcomes
e6"ectations4 affect,mood4 2'ality of life4
reso'rces4 "syc8iatric 8istory E
Ro'tinely screen for "syc8osocial

"ro!lems: de"ression4 dia!etes-related
distress4 an6iety4 eating disorders4
cognitive im"airment B
Re!o&&enations/
Re!o&&enations/
's%!)oso!ial Assess&ent an Ca#e
's%!)oso!ial Assess&ent an Ca#e
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S3$
Individ'als at risA for 8y"oglycemia s8o'ld

!e asAed a!o't sym"tomatic and
asym"tomatic 8y"oglycemia at eac8
enco'nter C
Gl'cose (1-D$/ 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 risA of severe
8y"oglycemia and caregivers,family
mem!ers instr'cted in administration E
Re!o&&enations/ 8%0o$l%!e&ia +1,
Cy"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
3eeAs4 to "artially reverse 8y"oglycemia
'na3areness4 and to red'ce risA 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 B
Consider !ariatric s'rgery for ad'lts 3it8

7&I =3- Ag,m
$
and ty"e $ dia!etes B
After s'rgery4 life-long lifestyle s'""ort

and medical monitoring is necessary B
Ins'fficient evidence to recommend

s'rgery in "atients 3it8 7&I G3- Ag,m
$

o'tside of a researc8 "rotocol E
Bell-designed4 RCs com"aring o"timal

medical,lifestyle t8era"y needed to
determine long-term !enefits4 cost-
effectiveness4 risAs E
Re!o&&enations/ Ba#iat#i! S1#$e#%
Re!o&&enations/ Ba#iat#i! S1#$e#%
Re!o&&enations/ I&&1ni?ation +1,
#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

F.- years of age if imm'ni5ed F- years ago
<t8er indications for re"eat vaccination:

ne"8rotic syndrome4 c8ronic renal disease4 ot8er
imm'nocom"romised states (s'c8 as after
trans"lantation)
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S3-
Administer 8e"atitis 7 vaccination to

'nvaccinated ad'lts 3it8 dia!etes 38o are
aged 1ED-E years C
Consider administering 8e"atitis B

vaccination to 'nvaccinated ad'lts 3it8
dia!etes 38o are aged =./ years C
ADA. +. Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S3-
9I( 'RE9ENTION AND
MANA"EMENT OF
DIABETES COM'LICATIONS
C+D is t8e maJor ca'se of mor!idity4

mortality for t8ose 3it8 dia!etes
1argest contri!'tor to direct,indirect costs
Common conditions coe6isting 3it8 ty"e $

dia!etes (e.g.4 8y"ertension4 dysli"idemia)
are clear risA factors for C+D
Dia!etes itself confers inde"endent risA
7enefits o!served 38en individ'al

cardiovasc'lar risA factors are controlled
to "revent,slo3 C+D in "eo"le 3it8
dia!etes
Ca#iovas!1la# Disease
Ca#iovas!1la# Disease
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S3.
Re!o&&enations/
Re!o&&enations/
8%0e#tension:Bloo '#ess1#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 B
Goals
#eo"le 3it8 dia!etes and 8y"ertension

s8o'ld !e treated to a systolic !lood
"ress're goal of G14/ mmCg B
1o3er systolic targets4 s'c8 as G13/

mmCg4 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 G*/ mmCg B
Re!o&&enations/
Re!o&&enations/
reatment (1)
#atients 3it8 !lood "ress're F1$/,*/

mmCg s8o'ld !e advised on lifestyle
c8anges to red'ce !lood "ress're B
#atients 3it8 confirmed !lood "ress're

8ig8er t8an 14/,*/ mmCg s8o'ld4 in
addition to lifestyle t8era"y4 8ave "rom"t
initiation and timely s'!se2'ent titration
of "8armacological t8era"y to ac8ieve
!lood "ress're goals B
Re!o&&enations/
Re!o&&enations/
reatment ($)
1ifestyle t8era"y for elevated !lood

"ress're B
Beig8t loss if over3eig8t
DASC-style dietary "attern incl'ding red'cing

sodi'm4 increasing "otassi'm intaAe
&oderation of alco8ol intaAe
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 !locAer9 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 !lood "ress're targets B
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 ser'm creatinine,eG?R and
"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/D1$E,.-D%E mmCg 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/
Screening
In most ad'lt "atients 3it8 dia!etes4

meas're fasting li"id "rofile at least
ann'ally B
In ad'lts 3it8 lo3-risA li"id val'es
1D1 c8olesterol G1// mg,d1
CD1 c8olesterol F-/ mg,d1
riglycerides G1-/ mg,d1)
Re"eat li"id assessments every $ years E

Re!o&&enations/
Re!o&&enations/
D%sli0ie&ia:Li0i Mana$e&ent +1,
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S3*
reatment recommendations and goals (1)
o im"rove li"id "rofile in "atients 3it8

dia!etes4 recommend lifestyle modification
A4 foc'sing on
Red'ction of sat'rated fat4 trans fat4

c8olesterol intaAe
Increase of n-3 fatty acids4 visco's fi!er4

"lant stanols,sterols
Beig8t 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 F4/ years of age 38o 8ave one

or more ot8er C+D risA factors A
?or "atients at lo3er risA (e.g.4 3it8o't

overt C+D4 G4/ years of age) C
Consider statin t8era"y in addition to lifestyle

t8era"y if 1D1 c8olesterol remains F1// mg,d1
In t8ose 3it8 m'lti"le C+D risA factors

Re!o&&enations/
Re!o&&enations/
In individ'als 3it8o't overt C+D
Goal is 1D1 c8olesterol G1// mg,d1

($.. mmol,1) B
In individ'als 3it8 overt C+D
1o3er 1D1 c8olesterol goal of G%/ mg,d1

(1.* mmol,1)4 3it8 a 8ig8 dose of a statin4
is an o"tion B
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/D4/> from !aseline B
riglyceride levels G1-/ mg,d1

(1.% mmol,1)4 CD1 c8olesterol F4/ mg,d1
(1./ mmol,1) in men and F-/ mg,d1
(1.3 mmol,1) in 3omen4 are desira!le C
Co3ever4 1D1 c8olesterolDtargeted statin

t8era"y remains t8e "referred strategy A
Re!o&&enations/
Re!o&&enations/
D%sli0ie&ia:Li0i Mana$e&ent +;,
D%sli0ie&ia:Li0i Mana$e&ent +;,
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 B
Re!o&&enations/
Re!o&&enations/
D%sli0ie&ia:Li0i Mana$e&ent +<,
D%sli0ie&ia:Li0i Mana$e&ent +<,
Re!o&&enations/ "l%!e&i!> Bloo
Re!o&&enations/ "l%!e&i!> Bloo
'#ess1#e> Li0i Cont#ol in A1lts
'#ess1#e> Li0i Cont#ol in A1lts
A1C G%./>
@
7lood "ress're G14/,*/ mmCg
M
1i"ids: 1D1
c8olesterol
G1// mg,d1 (G$.. mmol,1)
N
Statin t8era"y for t8ose 3it8
8istory of &I or age F4/O or
ot8er risA factors
@&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 Ano3n 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 lo3er S7# targets may !e a""ro"riate.
NIn individ'als 3it8 overt C+D4 a lo3er 1D1 c8olesterol goal of G%/ mg,d1 (1.* mmol,1)4 'sing a 8ig8
dose of a statin4 is an o"tion.
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S4/9 a!le 1/
Consider as"irin t8era"y (%-D1.$ mg,day)

C
As a "rimary "revention strategy in t8ose 3it8

ty"e 1 or ty"e $ dia!etes at increased
cardiovasc'lar risA (1/-year risA F1/>)
Incl'des most men F-/ years of age or 3omen

F./ years of age 38o 8ave at least one
additional maJor risA factor
?amily 8istory of C+D
Cy"ertension
SmoAing
Dysli"idemia
Al!'min'ria
Re!o&&enations/
Re!o&&enations/
Anti0latelet A$ents +1,
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S4/
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 risA4 since "otential adverse
effects from !leeding liAely offset "otential
!enefits C
1o3 risA: 1/-year C+D risA G->4 s'c8 as in

men G-/ years4 3omen G./ years 3it8 no
maJor additional C+D risA factors
In "atients in t8ese age gro'"s 3it8

m'lti"le ot8er risA factors (1/-year risA
-D1/>)4 clinical J'dgment is re2'ired E
Kse as"irin t8era"y (%-D1.$ 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 B
D'al anti"latelet t8era"y is reasona!le for

'" to a year after an ac'te coronary
syndrome B
Re!o&&enations/
Re!o&&enations/
Advise all "atients not to smoAe or 'se

to!acco "rod'cts A
Incl'de smoAing cessation co'nseling and

ot8er forms of treatment as a ro'tine
com"onent of dia!etes care B
Re!o&&enations/
Re!o&&enations/
S&o*in$ Cessation
S&o*in$ Cessation
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S41
Re!o&&enations/
Re!o&&enations/
Ca#iovas!1la# Disease +1,
Screening
In asym"tomatic "atients4 ro'tine

screening for CAD is not recommended
!eca'se it does not im"rove o'tcomes as
long as C+D risA factors are treated A
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S4$
reatment (1)
o red'ce risA of cardiovasc'lar events in

"atients 3it8 Ano3n C+D4 consider
ACE in8i!itor C
As"irin@ A
Statin t8era"y@ A
In "atients 3it8 a "rior &I
;-!locAers s8o'ld !e contin'ed for at least

$ years after t8e event B
Re!o&&enations/
Re!o&&enations/
@If not contraindicated.
reatment ($)
In "atients 3it8 sym"tomatic 8eart fail're4

avoid t8ia5olidinedione treatment C
In "atients 3it8 sta!le CC?4 metformin B
&ay !e 'sed if renal f'nction is normal
S8o'ld !e avoided in 'nsta!le or 8os"itali5ed

"atients 3it8 CC?
Re!o&&enations/
Re!o&&enations/
o red'ce t8e risA or slo3 t8e "rogression

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

Re!o&&enations/ Ne0)#o0at)%
Re!o&&enations/ Ne0)#o0at)%
Re!o&&enations/
Re!o&&enations/
Ne0)#o0at)% +1,
Ne0)#o0at)% +1,
Screening
Assess 'rine al!'min e6cretion ann'ally B
In ty"e 1 dia!etic "atients 3it8 dia!etes

d'ration of =- years
In all ty"e $ dia!etic "atients at diagnosis

reatment (1)
ACE in8i!itor4 AR7 not recommended in

dia!etic "atients 3it8 normal !lood
"ress're4 al!'min e6cretion G3/ mg,$4 8
for "rimary "revention of dia!etic Aidney
disease B
Non"regnant "atient 3it8 modestly

elevated (3/D$EE mg,day) C or 8ig8er
levels (F3// mg,day) A of 'rinary
al!'min e6cretion
Kse eit8er ACE in8i!itors or AR7s (not !ot8)

Re!o&&enations/
Re!o&&enations/
Ne0)#o0at)% +2,
Ne0)#o0at)% +2,
reatment ($)
?or "eo"le 3it8 dia!etes and dia!etic

Aidney disease (al!'min'ria F3/ mg,$4 8)4
red'cing dietary "rotein !elo3 's'al intaAe
not recommended A
B8en ACE in8i!itors4 AR7s4 or di'retics are

'sed4 monitor ser'm creatinine4 "otassi'm
levels for increased creatinine or c8anges in
"otassi'm E
Re!o&&enations/
Re!o&&enations/
Ne0)#o0at)% +2,
Ne0)#o0at)% +2,
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S4$DS43
reatment (3)
Reasona!le to contin'e monitoring 'rine

al!'min e6cretion to assess !ot8 res"onse
to t8era"y and disease "rogression E
B8en eG?R is G./ m1,min,1.%3 m$4

eval'ate and manage "otential
com"lications of CID E
Consider referral to a "8ysician

e6"erienced in care of Aidney disease B
Kncertainty a!o't etiology9 diffic'lt

management iss'es9 advanced Aidney disease
Re!o&&enations/
Re!o&&enations/
Ne0)#o0at)% +4,
Ne0)#o0at)% +4,
Definitions of Abno#&alities in
Definitions of Abno#&alities in
Alb1&in E@!#etion
Alb1&in E@!#etion
Category
S"ot collection
(Pg,mg
creatinine)
Normal G3/
Increased 'rinary
al!'min e6cretion@ =3/
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S449 a!le 11
@Cistorically4 ratios !et3een 3/ and $EE 8ave !een called microal!'min'ria and t8ose 3// or greater
8ave !een called macroal!'min'ria (or clinical al!'min'ria).
Sta$es of C)#oni! Aine% Disease
Sta$es of C)#oni! Aine% Disease
Stage Descri"tion
G?R (m1,min
"er 1.%3 m
$

!ody s'rface
area)
1 Iidney damage
@
3it8 normal or
increased G?R
=E/
$ Iidney damage
@
3it8 mildly
decreased G?R
./D*E
3 &oderately decreased G?R 3/D-E
4 Severely decreased G?R 1-D$E
- Iidney fail're G1- or dialysis
%idne& damage de"ined as abnormalities on 'athologic( urine( blood( or imaging tests)
*+, - glomerular "iltration rate
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S449 a!le 1$
Mana$e&ent of CAD in Diabetes +1,
G?R Recommended
All "atients Qearly meas'rement of creatinine4 'rinary
al!'min e6cretion4 "otassi'm
4--./ Referral to a ne"8rologist if "ossi!ility for
nondia!etic Aidney disease e6ists
Consider dose adJ'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. Dia!etes Care $/1493%(s'""l 1):S4-9 a!le 139
Ada"ted from 8tt":,,333.Aidney.org,"rofessionals,ID<RI,g'idelineSdia!etes,
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S4-9 a!le 139
Ada"ted from 8tt":,,333.Aidney.org,"rofessionals,ID<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 3D. mont8s
Consider need for dose adJ'stment of
medications
G3/ Referral to a ne"8rologist
Re!o&&enations/ Retino0at)%
Re!o&&enations/ Retino0at)%
o red'ce t8e risA or slo3 t8e "rogression

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

Screening (1)
Initial dilated and com"re8ensive eye

e6amination !y an o"8t8almologist or
o"tometrist
Ad'lts 3it8 ty"e 1 dia!etes

Bit8in - years after dia!etes onset B
#atients 3it8 ty"e $ dia!etes
S8ortly after diagnosis of dia!etes B

Re!o&&enations/
Re!o&&enations/
Retino0at)% +1,
Retino0at)% +1,
Screening ($)
If no evidence of retino"at8y for one or

more eye e6am
E6ams every $ years may !e considered B
If dia!etic retino"at8y if "resent
S'!se2'ent e6aminations for ty"e 1 and ty"e

$ dia!etic "atients s8o'ld !e re"eated ann'ally
!y an o"8t8almologist or o"tometrist B
If retino"at8y is "rogressing4 more

fre2'ent e6ams re2'ired B
Re!o&&enations/
Re!o&&enations/
Retino0at)% +2,
Retino0at)% +2,
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S44DS4-
Screening (3)
Cig8-2'ality f'nd's "8otogra"8s
Can detect most clinically significant

dia!etic retino"at8y E
Inter"retation of images
#erformed !y a trained eye care "rovider E
B8ile 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 recommended intervals E
Re!o&&enations/
Re!o&&enations/
Retino0at)% +2,
Retino0at)% +2,
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S4-
Screening (4)
Bomen 3it8 "ree6isting dia!etes 38o are

"lanning "regnancy or 38o 8ave !ecome
"regnant B
Com"re8ensive eye e6amination
Co'nseled on risA of develo"ment and,or

"rogression of dia!etic retino"at8y
Eye e6amination s8o'ld occ'r in t8e first

trimester B
Close follo3-'" t8ro'g8o't "regnancy
?or 1 year "ost"art'm

Re!o&&enations/
Re!o&&enations/
Retino0at)% +4,
Retino0at)% +4,
reatment (1)
#rom"tly refer "atients 3it8 any level of

mac'lar edema4 severe N#DR4 or any #DR
o an o"8t8almologist Ano3ledgea!le and

e6"erienced in management4 treatment of
dia!etic retino"at8y A
1aser "8otocoag'lation t8era"y is

indicated A
o red'ce risA of vision loss in "atients 3it8

Cig8-risA #DR
Clinically significant mac'lar edema
Some cases of severe N#DR
Re!o&&enations/
Re!o&&enations/
Retino0at)% +;,
Retino0at)% +;,
reatment ($)
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 risA of retinal 8emorr8age A
Re!o&&enations/
Re!o&&enations/
Retino0at)% +<,
Retino0at)% +<,
All "atients s8o'ld !e screened for distal

symmetric "olyne'ro"at8y (D#N) B
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
Re!o&&enations/
Re!o&&enations/
Ne1#o0at)% S!#eenin$> T#eat&ent +1,
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
Red'ce "ain B9 im"rove 2'ality of life E

Re!o&&enations/
Re!o&&enations/
?or all "atients 3it8 dia!etes4 "erform an

ann'al com"re8ensive foot e6amination to
identify risA factors "redictive of 'lcers
and am"'tations B
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$*-C5 t'ning forA
#in"ricA sensation
AnAle refle6es
+i!ration "erce"tion t8res8old

Re!o&&enations/ Foot Ca#e +1,
ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S4%
300e# 0anel
o "erform t8e 1/-g

monofilament test4 "lace
t8e device "er"endic'lar to
t8e sAin4 3it8 "ress're
a""lied 'ntil t8e
monofilament !'cAles
Cold in "lace for 1 second
and t8en release
Lo7e# 0anel
8e monofilament test
s8o'ld !e "erformed at t8e
8ig8lig8ted sites 38ile t8e
"atientHs eyes are closed
7o'lton AT&4 et al. Dia!etes Care $//*931:1.%ED1.*-
#rovide general foot self-care ed'cation B
Kse m'ltidisci"linary a""roac8
Individ'als 3it8 foot 'lcers4 8ig8-risA feet9

es"ecially "rior 'lcer or am"'tation B
Refer "atients to foot care s"ecialists for

ongoing "reventive care4 life-long
s'rveillance C
SmoAers
1oss of "rotective sensation or str'ct'ral

a!normalities
Cistory of "rior lo3er-e6tremity com"lications

ADA. +I. #revention4 &anagement of Com"lications. Dia!etes Care $/1493%(s'""l 1):S4%DS4*
Initial screening for "eri"8eral arterial

disease (#AD) C
Incl'de a 8istory for cla'dication4 assessment

of "edal "'lses
Consider o!taining an anAle-!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
9II( ASSESSMENT OF COMMON
COMORBID CONDITIONS
Re!o&&enation/ Assess&ent of
Re!o&&enation/ Assess&ent of
Co&&on Co&o#bi Conitions
Co&&on Co&o#bi Conitions
Consider assessing for and addressing

common comor!id conditions t8at may
com"licate t8e management of dia!etes B
Common comor!idities
ADA. +II. Assessment of Common Comor!id Conditions. Dia!etes Care $/1493%(s'""l 1):S4E
De"ression Cognitive im"airment
<!str'ctive slee" a"nea 1o3 testosterone in men
?atty liver disease #eriodontal disease
Cancer Cearing im"airment
?ract'res
9III( DIABETES CARE IN
S'ECIFIC 'O'3LATIONS
Re!o&&enations/ 'eiat#i!
"l%!e&i! Cont#ol +T%0e 1 Diabetes,
"l%!e&i! Cont#ol +T%0e 1 Diabetes,
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. Dia!etes Care $/1493%(s'""l 1):S-/
Screening
Ann'al screening for al!'min levels9

random s"ot 'rine sam"le for al!'min-to-
creatinine (ACR) ratio at start of "'!erty
or age =1/ years4 38ic8ever is earlier4
once yo't8 8as 8ad dia!etes for - years B
reatment
ACE in8i!itor 38en ACR confirmed on t3o

additional different s"ecimens from
different days over .-mont8 interval E
Ne0)#o0at)% +T%0e 1 Diabetes,
Ne0)#o0at)% +T%0e 1 Diabetes,
8%0e#tension +T%0e 1 Diabetes, +1,
Screening
&eas're !lood "ress're at eac8 ro'tine

visit9 confirm 8ig8-normal !lood "ress're
or 8y"ertension on a se"arate day B
reatment (1)
Initial treatment of 8ig8-normal !lood

"ress're (S7# or D7# consistently a!ove
E/
t8
"ercentile for age4 se64 and 8eig8t)
Dietary intervention and e6ercise4 aimed at

3eig8t control9 increased "8ysical activity4 if
a""ro"riate
If target !lood "ress're is not reac8ed

3it8 3D. mont8s of lifestyle intervention4
consider "8armacologic treatment E
reatment ($)
#8armacologic treatment of 8y"ertension
S7# or D7# consistently a!ove t8e E-t8

"ercentile for age4 se64 and 8eig8t
Or
Consistently F13/,*/ mmCg4 if E-> e6ceeds

t8at val'e
Consider treatment as soon as diagnosis

is confirmed E
ADA. +III. Dia!etes Care in S"ecific #o"'lations. Dia!etes Care $/1493%(s'""l 1):S-1
reatment (3)
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 G13/,*/ mmCg or

!elo3 t8e E/
t8
"ercentile for age4 se64 and
8eig8t4 38ic8ever is lo3er E
Screening (1)
If family 8istory of 8y"erc8olesterolemia

or a cardiovasc'lar event !efore age --
years4 or if family 8istory is 'nAno3n
Consider o!taining fasting li"id "rofile in

c8ildren F$ years of age soon after diagnosis
(after gl'cose control 8as !een esta!lis8ed) E
D%sli0ie&ia +T%0e 1 Diabetes, +1,
Screening ($)
If family 8istory is not of concern
Consider first li"id screening at "'!erty

(=1/ years) E
C8ildren diagnosed 3it8 dia!etes at or

after "'!erty
Consider o!taining 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 risA levels (G1// 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" $ ACA diet aimed at
decreasing dietary sat'rated fat E
F1/ years4 statin reasona!le in t8ose

(after &N and lifestyle c8anges) 3it8 E
1D1 c8olesterol F1./ mg,d1 (4.1 mmol,1) or
1D1 c8olesterol F13/ mg,d1 (3.4 mmol,1) and

one or more C+D risA factors
Goal: 1D1 c8olesterol G1// mg,d1

($.. mmol,1) E
&NWmedical n'trition t8era"y
Initial dilated and com"re8ensive eye

e6amination s8o'ld !e considered
Start of "'!erty or age =1/ years4 38ic8ever

is earlier4 once t8e yo't8 8as 8ad dia!etes for
3D- years B
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
Retino0at)% +T%0e 1 Diabetes,
Retino0at)% +T%0e 1 Diabetes,
ADA. +III. Dia!etes Care in S"ecific #o"'lations. Dia!etes Care $/1493%(s'""l 1):S-$
Screen for !y meas'ring IgA antitiss'e

transgl'taminase or antiendomysial
anti!odies9 doc'ment normal total ser'm
IgA levels soon after dia!etes diagnosis E
Consider testing in c8ildren 3it8
#ositive family 8istory of celiac disease
Gro3t8 fail're
?ail're to gain 3eig8t4 3eig8t loss
Diarr8ea4 flat'lence4 a!dominal "ain4 signs of

mala!sor"tion
?re2'ent 'ne6"lained 8y"oglycemia or

deterioration in glycemic control E
Celia! Disease +T%0e 1 Diabetes, +1,
Asym"tomatic c8ildren 3it8 "ositive

anti!odies
Consider referral to a gastroenterologist for

eval'ation 3it8 "ossi!le endosco"y and !io"sy
for confirmation of celiac disease 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 B
C8ildren 3it8 ty"e 1 dia!etes
Screen for antit8yroid "ero6idase4

antit8yroglo!'lin anti!odies soon after
diagnosis E
8yroid-stim'lating 8ormone (SC)

concentrations
&eas're after meta!olic control esta!lis8ed
If normal4 consider rec8ecAing every 1D$ years4

es"ecially if "atient develo"s sym"toms of t8yroid
dysf'nction4 t8yromegaly4 an a!normal gro3t8 rate4
or 'n's'al glycemic variation E
8%0ot)%#oiis& +T%0e 1 Diabetes,
8%0ot)%#oiis& +T%0e 1 Diabetes,
As teens transition into emerging

ad'lt8ood4 8ealt8 care "roviders and
families m'st recogni5e t8eir many
v'lnera!ilities B 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 linAs to reso'rces for t8e
teen and emerging ad'lt B
Re!o&&enations/ T#ansition f#o&
Re!o&&enations/ T#ansition f#o&
'eiat#i! to A1lt Ca#e
'eiat#i! to A1lt Ca#e
A1C levels s8o'ld !e as close to normal as

"ossi!le (%>) in an individ'al "atient
!efore conce"tion is attem"ted B
Starting at "'!erty4 incor"orate

"reconce"tion co'nseling in ro'tine
dia!etes clinic visit for all 3omen of
c8ild!earing "otential B
Bomen 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 B
Re!o&&enations/
Re!o&&enations/
'#e!on!e0tion Ca#e +1,
Eval'ate medications "rior to conce"tion4

since dr'gs commonly 'sed to treat
dia!etes,com"lications may !e
contraindicated or not recommended in
"regnancy
Statins4 ACE in8i!itors4 AR7s4 most nonins'lin

t8era"ies E
&any "regnancies are 'n"lanned9 consider

"otential risAs,!enefits of medications
contraindicated in "regnancy in all 3omen
of c8ild!earing "otential9 co'nsel
accordingly E
Re!o&&enations/
Re!o&&enations/
?'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 some older ad'lts

mig8t reasona!ly !e related4 'sing
individ'al criteria4 !'t 8y"erglycemia
leading to sym"toms or risA of ac'te
8y"erglycemic com"lications s8o'ld !e
avoided in all "atients E
Re!o&&enations/ Ole# A1lts +1,
reat ot8er cardiovasc'lar risA factors 3it8

consideration of time frame of !enefit and
t8e individ'al "atient
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
ADA. +III. Dia!etes Care in S"ecific #o"'lations. Dia!etes Care $/1493%(s'""l 1):S-4DS--
Re!o&&enations/ C%sti! Fib#osis
B
B
Relate Diabetes +CFRD, +1,
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 B
A1C as a screening test for C?RD is not

recommended B
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. Dia!etes Care $/1493%(s'""l 1):S-.
B
B
#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. Dia!etes Care $/1493%(s'""l 1):S-.
IC( DIABETES CARE IN
S'ECIFIC SETTIN"S
Re!o&&enations/
Re!o&&enations/
Diabetes Ca#e in t)e 8os0ital +1,
Dia!etes disc8arge "lanning s8o'ld start

at 8os"ital admission4 and clear dia!etes
management instr'ctions s8o'ld !e
"rovided at disc8arge E
8e sole 'se of sliding scale ins'lin in t8e

in"atient 8os"ital setting is disco'raged E
ADA. I0. Dia!etes Care in S"ecific Settings. Dia!etes Care $/1493%(s'""l 1):S-.
Re!o&&enations/
Re!o&&enations/
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
Re!o&&enations/
Re!o&&enations/
Goals for !lood gl'cose levels
Critically ill "atients (1)
Initiate ins'lin t8era"y for "ersistent

8y"erglycemia starting no greater t8an 1*/ mg,d1
(1/ mmol,1)9 once started4 gl'cose range of 14/D
1*/ mg,d1 (%.*D1/ mmol,1) is recommended A
&ore stringent goals4 11/D14/ mg,d1 (..1D%.*

mmol,1) may !e a""ro"riate for selected "atients
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 risA for
severe 8y"oglycemia E
Re!o&&enations/
Re!o&&enations/
Goals for !lood gl'cose levels
NonDcritically 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 G14/ mg,d1 (%.* mmol,1) 3it8 random
!lood gl'cose G1*/ 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
Re!o&&enations/
Re!o&&enations/
Diabetes Ca#e in t)e 8os0ital +;,
Diabetes Ca#e in t)e 8os0ital +;,
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/
Diabetes Ca#e in t)e 8os0ital +<,
Diabetes Ca#e in t)e 8os0ital +<,
Initiate gl'cose monitoring in any "atient

not Ano3n to !e dia!etic 38o receives
t8era"y associated 3it8 8ig8-risA for
8y"erglycemia
Cig8-dose gl'cocorticoid t8era"y4 initiation of

enteral or "arenteral n'trition4 or ot8er
medications s'c8 as octreotide or
imm'nos'""ressive medications B
If 8y"erglycemia is doc'mented and

"ersistent4 consider treating s'c8 "atients
to t8e same glycemic goals as "atients 3it8
Ano3n dia!etes E
A 8y"oglycemia management "rotocol

s8o'ld !e ado"ted and im"lemented !y
eac8 8os"ital or 8os"ital system E
Consider o!taining an A1C in "atients
Bit8 dia!etes admitted to t8e 8os"ital if

testing res'lt in "revio's $D3 mo 'navaila!le E
Bit8 risA factors for 'ndiagnosed dia!etes 38o

e68i!it 8y"erglycemia in t8e 8os"ital E
#atients 3it8 8y"erglycemia 3it8o't a

"rior diagnosis: doc'ment "lans for follo3-
'" testing and care at disc8arge E
Re!o&&enations/
Re!o&&enations/
Diabetes Ca#e in t)e 8os0ital +=,
Diabetes Ca#e in t)e 8os0ital +=,
ADA. I0. Dia!etes Care in S"ecific Settings. Dia!etes Care $/1493%(s'""l 1):S-.DS-%
1argest randomi5ed controlled trial to date
ested effect of tig8t glycemic control

(target *1D1/* mg,d1) on o'tcomes
among .41/4 critically ill "artici"ants
&aJority (FE->) re2'ired mec8anical

ventilation
Diabetes Ca#e in t)e 8os0ital/
NICE5S3"AR St1% +1,
NICE5S3"AR St1% +1,
ADA. I0. Dia!etes Care in S"ecific Settings. Dia!etes Care $/1493%(s'""l 1):S-%
NICE5S3"AR St1% +2,
NICE5S3"AR St1% +2,
In !ot8 s'rgical,medical "atients4 E/-day

mortality significantly 8ig8er in intensively
treated vs conventional gro'" (target
144D1*/ mg,d1)
Severe 8y"oglycemia more common

(..*> vs. /.->9 P G /.//1)
?indings strongly s'ggest may not !e

necessary to target !lood gl'cose levels
G14/ mg,d19 8ig8ly stringent target of
G11/ mg,d1 may act'ally !e dangero's
ADA. I0. Dia!etes Care in S"ecific Settings. Dia!etes Care $/1493%(s'""l 1):S-%
C( STRATE"IES FOR
IM'RO9IN"
DIABETES CARE
Re!o&&enations/ St#ate$ies fo#
I&0#ovin$ Diabetes Ca#e +1,
ADA. 0. Strategies for Im"roving Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S.1
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
B8en 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 B
reatment decisions s8o'ld !e timely4

!ased on evidence-!ased g'idelines
tailored to individ'al "atient "references4
"rognoses4 and comor!idities B
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 B
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

ObDe!tive 1/
ObDe!tive 1/
O0ti&i?e '#ovie# an Tea& Be)avio#
O0ti&i?e '#ovie# an Tea& Be)avio#
ObDe!tive 2/
ObDe!tive 2/
S100o#t 'atient Be)avio# C)an$e
S100o#t 'atient Be)avio# C)an$e
Im"lement a systematic a""roac8 to

s'""ort "atient !e8avior c8ange efforts
a) Cealt8y lifestyle: "8ysical activity4 8ealt8y
eating4 non'se of to!acco4 3eig8t
management4 effective co"ing
!) Disease self-management: medication taAing
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
ADA. 0. Strategies for Im"roving Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S.$
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
ObDe!tive 2/
ObDe!tive 2/
C)an$e t)e S%ste& of Ca#e
C)an$e t)e S%ste& of Ca#e
ADA. 0. Strategies for Im"roving Dia!etes Care. Dia!etes Care $/1493%(s'""l 1):S.$

ADA Standards of Medical Care 2014 FINAL 8 Jan 2014 LOCKED

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

ADA Standards of Medical Care 2014 FINAL 8 Jan 2014 LOCKED

Transféré par

Droits d'auteur :

Formats disponibles

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&)

est over3eig8t,o!ese ad'lts (7&I =$-

If tests are normal4 re"eat testing at least

o test for dia!etes,"redia!etes4 t8e A1C4

In t8ose 3it8 "redia!etes4 identify and4 if

esting to detect ty"e $ dia!etes and

Inform ty"e 1 dia!etes "atients of t8e

Screen for 'ndiagnosed ty"e $ dia!etes

Screen for GD& at $4D$* 3eeAs of

Screen 3omen 3it8 GD& for "ersistent

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

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

?'rt8er researc8 is needed to esta!lis8 a

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

#erform <G in t8e morning after an

GD& diagnosis: 38en any of t8e follo3ing

#erform -/-g G1 (nonfasting) 3it8 "lasma

If "lasma gl'cose level meas'red at 1 8

GD& diagnosis: "lasma gl'cose meas'red

Refer "atients 3it8 IG A4 I?G E4 or A1C

argeting 3eig8t loss of %> of !ody 3eig8t

Increasing "8ysical activity to at least 1-/

?ollo3-'" co'nseling a""ears to !e

7ased on cost-effectiveness of dia!etes

Consider metformin for "revention of ty"e

Es"ecially for t8ose 3it8 7&I F3- Ag,m

In t8ose 3it8 "redia!etes4 monitor for

Screen for and treat modifia!le risA

A com"lete medical eval'ation s8o'ld !e

Classify t8e dia!etes

#erform la!oratory tests necessary to

Age and c8aracteristics of onset of

Eating "atterns4 "8ysical activity 8a!its4

Dia!etes ed'cation 8istory

Revie3 of "revio's treatment regimens

C'rrent treatment of dia!etes4 incl'ding

Res'lts of gl'cose monitoring4 "atientHs

DIA fre2'ency4 severity4 ca'se

Any severe 8y"oglycemia: fre2'ency4 ca'se

Cistory of dia!etes-related com"lications

&icrovasc'lar: retino"at8y4 ne"8ro"at8y4

&acrovasc'lar: CCD4 cere!rovasc'lar disease4

<t8er: "syc8osocial "ro!lems4@ dental

Ceig8t4 3eig8t4 7&I

7lood "ress're determination4 incl'ding

SAin e6amination (for acant8osis nigricans

Com"re8ensive foot e6amination

#al"ation of dorsalis "edis and "osterior

#resence,a!sence of "atellar and Ac8illes

Determination of "ro"rioce"tion4 vi!ration4

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

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

?asting li"id "rofile4 incl'ding total4 1D14 and

1iver f'nction tests

est for 'rine al!'min e6cretion 3it8 s"ot 'rine

Ser'm creatinine and calc'lated G?R

SC in ty"e 1 dia!etes4 dysli"idemia4 or