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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI

Visit NDEI.org for interactive summary recommendations on the ADA 2014 guidelines. Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Diagnosis & A1C Testing Criteria for Diabetes Diagnosis: 4 options A1C ≥6.5%* Perform in lab using NGSP-certified method and standardized to DCCT assay FPG ≥126 mg/dL (7.0 mmol/L)* Fasting defined as no caloric intake for ≥8 hrs 2-hr PG ≥200 mg/dL (11.1 mmol/L) during OGTT (75-g)* Random PG ≥200 mg/dL (11.1 mmol/L) In persons with symptoms of hyperglycemia or hyperglycemic crisis *In the absence of unequivocal hyperglycemia results should be confirmed using repeat testing Frequency of A1C Testing Perform A1C test At least 2 times each year in patients who are meeting treatment targets and have stable glycemic control

Quarterly in patients whose therapy has changed or who are not meeting glycemic targets

Point-of-care A1C testing allows for more timely treatment changes DCCT=Diabetes Control and Complications Trial; FPG=fasting plasma glucose; OGTT=oral glucose tolerance test; PG=plasma glucose

See the end of this document for slides available for in the NDEI.org Slide Library. January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.



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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Glycemic, BP, and Lipid Treatment Targets Glycemic Targets for Adults With Diabetes <7.0% Lowering A1C below or around 7.0% shown to reduce A1C

• •

Microvascular complications Macrovascular disease*

Preprandial capillary PG

70-130 mg/dL (3.9-7.2 mmol/L)

Peak postprandial capillary PG

<180 mg/dL (<10.0 mmol/L) Postprandial glucose measurements should be made 1-2 h after the beginning of the meal

Individualize targets based on:

• • • • • •

Age/life expectancy Comorbid conditions Diabetes duration Hypoglycemia status Individual patient considerations Known CVD/advanced microvascular complications

More or less stringent targets may be appropriate if achieved without significant hypoglycemia or adverse events More stringent (<6.5%) • • •

Short diabetes duration Long life expectancy No significant CVD

Less stringent (<8%) • • • • •

Severe hypoglycemia history Limited life expectancy Advanced microvascular or macrovascular complications Extensive comorbidities Long-term diabetes in whom general A1C target difficult to attain†

Targets shown are for nonpregnant adults *If implemented soon after diagnosis † Despite diabetes self-management, appropriate glucose monitoring, effective doses of antihyperglycemic agents (including insulin) Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug istration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States. January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.




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Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Continued from previous page Blood Pressure and Lipid Targets Blood Pressure: <140/<80 mm Hg Lower SBP targets may be appropriate based on individual patient characteristics and therapeutic response Lipids: LDL-C <100 mg/dL (<2.6 mmol/L) A lower LDL-C target of <70 mg/dL, using a high dose of a statin, may be appropriate in persons with overt CVD

CVD=cardiovascular disease; SBP=systolic blood pressure; PG=plasma glucose

Type 2 Diabetes Prevention Prevention/Delay of Type 2 Diabetes Patients with IGT, IFG, or A1C 5.7%-6.4%

Refer to ongoing program targeting • •

Weight loss (7% of body weight) Increased physical activity (≥150 min/week moderate activity)

Consider metformin therapy for type 2 diabetes Especially in presence of prevention in patients with IGT, IFG, or A1C 5.7%-6.4% • BMI >35 kg/m2 • Age <60 years • Women with prior GDM Annual monitoring of individuals with prediabetes Screening for and treatment of modifiable CVD risk factors (obesity, hypertension, and dyslipidemia) suggested BMI=body mass index; CVD=cardiovascular disease; GDM=gestational diabetes mellitus; IFG=impaired fasting glucose; IGT=impaired glucose tolerance

Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug istration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States. January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.




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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating.

Pharmacologic Therapy for Type 2 Diabetes Medications for Hyperglycemia in Type 2 Diabetes Metformin

Preferred initial therapy (if tolerated and not contraindicated)

Consider insulin therapy with or without other agents →

At outset in newly diagnosed patients with markedly symptomatic and/or elevated blood glucose levels or A1C

Add 2nd oral agent, GLP-1 receptor agonist, or insulin →

If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain A1C target over 3 mos

Choice of pharmacologic therapy should be based on patient-centered approach • • • • • • •

Consider:

Efficacy Cost Potential side effects Effects on weight Comorbidities Hypoglycemia risk Patient preferences

Insulin eventually needed for many patients due to progressive nature of type 2 diabetes GLP=glucagon-like peptide

Visit NDEI.org for summary recommendations on the ADA/European Association for the Study of Diabetes (EASD) management of hyperglycemia in type 2 diabetes guidelines.





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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Insulin & Glucose Monitoring Self-Monitoring of Blood Glucose (SMBG) Encourage for patients receiving multiple dose insulin or insulin pump therapy:

• • • • • • •

Prior to meals and snacks Occasionally postprandially At bedtime Prior to exercise When low blood glucose is suspected After treating low blood glucose until normoglycemic Prior to critical tasks (eg, driving)

Results may be useful for guiding treatment and/or self-management for patients using less frequent insulin injections or noninsulin therapies •

Provide ongoing instruction and regular evaluation of SMBG technique and results and patient’s ability to use data to adjust therapy

Continuous Glucose Monitoring (CGM) •

Useful for A1C lowering in select adults (aged ≥25 yrs) with type 1 diabetes requiring intensive insulin regimens

•

May be a useful supplement to SMBG among patients with

• •

May be useful among children, teens, and younger adults* Success related to adherence to ongoing use Hypoglycemia unawareness and/or Frequent hypoglycemic episodes

*Evidence for A1C lowering less strong in these populations





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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Cardiovascular Disease (CVD) & Diabetes CVD Screening and Treatment Screening

Asymptomatic patients: routine CAD screening not recommended; treatment of CVD risk factors is focus Overt CVD: consider ACEI, and use aspirin and statin to reduce CV event risk Prior MI: continue use of beta-blockers for ≥2 yrs after event Symptomatic heart failure: avoid TZDs Metformin

Treatment

• •

Stable heart failure: may use metformin in presence of normal renal function Avoid metformin in unstable or hospitalized heart failure patients

Management of High Blood Pressure Screening

Measure BP at every visit; confirm elevated BP at separate visit

Treatment targets

Diabetes and hypertension: SBP <140 mm Hg •

Lower SBP targets (eg, <130 mm Hg) may be appropriate*

Diabetes: DBP <80 mm Hg BP >120/80 mm Hg: lifestyle changes • • • • Treatment

Weight loss (if overweight) DASH-style diet including sodium restriction, potassium increase Moderate alcohol intake Increased physical activity

BP >140/80 mm Hg: lifestyle changes + pharmacologic therapy • • • •

Treatment and targets for pregnant women

Diabetes and hypertension: ACEI or ARB† ≥2 agents at max doses usually required to achieve targets ister ≥1 agent at bedtime ACEI, ARB, diuretic: monitor serum creatinine/eGFR and serum potassium

Diabetes and hypertension: 110-129/65-79 mm Hg target ACEI, ARB contraindicated

*In certain individuals, if achieved without treatment burden ; †If one class not tolerated, substitute other class Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug istration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States. January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.




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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: Source:American AmericanDiabetes DiabetesAssociation. Association. Standards Standardsofofmedical medicalcare careinindiabetes—2014. diabetes—2014.Diabetes DiabetesCare. Care.2014;37(suppl 2014;37(suppl1):S14-S80. 1):S14-S80. Refer to source document for full recommendations, including Refer to source document for full recommendations, includinglevel levelofofevidence evidencerating. rating. Continued from previous page Management of Dyslipidemia Screening

Measure fasting lipids at least annually Every 2 yrs for adults with low-risk lipid values: LDL-C <100 mg/dL (2.6 mmol/L), HDL-C >50 mg/dL (1.3 mmol/L), TG <150 mg/dL (1.7 mmol/L)

Targets

• • •

No overt CVD: LDL-C <100 mg/dL (2.6 mmol/L) Overt CVD: LDL-C <70 mg/dL (1.8 mmol/L), with high-dose statin* If targets not achieved on max statin therapy: ~30-40% LDL-C reduction from baseline

Lifestyle modification • • • • Treatment

Reduce saturated fat, trans fat, cholesterol intake Increase omega-3 fatty acids, viscous fiber, plant stenols/sterols intake Weight loss (if indicated) Increase physical activity

Statin therapy* and lifestyle changes in patients with • • •

Overt CVD No CVD, aged >40 yrs, ≥1 CVD risk factor† Consider statins in lower-risk patients (no overt CVD, aged <40 yrs) if LDL-C >100 mg/dL or if multiple CVD risk factors

Combination therapy not recommended *Contraindicated in pregnancy † Hypertension, smoking, dyslipidemia, albuminuria, family history of CVD





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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Source: American Diabetes Association.

Continued from previous page Antiplatelet Therapy 75-162 mg/day: type 1 and type 2 diabetes at increased CVD risk (10-yr risk >10%)* Aspirin: Primary prevention

Low-risk patients (10-yr risk <5%):† not recommended; potential for bleeds likely offsets potential benefits Men <50 yrs, women <60 yrs with multiple other risk factors (10-yr risk 5%-10%): use clinical judgment

Aspirin: Secondary prevention

75-162 mg/day: diabetes and CVD history

CVD and aspirin allergy

Clopidogrel 75 mg/day

Dual antiplatelet therapy Reasonable for ≤1 year after ACS *Includes most men aged >50 yrs or women aged >60 yrs with ≥1 add’l major risk factor: family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria † Men aged <50 yrs and women aged >60 yrs with no major additional CVD risk factors ACEI=angiotensin-converting enzyme inhibitor; ACS=acute coronary syndrome; ARB=angiotensin receptor blocker; BP=blood pressure; CAD=coronary artery disease; CVD=cardiovascular disease; DASH=Dietary Approaches to Stop Hypertension; DBP=diastolic blood pressure; eGFR=estimated glomerular filtration rate; MI=myocardial infarction; SBP=systolic blood pressure; TZD=thiazolidinedione





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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Microvascular Complications Nephropathy Screening and Treatment Optimize glucose and BP control to reduce risk or slow progression of nephropathy Screening

Annually measure urine albumin excretion in type 1 patients with ≥5-yr diabetes duration, and all type 2 patients starting at diagnosis

Treatment

Normal BP and albumin excretion <30 mg/24 h

ACEI or ARB for primary prevention of kidney disease not recommended

Nonpregnant with modest elevations Use ACEI or ARB (but not in combination) (30-299 mg/24 h) or higher levels (≥300 mg/24 h) of urinary albumin excretion Diabetic kidney disease (albuminuria >30 mg/24 h)

Limiting protein intake not recommended

When using ACEI, ARB, diuretic

Monitor creatinine and potassium levels

Monitor urine albumin excretion continually to assess therapeutic response, disease progression If eGFR <60 mL/min/1.73 m2

Evaluate, manage CKD complications

Consider specialist referral

Uncertainty re: kidney disease etiology, difficult management issues, advanced kidney disease

Retinopathy Screening and Treatment Optimize glucose and BP control to reduce risk or slow progression of retinopathy Screening Initial dilated and comprehensive eye exam by an ophthalmologist or optometrist • •

Adults with type 1 diabetes: within 5 yrs after diabetes onset Patients with type 2 diabetes: shortly after diagnosis

• • •

If no retinopathy for ≥1 eye exam: consider exams every 2 yrs If retinopathy: annual exam Retinopathy progressing or sight threatening: more frequent exams

Fundus photographs: screening tool; not a substitute for comprehensive exam Pregnant women or women planning pregnancy with preexisting diabetes • •

Retinopathy counseling, eye exam in first trimester Close follow-up throughout pregnancy and 1 yr postpartum





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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Continued from previous page Treatment Macular edema, severe Refer to ophthalmologist specializing in retinopathy NPDR, any PDR Laser photocoagulation Indicated to reduce risk of vision loss for high-risk PDR, therapy clinically significant macular edema, some cases of severe NPDR Anti-VEGF therapy

Indicated for diabetic macular edema

Retinopathy not a contraindication to aspirin therapy for cardioprotection

Neuropathy Screening and Treatment Screening

Screen all patients for distal symmetric polyneuropathy • •

Type 2 diabetes: at diagnosis Type 1 diabetes: 5 yrs after diagnosis and at least annually thereafter

Electrophysiological testing or neurologist referral rarely needed except with atypical clinical features Screening for cardiovascular autonomic neuropathy • •

Treatment

Type 2 diabetes: at diagnosis Type 1 diabetes: 5 yrs after diagnosis

Medications for relief of distal symmetric polyneuropathy and autonomic neuropathy symptoms

ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; BP=blood pressure; CKD=chronic kidney disease; eGFR=estimated glomerular filtration rate; NPDR=nonproliferative diabetic retinopathy; PDR=proliferative diabetic retinopathy; VEGF=vascular endothelial growth factor





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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Diabetes in Pregnancy (Gestational Diabetes) Preconception Care Maintain A1C levels as close to <7.0% as possible before attempting conception All women of childbearing potential Evaluate and treat (if necessary) in women contemplating pregnancy

Evaluate, consider risk/benefit profile of medications being used for diabetes and associated conditions prior to conception

Provide preconception counseling starting at puberty • • • •

Retinopathy Nephropathy Neuropathy CVD

Contraindicated/not recommended in pregnancy • • • •

Statins ACEIs ARBs Most noninsulin therapies

Gestational Diabetes Pregnant women with risk factors

First prenatal visit: screen for undiagnosed type 2 diabetes using standard criteria

Pregnant women without known Screen at 24-28 wks prior diabetes Women with GDM

Screen for persistent diabetes 6-12 wks postpartum using OGTT and nonpregnancy diagnostic criteria

Women with GDM history and prediabetes

Lifestyle interventions or metformin for diabetes prevention

Glycemic targets

• • •

Preprandial: ≤95 mg/dL (5.3 mmol/L) and either 1-h postmeal: ≤140 mg/dL (7.8 mmol/L) or 2-h postmeal: ≤120 mg/dL (6.7 mmol/L)





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Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating.

Continued from previous page Gestational Diabetes Screening and Diagnosis No uniform approach for GDM diagnosis Two options for women not previously diagnosed with overt diabetes: “One-Step” (IADPSG) • • •

75-g OGTT with PG measurement fasting and at 1 h and 2 h, at 24-28 wks Perform OGTT in am after overnight fast (≥8 h) GDM diagnosis made if PG values in excess of o Fasting: ≥92 mg/dL (5.1 mmol/L) o 1 h: ≥180 mg/dL (10.0 mmol/L) o 2 h: ≥153 mg/dL (8.5 mmol/L)

“Two-Step” (NIH) • •

•

50-g GLT (nonfasting) with PG measurement at 1 h (Step 1), at 24-28 wks If PG at 1 h after load is ≥140 mg/dL* (10.0 mmol/L), proceed to 100-g OGTT (Step 2), performed while patient is fasting GDM diagnosis made when PG measured 3 h post-test is ≥140 mg/dL (7.8 mmol/L)

*Threshold of 135 mg/dL in high-risk ethnic minorities with higher prevalence of GDM recommended by ACOG ACEI=angiotensin-converting enzyme inhibitor; ACOG=American College of Obstetricians and Gynecologists; ARB=angiotensin receptor blocker; CVD=cardiovascular disease; GDM=gestational diabetes mellitus; GLT=glucose load test; IADPSG=International Association of Diabetes and Pregnancy Study Groups; NIH=National Institutes of Health; OGTT=oral glucose tolerance test; PG=plasma glucose





American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Lifestyle Changes Medical Nutrition Therapy Nutrition therapy for all patients with type 1 and type 2 diabetes •

As part of overall treatment plan

Prediabetes or diabetes

Individualized medical nutrition therapy as needed to achieve treatment targets, preferably provided by ed dietitian

Individuals at high risk for developing type 2 diabetes Begin structured program emphasizing lifestyle changes, including →

• •

Moderate weight loss (7% body weight) Regular physical activity (150 min/wk) with dietary strategies, including reduced caloric and fat intake

Achieve dietary fiber intake of 14 g/1,000 kcal and whole grains 50% of grain intake

Visit NDEI.org for summary recommendations on the ADA nutrition guidelines.

Physical Activity Adults with diabetes Exercise programs should include • •

≥150 min/wk moderate-intensity aerobic activity (50%-70% max heart rate), spread over ≥3 days/wk with no more than 2 consecutive days without exercise Resistance training ≥2 times/wk (in absence of contraindications)*

Evaluate patients for contraindications prohibiting certain types of exercise before recommending exercise program† Consider age and previous level of physical activity Children with diabetes, prediabetes ≥60 min physical activity/day *Adults with type 2 diabetes † Eg, uncontrolled hypertension, severe autonomic or peripheral neuropathy, history of foot lesions, unstable proliferative retinopathy January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.




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Continued from previous page Smoking Cessation Advise patients with diabetes not to smoke or use tobacco products Counsel on smoking prevention and cessation as part of routine care Assess level of nicotine dependence Offer pharmacologic therapy as appropriate

Risk Factors & Prediabetes Categories of Increased Risk for Diabetes (Prediabetes) Impaired Fasting Glucose (IFG) FPG 100 mg/dL-125 mg/dL (5.6 mmol/L-6.9 mmol/L) OR Impaired Glucose Tolerance (IGT) 2-hr PG in 75-g OGTT 140 mg/dL-199 mg/dL (7.8 mmol/L-11.0 mmol/L) OR A1C 5.7%-6.4% For all tests

Risk is continuous, extending below lower limit of range and becoming disproportionately greater at higher ends of range

IFG and IGT

View as risk factors for diabetes and CVD

Criteria for Type 2 Diabetes, Prediabetes Testing in Asymptomatic Adults Consider testing in all adults with BMI* ≥25 kg/m2 (overweight) and additional risk factors: • • • • • • •

Physical inactivity • First-degree relative with diabetes • High-risk race/ethnicity Women who delivered a baby >9 lb or were diagnosed with GDM HDL-C <35 mg/dL ± TG >250 mg/dL Hypertension (≥140/90 mm Hg or on therapy) A1C ≥5.7%, IGT, or IFG on previous testing Conditions associated with insulin resistance: severe obesity, acanthosis nigricans, PCOS CVD history

If no risk factors: begin testing no later than age 45 *At-risk BMI may be lower in some ethnic groups If normal results: repeat testing in ≥3-yr intervals • •

More frequent testing depending on initial test results, risk factors Prediabetes: test yearly





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Continued from previous page Common Comorbidities Associated With Diabetes • • • • • • • • • • • •

Certain cancers (liver, pancreas, bladder, endometrium, breast, colon/rectum)* Cognitive impairment Depression Dyslipidemia Fatty liver disease Fractures Hearing impairment Hypertension Low testosterone (men) Obesity Obstructive sleep apnea Periodontal disease

*Possibly only associated with type 2 diabetes BMI=body mass index; CVD=cardiovascular disease; FPG=fasting plasma glucose; GDM=gestational diabetes mellitus; HDL-C=high-density lipoprotein cholesterol; IFG=impaired fasting glucose; IGT=impaired glucose tolerance; OGTT=oral glucose tolerance test; PCOS=polycystic ovarian syndrome; PG=plasma glucose; TG=triglycerides

Diabetes Self-Management Education and Provide at diabetes diagnosis and as needed thereafter Measure and monitor effectiveness of self-management and quality of life as part of overall care Programs should

• •

Address psychosocial issues Provide education and to persons with prediabetes to encourage behaviors that may prevent or delay diabetes onset

January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.




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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Hypoglycemia At-risk patients

Ask about symptomatic and asymptomatic hypoglycemia at each encounter

Preferred treatment: glucose (15-20 g)* • •

After 15 mins of treatment, repeat if hypoglycemia continues (per SMBG) When SMBG normal: patient should consume meal or snack to prevent recurrence

Prescribe glucagon if significant risk of severe hypoglycemia Hypoglycemia unawareness or episode of severe hypoglycemia Low or declining cognition

• •

Reevaluate treatment regimen Insulin-treated patients: raise glycemic targets for several weeks to partially reverse hypoglycemia unawareness and reduce recurrence

Continually assess cognitive function with increased vigilance for hypoglycemia

*Any form of glucose-containing carbohydrate can be used SMBG=self-monitoring of blood glucose

Visit NDEI.org for summary recommendations on the ADA and The Endocrine Society guidelines on hypoglycemia and diabetes.





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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Type 1 Diabetes Insulin Therapy Most patients with type 1 diabetes:

• • • •

Treat with multiple-dose insulin injections (3-4 injections/day of basal and prandial insulin) or continuous subcutaneous insulin infusion Educate on how to match prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated activity Use insulin analogs to reduce risk of hypoglycemia Consider using sensor-augmented low glucose suspend threshold pump in patients with frequent nocturnal hypoglycemia and/or hypoglycemia unawareness

Most patients with type 1 diabetes: Consider screening for autoimmune diseases as appropriate •

Thyroid dysfunction, vitamin B12 deficiency, celiac disease

Screening Inform individuals with type 1 diabetes of the opportunity to have relatives screened for risk of type 1 diabetes in the clinical research setting •

Early diagnosis may limit complications, extend long-term endogenous insulin production

Widespread testing of asymptomatic low-risk persons: not recommended Screen high-risk persons only in clinical research setting





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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Hospital Care (In-Patient) Diabetes Care Discharge planning

• •

Begin at ission Clear diabetes management instructions provided at discharge

Sole use of sliding scale insulin in inpatient setting discouraged All patients

• •

Clearly document diabetes in medical record Order blood glucose monitoring; results available to healthcare team

Nondiabetic patients receiving therapy associated with high hyperglycemia risk

• •

Monitor glucose Consider treating to same targets as patients with known diabetes

Establish hypoglycemia management protocol and create a plan for each patient for treating and preventing hypoglycemia •

Document and track all hypoglycemia episodes

Consider A1C test for patients with

• •

Diabetes if no test results from prior 2-3 mos Risk factors for undiagnosed diabetes who exhibit hyperglycemia

Patients with hyperglycemia, no prior diabetes

•

Plan for follow-up testing and care documented at discharge





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Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Continued from previous page Glycemic Targets Critically ill patients

Persistent hyperglycemia: • •

Initiate insulin starting at ≤180 mg/dL (≤10.0 mmol/L) Once insulin started, 140-180 mg/dL (7.8-10.0 mmol/L) recommended glucose range for most patients

More stringent targets may be appropriate for certain patients providing no increased hypoglycemia risk IV insulin protocol with demonstrated efficacy, safety in achieving targets with no increased hypoglycemia risk Non-critically ill patients

No clear evidence for specific glucose targets Insulin-treated: premeal target <140 mg/dL (<7.8 mmol/L) with random blood glucose <180 mg/dL (<10.0 mmol/L) More or less stringent targets may be appropriate • •

More stringent: stable patients with previous tight glycemic control Less stringent: severe comorbidities

Preferred method for achieving/maintaining glucose control: scheduled subcutaneous insulin with basal, nutritional, correction components

Bariatric Surgery in Type 2 Diabetes Consider for adults with In particular, if diabetes or associated comorbidities difficult to control with lifestyle and pharmacologic therapy BMI >35 kg/m2 Lifelong lifestyle , medical monitoring necessary post-surgery Insufficient evidence to recommend surgery with BMI <35 kg/m2 outside of a research protocol BMI=body mass index





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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Foot Care All patients with diabetes

• • •

Patients with foot ulcers, high-risk feet (previous ulcer or amputation) Refer to foot care specialist

Annual foot exam to identify risk factors predictive of ulcers and amputations Exam to include: inspection, assessment of foot pulses, LOPS testing Provide foot self-care education

Use multidisciplinary approach • • •

People who smoke LOPS and structural abnormalities History of prior lower-extremity complications Lifelong surveillance

Include in initial PAD screening

• •

Refer for further vascular assessment

• •

History for claudication and assessment of pedal pulses Obtain ABI Patients with positive ABI, significant claudication Consider exercise, medications, surgical options

ABI=ankle-brachial index; LOPS=loss of protective sensation; PAD=peripheral arterial disease January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.




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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Vaccination & Immunization Influenza vaccine Pneumococcal polysaccharide vaccine

Annually in all patients with diabetes aged ≥6 mos •

All patients with diabetes aged ≥2 yrs

•

Aged >65 yrs: one-time revaccination if vaccine istered >5 yrs prior Repeat vaccination for those with nephrotic syndrome, chronic renal disease, other immunocompromised states

•

Hepatitis B vaccine

• •

Unvaccinated adults with diabetes aged 19-59 yrs Consider in unvaccinated adults aged ≥60 yrs

Psychosocial Considerations Reasonable to include psychological and social assessments of patient as part of diabetes management Psychosocial screening and follow-up may include:

• • • • • •

Attitudes about diabetes Expectations for medical management and outcomes Mood Quality of life Financial, social, emotional resources Psychiatric history

Screen on routine basis for depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment





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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Diabetes Care in Older Adults Older adults who are • • •

Same treatment goals as younger adults

Functional Cognitively intact Expected to live long enough to reap benefits

Glycemic targets: may be relaxed for some older adults based on individual criteria •

Avoid hyperglycemic complications

Treat CV risk factors considering

• • •

Timeframe of benefit, individual patient characteristics Hypertension treatment indicated in many older adults Lipid, aspirin therapy may benefit patients whose life expectancy is equal to timeframe of primary or secondary prevention trials

Individualize screening for complications •

Be mindful of complications that may lead to functional impairment

Cystic Fibrosis-Related Diabetes • •

Screening

•

Annually using OGTT Begin by age 10 in patients with cystic fibrosis who do not have CFRD A1C not recommended as screening test

Diagnosis

Use usual glucose criteria during period of stable health

Treatment

Use insulin to achieve individualized glycemic targets

Monitoring for diabetes complications

Annually; start 5 yrs post-CFRD diagnosis

CFRD=cystic fibrosis-related diabetes; OGTT=oral glucose tolerance test





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American Diabetes Association (ADA) 2014 Guidelines Summary Recommendations from NDEI Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Children & Adolescents Type 2 Diabetes in Children & Adolescents Screening for Type 2 Diabetes and Prediabetes Consider for all children who are overweight* and have ≥2 of any of the following risk factors: • • • •

Family history of type 2 diabetes in first- or second-degree relative Race/ethnicity† Signs of insulin resistance or conditions associated with insulin resistance‡ Maternal history of diabetes or GDM during child’s gestation Begin testing at age 10 yrs or onset of puberty Test every 3 yrs A1C test recommended for diagnosis in children and adolescents At Diagnosis

• •

Perform eye exam Measure risk factors o Blood pressure o Fasting lipids o Albumin excretion

After Diagnosis Similar screening, treatment as for type 1 diabetes for • • • •

Hypertension Albumin excretion Dyslipidemia Retinopathy

Other issues that may need to be addressed: polycystic ovarian disease, other pediatric obesity comorbidities§ Children: age ≤18 yrs *BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% ideal for height † Native American, African American, Latino, Asian American, Pacific Islander ‡ Acanthosis nigricans, hypertension, dyslipidemia, PCOS, or small-for-gestational-age birth weight § Sleep apnea, hepatic steatosis, orthopedic complications, psychosocial concerns

Visit NDEI.org for summary recommendations on the American Academy of Pediatrics, Pediatric Endocrine Society, American Academy of Family Physicians, ADA, and Academy of Nutrition and Dietetics guidelines on managing newly diagnosed type 2 diabetes in children and adolescents.





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Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. Type 1 Diabetes in Children & Adolescents Glycemic Targets Consider risk-benefit assessment, including hypoglycemia risk, when individualizing targets* 0-6 yrs

6-12 yrs †

13-19 yrs

<8.5%

<8%

<7.5%†

PG: prior to meals

100-180 mg/dL

90-180 mg/dL

90-130 mg/dL

PG: bedtime & overnight

110-200 mg/dL

100-180 mg/dL

90-150 mg/dL

A1C

†

*If on basal-bolus: measure postprandial PG to monitor glycemic values and if discrepancy between preprandial PG and A1C; modification of targets may be needed in children aged <7 yrs due to hypoglycemic unawareness; †Reasonable to consider lower target if achieved in absence of excessive hypoglycemia Microvascular Complications in Children & Adolescents With Type 1 Diabetes Nephropathy Screening

Aged ≥10 yrs or puberty onset (whichever occurs first) with 5-yr diabetes duration • •

Treatment

Albumin levels: yearly ACR: random urine sample

ACEI titrated to normalization of albumin excretion •

If elevated ACR confirmed over 6 mos, after efforts to control glucose, normalize BP

Retinopathy Screening

Follow-up

Initial dilated and comprehensive eye exam •

Aged ≥10 yrs or puberty onset (whichever occurs first) with 3-5–yr diabetes duration

• •

Yearly Less frequently: per recommendation of eye care professional

ACEIs are not approved by the U.S. Food and Drug istration (FDA) for treatment of nephropathy. Not all ACEIs are indicated for use in children/adolescents by the FDA. Refer to full prescribing information for indications and uses in pediatric populations. Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug istration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States. January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.





Source: American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. Refer to source document for full recommendations, including level of evidence rating. High Blood Pressure in Children & Adolescents With Type 1 Diabetes Screening

• •

Measure BP at every visit Confirm elevated BP at separate visit

Treatment SBP or DBP >90th percentile* • •

Lifestyle changes (diet & exercise) If target BP not met in 3-6 mos Æ

Pharmacologic therapy ACEI: initial treatment†

SBP or DBP >95th percentile* or >130/80 mm Hg Æ Target: <130/80 mm Hg or <90th percentile* †

*For age, sex, height; Provide counseling re: potential teratogenic effects. Not all ACEIs are indicated for use in children/adolescents by the U.S. Food and Drug istration (FDA). Refer to full prescribing information for indications and uses in pediatric populations. Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug istration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States. January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.




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Dyslipidemia in Children & Adolescents With Type 1 Diabetes Screening

Obtain fasting lipids Family history

CV event aged <55 yrs or hypercholesterolemia Æ

Aged >2 yrs post-diagnosis*

Unknown Æ Unremarkable Æ Diabetes diagnosed prior to/post-puberty

Aged ≥10 yrs Post-diagnosis*

Lipid monitoring: all patients • •

Treatment

If lipids abnormal: yearly LDL-C <100 mg/dL (<2.6 mmol/L): every 5 yrs

Initial

• •

Control glucose MNT: decrease saturated fat intake†

Aged ≥10 yrs

• •

Lifestyle changes and MNT After lifestyle changes, add statin‡ if LDL-C >160 mg/dL (>4.1 mmol/L) or >130 mg/dL (>3.4 mmol/L) + ≥1 CVD risk factor

Target: LDL-C <100 mg/dL (<2.6 mmol/L) *When glucose levels well controlled † Use American Heart Association Step 2 diet: saturated fat 7% of total calories; dietary cholesterol 200 mg/d ‡ Statins are approved by the U.S. Food and Drug istration for treatment of heterozygous familial hypercholesterolemia in children and adolescents. Not all statins are FDA approved for use under the age of 10 yrs; statins should generally not be used in children with type 1 diabetes before age 10. Refer to full prescribing information for indications and uses in pediatric populations. For postpubertal girls, pregnancy prevention is important as statins are contraindicated in pregnancy. Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug istration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States. January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.




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Screening for Comorbidities in Children & Adolescents With Type 1 Diabetes Hypothyroidism Post-diagnosis of type 1 diabetes consider

Screening for • •

Antithyroid peroxidase antibodies Antithyroglobulin antibodies

Measuring TSH* •

Reassess every 1-2 yrs if normal

Post-diagnosis of type 1 diabetes consider measuring

• •

IgA antitissue transglutaminase Antiendomysial antibodies

Candidates for testing

• • • • • • •

Family history of celiac disease Failure to grow or gain weight Weight loss Diarrhea or flatulence Abdominal pain Signs of malabsorption Repeated hypoglycemia of unknown cause or decline in glycemic control

Celiac disease

Asymptomatic with positive antibodies

Gastroenterologist referral for confirmatory endoscopy and biopsy

If diagnosis confirmed

Gluten-free diet; dietitian consultation

*When metabolic levels well controlled January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.




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Monogenic Diabetes Syndromes in Children & Adolescents Neonatal diabetes • Maturity-onset diabetes of the young Consider if: • • • •

Diabetes diagnosed within first 6 mos after birth Strong diabetes family history; no typical features of type 2 diabetes Mild fasting hyperglycemia,* esp if young and nonobese Diabetes with negative autoantibodies, no signs of obesity or insulin resistance

*100-150 mg/dL (5.5-8.5 mmol/L) ACEI=angiotensin-converting enzyme inhibitor; ACR=albumin-to-creatinine ratio; AHA=American Heart Association; BMI=body mass index; BP=blood pressure; CV=cardiovascular; CVD=cardiovascular disease; GDM=gestational diabetes mellitus; MNT=medical nutrition therapy; PCOS=polycystic ovarian syndrome; PG=plasma glucose; TSH=thyroid-stimulating hormone January 2014 This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.

All slides on the following pages available for in the NDEI.org Slide Library.




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This content was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.





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