Current criteria for the diagnosis of diabetes
A1C ≥6.5%. The test should be performed in a laboratory using a method that is National
Glycohemoglobin Standardization Program (NGSP)-certified and standardized to the Diabetes
Control and Complications Trial (DCCT) assay
fasting plasma glucose (FPG) ≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric
intake for at least 8 h, or
2-h plasma glucose ≥200 mg/dl (11.1 mmol/l) during an oral glucose tolerance test
(OGTT). The test should be performed as described by the World Health Organization,
using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved
in water
in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random
plasma glucose ≥200 mg/dl (11.1 mmol/l)
in the absence of unequivocal hyperglycemia, result should be confirmed by repeat
testing.
Testing for diabetes in asymptomatic patients
Testing to detect type 2 diabetes and assess risk for future diabetes in asymptomatic
people should be considered in adults of any age who are overweight or obese (BMI
≥25 kg/m2) and who have one or more additional risk factors for diabetes (see Table
4 of the “Standards of Medical Care in Diabetes—2011”). In those without these risk
factors, testing should begin at age 45 years. (B)
If tests are normal, repeat testing carried out at least at 3-year intervals is reasonable.
(E)
To test for diabetes or to assess risk of future diabetes, A1C, FPG, or 2-h 75-g OGTT
are appropriate. (B)
In those identified with increased risk for future diabetes, identify and, if appropriate,
treat other cardiovascular disease (CVD) risk factors. (B)
Detection and diagnosis of gestational diabetes mellitus (GDM)
Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk
factors, using standard diagnostic criteria. (B)
In pregnant women not known to have diabetes, screen for GDM at 24–28 weeks of gestation,
using a 75-g 2-h OGTT and the diagnostic cut points in Table 6 of the “Standards of
Medical Care in Diabetes—2011”. (B)
Screen women with GDM for persistent diabetes 6–12 weeks postpartum. (E)
Women with a history of GDM should have lifelong screening for the development of
diabetes or prediabetes at least every 3 years. (E)
Prevention/delay of type 2 diabetes
Patients with impaired glucose tolerance (IGT) (A), impaired fasting glucose (IFG)
(E), or an A1C of 5.7–6.4% (E) should be referred to an effective ongoing support
program targeting weight loss of 7% of body weight and increasing physical activity
to at least 150 min/week of moderate activity such as walking.
Follow-up counseling appears to be important for success. (B)
Based on potential cost-savings of diabetes prevention, such programs should be covered
by third-party payors. (E)
Metformin therapy for prevention of type 2 diabetes may be considered in those at
highest risk for developing diabetes, such as those with multiple risk factors, especially
if they demonstrate progression of hyperglycemia (e.g. A1C ≥6%) despite lifestyle
interventions. (B)
Monitoring for the development of diabetes in those with prediabetes should be performed
every year. (E)
Glucose monitoring
Self-monitoring of blood glucose (SMBG) should be carried out three or more times
daily for patients using multiple insulin injections or insulin pump therapy. (A)
For patients using less-frequent insulin injections, non-insulin therapies, or medical
nutrition therapy (MNT) alone, SMBG may be useful as a guide to the success of therapy.
(E)
To achieve postprandial glucose targets, postprandial SMBG may be appropriate. (E)
When prescribing SMBG, ensure that patients receive initial instruction in, and routine
follow-up evaluation of, SMBG technique and their ability to use data to adjust therapy.
(E)
Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens
can be a useful tool to lower A1C in selected adults (age ≥25 years) with type 1 diabetes.
(A)
Although the evidence for A1C-lowering is less strong in children, teens, and younger
adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing
use of the device. (C)
CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or
frequent hypoglycemic episodes. (E)
A1C
Perform the A1C test at least two times a year in patients who are meeting treatment
goals (and who have stable glycemic control). (E)
Perform the A1C test quarterly in patients whose therapy has changed or who are not
meeting glycemic goals. (E)
Use of point-of-care testing for A1C allows for timely decisions on therapy changes,
when needed. (E)
Glycemic goals in adults
Lowering A1C to below or around 7% has been shown to reduce microvascular and neuropathic
complications of diabetes and, if implemented soon after the diagnosis of diabetes,
is associated with long-term reduction in macrovascular disease. Therefore, a reasonable
A1C goal for many nonpregnant adults is <7%. (B)
Because additional analyses from several randomized trials suggest a small but incremental
benefit in microvascular outcomes with A1C values closer to normal, providers might
reasonably suggest more stringent A1C goals for selected individual patients, if this
can be achieved without significant hypoglycemia or other adverse effects of treatment.
Such patients might include those with short duration of diabetes, long life expectancy,
and no significant cardiovascular disease. (B)
Conversely, less stringent A1C goals may be appropriate for patients with a history
of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular
complications, extensive comorbid conditions, and those with longstanding diabetes
in whom the general goal is difficult to attain despite diabetes self-management education,
appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents
including insulin. (C)
Diabetes self-management education (DSME)
People with diabetes should receive DSME according to national standards when their
diabetes is diagnosed and as needed thereafter. (B)
Effective self-management and quality of life are the key outcomes of DSME and should
be measured and monitored as part of care. (C)
DSME should address psychosocial issues, since emotional well-being is associated
with positive diabetes outcomes. (C)
Because DSME can result in cost-savings and improved outcomes (B), DSME should be
adequately reimbursed by third-party payors. (E)
Medical nutrition therapy (MNT) General recommendations
Individuals who have prediabetes or diabetes should receive individualized MNT as
needed to achieve treatment goals, preferably provided by a registered dietitian familiar
with the components of diabetes MNT. (A)
Because MNT can result in cost-savings and improved outcomes (B), MNT should be adequately
covered by insurance and other payors. (E)
Energy balance, overweight, and obesity
In overweight and obese insulin-resistant individuals, modest weight loss has been
shown to reduce insulin resistance. Thus, weight loss is recommended for all overweight
or obese individuals who have or are at risk for diabetes. (A)
For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean
diets may be effective in the short term (up to 2 years). (A)
For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and
protein intake (in those with nephropathy) and adjust hypoglycemic therapy as needed.
(E)
Physical activity and behavior modification are important components of weight loss
programs and are most helpful in maintenance of weight loss. (B)
Recommendations for primary prevention of diabetes
Among individuals at high risk for developing type 2 diabetes, structured programs
that emphasize lifestyle changes that include moderate weight loss (7% of body weight)
and regular physical activity (150 min/week), with dietary strategies including reduced
calories and reduced intake of dietary fat, can reduce the risk for developing diabetes
and are therefore recommended. (A)
Individuals at high risk for type 2 diabetes should be encouraged to achieve the U.S.
Department of Agriculture (USDA) recommendation for dietary fiber (14 g fiber/1,000
kcal) and foods containing whole grains (one-half of grain intake). (B)
Recommendations for management of diabetes: macronutrients in diabetes management
The best mix of carbohydrate, protein, and fat may be adjusted to meet the metabolic
goals and individual preferences of the person with diabetes. (E)
Monitoring carbohydrate, whether by carbohydrate counting, choices, or experience-based
estimation, remains a key strategy in achieving glycemic control. (A)
For individuals with diabetes, the use of the glycemic index and glycemic load may
provide a modest additional benefit for glycemic control over that observed when total
carbohydrate is considered alone. (B)
Saturated fat intake should be <7% of total calories. (A)
Reducing intake of trans fat lowers LDL cholesterol and increases HDL cholesterol
(A); therefore, intake of trans fat should be minimized. (E)
Other nutrition recommendations
If adults with diabetes choose to use alcohol, daily intake should be limited to a
moderate amount (one drink per day or less for adult women and two drinks per day
or less for adult men). (E)
Routine supplementation with antioxidants, such as vitamins E and C and carotene,
is not advised because of lack of evidence of efficacy and concern related to long-term
safety. (A)
Individualized meal planning should include optimization of food choices to meet recommended
daily allowance (RDA)/dietary reference intake (DRI) for all micronutrients. (E)
Physical activity
People with diabetes should be advised to perform at least 150 min/week of moderate-intensity
aerobic physical activity (50–70% of maximum heart rate). (A)
In the absence of contraindications, people with type 2 diabetes should be encouraged
to perform resistance training three times per week. (A)
Psychosocial assessment and care
Assessment of psychological and social situation should be included as an ongoing
part of the medical management of diabetes. (E)
Psychosocial screening and follow-up should include, but is not limited to, attitudes
about the illness, expectations for medical management and outcomes, affect/mood,
general and diabetes-related quality of life, resources (financial, social, and emotional),
and psychiatric history. (E)
Screen for psychosocial problems such as depression and diabetes-related distress,
anxiety, eating disorders, and cognitive impairment when self-management is poor.
(C)
Hypoglycemia
Glucose (15–20 g) is the preferred treatment for the conscious individual with hypoglycemia,
although any form of carbohydrate that contains glucose may be used. If SMBG 15 min
after treatment shows continued hypoglycemia, the treatment should be repeated. Once
SMBG glucose returns to normal, the individual should consume a meal or snack to prevent
recurrence of hypoglycemia. (E)
Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemia,
and caregivers or family members of these individuals should be instructed in its
administration. Glucagon administration is not limited to health care professionals.
(E)
Individuals with hypoglycemia unawareness or one or more episodes of severe hypoglycemia
should be advised to raise their glycemic targets to strictly avoid further hypoglycemia
for at least several weeks, to partially reverse hypoglycemia unawareness and reduce
the risk of future episodes. (B)
Bariatric surgery
Bariatric surgery may be considered for adults with BMI >35 kg/m2 and type 2 diabetes,
especially if the diabetes or associated comorbidities are difficult to control with
lifestyle and pharmacologic therapy. (B)
Patients with type 2 diabetes who have undergone bariatric surgery need life-long
lifestyle support and medical monitoring. (E)
Although small trials have shown glycemic benefit of bariatric surgery in patients
with type 2 diabetes and BMI of 30–35 kg/m2, there is currently insufficient evidence
to generally recommend surgery in patients with BMI <35 kg/m2 outside of a research
protocol. (E)
The long-term benefits, cost-effectiveness, and risks of bariatric surgery in individuals
with type 2 diabetes should be studied in well-designed controlled trials with optimal
medical and lifestyle therapy as the comparator. (E)
Immunization
Annually provide an influenza vaccine to all diabetic patients ≥6 months of age. (C)
Administer pneumococcal polysaccharide vaccine to all diabetic patients ≥2 years of
age. A one-time revaccination is recommended for individuals >64 years of age previously
immunized when they were <65 years of age if the vaccine was administered >5 years
ago. Other indications for repeat vaccination include nephrotic syndrome, chronic
renal disease, and other immunocompromised states, such as after transplantation.
(C)
Hypertension/blood pressure control
Screening and diagnosis
Blood pressure should be measured at every routine diabetes visit. Patients found
to have systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg should
have blood pressure confirmed on a separate day. Repeat systolic blood pressure ≥130
mmHg or diastolic blood pressure ≥80 mmHg confirms a diagnosis of hypertension. (C)
Goals
A goal systolic blood pressure <130 mmHg is appropriate for most patients with diabetes.
(C)
Based on patient characteristics and response to therapy, higher or lower systolic
blood pressure targets may be appropriate. (B)
Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg. (B)
Treatment
Patients with a systolic blood pressure of 130–139 mmHg or a diastolic blood pressure
of 80–89 mmHg may be given lifestyle therapy alone for a maximum of 3 months and then,
if targets are not achieved, be treated with the addition of pharmacological agents.
(E)
Patients with more severe hypertension (systolic blood pressure ≥140 or diastolic
blood pressure ≥90 mmHg) at diagnosis or follow-up should receive pharmacologic therapy
in addition to lifestyle therapy. (A)
Lifestyle therapy for hypertension consists of: weight loss, if overweight; DASH (Dietary
Approaches to Stop Hypertension)-style dietary pattern, including reducing sodium
and increasing potassium intake; moderation of alcohol intake; and increased physical
activity. (B)
Pharmacologic therapy for patients with diabetes and hypertension should be with a
regimen that includes either an ACE inhibitor or an ARB. If one class is not tolerated,
the other should be substituted. If needed to achieve blood pressure targets, a thiazide
diuretic should be added to those with an estimated glomerular filtration rate (GFR)
≥30 ml/min/1.73 m2 and a loop diuretic for those with an estimated GFR <30 ml/min/1.73
m2. (C)
Multiple drug therapy (two or more agents at maximal doses) is generally required
to achieve blood pressure targets. (B)
If ACE inhibitors, ARBs, or diuretics are used, kidney function and serum potassium
levels should be monitored. (E)
In pregnant patients with diabetes and chronic hypertension, blood pressure target
goals of 110–129/65–79 mmHg are suggested in the interest of long-term maternal health
and minimizing impaired fetal growth. ACE inhibitors and ARBs are contraindicated
during pregnancy. (E)
Dyslipidemia/lipid management
Screening
In most adult patients, measure fasting lipid profile at least annually. In adults
with low-risk lipid values (LDL cholesterol <100 mg/dl, HDL cholesterol >50 mg/dl,
and triglycerides <150 mg/dl), lipid assessments may be repeated every 2 years. (E)
Treatment recommendations and goals
Lifestyle modification focusing on the reduction of saturated fat, trans fat, and
cholesterol intake; the increase of omega-3 fatty acids, viscous fiber, and plant
stanols/sterols; weight loss (if indicated); and increased physical activity should
be recommended to improve the lipid profile in patients with diabetes. (A)
Statin therapy should be added to lifestyle therapy, regardless of baseline lipid
levels, for diabetic patients:
with overt CVD (A)
without CVD who are over the age of 40 years and have one or more other CVD risk factors
(A)
For patients at lower risk than above (e.g. without overt CVD and under the age of
40 years), statin therapy should be considered in addition to lifestyle therapy if
LDL cholesterol remains >100 mg/dl or in those with multiple CVD risk factors. (E)
In individuals without overt CVD, the primary goal is an LDL cholesterol <100 mg/dl
(2.6 mmol/l). (A)
In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l),
using a high dose of a statin, is an option. (B)
If drug-treated patients do not reach the above targets on maximal tolerated statin
therapy, a reduction in LDL cholesterol of ∼30–40% from baseline is an alternative
therapeutic goal. (A)
Triglyceride levels <150 mg/dl (1.7 mmol/l) and HDL cholesterol >40 mg/dl (1.0 mmol/l)
in men and >50 mg/dl (1.3 mmol/l) in women are desirable. However, LDL cholesterol–targeted
statin therapy remains the preferred strategy. (C)
If targets are not reached on maximally tolerated doses of statins, combination therapy
using statins and other lipid-lowering agents may be considered to achieve lipid targets
but has not been evaluated in outcome studies for either CVD outcomes or safety. (E)
Statin therapy is contraindicated in pregnancy. (E)
Antiplatelet agents
Consider aspirin therapy (75–162 mg/day) as a primary prevention strategy in those
with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk >10%).
This includes most men >50 years of age or women >60 years of age who have at least
one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia,
or albuminuria). (C)
Aspirin should not be recommended for CVD prevention for adults with diabetes at low
CVD risk (10-year CVD risk <5%, such as in men <50 years of age and women <60 years
of age with no major additional CVD risk factors), since the potential adverse effects
from bleeding likely offset the potential benefits. (C)
In patients in these age-groups with multiple other risk factors (e.g. 10-year risk
5–10%), clinical judgment is required. (E)
Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with
diabetes with a history of CVD. (A)
For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should
be used. (B)
Combination therapy with ASA (75–162 mg/day) and clopidogrel (75 mg/day) is reasonable
for up to a year after an acute coronary syndrome. (B)
Smoking cessation
Advise all patients not to smoke. (A)
Include smoking cessation counseling and other forms of treatment as a routine component
of diabetes care. (B)
Coronary heart disease (CHD) screening and treatment
Screening
In asymptomatic patients, routine screening for CAD is not recommended, as it does
not improve outcomes as long as CVD risk factors are treated. (A)
Treatment
In patients with known CVD, ACE inhibitor (C) and aspirin and statin therapy (A) (if
not contraindicated) should be used to reduce the risk of cardiovascular events.
In patients with a prior myocardial infarction, β-blockers should be continued for
at least 2 years after the event. (B)
Longer-term use of β-blockers in the absence of hypertension is reasonable if well
tolerated, but data are lacking. (E)
Avoid thiazolidinedione (TZD) treatment in patients with symptomatic heart failure.
(C)
Metformin may be used in patients with stable congestive heart failure (CHF) if renal
function is normal. It should be avoided in unstable or hospitalized patients with
CHF. (C)
Nephropathy screening and treatment
General recommendations
To reduce the risk or slow the progression of nephropathy, optimize glucose control.
(A)
To reduce the risk or slow the progression of nephropathy, optimize blood pressure
control. (A)
Screening
Perform an annual test to assess urine albumin excretion in type 1 diabetic patients
with diabetes duration of ≥5 years and in all type 2 diabetic patients starting at
diagnosis. (E)
Measure serum creatinine at least annually in all adults with diabetes regardless
of the degree of urine albumin excretion. The serum creatinine should be used to estimate
GFR and stage the level of chronic kidney disease (CKD), if present. (E)
Treatment
In the treatment of the nonpregnant patient with micro- or macroalbuminuria, either
ACE inhibitors or ARBs should be used. (A)
While there are no adequate head-to-head comparisons of ACE inhibitors and ARBs, there
is clinical trial support for each of the following statements:
In patients with type 1 diabetes, with hypertension and any degree of albuminuria,
ACE inhibitors have been shown to delay the progression of nephropathy. (A)
In patients with type 2 diabetes, hypertension, and microalbuminuria, both ACE inhibitors
and ARBs have been shown to delay the progression to macroalbuminuria. (A)
In patients with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency
(serum creatinine >1.5 mg/dl), ARBs have been shown to delay the progression of nephropathy.
(A)
If one class is not tolerated, the other should be substituted. (E)
Reduction of protein intake to 0.8–1.0 g · kg body wt–1 · day–1 in individuals with
diabetes and the earlier stages of CKD and to 0.8 g · kg body wt–1 · day–1 in the
later stages of CKD may improve measures of renal function (urine albumin excretion
rate, GFR) and is recommended. (B)
When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine and potassium
levels for the development of acute kidney disease and hyperkalemia. (E)
Continued monitoring of urine albumin excretion to assess both response to therapy
and progression of disease is recommended. (E)
When estimated GFR (eGFR) is <60 ml.min/1.73 m2, evaluate and manage potential complications
of CKD. (E)
Consider referral to a physician experienced in the care of kidney disease when there
is uncertainty about the etiology of kidney disease (heavy proteinuria, active urine
sediment, absence of retinopathy, rapid decline in GFR), difficult management issues,
or advanced kidney disease. (B)
Retinopathy screening and treatment
General recommendations
To reduce the risk or slow the progression of retinopathy, optimize glycemic control.
(A)
To reduce the risk or slow the progression of retinopathy, optimize blood pressure
control. (A)
Screening
Adults and children aged 10 years or older with type 1 diabetes should have an initial
dilated and comprehensive eye examination by an ophthalmologist or optometrist within
5 years after the onset of diabetes. (B)
Patients with type 2 diabetes should have an initial dilated and comprehensive eye
examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes.
(B)
Subsequent examinations for type 1 and type 2 diabetic patients should be repeated
annually by an ophthalmologist or optometrist. Less-frequent exams (every 2–3 years)
may be considered following one or more normal eye exams. Examinations will be required
more frequently if retinopathy is progressing. (B)
High-quality fundus photographs can detect most clinically significant diabetic retinopathy.
Interpretation of the images should be performed by a trained eye care provider. While
retinal photography may serve as a screening tool for retinopathy, it is not a substitute
for a comprehensive eye exam, which should be performed at least initially and at
intervals thereafter as recommended by an eye care professional. (E)
Women with pre-existing diabetes who are planning a pregnancy or who have become pregnant
should have a comprehensive eye examination and be counseled on the risk of development
and/or progression of diabetic retinopathy. Eye examination should occur in the first
trimester with close follow-up throughout pregnancy and for 1 year postpartum. (B)
Treatment
Promptly refer patients with any level of macular edema, severe nonproliferative diabetic
retinopathy (NPDR), or any proliferative diabetic retinopathy (PDR) to an ophthalmologist
who is knowledgeable and experienced in the management and treatment of diabetic retinopathy.
(A)
Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients
with high-risk PDR, clinically significant macular edema, and some cases of severe
NPDR. (A)
The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection,
as this therapy does not increase the risk of retinal hemorrhage. (A)
Neuropathy screening and treatment
All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis
and at least annually thereafter, using simple clinical tests. (B)
Electrophysiological testing is rarely needed, except in situations where the clinical
features are atypical. (E)
Screening for signs and symptoms of cardiovascular autonomic neuropathy should be
instituted at diagnosis of type 2 diabetes and 5 years after the diagnosis of type
1 diabetes. Special testing is rarely needed and may not affect management or outcomes.
(E)
Medications for the relief of specific symptoms related to DPN and autonomic neuropathy
are recommended, as they improve the quality of life of the patient. (E)
Foot care
For all patients with diabetes, perform an annual comprehensive foot examination to
identify risk factors predictive of ulcers and amputations. The foot examination should
include inspection, assessment of foot pulses, and testing for loss of protective
sensation (10-g monofilament plus testing any one of: vibration using 128-Hz tuning
fork, pinprick sensation, ankle reflexes, or vibration perception threshold). (B)
Provide general foot self-care education to all patients with diabetes. (B)
A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk
feet, especially those with a history of prior ulcer or amputation. (B)
Refer patients who smoke, have loss of protective sensation and structural abnormalities,
or have history of prior lower-extremity complications to foot care specialists for
ongoing preventive care and life-long surveillance. (C)
Initial screening for peripheral arterial disease (PAD) should include a history for
claudication and an assessment of the pedal pulses. Consider obtaining an ankle-brachial
index (ABI), as many patients with PAD are asymptomatic. (C)
Refer patients with significant claudication or a positive ABI for further vascular
assessment and consider exercise, medications, and surgical options. (C)
Children and adolescents
Glycemic control
Consider age when setting glycemic goals in children and adolescents with type 1 diabetes.
(E)
Screening and management of chronic complications in children and adolescents with
type 1 diabetes
Nephropathy
Annual screening for microalbuminuria, with a random spot urine sample for albumin-to-creatinine
ratio (ACR), should be considered once the child is 10 years of age and has had diabetes
for 5 years. (E)
Confirmed, persistently elevated ACR on two additional urine specimens from different
days should be treated with an ACE inhibitor, titrated to normalization of albumin
excretion if possible. (E)
Hypertension
Treatment of high-normal blood pressure (systolic or diastolic blood pressure consistently
above the 90th percentile for age, sex, and height) should include dietary intervention
and exercise, aimed at weight control and increased physical activity, if appropriate.
If target blood pressure is not reached with 3–6 months of lifestyle intervention,
pharmacologic treatment should be considered. (E)
Pharmacologic treatment of hypertension (systolic or diastolic blood pressure consistently
above the 95th percentile for age, sex, and height or consistently >130/80 mmHg, if
95% exceeds that value) should be initiated as soon as the diagnosis is confirmed.
(E)
ACE inhibitors should be considered for the initial treatment of hypertension, following
appropriate reproductive counseling due to its potential teratogenic effects. (E)
The goal of treatment is a blood pressure consistently <130/80 or below the 90th percentile
for age, sex, and height, whichever is lower. (E)
Dyslipidemia
Screening
If there is a family history of hypercholesterolemia (total cholesterol >240 mg/dl)
or a cardiovascular event before age 55 years, or if family history is unknown, then
a fasting lipid profile should be performed on children >2 years of age soon after
diagnosis (after glucose control has been established). If family history is not of
concern, then the first lipid screening should be considered at puberty (≥10 years).
All children diagnosed with diabetes at or after puberty should have a fasting lipid
profile performed soon after diagnosis (after glucose control has been established).
(E)
For both age-groups, if lipids are abnormal, annual monitoring is recommended. If
LDL cholesterol values are within the accepted risk levels (<100 mg/dl [2.6 mmol/l]),
a lipid profile should be repeated every 5 years. (E)
Treatment
Initial therapy should consist of optimization of glucose control and MNT using a
Step 2 American Heart Association diet aimed at a decrease in the amount of saturated
fat in the diet. (E)
After the age of 10 years, the addition of a statin in patients who, after MNT and
lifestyle changes, have LDL cholesterol >160 mg/dl (4.1 mmol/l), or LDL cholesterol
>130 mg/dl (3.4 mmol/l) and one or more CVD risk factors, is reasonable. (E)
The goal of therapy is an LDL cholesterol value <100 mg/dl (2.6 mmol/l). (E)
Retinopathy
The first ophthalmologic examination should be obtained once the child is ≥10 years
of age and has had diabetes for 3–5 years. (E)
After the initial examination, annual routine follow-up is generally recommended.
Less frequent examinations may be acceptable on the advice of an eye care professional.
(E)
Celiac disease
Children with type 1 diabetes should be screened for celiac disease by measuring tissue
transglutaminase or anti-endomysial antibodies, with documentation of normal total
serum IgA levels, soon after the diagnosis of diabetes. (E)
Testing should be repeated in children with growth failure, failure to gain weight,
weight loss, diarrhea, flatulence, abdominal pain, or signs of malabsorption or in
children with frequent unexplained hypoglycemia or deterioration in glycemic control.
(E)
Children with positive antibodies should be referred to a gastroenterologist for evaluation
with endoscopy and biopsy. (E)
Children with biopsy-confirmed celiac disease should be placed on a gluten-free diet
and have consultation with a dietitian experienced in managing both diabetes and celiac
disease. (E)
Hypothyroidism
Children with type 1 diabetes should be screened for thyroid peroxidase and thyroglobulin
antibodies at diagnosis. (E)
TSH concentrations should be measured after metabolic control has been established.
If normal, they should be rechecked every 1–2 years, or if the patient develops symptoms
of thyroid dysfunction, thyromegaly, or an abnormal growth rate. (E)
Preconception care
A1C levels should be as close to normal as possible (<7%) in an individual patient
before conception is attempted. (B)
Starting at puberty, preconception counseling should be incorporated in the routine
diabetes clinic visit for all women of child-bearing potential. (C)
Women with diabetes who are contemplating pregnancy should be evaluated and, if indicated,
treated for diabetic retinopathy, nephropathy, neuropathy, and CVD. (E)
Medications used by such women should be evaluated prior to conception, since drugs
commonly used to treat diabetes and its complications may be contraindicated or not
recommended in pregnancy, including statins, ACE inhibitors, ARBs, and most non-insulin
therapies. (E)
Since many pregnancies are unplanned, consider the potential risks and benefits of
medications that are contraindicated in pregnancy in all women of child-bearing potential,
and counsel women using such medications accordingly. (E)
Older adults
Older adults who are functional, cognitively intact, and have significant life expectancy
should receive diabetes care using goals developed for younger adults. (E)
Glycemic goals for older adults not meeting the above criteria may be relaxed using
individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic
complications should be avoided in all patients. (E)
Other cardiovascular risk factors should be treated in older adults with consideration
of the time frame of benefit and the individual patient. Treatment of hypertension
is indicated in virtually all older adults, and lipid and aspirin therapy may benefit
those with life expectancy at least equal to the time frame of primary or secondary
prevention trials. (E)
Screening for diabetes complications should be individualized in older adults, but
particular attention should be paid to complications that would lead to functional
impairment. (E)
Diabetes care in the hospital
All patients with diabetes admitted to the hospital should have their diabetes clearly
identified in the medical record. (E)
All patients with diabetes should have an order for blood glucose monitoring, with
results available to all members of the health care team. (E)
Goals for blood glucose levels:
Critically ill patients: Insulin therapy should be initiated for treatment of persistent
hyperglycemia starting at a threshold of no greater than 180 mg/dl (10 mmol/l). Once
insulin therapy is started, a glucose range of 140–180 mg/dl (7.8 to 10 mmol/l) is
recommended for the majority of critically ill patients. (A)
More stringent goals, such as 110–140 mg/dl (6.1–7.8 mmol/l) may be appropriate for
selected patients, as long as this can be achieved without significant hypoglycemia.
(C)
Critically ill patients require an intravenous insulin protocol that has demonstrated
efficacy and safety in achieving the desired glucose range without increasing risk
for severe hypoglycemia. (E)
Non–critically ill patients: There is no clear evidence for specific blood glucose
goals. If treated with insulin, the pre-meal blood glucose target should generally
be <140 mg/dl (7.8 mmol/l) with random blood glucose <180 mg/dl (10.0 mmol/l), provided
these targets can be safely achieved. More stringent targets may be appropriate in
stable patients with previous tight glycemic control. Less stringent targets may be
appropriate in those with severe comorbidites. (E)
Scheduled subcutaneous insulin with basal, nutritional, and correction components
is the preferred method for achieving and maintaining glucose control in non–critically
ill patients. (C) Using correction dose or “supplemental” insulin to correct pre-meal
hyperglycemia in addition to scheduled prandial and basal insulin is recommended.
(E)
Glucose monitoring should be initiated in any patient not known to be diabetic who
receives therapy associated with high risk for hyperglycemia, including high-dose
glucocorticoid therapy, initiation of enteral or parenteral nutrition, or other medications
such as octreotide or immunosuppressive medications. (B) If hyperglycemia is documented
and persistent, treatment is necessary. Such patients should be treated to the same
glycemic goals as patients with known diabetes. (E)
A hypoglycemia management protocol should be adopted and implemented by each hospital
or hospital system. A plan for treating hypoglycemia should be established for each
patient. Episodes of hypoglycemia in the hospital should be documented in the medial
record and tracked. (E)
All patients with diabetes admitted to the hospital should have an A1C obtained if
the result of testing in the previous 2–3 months is not available. (E)
Patients with hyperglycemia in the hospital who do not have a diagnosis of diabetes
should have appropriate plans for follow-up testing and care documented at discharge.
(E)