The American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes
is updated and published annually in a supplement to the January issue of Diabetes
Care (1). Formerly called Clinical Practice Recommendations, the “Standards” includes
the most current evidence-based recommendations for diagnosing and treating adults
and children with all forms of diabetes. ADA’s grading system uses A, B, C, or E to
show the evidence level that supports each recommendation (Table 1).
TABLE 1.
ADA Evidence Grading System for “Standards of Medical Care in Diabetes”
Level of evidence
Description
A
Clear evidence from well-conducted, generalizable randomized controlled trials that
are adequately powered
B
Supportive evidence from well-conducted cohort studies
C
Supportive evidence from poorly controlled or uncontrolled studiesConflicting evidence
with the weight of evidence supporting the recommendation
E
Expert consensus or clinical experience
For additional information, please refer to the complete 2015 Standards (1).
This is an abridged version of the current Standards containing only the evidence-based
recommendations most pertinent to primary care. The tables, figures, and references
have been renumbered from the original document. The complete 2015 Standards supplement
is available at professional.diabetes.org/standards.
STRATEGIES FOR IMPROVING CARE
Recommendations
Patient-centered communication that incorporates patient preferences, assesses literacy
and numeracy, and addresses cultural barriers to care should be used. B
Care should be aligned with components of the Chronic Care Model (CCM) to ensure productive
interactions between a prepared proactive practice team and an informed activated
patient. A
Diabetes Care Concepts
Patient centeredness. Because patients with diabetes are also at greatly increased
risk of cardiovascular disease (CVD), a patient-centered approach should include a
comprehensive plan to reduce CVD risk.
Diabetes across the life span. As people with diabetes live well into older age and
incidence of type 2 diabetes is on the rise in children and young adults, the demographics
of diabetes are changing. There is therefore a need to improve coordination between
clinical teams as patients pass through different stages of life, including pregnancy.
Advocacy for patients with diabetes. Given the tremendous toll that lifestyle factors
such as obesity, physical inactivity, and smoking have on the health of patients with
diabetes, ongoing and energetic efforts are needed to address and change the societal
determinants at the root of these problems.
Care Delivery Systems
The mean A1C nationally has declined. This has been accompanied by improvements in
lipids and blood pressure control. Nevertheless, 33–49% of patients do not meet targets
for glycemic, blood pressure, or cholesterol control, and only 14% meet targets for
all three measures and nonsmoking status (2).
Chronic Care Model
The CCM has been shown to be effective for improving the quality of diabetes care
(3). Collaborative, multidisciplinary teams are best suited to provide care for people
with diabetes and to facilitate patients’ self-management (4–7).
Key Objectives
Optimize provider and team behavior. The care team should prioritize intensification
of lifestyle and/or pharmaceutical therapy for patients with inadequate levels of
blood pressure, lipid, or glucose control (8).
Support patient behavior change. Successful diabetes care requires a systematic approach
to supporting patients’ behavior change efforts. High-quality diabetes self-management
education (DSME) and support (DSMS) have been shown to improve patient self-management,
satisfaction, and glucose control (9,10).
Change the care system. Optimal diabetes management requires an organized, systematic
approach and the involvement of a coordinated team of dedicated health care professionals
working in an environment where patient-centered high-quality care is a priority (11).
When Treatment Goals Are Not Met
When patients are not meeting treatment goals, reassessing the treatment regimen may
require evaluation of barriers such as income, health literacy, diabetes-related distress,
depression, poverty, and competing demands, including those related to family responsibilities
and dynamics.
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Diabetes can be classified into the following general categories:
Type 1 diabetes (due to β-cell destruction, usually leading to absolute insulin deficiency)
Type 2 diabetes (due to a progressive insulin secretory defect on the background of
insulin resistance)
Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester
of pregnancy that is not clearly overt diabetes)
Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes
(such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases
of the exocrine pancreas (such as cystic fibrosis), and drug- or chemical-induced
diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)
Diagnostic Tests for Diabetes
Diabetes may be diagnosed based on A1C criteria or plasma glucose criteria, either
the fasting plasma glucose (FPG) or the 2-h plasma glucose value after a 75-g oral
glucose tolerance test (OGTT) (12,13) (Table 2). The same tests are used to screen
for and diagnose diabetes and to detect individuals with prediabetes (Table 3).
TABLE 2.
Criteria for the Diagnosis of Prediabetes and Diabetes
Prediabetes
Diabetes
A1C
5.7–6.4%
≥6.5%
FPG
100–125 mg/dL (5.6–6.9 mmol/L)
≥126 mg/dL (7.0 mmol/L)
OGTT
140–199 mg/dL (7.8–11.0 mmol/L)
≥200 mg/dL (11.1 mmol/L)*
RPG
≥200 mg/dL (11.1 mmol/L)†
*
In the absence of unequivocal hyperglycemia, results should be confirmed by repeat
testing.
†
Only diagnostic in a patient with classic symptoms of hyperglycemia or hyperglycemic
crisis. RPG, random plasma glucose.
TABLE 3.
Criteria for Testing for Diabetes or Prediabetes in Asymptomatic Adults
Testing should be considered in adults who are overweight (BMI ≥25 kg/m2 or ≥23 kg/m2
in Asian Americans) and have additional risk factors:
• Physical inactivity
• First-degree relative with diabetes
• High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian
American, Pacific Islander)
• Women who delivered a baby weighing >9 lb or were diagnosed with GDM
• Hypertension (≥140/90 mmHg or on therapy for hypertension)
• HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL
(2.82 mmol/L)
• Women with polycystic ovary syndrome
• A1C ≥5.7%, IGT, or IFG on previous testing
• Other clinical conditions associated with insulin resistance (e.g., severe obesity,
acanthosis nigricans)
• History of CVD
Type 2 Diabetes and Prediabetes
Recommendations
Testing to detect type 2 diabetes in asymptomatic people should be considered in adults
of any age who are overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans)
and who have one or more additional risk factors for diabetes. For all patients, particularly
those who are overweight or obese, testing should begin at age 45 years. B
If tests are normal, repeat testing carried out at a minimum of 3-year intervals is
reasonable. C
In patients with prediabetes or diabetes, identify and, if appropriate, treat other
CVD risk factors. B
Testing to detect prediabetes and type 2 diabetes should be considered in children
and adolescents who are overweight or obese and who have two or more additional risk
factors for diabetes. E
The modified recommendations of the ADA consensus report “Type 2 Diabetes in Children
and Adolescents” (14) are summarized in Table 4.
TABLE 4.
Testing for Type 2 Diabetes or Prediabetes in Asymptomatic Children (≤18 Years of
Age)
Criteria
• Overweight (BMI >85th percentile for age and sex, weight for height >85th percentile,
or weight >120% of ideal for height)
Plus any two of the following risk factors:
• Family history of type 2 diabetes in first- or second-degree relative
• Race/ethnicity (Native American, African American, Latino, Asian American, Pacific
Islander)
• Signs of insulin resistance or conditions associated with insulin resistance (acanthosis
nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age
birth weight)
• Maternal history of diabetes or GDM during the child’s gestation
Age of initiation: Age 10 years or at onset of puberty, if puberty occurs at a younger
age
Frequency: Every 3 years
Gestational Diabetes Mellitus
Recommendations
Test for undiagnosed type 2 diabetes at the first prenatal visit in those with risk
factors, using standard diagnostic criteria. B
Test for GDM at 24–28 weeks of gestation in pregnant women not previously known to
have diabetes. A
Screen women with GDM for persistent diabetes at 6–12 weeks postpartum, using the
OGTT and clinically appropriate nonpregnancy diagnostic criteria. E
Women with a history of GDM should have lifelong screening for the development of
diabetes or prediabetes at least every 3 years. B
Women with a history of GDM found to have prediabetes should receive lifestyle interventions
or metformin to prevent diabetes. A
INITIAL EVALUATION AND DIABETES MANAGEMENT PLANNING
Medical Evaluation
A complete medical evaluation should be performed at the initial visit to:
Classify diabetes
Detect diabetes complications
Review previous treatment and risk factor control in patients with diabetes
Assist in formulating a management plan
Provide a basis for continuing care
Laboratory tests appropriate to the evaluation of each patient’s medical condition
should be completed. A focus on the components of comprehensive care (Table 5) will
enable the health care team to optimally manage the patient with diabetes.
TABLE 5.
Components of the Comprehensive Diabetes Evaluation
Medical history
• Age and characteristics of onset of diabetes (e.g., diabetic ketoacidosis, asymptomatic
laboratory finding)
• Eating patterns, physical activity habits, nutritional status, and weight history;
growth and development in children and adolescents
• Presence of common comorbidities, psychosocial problems, and dental disease
• Diabetes education history
• Review of previous treatment regimens and response to therapy (A1C records)
• Current treatment of diabetes, including medications, medication adherence and barriers
thereto, meal plan, physical activity patterns, and readiness for behavior change
• Results of glucose monitoring and patient’s use of data
• Diabetic ketoacidosis frequency, severity, and cause
• Hypoglycemic episodes
○ Hypoglycemia awareness
○ Any severe hypoglycemia: frequency and cause
• History of diabetes-related complications
○ Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history
of foot lesions; autonomic, including sexual dysfunction and gastroparesis)
○ Macrovascular: coronary heart disease, cerebrovascular disease, and peripheral
arterial disease
Physical examination
• Height, weight, BMI
• Blood pressure determination, including orthostatic measurements when indicated
• Fundoscopic examination
• Thyroid palpation
• Skin examination (for acanthosis nigricans and insulin injection sites)
• Comprehensive foot examination
○ Inspection
○ Palpation of dorsalis pedis and posterior tibial pulses
○ Presence/absence of patellar and Achilles reflexes
○ Determination of proprioception, vibration, and monofilament sensation
Laboratory evaluation
• A1C, if results not available within past 3 months
• If not performed/available within past year
○ Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides,
as needed
○ Liver function tests
○ Test for urine albumin excretion with spot urine albumin-to-creatinine ratio
○ Serum creatinine and calculated glomerular filtration rate
○ TSH in type 1 diabetes, dyslipidemia, or women over age 50 years
Referrals
• Eye care professional for annual dilated eye exam
• Family planning for women of reproductive age
• Registered dietitian for medical nutrition therapy
• DSME/DSMS
• Dentist for comprehensive periodontal examination
• Mental health professional, if needed
Management Plan
People with diabetes should receive medical care from a collaborative, integrated
team with expertise in diabetes. The management plan should be written with input
from the patient and family, the physician, and other members of the health care team.
Common Comorbid Conditions
Recommendations
Consider screening those with type 1 diabetes for autoimmune diseases (e.g., thyroid
dysfunction, celiac disease) as appropriate. E
Consider assessing for and addressing common comorbid conditions (e.g., depression,
obstructive sleep apnea) that may complicate diabetes management. B
Additional comorbid conditions to consider assessing include fatty liver disease,
cancer, fractures, cognitive impairment, low testosterone in men, periodontal disease,
and hearing impairment.
FOUNDATIONS OF CARE: EDUCATION, NUTRITION, PHYSICAL ACTIVITY, SMOKING CESSATION, PSYCHOSOCIAL
CARE, AND IMMUNIZATION
Diabetes Self-Management Education and Support
Recommendations
People with diabetes should receive DSME and DSMS according to the national standards
for DSME and DSMS when their diabetes is diagnosed and as needed thereafter. B
Effective self-management and quality of life are the key outcomes of DSME and DSMS
and should be measured and monitored as part of care. C
DSME and DSMS should address psychosocial issues, as emotional well-being is associated
with positive diabetes outcomes. C
DSME and DSMS programs are appropriate venues for people with prediabetes to receive
education and support to develop and maintain behaviors that can prevent or delay
the onset of diabetes. C
Because DSME and DSMS can result in cost-savings and improved outcomes B, DSME and
DSMS should be adequately reimbursed by third-party payers. E
Medical Nutrition Therapy
For many individuals with diabetes, the most challenging part of the treatment plan
is determining what to eat. It is the position of the ADA that there is not a one-size-fits-all
eating pattern for individuals with diabetes. Therefore, it is important that all
members of the health care team be knowledgeable about diabetes nutrition therapy
and support its implementation.
Goals of Nutrition Therapy for Adults With Diabetes
To promote and support healthful eating patterns, emphasizing a variety of nutrient-dense
foods in appropriate portion sizes, in order to improve overall health and specifically
to:
Attain individualized glycemic, blood pressure, and lipid goals
Achieve and maintain body weight goals
Delay or prevent complications of diabetes
To address individual nutrition needs based on personal and cultural preferences,
health literacy and numeracy, access to healthful food choices, willingness and ability
to make behavioral changes, and barriers to change
To maintain the pleasure of eating by providing positive messages about food choices
while limiting food choices only when indicated by scientific evidence
To provide the individual with diabetes with practical tools for day-to-day meal planning
rather than focusing on individual macronutrients, micronutrients, or single foods
Physical Activity
Recommendations
Children with diabetes or prediabetes should be encouraged to engage in at least 60
min of physical activity each day. B
Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity
aerobic physical activity (50–70% of maximum heart rate), spread over at least 3 days/week
with no more than 2 consecutive days without exercise. A
Evidence supports that all individuals, including those with diabetes, should be encouraged
to reduce sedentary time, particularly by breaking up extended amounts of time (>90
min) spent sitting. B
In the absence of contraindications, adults with type 2 diabetes should be encouraged
to perform resistance training at least twice per week. A
Smoking Cessation
Recommendations
Advise all patients not to smoke or use tobacco products. A
Include smoking cessation counseling and other forms of treatment as a routine component
of diabetes care. B
Psychosocial Assessment and Care
Recommendations
Include assessment of the patient’s psychological and social situation as an ongoing
part of the medical management of diabetes. B
Psychosocial screening and follow-up may include, but are 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
Routinely screen for psychosocial problems such as depression, diabetes-related distress,
anxiety, eating disorders, and cognitive impairment. B
Older adults (aged ≥65 years) with diabetes should be considered a high-priority population
for depression screening and treatment. B
Patients with comorbid diabetes and depression should receive astepwise collaborative
care app-roach for the management of depression. A
Immunization
Recommendations
Provide routine vaccinations for children and adults with diabetes as for the general
population. C
Annually provide an influenza vaccine to all patients with diabetes ≥6 months of age.
C
Administer pneumococcal polysaccharide vaccine 23 (PPSV23) to all patients with diabetes
≥2 years of age. C
Adults ≥65 years of age, if not previously vaccinated, should receive pneumococcal
conjugate vaccine 13 (PCV13), followed by PPSV23 6–12 months after initial vaccination.
C
Adults ≥65 years of age, if previously vaccinated with PPSV23, should receive a follow-up
≥12 months with PCV13. C
Administer hepatitis B vaccination to unvaccinated adults with diabetes who are aged
19–59 years. C
Consider administering hepatitis B vaccination to unvaccinated adults with diabetes
who are aged ≥60 years. C
PREVENTION OR DELAY OF TYPE 2 DIABETES
Recommendations
Patients with impaired glucose tolerance (IGT) A, impaired fasting glucose (IFG) E,
or an A1C 5.7–6.4% E should be referred to an intensive diet and physical activity
behavioral counseling program targeting loss of 7% of body weight and increasing moderate-intensity
physical activity (such as brisk walking) to at least 150 min/week.
Metformin therapy for prevention of type 2 diabetes may be considered in those with
IGT A, IFG E, or an A1C 5.7–6.4% E, especially for those with BMI >35 kg/m2, aged
<60 years, and women with prior GDM. A
At least annual monitoring for the development of diabetes in those with prediabetes
is suggested. E
Screening for and treatment of modifiable risk factors for CVD is suggested. B
Intensive lifestyle modification programs have been shown to be very effective (∼58%
reduction after 3 years) (15–17), and pharmacological agents metformin, α-glucosidase
inhibitors, orlistat, and thiazolidinediones (TZDs) have been shown to decrease incident
diabetes to various degrees.
Individuals with an A1C of 5.7–6.4%, IGT, or IFG should be counseled on lifestyle
changes with goals similar to those of the Diabetes Prevention Program (7% weight
loss and moderate physical activity of at least 150 min/week). Metformin has demonstrated
long-term safety as pharmacological therapy for diabetes prevention.
GLYCEMIC TARGETS
Assessment of Glycemic Control
Recommendation
Patients on multiple-dose insulin or insulin pump therapy should perform self-monitoring
of blood glucose (SMBG) prior to meals and snacks, occasionally postprandially, at
bedtime, prior to exercise, when they suspect low blood glucose, after treating low
blood glucose until they are normoglycemic, and prior to critical tasks such as driving.
B
Two primary techniques are available for health providers and patients to assess the
effectiveness of the management plan on glycemic control: patient SMBG or interstitial
glucose and A1C. Continuous glucose monitoring (CGM) may be a useful adjunct to SMBG
in selected patients.
SMBG frequency and timing should be dictated by the patient’s specific needs and goals.
SMBG is especially important for patients treated with insulin to monitor for and
prevent asymptomatic hypoglycemia and hyperglycemia. For patients on nonintensive
insulin regimens, such as those with type 2 diabetes on basal insulin, when to prescribe
SMBG and the testing frequency are less established.
SMBG allows patients to evaluate their individual response to therapy and assess whether
glycemic targets are being achieved. Results of SMBG can be useful in preventing hypoglycemia
and adjusting medications (particularly prandial insulin doses), medical nutrition
therapy, and physical activity. Evidence also supports a correlation between SMBG
frequency and lower A1C (18).
SMBG accuracy is instrument and user dependent (19), so it is important to evaluate
each patient’s monitoring technique, both initially and at regular intervals thereafter.
The ongoing need for and frequency of SMBG should be reevaluated at each routine visit.
A1C Testing
Recommendations
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 provides the opportunity for more timely treatment
changes. E
For patients in whom A1C/estimated average glucose and measured blood glucose appear
discrepant, clinicians should consider the possibilities of hemoglobinopathy or altered
red blood cell turnover and the options of more frequent and/or different timing of
SMBG or use of CGM. Other measures of chronic glycemia such as fructosamine are available,
but their linkage to average glucose and their prognostic significance are not as
clear as for A1C.
A1C Goals
See the sections CHILDREN AND ADOLESCENTS and MANAG-EMENT OF DIABETES IN PREGNANCY
for glycemic goals for children and pregnant women. The complete 2015 Standards include
additional goals for children (20) and pregnant women (21).
Recommendations
Lowering A1C to approximately 7% or less has been shown to reduce microvascular complications
of diabetes, and, if implemented soon after the diagnosis of diabetes, it is associated
with long-term reduction in macrovascular disease. Therefore, a reasonable A1C goal
for many nonpregnant adults is <7%. B
Providers might reasonably suggest more stringent A1C goals (such as <6.5%) for selected
individual patients if this can be achieved without significant hypoglycemia or other
adverse effects of treatment. Appropriate patients might include those with short
duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long
life expectancy, or no significant CVD. C
Less stringent A1C goals (such as <8%) may be appropriate for patients with a history
of severe hypoglycemia, limited life expectancy, advanced micro- or macrovascular
complications, extensive comorbid conditions, or long-standing diabetes in whom the
general goal is difficult to attain despite DSME, appropriate glucose monitoring,
and effective doses of multiple glucose-lowering agents including insulin. B
See Figure 1 for patient and disease factors used to determine optimal A1C targets.
Recommended glycemic targets are provided in Table 6. The recommendations are based
on those for A1C values, with blood glucose levels that appear to correlate with achievement
of an A1C of <7%.
FIGURE 1.
Depicted are patient and disease factors used to determine optimal A1C targets. Characteristics
and predicaments toward the left justify more stringent efforts to lower A1C; those
toward the right suggest less stringent efforts. Adapted with permission from Inzucchi
et al. (22).
TABLE 6.
Summary of Glycemic Recommendations for Nonpregnant Adults With Diabetes
A1C
<7.0%*
Preprandial capillary plasma glucose
80–130 mg/dL* (4.4–7.2 mmol/L)
Peak postprandial capillary plasma glucose†
<180 mg/dL* (<10.0 mmol/L)
*
More or less stringent glycemic goals may be appropriate for individual patients.
Goals should be individualized based on duration of diabetes, age/life expectancy,
comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia
unawareness, and individual patient considerations.
†
Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial
glucose goals. Postprandial glucose measurements should be made 1–2 h after the beginning
of the meal, generally peak levels in patients with diabetes.
Hypoglycemia
Recommendations
Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic
hypoglycemia at each encounter. C
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. Fifteen minutes
after treatment, if SMBG shows continued hypoglycemia, the treatment should be repeated.
Once SMBG 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 an increased risk of severe hypoglycemia,
and caregivers or family members of these individuals should be instructed on its
administration. Glucagon administration is not limited to health care professionals.
E
Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger
reevaluation of the treatment regimen. E
Insulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia
should be advised to raise their glycemic targets to strictly avoid further hypoglycemia
for at least several weeks in order to partially reverse hypoglycemia unawareness
and reduce risk of future episodes. A
Ongoing assessment of cognitive function is suggested with increased vigilance for
hypoglycemia by the clinician, patient, and caregivers if low cognition and/or declining
cognition is found. B
Pure glucose is the preferred treatment, but any form of carbohydrate that contains
glucose will raise blood glucose. Added fat may retard and then prolong the acute
glycemic response. Ongoing insulin activity or insulin secretagogues may lead to recurrent
hypoglycemia unless further food is ingested after recovery.
Family members, roommates, school personnel, child care providers, correctional institution
staff, or coworkers should be instructed on use of glucagon kits. An individual does
not need to be a health care professional to safely administer glucagon.
APPROACHES TO GLYCEMIC TREATMENT
Pharmacological Therapy for Type 1 Diabetes
Recommendations
Most people with type 1 diabetes should be treated with multiple-dose insulin injections
(three to four injections per day of basal and prandial insulin) or continuous subcutaneous
insulin infusion therapy. A
Most people with type 1 diabetes should be educated in how to match prandial insulin
dose to carbohydrate intake, premeal blood glucose, and anticipated physical activity.
E
Most people with type 1 diabetes should use insulin analogs to reduce hypoglycemia
risk. A
For patients with frequent noc-turnal hypoglycemia and/or hypo-glycemia unawareness,
a sensor-augmented low glucose threshold suspend pump may be considered.
Pharmacological Therapy for Type 2 Diabetes
Recommendations
Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacological
agent for type 2 diabetes. A
In patients with newly diagnosed type 2 diabetes and markedly symptomatic and/or elevated
blood glucose levels or A1C, consider initiating insulin therapy (with or without
additional agents). E
If noninsulin monotherapy at maximum tolerated dose does not achieve or maintain the
A1C target over 3 months, add a second oral agent, a glucagon-like peptide 1 (GLP-1)
receptor agonist, or basal insulin. A
A patient-centered approach should be used to guide choice of pharmacological agents.
Considerations include efficacy, cost, potential side effects, weight, comorbidities,
hypoglycemia risk, and patient preferences. E
Due to the progressive nature of type 2 diabetes, insulin therapy is eventually indicated
for many patients with type 2 diabetes. B
Figure 2 emphasizes drugs commonly used in the U.S. and/or Europe.
FIGURE 2.
Antihyperglycemic therapy in type 2 diabetes: general recommendations (22). The order
in the chart was determined by historical availability and the route of administration,
with injectables to the right; it is not meant to denote any specific preference.
Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes
are displayed, with the usual transition moving vertically from top to bottom (although
horizontal movement within therapy stages is also possible, depending on the circumstances).
DPP-4-i, DPP-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1-RA, GLP-1 receptor
agonist; GU, genitourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, sodium-glucose
cotransporter 2 inhibitor; SU, sulfonylurea. *See ref. 22 for description of efficacy
categorization. †Consider starting at this stage when A1C is ≥9%. ‡Consider starting
at this stage when blood glucose is ≥300–350 mg/dL (16.7–19.4 mmol/L) and/or A1C is
≥10–12%, especially if symptomatic or catabolic features are present, in which case
insulin + mealtime is the preferred initial regimen. §Usually a basal insulin (NPH,
glargine, detemir, degludec). Adapted with permission from Inzucchi et al. (22).
A comprehensive list of the properties of available glucose-lowering agents in the
U.S. and Europe that may guide individualized treatment choices in patients with type
2 diabetes is available in the complete 2015 Standards, reprinted from Inzucchi et
al. (22).
Many patients with type 2 diabetes eventually require and benefit from insulin therapy.
The progressive nature of type 2 diabetes and its therapies should be regularly and
objectively explained to patients. Providers should avoid using insulin as a threat
or describing it as a failure or punishment. Equipping patients with an algorithm
for self-titration of insulin doses based on SMBG results improves glycemic control
in patients with type 2 diabetes initiating insulin. Refer to the ADA–European Association
for the Study of Diabetes (EASD) position statement (22) for more details on pharmacotherapy
for hyperglycemia in type 2 diabetes.
Bariatric Surgery
Recommendations
Bariatric surgery may be considered for adults with BMI >35 kg/m2 and type 2 diabetes,
especially if diabetes or associated comorbidities are difficult to control with lifestyle
and pharmacological therapy. B
Patients with type 2 diabetes who have undergone bariatric surgery need lifelong lifestyle
support and medical monitoring. B
Although small trials have shown glycemic benefit of bariatric surgery in patients
with type 2 diabetes and BMI 30–35 kg/m2, there is currently insufficient evidence
to generally recommend surgery in patients with BMI <35 kg/m2. E
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
CVD is the major cause of morbidity and mortality for individuals with diabetes and
the largest contributor to the direct and indirect costs of diabetes. Efficacy of
controlling individual cardiovascular risk factors in preventing or slowing CVD in
people with diabetes is proven. Large benefits are seen when multiple risk factors
are addressed globally (23,24).
At least annually, assess CVD risk factors (dyslipidemia, hypertension, smoking, family
history of premature coronary disease, and the presence of albuminuria) in all patients
with diabetes.
Hypertension
Recommendations
People with diabetes and hypertension should be treated to a systolic blood pressure
(SBP) goal of <140 mmHg. A
Lower systolic targets, such as <130 mmHg, may be appropriate for certain individuals,
such as younger patients, if they can be achieved without undue treatment burden.
C
Individuals with diabetes should be treated to a diastolic blood pressure (DBP) <90
mmHg. A
Lower diastolic targets, such as <80 mmHg, may be appropriate for certain individuals,
such as younger patients, if they can be achieved without undue treatment burden.
B
Patients with blood pressure >120/80 mmHg should be advised on lifestyle changes to
reduce blood pressure. B
Patients with confirmed office-based blood pressure >140/90 mmHg should, in addition
to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological
therapy to achieve blood pressure goals. A
Lifestyle therapy for elevated blood pressure consists of weight loss, if overweight
or obese; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern including
reducing sodium and increasing potassium intake; moderation of alcohol intake; and
increased physical activity. B
Pharmacological therapy for patients with diabetes and hypertension should comprise
a regimen that includes either an ACE inhibitor or an angiotensin receptor blocker
(ARB). B If one class is not tolerated, the other should be substituted. C
Multiple-drug therapy (including a thiazide diuretic and ACE inhibitor/ARB, at maximal
doses) is generally required to achieve blood pressure targets. B
Dyslipidemia/Lipid Management
Lifestyle intervention may allow some patients to reduce CVD risk factors. Glycemic
control can also benefit lipid levels, particularly in patients with high triglycerides
and poor glycemic control.
Initiating and intensifying statin therapy based on age and risk factors is recommended
(Table 7).
TABLE 7.
Recommendations for Statin Treatment in People With Diabetes
Age
Risk factors
Recommended statin dose*
Monitoring with lipid panel
<40 years
None
None
Annually or as needed to monitor for adherence
CVD risk factor(s)**
Moderate or high
Overt CVD***
High
40–75 years
None
Moderate
As needed to monitor adherence
CVD risk factors
High
Overt CVD
High
>75 years
None
Moderate
As needed to monitor adherence
CVD risk factors
Moderate or high
Overt CVD
High
*
In addition to lifestyle therapy.
**
CVD risk factors include LDL cholesterol ≥100 mg/dL (2.6 mmol/L), high blood pressure,
smoking, and overweight and obesity.
***
Overt CVD includes those with previous cardiovascular events or acute coronary syndromes.
In all patients ≥40 years of age with diabetes, moderate-intensity statin treatment
should be considered in addition to lifestyle therapy. High-dose statin therapy should
be considered if increased CVD risk is present (e.g., LDL cholesterol ≥100 mg/dL,
high blood pressure, smoking, and overweight/obesity).
In patients under 40 years of age and in those with type 1 diabetes, treatment with
a moderate dose of statin should be considered if the patient has increased CVD risk
and with a high dose of statin if the patient has overt CVD.
Obtain a lipid panel at the time of the first diagnosis, at the first medical evaluation,
and/or at age 40 years and periodically (e.g., every 1–2 years) thereafter. Once a
patient is on a statin, testing for LDL cholesterol can monitor for efficacy and adherence.
Extremely low, less than daily, statin doses may lower LDL cholesterol significantly
(25).
Statin–fibrate combination therapy is associated with an increased risk for abnormal
transaminase levels, myositis, or rhabdomyolysis (26) and does not lower the risk
of cardiovascular events more than simvastatin alone (27). Statin–niacin combination
therapy is not recommended given the lack of efficacy and possible increase in risk
of ischemic stroke and side effects (28).
There is an increased risk of incident diabetes with statin use (29,30), but this
increase is far outweighed by the reduction in cardiovascular events (31).
Antiplatelet Agents
Aspirin is effective in reducing cardiovascular morbidity and mortality in high-risk
patients with previous myocardial infarction or stroke, but the benefit in primary
prevention is more controversial both for patients with and without diabetes (32,33).
Low-dose aspirin (75–162 mg/day) for primary prevention is reasonable for most men
over age 50 years and most women over age 60 years with one or more major risk factors
(smoking, hypertension, dyslipidemia, family history of premature CVD, and albuminuria).
MICROVASCULAR COMPLICATIONS AND FOOT CARE
Nephropathy
Recommendations
Optimize glucose control and blood pressure to reduce the risk or slow the progression
of diabetic kidney disease (DKD). A
At least once a year, quantitatively assess urinary albumin (e.g., urine albumin-to-creatinine
ratio [UACR]) and estimated glomerular filtration rate (eGFR) in patients with type
1 diabetes duration of ≥5 years and in all patients with type 2 diabetes. B
Complications of CKD correlate with levels of kidney function (Table 8).
TABLE 8.
Management of CKD in Diabetes*
GFR (mL/min/1.73 m2)
Recommended management
All patients
Yearly measurement of creatinine, urinary albumin excretion, potassium
45–60
Referral to a nephrologist if possibility for nondiabetic kidney disease exists (duration
of type 1 diabetes <10 years, heavy proteinuria, abnormal findings on renal ultrasound,
resistant hypertension, rapid fall in GFR, or active urinary sediment on urinalysis)
Consider need for dose adjustment of medications
Monitor eGFR every 6 months
Monitor electrolytes, bicarbonate, hemoglobin, calcium, phosphorus, parathyroid hormone
at least yearly
Assure vitamin D sufficiency
Consider bone density testing
Referral for dietary counseling
30–44
Monitor eGFR every 3 months
Monitor electrolytes, bicarbonate, calcium, phosphorus, parathyroid hormone, hemoglobin,
albumin, weight every 3–6 months
Consider need for dose adjustment of medications
<30
Referral to a nephrologist
*
National Kidney Foundation. KDOQI clinical practice guideline for diabetes and CKD:
2012 update. Am J Kidney Dis 2012;60:850–886
Intensive diabetes management with the goal of achieving near-normoglycemia has been
shown in large prospective randomized studies to delay the onset and progression of
increased urinary albumin excretion and reduced eGFR in patients with type 1 diabetes
(1) and type 2 diabetes (34). Screening for increased urinary albumin excretion can
be performed by UACR in a random spot urine collection; 24-h or timed collections
are more burdensome and add little to prediction or accuracy (35,36). Two of three
specimens collected within a 3- to 6-month period should be abnormal before considering
a patient to have developed albuminuria.
ACE inhibitors and ARBs provide selective benefit in slowing decline in GFR in patients
with higher levels of albumin (37–40). ACE inhibitors reduce major CVD outcomes in
patients with diabetes, supporting their use in patients with elevated albuminuria
(a CVD risk factor) (41). ARBs reduce progression of albuminuria and end-stage renal
disease in patients with type 2 diabetes (42–44), but they do not reduce risk of CVD
events or albuminuria in normotensive patients with type 1 or type 2 diabetes (41).
Additional blood pressure lowering can be accomplished with diuretics, calcium channel
blockers, and β-blockers.
Combining an ACE inhibitor and an ARB provides no additional benefit for CVD or DKD
and has a higher adverse event risk (45). Thus, combined use should be avoided.
Retinopathy
Recommendations
Optimize glycemic and blood pressure control to reduce the risk or slow the progression
of retinopathy. A
Adults 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
Intensive diabetes management with the goal of achieving near-normoglycemia has been
shown in large prospective randomized studies to prevent and/or delay the onset and
progression of diabetic retinopathy (34,46).
Because retinopathy is estimated to take at least 5 years to develop after the onset
of hyperglycemia, patients with type 1 diabetes should have an initial dilated and
comprehensive eye examination within 5 years after the diabetes diagnosis (47). These
exams should be repeated annually. Photos are not a substitute for a comprehensive
eye exam.
Neuropathy
Recommendations
All patients should be screened for diabetic peripheral neuropathy (DPN) starting
at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes
and at least annually thereafter, using simple clinical tests, such as a 10-g monofilament.
B
Screening for signs and symptoms (e.g., orthostasis, resting tachycardia) of cardiovascular
autonomic neuropathy (CAN) should be considered with more advanced disease. E
Tight glycemic control is the only strategy convincingly shown to prevent or delay
the development of DPN and CAN in patients with type 1 diabetes A and to slow the
progression of neuropathy in some patients with type 2 diabetes. B
Clinical tests for DPN include pinprick sensation, vibration threshold using 128-Hz
tuning fork, and 10-g monofilament and ankle reflexes.
DPN can be debilitating (48) but may be treated with pregabalin, duloxetine, and tapentadol.
For persistent painful DPN, venlafaxine, amitriptyline, gabapentin, valproate, and
opioids may be considered. A tailored and stepwise strategy is recommended (49).
Autonomic neuropathy, particularly CAN, is an independent risk factor for cardiovascular
mortality (50,51). Major clinical manifestations of autonomic neuropathy include resting
tachycardia, exercise intolerance, orthostatic hypotension, gastroparesis, constipation,
erectile dysfunction, impaired neurovascular function, and autonomic failure in response
to hypoglycemia. In men, diabetic autonomic neuropathy may cause erectile dysfunction
or retrograde ejaculation.
Gastrointestinal neuropathies may involve any section of the gastrointestinal tract.
Gastroparesis should be suspected in individuals with erratic glucose control and
upper gastrointestinal symptoms. Constipation is the most common lower gastrointestinal
symptom but can alternate with diarrhea.
Gastroparesis may improve with dietary changes and prokinetic agents such as erythromycin.
Due to side effects, metoclopramide is reserved for the most severe and unresponsive
case.
Recurrent urinary tract infections, pyelonephritis, incontinence, or palpable bladder
should evoke evaluation of bladder dysfunction.
Control of lipids, blood pressure, smoking, and other lifestyle factors can reduce
the progression and development of CAN (52).
Foot Care
Recommendation
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 and assessment of foot pulses. B
Previous amputation, prior foot ulcer, peripheral neuropathy, foot deformity, peripheral
vascular disease, visual impairment, peripheral neuropathy (especially if on dialysis),
poor glycemic control, and smoking all represent high risk.
Components of the screening exam include inspection of skin integrity and musculoskeletal
deformity and assessment of pedal pulses. The exam should seek to identify loss of
peripheral sensation (LOPS). Five simple tests (10-g monofilament, 128-Hz tuning fork,
pinprick sensation, ankle reflexes, and testing vibration perception threshold with
biothesiometer) can identify LOPS in the diabetic foot. Two of these tests should
be performed annually. One or more abnormal tests would suggest LOPS and two or more
normal tests would rule out LOPS.
Screening for peripheral arterial disease (PAD) (ankle-brachial index evaluation)
should include a history of claudication and assessment of pedal pulses. Screening
for PAD should start at age 50 years and be considered at <50 years of age in those
with PAD risk factors.
Patients with high-risk foot conditions should be educated about their risk and appropriate
management. This may be managed with well-fitted walking shoes that cushion the feet
and redistribute pressure. Those with boney deformities may need extra wide or deep
shoes. Some with more advanced disease may need custom fitted shoes.
OLDER ADULTS
Recommendations
Older adults who are functional and cognitively intact and have significant life expectancy
should receive diabetes care with goals similar to those developed for younger adults.
E
Glycemic goals for some older adults might reasonably 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-lowering 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
Older adults (≥65 years of age) with diabetes should be considered a high-priority
population for depression screening and treatment. B
The care of older adults with diabetes is complicated by their clinical and functional
heterogeneity. Providers caring for older adults with diabetes must take this heterogeneity
into consideration when setting and prioritizing treatment goals (Table 9).
TABLE 9.
Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia
in Older Adults With Diabetes
Patient characteristics/health status
Rationale
Reasonable A1C goal‡
Fasting or preprandial glucose (mg/dL)
Bedtime glucose (mg/dL)
Blood pressure (mmHg)
Lipids
Healthy (few coexisting chronic illnesses, intact cognitive and functional status)
Longer remaining life expectancy
<7.5%
90–130
90–150
<140/90
Statin unless contraindicated or not tolerated
Complex/intermediate (multiple coexisting chronic illnesses* or 2+ instrumental ADL
impairments or mild-to-moderate cognitive impairment)
Intermediate remaining life expectancy, high treatment burden, hypoglycemia vulnerability,
fall risk
<8.0%
90–150
100–180
<140/90
Statin unless contraindicated or not tolerated
Very complex/poor health (long-term care or end-stage chronic illnesses** or moderate-to-severe
cognitive impairment or 2+ ADL dependencies)
Limited remaining life expectancy makes benefit uncertain
<8.5%†
100–180
110–200
<150/90
Consider likelihood of benefit with statin (secondary prevention more so than primary)
This represents a consensus framework for considering treatment goals for glycemia,
blood pressure, and dyslipidemia in older adults with diabetes. The patient characteristic
categories are general concepts. Not every patient will clearly fall into a particular
category. Consideration of patient and caregiver preferences is an important aspect
of treatment individualization. Additionally, a patient’s health status and preferences
may change over time. ADL, activities of daily living.
‡
A lower A1C goal may be set for an individual if achievable without recurrent or severe
hypoglycemia or undue treatment burden.
*
Coexisting chronic illnesses are conditions serious enough to require medications
or lifestyle management and may include arthritis, cancer, congestive heart failure,
depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic
kidney disease, myocardial infarction, and stroke. By “multiple,” we mean at least
three, but many patients may have five or more (Laiteerapong N, Iveniuk J, John PM,
Laumann EO, Huang ES. Classification of older adults who have diabetes by comorbid
conditions, United States, 2005–2006. Prev Chronic Dis 2012;9:E100).
**
The presence of a single end-stage chronic illness, such as stage 3–4 congestive heart
failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis,
or uncontrolled metastatic cancer, may cause significant symptoms or impairment of
functional status and significantly reduce life expectancy.
†
A1C of 8.5% equates to an estimated average glucose of ∼200 mg/dL. Looser glycemic
targets than this may expose patients to acute risks from glycosuria, dehydration,
hyperglycemic hyperosmolar syndrome, and poor wound healing.
Treatment Goals
There are few long-term studies in older adults demonstrating the benefits of intensive
glycemic, blood pressure, and lipid control. Patients who are expected to live long
enough to reap the benefits of long-term intensive diabetes management, who have good
cognitive and physical function, and who choose to do so via shared decision-making
may be treated using therapeutic interventions and goals similar to those for younger
adults with diabetes. Less intensive management goals may be appropriate for those
with life-limiting complications, comorbid conditions, or substantial cognitive or
functional impairment. However, glycemic goals at a minimum should avoid acute complications
of diabetes, including dehydration, poor wound healing, hyperglycemic hyperosmolar
coma, and hypoglycemia. DSME and ongoing DSMS are vital components of diabetes care.
Benefit for older adults with diabetes is likely to result from control of other cardiovascular
risk factors, particularly with respect to hypertension (53,54). There is less evidence
for lipid-lowering and aspirin therapy, although the benefits of these interventions
are likely to apply to older adults whose life expectancies equal or exceed the time
frames seen in clinical trials.
Hypoglycemia
Older adults are at a higher risk of hypoglycemia for many reasons, including:
Insulin deficiency
Progressive renal insufficiency
Unidentified cognitive deficits, causing difficulty in complex self-care activities
(e.g., glucose monitoring, adjusting insulin doses)
Pharmacological Therapy
Special care is required in prescribing and monitoring pharmacological therapy in
older adults (55).
CHILDREN AND ADOLESCENTS
The Centers for Disease Control and Prevention estimates that type 2 diabetes in those
under 20 years of age will quadruple in 40 years (56,57). Three-quarters of all cases
of type 1 diabetes are diagnosed in individuals <18 years of age. Given the current
obesity epidemic, distinguishing between type 1 and type 2 diabetes in children can
be difficult.
The following recommendations were developed for children and adolescents with type
1 diabetes. However, the guidelines are the same for children and adolescents with
type 2 diabetes with the addition of blood pressure measurement, a fasting lipid panel,
assessment for albumin excretion, and dilated eye examination at type 2 diabetes diagnosis.
Glycemic Control and Hypertension
Recommendations
An A1C goal of <7.5% is recommended across all pediatric age-groups. E
Blood pressure should be measured at each routine visit. Children found to have high-normal
blood pressure (SBP or DBP ≥90th percentile for age, sex, and height) or hypertension
(SBP or DBP ≥95th percentile for age, sex, and height) should have blood pressure
confirmed on three separate days. B
The benefit of A1C control should be balanced against the risk of hypoglycemia and
the developmental burden of intensive regimens for children and youth (58).
Blood pressure measurements should be determined using the appropriate size cuff and
with the child seated and relaxed. ACE inhibitors or ARBs should be considered first
line, following appropriate reproductive counseling due to teratogenic effects.
Dyslipidemia
Recommendations
Obtain a fasting lipid profile on children ≥2 years of age soon after the diagnosis
(after glucose control has been established). E
If lipids are abnormal, annual monitoring is reasonable. If LDL cholesterol values
are within the accepted risk levels (<100 mg/dL [2.6 mmol/L]), a lipid profile repeated
every 5 years is reasonable. E
Lipids should be obtained at diagnosis of type 2 diabetes due to the presence of increased
comorbid conditions (59). Annual monitoring is recommended if LDL is <100 mg/dL.
For specific recommendations and additional guidance, refer to “Type 2 Diabetes in
Children and Adolescents” (14).
MANAGEMENT OF DIABETES IN PREGNANCY
Recommendations
GDM should be managed first with diet and exercise, and medications should be added
if needed. A
Due to alterations in red blood cell turnover that lower the normal A1C level in pregnancy,
the A1C target in pregnancy is <6% if this can be achieved without significant hypoglycemia.
B
Medications widely used in pregnancy include insulin, metformin, and glyburide; most
oral agents cross the placenta or lack long-term safety data. B
Optimal glycemic goals for women with GDM and for women with preexisting type 1 or
type 2 diabetes who become pregnant are available in the complete 2015 Standards (21).
Insulin is the preferred agent for management due to the lack of long-term safety
data for noninsulin agents. In type 2 diabetes, care with weight gain and management
of comorbid conditions remains paramount (60,61).
For women with GDM, screening for persistent diabetes at 6–12 weeks postpartum and
every 1–3 years thereafter is recommended (62).
DIABETES CARE IN THE HOSPITAL, NURSING HOME, AND SKILLED NURSING FACILITY
Recommendations
Diabetes discharge planning should start at hospital admission, and clear diabetes
management instructions should be provided at discharge. E
The sole use of sliding-scale insulin in the inpatient hospital setting is strongly
discouraged. A
All patients with diabetes admitted to the hospital should have their diabetes type
clearly identified in the medical record. E
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 (7.8–10 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
Noncritically Ill Patients
If treated with insulin, generally premeal blood glucose targets of <140 mg/dL (7.8
mmol/L) with random blood glucose <180 mg/dL (10.0 mmol/L) are reasonable, 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 comorbidities. C
A basal plus correction insulin regimen is the preferred treatment for patients with
poor oral intake or who are taking nothing by mouth. An insulin regimen with basal,
nutritional, and correction components is the preferred treatment for patients with
good nutritional intake. A
A hypoglycemia management protocol should be adopted and implemented by each hospital
or hospital system. A plan for preventing and treating hypoglycemia should be established
for each patient. Episodes of hypoglycemia in the hospital should be documented in
the medical record and tracked. E
Consider obtaining an A1C in patients with diabetes admitted to the hospital if the
result of testing in the previous 3 months is not available. E
Consider obtaining an A1C in patients with risk factors for undiagnosed diabetes who
exhibit hyperglycemia in the hospital. E
Patients with hyperglycemia in the hospital who do not have a prior diagnosis of diabetes
should have appropriate follow-up testing and care documented at discharge. E
Medical Nutrition Therapy in the Hospital
No specific meal plan is endorsed by the ADA, and the term “ADA diet” should no longer
be used. Consistent carbohydrate meal plans are preferred with respect to prandial
insulin dosing (63). A registered dietitian, knowledgeable and skilled in medical
nutrition therapy, should serve as an inpatient team member (64).
Bedside Blood Glucose Monitoring
Bedside point-of-care blood glucose monitoring is used to guide insulin dosing. In
the patient receiving nutrition, the timing of glucose monitoring should match carbohydrate
exposure. In the patient not receiving nutrition, glucose monitoring is performed
every 4–6 h (65,66). More frequent blood glucose testing ranging from every 30 min
to every 2 h is required for patients on intravenous insulin infusions.
Discharge Planning
Diabetes discharge planning, including DSME, is an important part of an overall discharge
plan. An outpatient follow-up visit with the primary care provider, endocrinologist,
or diabetes educator within 1 month of discharge is advised for all patients having
hyperglycemia in the hospital, with clear communication of the diabetes care plan
to include medication and diabetes supply (e.g., strips, lancets) reconciliation.
DIABETES ADVOCACY
Advocacy Position Statements
For a list of ADA advocacy position statements, including “Diabetes and Driving” (67)
and “Diabetes and Employment” (68), refer to the Diabetes Advocacy section of the
complete 2015 Standards (69).
Supplementary Material
References