diabetes guidelines

Executive Summary: Standards of Medical Carein Diabetesd2014

CURRENT CRITERIA FOR THEDIAGNOSIS OF DIABETES

c A1C $6.5%. The test should beperformed in a laboratory using amethod that is NGSP certified andstandardized to the DCCT assay. Or

c Fasting plasma glucose (FPG) $126mg/dL (7.0 mmol/L). Fasting isdefined as no caloric intake for atleast 8 h. Or

c Two-hour plasma glucose $200 mg/dL (11.1 mmol/L) during an oralglucose tolerance test (OGTT). Thetest should be performed asdescribed by the World HealthOrganization, using a glucose loadcontaining the equivalent of 75 ganhydrous glucose dissolved in water.Or

c In a patient with classic symptoms ofhyperglycemia or hyperglycemiccrisis, a random plasma glucose$200mg/dL (11.1 mmol/L).

c In the absence of unequivocalhyperglycemia, result should beconfirmed by repeat testing.

TESTING FOR DIABETES INASYMPTOMATIC PATIENTS

c Testing to detect type 2 diabetes andprediabetes in asymptomatic peopleshould be considered in adults of anyage who are overweight or obese(BMI $25 kg/m2) and who have oneor more additional risk factors fordiabetes. In those without these riskfactors, testing should begin at age 45years. B

c If tests are normal, repeat testing atleast at 3-year intervals is reasonable.E

c To test for diabetes or prediabetes, theA1C, FPG, or 2-h 75-g OGTT areappropriate. B

c In those identified with prediabetes,identify and, if appropriate, treat

other cardiovascular disease (CVD)risk factors. B

SCREENING FOR TYPE 2 DIABETESIN CHILDREN

c Testing to detect type 2 diabetes andprediabetes should be considered inchildren and adolescents who areoverweight and who have two ormore additional risk factors fordiabetes. E

SCREENING FOR TYPE 1 DIABETES

c Inform type 1 diabetic patients of theopportunity to have their relativesscreened for type 1 diabetes risk inthe setting of a clinical researchstudy. E

DETECTION AND DIAGNOSIS OFGESTATIONAL DIABETES MELLITUS

c Screen for undiagnosed type 2diabetes at the first prenatal visit in

those with risk factors, using standard

diagnostic criteria. Bc Screen for gestational diabetes

mellitus (GDM) at 24–28 weeks of

gestation in pregnant women not

previously known to have diabetes. Ac Screen women with GDM for

persistent diabetes at 6–12 weeks

postpartum, using the OGTT and

nonpregnancy diagnostic criteria. Ec Women with a history of GDM should

have lifelong screening for the

development of diabetes or

prediabetes at least every 3 years. Bc Women with a history of GDM found

to have prediabetes should receivelifestyle interventions or metforminto prevent diabetes. A

c Further research is needed toestablish a uniform approach todiagnosing GDM. E

PREVENTION/DELAY OF TYPE 2DIABETES

c Patients with impaired glucosetolerance (IGT) A, impaired fastingglucose (IFG) E, or an A1C 5.7–6.4% Eshould be referred to an effectiveongoing support program targetingweight loss of 7% of body weight andincreasing physical activity to at least150 min/week of moderate activitysuch as walking.

c Follow-up counseling appears to beimportant for success. B

c Based on the cost-effectiveness ofdiabetes prevention, such programsshould be covered by third-partypayers. B

c Metformin therapy for prevention oftype 2 diabetes may be considered inthose with IGTA, IFG E, or an A1C 5.7–6.4% E, especially for those with BMI.35 kg/m2, aged ,60 years, andwomen with prior GDM. A

c At least annual monitoring for thedevelopment of diabetes in thosewith prediabetes is suggested. E

c Screening for and treatment ofmodifiable risk factors for CVD issuggested. B

GLUCOSE MONITORING

c Patients on multiple-dose insulin(MDI) or insulin pump therapy shoulddo self-monitoring of blood glucose(SMBG) prior to meals and snacks,occasionally postprandially, atbedtime, prior to exercise, when theysuspect low blood glucose, aftertreating low blood glucose until theyare normoglycemic, and prior tocritical tasks such as driving. B

c When prescribed as part of a broadereducational context, SMBG resultsmay be helpful to guide treatmentdecisions and/or patient self-management for patients using less

DOI: 10.2337/dc14-S005

© 2014 by the American Diabetes Association. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

Diabetes Care Volume 37, Supplement 1, January 2014 S5

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frequent insulin injections ornoninsulin therapies. E

c When prescribing SMBG, ensure thatpatients receive ongoing instructionand regular evaluation of SMBGtechnique and SMBG results, as wellas their ability to use SMBG data toadjust therapy. E

c When used properly, continuousglucose monitoring (CGM) inconjunction with intensive insulinregimens is a useful tool to lower A1Cin selected adults (aged $25 years)with type 1 diabetes. A

c Although the evidence for A1Clowering is less strong in children,teens, and younger adults, CGM maybe helpful in these groups. Successcorrelates with adherence to ongoinguse of the device. C

c CGM may be a supplemental tool toSMBG in those with hypoglycemiaunawareness and/or frequenthypoglycemic episodes. E

A1C

c Perform the A1C test at least twotimes a year in patients who aremeeting treatment goals (and whohave stable glycemic control). E

c Perform the A1C test quarterly inpatients whose therapy has changed orwho are not meeting glycemic goals. E

c Use of point-of-care (POC) testing forA1C provides the opportunity formore timely treatment changes. E

GLYCEMIC GOALS IN ADULTS

c Lowering A1C to below or around 7%has been shown to reducemicrovascular complications ofdiabetes and, if implemented soonafter the diagnosis of diabetes, isassociated with long-term reductionin macrovascular disease.Therefore, a reasonable A1C goal formany nonpregnant adults is ,7%. B

c Providers might reasonably suggestmore stringent A1C goals (such as,6.5%) for selected individualpatients, if this can be achievedwithout significant hypoglycemia orother adverse effects of treatment.Appropriate patients might includethose with short duration of diabetes,long life expectancy, and nosignificant CVD. C

c Less stringent A1C goals (such as,8%) may be appropriate for

patients with a history of severehypoglycemia, limited lifeexpectancy, advanced microvascularor macrovascular complications, andextensive comorbid conditions and inthose with long-standing diabetes inwhom the general goal is difficult toattain despite diabetes self-management education (DSME),appropriate glucose monitoring, andeffective doses of multiple glucose-lowering agents including insulin. B

PHARMACOLOGICAL AND OVERALLAPPROACHES TO TREATMENT

Insulin Therapy for Type 1 Diabetesc Most people with type 1 diabetes

should be treated with MDI injections(three to four injections per day ofbasal and prandial insulin) orcontinuous subcutaneous insulininfusion (CSII). A

c Most people with type 1 diabetesshould be educated in how to matchprandial insulin dose to carbohydrateintake, premeal blood glucose, andanticipated activity. E

c Most people with type 1 diabetesshould use insulin analogs to reducehypoglycemia risk. A

Screeningc Consider screening those with type 1

diabetes for other autoimmunediseases (thyroid, vitamin B12deficiency, celiac) as appropriate. B

Pharmacological Therapy forHyperglycemia in Type 2 Diabetesc Metformin, if not contraindicated

and if tolerated, is the preferredinitial pharmacological agent for type2 diabetes. A

c In newly diagnosed type 2 diabeticpatients with markedly symptomaticand/or elevated blood glucose levelsor A1C, consider insulin therapy, withor without additional agents, fromthe outset. E

c If noninsulin monotherapy atmaximum tolerated dose does notachieve or maintain the A1C targetover 3 months, add a second oralagent, a glucagon-like peptide 1 (GLP-1) receptor agonist, or insulin. A

c A patient-centered approach shouldbe used to guide choice ofpharmacological agents.Considerations include efficacy, cost,potential side effects, effects on

weight, comorbidities, hypoglycemiarisk, and patient preferences. E

c Due to the progressive nature of type2 diabetes, insulin therapy iseventually indicated for manypatients with type 2 diabetes. B

MEDICAL NUTRITION THERAPY

General Recommendationsc Nutrition therapy is recommended

for all people with type 1 and type 2diabetes as an effective componentof the overall treatment plan. A

c Individuals who have prediabetes ordiabetes should receiveindividualized medical nutritiontherapy (MNT) as needed to achievetreatment goals, preferably providedby a registered dietitian familiar withthe components of diabetes MNT. A

c Because diabetes nutrition therapycan result in cost savings B andimproved outcomes such as reductionin A1C A, nutrition therapy should beadequately reimbursed by insuranceand other payers. E

Energy Balance, Overweight, andObesityc For overweight or obese adults with

type 2 diabetes or at risk for diabetes,reducing energy intake whilemaintaining a healthful eatingpattern is recommended to promoteweight loss. A

c Modest weight loss may provideclinical benefits (improved glycemia,blood pressure, and/or lipids) in someindividuals with diabetes, especiallythose early in the disease process. Toachieve modest weight loss, intensivelifestyle interventions (counselingabout nutrition therapy, physicalactivity, and behavior change) withongoing support are recommended. A

Eating Patterns and MacronutrientDistributionc Evidence suggests that there is not an

ideal percentage of calories fromcarbohydrate, protein, and fat for allpeople with diabetes B; therefore,macronutrient distribution should bebased on individualized assessmentof current eating patterns, preferences,and metabolic goals. E

c A variety of eating patterns(combinations of different foods orfood groups) are acceptable for themanagement of diabetes. Personal

S6 Executive Summary Diabetes Care Volume 37, Supplement 1, January 2014




preference (e.g., tradition, culture,religion, health beliefs and goals,economics) and metabolic goalsshould be considered whenrecommending one eating patternover another. E

Carbohydrate Amount and Qualityc Monitoring carbohydrate intake,

whether by carbohydrate counting orexperience-based estimation,remains a key strategy in achievingglycemic control. B

c For good health, carbohydrate intakefrom vegetables, fruits, whole grains,legumes, and dairy products shouldbe advised over intake from othercarbohydrate sources, especiallythose that contain added fats, sugars,or sodium. B

c Substituting low-glycemic load foodsfor higher-glycemic load foods maymodestly improve glycemic control. C

c People with diabetes should consumeat least the amount of fiber andwholegrains recommended for the generalpublic. C

c While substituting sucrose-containing foods for isocaloricamounts of other carbohydrates mayhave similar blood glucose effects,consumption should be minimized toavoid displacing nutrient-dense foodchoices. A

c People with diabetes and those at riskfor diabetes should limit or avoidintake of sugar-sweetened beverages(from any caloric sweetener includinghigh-fructose corn syrup and sucrose)to reduce risk for weight gain andworsening of cardiometabolic riskprofile. B

Dietary Fat Quantity and Qualityc Evidence is inconclusive for an ideal

amount of total fat intake for peoplewith diabetes; therefore, goals shouldbe individualized. C Fat qualityappears to be far more importantthan quantity. B

c In people with type 2 diabetes, aMediterranean-style, MUFA-rich eatingpattern may benefit glycemic controland CVD risk factors and can thereforebe recommended as an effectivealternative to a lower-fat, higher-carbohydrate eating pattern. B

c As recommended for the generalpublic, an increase in foods

containing long-chain n-3 fatty acids(EPA and DHA) (from fatty fish) andn-3 linolenic acid (ALA) is recommendedfor individuals with diabetes becauseof their beneficial effects onlipoproteins, prevention of heartdisease, and associations with positivehealth outcomes in observationalstudies. B

c The amount of dietary saturated fat,cholesterol, and trans fatrecommended for people withdiabetes is the same as thatrecommended for the generalpopulation. C

Supplements for DiabetesManagementc There is no clear evidence of benefit

from vitamin or mineralsupplementation in people withdiabetes who do not have underlyingdeficiencies. C

c Routine supplementation withantioxidants, such as vitamins E andC and carotene, is not advisedbecause of lack of evidence of efficacyand concern related to long-termsafety. A

c Evidence does not supportrecommending n-3 (EPA and DHA)supplements for people with diabetesfor the prevention or treatment ofcardiovascular events. A

c There is insufficient evidence tosupport the routine use ofmicronutrients such as chromium,magnesium, and vitamin D toimprove glycemic control in peoplewith diabetes. C

c There is insufficient evidence tosupport the use of cinnamon or otherherbs/supplements for the treatmentof diabetes. C

c It is reasonable for individualized mealplanning to include optimization of foodchoices to meet recommended dailyallowance/dietary reference intake forall micronutrients. E

Alcoholc If adults with diabetes choose to drink

alcohol, they should be advised to doso in moderation (one drink per day orless for adult women and two drinksper day or less for adult men). E

c Alcohol consumption may placepeople with diabetes at increased riskfor delayed hypoglycemia, especiallyif taking insulin or insulin

secretagogues. Education andawareness regarding the recognitionand management of delayedhypoglycemia is warranted. C

Sodiumc The recommendation for the general

population to reduce sodium to,2,300 mg/day is also appropriatefor people with diabetes. B

c For individuals with both diabetesand hypertension, further reductionin sodium intake should beindividualized. B

Primary Prevention of Type 2 Diabetesc Among individuals at high risk for

developing type 2 diabetes,structured programs that emphasizelifestyle changes that includemoderate weight loss (7% of bodyweight) and regular physical activity(150 min/week), with dietarystrategies including reduced caloriesand reduced intake of dietary fat, canreduce the risk for developingdiabetes and are thereforerecommended. A

c Individuals at high risk for type 2diabetes should be encouraged toachieve the U.S. Department ofAgriculture (USDA) recommendationfor dietary fiber (14 g fiber/1,000 kcal)and foods containing whole grains(one-half of grain intake). B

DIABETES SELF-MANAGEMENTEDUCATION AND SUPPORT

c People with diabetes should receiveDSME and diabetes self-managementsupport (DSMS) according to NationalStandards for Diabetes Self-Management Education and Supportwhen their diabetes is diagnosed andas needed thereafter. B

c Effective self-management andquality of life are the key outcomes ofDSME and DSMS and should bemeasured and monitored as part ofcare. C

c DSME and DSMS should addresspsychosocial issues, since emotionalwell-being is associated with positivediabetes outcomes. C

c DSME and DSMS programs areappropriate venues for people withprediabetes to receive education andsupport to develop and maintainbehaviors that can prevent or delaythe onset of diabetes. C

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c Because DSME and DSMS can resultin cost-savings and improvedoutcomes B, DSME and DSMS shouldbe adequately reimbursed by third-party payers. E

PHYSICAL ACTIVITY

c As is the case for all children, childrenwith diabetes or prediabetes shouldbe encouraged to engage in at least60 min of physical activity each day. B

c Adults with diabetes should beadvised to perform at least 150 min/week of moderate-intensity aerobicphysical activity (50–70% ofmaximum heart rate), spread overat least 3 days/week with no morethan 2 consecutive days withoutexercise. A

c In the absence of contraindications,adults with type 2 diabetes should beencouraged to perform resistancetraining at least twice per week. A

PSYCHOSOCIAL ASSESSMENT ANDCARE

c It is reasonable to include assessmentof the patient’s psychological andsocial situation as an ongoing partof the medical management ofdiabetes. B

c Psychosocial screening and follow-upmay include, but are not limited to,attitudes about the illness,expectations for medicalmanagement and outcomes, affect/mood, general and diabetes-relatedquality of life, resources (financial,social, and emotional), andpsychiatric history. E

c Routinely screen for psychosocialproblems such as depression anddiabetes-related distress, anxiety,eating disorders, and cognitiveimpairment. B

HYPOGLYCEMIA

c Individuals at risk for hypoglycemiashould be asked about symptomaticand asymptomatic hypoglycemia ateach encounter. C

c Glucose (15–20 g) is the preferredtreatment for the consciousindividual with hypoglycemia,although any form of carbohydratethat contains glucose may be used.After 15 min of treatment, if SMBGshows continued hypoglycemia, thetreatment should be repeated. Once

SMBG returns to normal, theindividual should consume a meal orsnack to prevent recurrence ofhypoglycemia. E

c Glucagon should be prescribed for allindividuals at significant risk of severehypoglycemia, and caregivers orfamily members of these individualsshould be instructed on itsadministration. Glucagonadministration is not limited to healthcare professionals. E

c Hypoglycemia unawareness or one ormore episodes of severe hypoglycemiashould trigger re-evaluation of thetreatment regimen. E

c Insulin-treated patients withhypoglycemia unawareness or anepisode of severe hypoglycemiashould be advised to raise theirglycemic targets to strictly avoidfurther hypoglycemia for at leastseveral weeks, to partially reversehypoglycemia unawareness andreduce risk of future episodes. A

c Ongoing assessment of cognitivefunction is suggested with increasedvigilance for hypoglycemia by theclinician, patient, and caregivers iflow cognition and/or decliningcognition is found. B

BARIATRIC SURGERY

c Bariatric surgery may beconsidered for adults with BMI.35 kg/m2 and type 2 diabetes,especially if diabetes or associatedcomorbidities are difficult to controlwith lifestyle and pharmacologicaltherapy. B

c Patients with type 2 diabetes whohave undergone bariatric surgeryneed lifelong lifestyle support andmedical monitoring. B

c Although small trials have shownglycemic benefit of bariatric surgeryin patients with type 2 diabetes andBMI 30–35 kg/m2, there is currentlyinsufficient evidence to generallyrecommend surgery in patients withBMI,35 kg/m2 outside of a researchprotocol. E

c The long-term benefits, cost-effectiveness, and risks of bariatricsurgery in individuals with type 2diabetes should be studied in well-designed controlled trials withoptimal medical and lifestyle therapyas the comparator. E

IMMUNIZATION

c Annually provide an influenza vaccineto all diabetic patients $6 months ofage. C

c Administer pneumococcalpolysaccharide vaccine to all diabeticpatients $2 years of age. A one-timerevaccination is recommended forindividuals .65 years of age whohave been immunized .5 years ago.Other indications for repeatvaccination include nephroticsyndrome, chronic renal disease, andother immunocompromised states,such as after transplantation. C

c Administer hepatitis B vaccinationto unvaccinated adults with diabeteswho are aged 19–59 years. C

c Consider administering hepatitis Bvaccination to unvaccinated adultswith diabetes who are aged$60 years. C

HYPERTENSION/BLOOD PRESSURECONTROL

Screening and Diagnosisc Blood pressure should be measured

at every routine visit. Patients foundto have elevated blood pressureshould have blood pressureconfirmed on a separate day. B

Goalsc People with diabetes and

hypertension should be treated to asystolic blood pressure (SBP) goal of,140 mmHg. B

c Lower systolic targets, such as ,130mmHg, may be appropriate forcertain individuals, such as youngerpatients, if it can be achieved withoutundue treatment burden. C

c Patients with diabetes should betreated to a diastolic blood pressure(DBP) ,80 mmHg. B

Treatmentc Patients with blood pressure

.120/80mmHg should be advised onlifestyle changes to reduce bloodpressure. B

c Patients with confirmed bloodpressure higher than 140/80 mmHgshould, in addition to lifestyletherapy, have prompt initiation andtimely subsequent titration ofpharmacological therapy to achieveblood pressure goals. B

c Lifestyle therapy for elevated bloodpressure consists of weight loss, if





overweight; Dietary Approaches toStop Hypertension (DASH)-styledietary pattern including reducingsodium and increasing potassiumintake; moderation of alcohol intake;and increased physical activity. B

c Pharmacological therapy for patientswith diabetes and hypertensionshould comprise a regimen thatincludes either an ACE inhibitor or anangiotensin receptor blocker (ARB). Ifone class is not tolerated, the othershould be substituted. C

c Multiple-drug therapy (two or moreagents at maximal doses) is generallyrequired to achieve blood pressuretargets. B

c Administer one or moreantihypertensive medications atbedtime. A

c If ACE inhibitors, ARBs, or diureticsare used, serum creatinine/estimatedglomerular filtration rate (eGFR) andserum potassium levels should bemonitored. E

c In pregnant patients with diabetesand chronic hypertension, bloodpressure target goals of 110–129/65–79 mmHg are suggested in theinterest of long-term maternal healthand minimizing impaired fetalgrowth. ACE inhibitors and ARBs arecontraindicated during pregnancy. E

DYSLIPIDEMIA/LIPID MANAGEMENT

Screeningc In most adult patients with diabetes,

measure fasting lipid profile at leastannually. B

c In adults with low-risk lipid values(LDL cholesterol ,100 mg/dL, HDLcholesterol .50 mg/dL, andtriglycerides ,150 mg/dL), lipidassessments may be repeated every 2years. E

Treatment Recommendations andGoalsc Lifestyle modification focusing on the

reduction of saturated fat, trans fat,and cholesterol intake; increase ofn-3 fatty acids, viscous fiber and plantstanols/sterols; weight loss (ifindicated); and increased physicalactivity should be recommended toimprove the lipid profile in patientswith diabetes. A

c Statin therapy should be added tolifestyle therapy, regardless of

baseline lipid levels, for diabeticpatients:

c with overt CVD Ac without CVD who are over the ageof 40 years and have one or moreother CVD risk factors (familyhistory of CVD, hypertension,smoking, dyslipidemia, oralbuminuria). A

c For lower-risk patients than theabove (e.g., without overt CVD andunder the age of 40 years), statintherapy should be considered inaddition to lifestyle therapy if LDLcholesterol remains above 100mg/dLor in those with multiple CVD riskfactors. C

c In individuals without overt CVD, thegoal is LDL cholesterol ,100 mg/dL(2.6 mmol/L). B

c In individuals with overt CVD, a lowerLDL cholesterol goal of ,70 mg/dL(1.8 mmol/L), with a high dose of astatin, is an option. B

c If drug-treated patients do not reachthe above targets on maximumtolerated statin therapy, a reductionin LDL cholesterol of ;30–40% frombaseline is an alternative therapeuticgoal. B

c Triglyceride levels ,150 mg/dL(1.7 mmol/L) and HDL cholesterol.40 mg/dL (1.0 mmol/L) in menand .50 mg/dL (1.3 mmol/L) inwomen are desirable. C However, LDLcholesterol–targeted statin therapyremains the preferred strategy. A

c Combination therapy has been shownnot to provide additionalcardiovascular benefit above statintherapy alone and is not generallyrecommended. A

c Statin therapy is contraindicated inpregnancy. B

ANTIPLATELET AGENTS

c Consider aspirin therapy (75–162mg/day) as a primary prevention strategyin thosewith type 1 or type 2 diabetesat increased cardiovascular risk (10-year risk .10%). This includes mostmen aged .50 years or women aged.60 years who have at least oneadditional major risk factor (familyhistory of CVD, hypertension,smoking, dyslipidemia, oralbuminuria). C

c Aspirin should not be recommendedfor CVD prevention for adults withdiabetes at low CVD risk (10-year CVDrisk ,5%, such as in men aged ,50years and women aged ,60 yearswith no major additional CVD riskfactors), since the potential adverseeffects from bleeding likely offset thepotential benefits. C

c In patients in these age-groups withmultiple other risk factors (e.g.,10-year risk 5–10%), clinical judgmentis required. E

c Use aspirin therapy (75–162 mg/day)as a secondary prevention strategy inthose with diabetes with a history ofCVD. A

c For patients with CVD anddocumented aspirin allergy,clopidogrel (75 mg/day) should beused. B

c Dual antiplatelet therapy isreasonable for up to a year after anacute coronary syndrome. B

SMOKING CESSATION

c Advise all patients not to smoke oruse tobacco products. A

c Include smoking cessation counselingand other forms of treatment as aroutine component of diabetescare. B

CARDIOVASCULAR DISEASE

Screeningc In asymptomatic patients, routine

screening for coronary arterydisease (CAD) is not recommendedbecause it does not improveoutcomes as long as CVD risk factorsare treated. A

Treatmentc In patients with known CVD, consider

ACE inhibitor therapy C and useaspirin and statin therapy A (if notcontraindicated) to reduce the risk ofcardiovascular events.

c In patients with a prior myocardialinfarction (MI), b-blockers should becontinued for at least 2 years after theevent. B

c In patients with symptomatic heartfailure, avoid thiazolidinedionetreatment. C

c In patients with stable congestiveheart failure (CHF), metformin maybe used if renal function is normal butshould be avoided in unstable orhospitalized patients with CHF. B






NEPHROPATHY

General Recommendationsc Optimize glucose control to reduce

the risk or slow the progression ofnephropathy. A

c Optimize blood pressure control toreduce the risk or slow theprogression of nephropathy. A

Screeningc Perform an annual test to quantitate

urine albumin excretion in type 1diabetic patients with diabetesduration of$5 years and in all type 2diabetic patients starting atdiagnosis. B

Treatmentc An ACE inhibitor or ARB for the

primary prevention of diabetic kidneydisease is not recommended indiabetic patients with normal bloodpressure and albumin excretion,30 mg/24 h. B

c Either ACE inhibitors or ARBs (but notboth in combination) arerecommended for the treatment ofthe nonpregnant patient withmodestly elevated (30–299 mg/24 h)C or higher levels (.300 mg/24 h) ofurinary albumin excretion. A

c For people with diabetes anddiabetic kidney disease(albuminuria .30 mg/24 h),reducing the amount of dietaryprotein below usual intake is notrecommended because it does notalter glycemic measures,cardiovascular risk measures, or thecourse of GFR decline. A

c When ACE inhibitors, ARBs, ordiuretics are used, monitor serumcreatinine and potassium levelsfor the development of increasedcreatinine or changes in potassium. E

c Continued monitoring of urinealbumin excretion to assess bothresponse to therapy and progressionof disease is reasonable. E

c When eGFR is ,60 mL/min/1.73 m2,evaluate and manage potentialcomplications of chronic kidneydisease (CKD). E

c Consider referral to a physicianexperienced in the care of kidneydisease for uncertainty about theetiology of kidney disease, difficultmanagement issues, or advancedkidney disease. B

RETINOPATHY

General Recommendationsc Optimize glycemic control to reduce

the risk or slow the progression ofretinopathy. A

c Optimize blood pressure control toreduce the risk or slow theprogression of retinopathy. A

Screeningc Adults with type 1 diabetes should

have an initial dilated andcomprehensive eye examination byan ophthalmologist or optometristwithin 5 years after the onset ofdiabetes. B

c Patients with type 2 diabetes shouldhave an initial dilated andcomprehensive eye examination by anophthalmologist or optometrist shortlyafter the diagnosis of diabetes. B

c If there is no evidence of retinopathyfor one or more eye exams, thenexams every 2 years may beconsidered. If diabetic retinopathy ispresent, subsequent examinationsfor type 1 and type 2 diabetic patientsshould be repeated annually by anophthalmologist or optometrist. Ifretinopathy is progressing or sightthreatening, then examinations willbe required more frequently. B

c High-quality fundus photographs candetect most clinically significantdiabetic retinopathy. Interpretationof the images should be performedby a trained eye care provider. Whileretinal photography may serve as ascreening tool for retinopathy, it isnot a substitute for a comprehensiveeye exam, which should beperformed at least initially and atintervals thereafter as recommendedby an eye care professional. E

c Women with preexisting diabeteswho are planning pregnancy or whohave become pregnant should havea comprehensive eye examinationand be counseled on the risk ofdevelopment and/or progressionof diabetic retinopathy. Eyeexamination should occur in the firsttrimester with close follow-upthroughout pregnancy and for 1 yearpostpartum. B

Treatmentc Promptly refer patients with any level

of macular edema, severenonproliferative diabetic

retinopathy (NPDR), or anyproliferative diabetic retinopathy(PDR) to an ophthalmologist who isknowledgeable and experienced inthe management and treatment ofdiabetic retinopathy. A

c Laser photocoagulation therapy isindicated to reduce the risk ofvision loss in patients with high-riskPDR, clinically significant macularedema, and in some cases severeNPDR. A

c Anti-vascular endothelial growthfactor (VEGF) therapy is indicated fordiabetic macular edema. A

c The presence of retinopathy is not acontraindication to aspirin therapyfor cardioprotection, as this therapydoes not increase the risk of retinalhemorrhage. A

NEUROPATHY

c All patients should be screened fordistal symmetric polyneuropathy(DPN) starting at diagnosis of type 2diabetes and 5 years after thediagnosis of type 1 diabetes and atleast annually thereafter, usingsimple clinical tests. B

c Electrophysiological testing orreferral to a neurologist is rarelyneeded, except in situations wherethe clinical features are atypical. E

c Screening for signs and symptoms ofcardiovascular autonomicneuropathy (CAN) should beinstituted at diagnosis of type 2diabetes and 5 years after thediagnosis of type 1 diabetes. Specialtesting is rarely needed and may notaffect management or outcomes. E

c Medications for the relief of specificsymptoms related to painful DPN andautonomic neuropathy arerecommended because they mayreduce pain B and improve quality oflife. E

FOOT CARE

c For all patients with diabetes,perform an annual comprehensivefoot examination to identify riskfactors predictive of ulcers andamputations. The foot examinationshould include inspection,assessment of foot pulses, and testingfor loss of protective sensation (LOPS)(10-g monofilament plus testing anyone of the following: vibration using





128-Hz tuning fork, pinpricksensation, ankle reflexes, or vibrationperception threshold). B

c Provide general foot self-careeducation to all patients withdiabetes. B

c A multidisciplinary approach isrecommended for individuals withfoot ulcers and high-risk feet,especially those with a history of priorulcer or amputation. B

c Refer patients who smoke, haveLOPS and structural abnormalities,or have history of prior lower-extremity complications to foot carespecialists for ongoing preventivecare and lifelong surveillance. C

c Initial screening for peripheralarterial disease (PAD) shouldinclude a history for claudication andan assessment of the pedal pulses.Consider obtaining an ankle-brachialindex (ABI), as many patients withPAD are asymptomatic. C

c Refer patients with significantclaudication or a positive ABI forfurther vascular assessment andconsider exercise, medications, andsurgical options. C

ASSESSMENT OF COMMONCOMORBID CONDITIONS

c Consider assessing for and addressingcommon comorbid conditions thatmay complicate the management ofdiabetes. B

CHILDREN AND ADOLESCENTS

Type 1 Diabetes

Glycemic Control

c Consider age when setting glycemicgoals in children and adolescents withtype 1 diabetes. E

Screening and Management of

Complications

Nephropathy

Screeningc Annual screening for albumin levels,

with a random spot urine sample foralbumin-to-creatinine ratio (ACR),should be considered for the child at thestart of puberty or at age$10 years,whichever is earlier, once the youth hashad diabetes for 5 years. B

Treatmentc Treatment with an ACE inhibitor,

titrated to normalization of albuminexcretion, should be consideredwhen elevated ACR is subsequently

confirmed on two additionalspecimens from different days. Thisshould be obtained over a 6-monthinterval following efforts to improveglycemic control and normalize bloodpressure for age. E

HypertensionScreeningc Blood pressure should be measured

at each routine visit. Children foundto have high-normal blood pressureor hypertension should have bloodpressure confirmed on a separateday. B

Treatmentc Initial treatment of high-normal blood

pressure (SBP or DBP consistentlyabove the 90th percentile for age, sex,and height) includes dietaryintervention and exercise, aimed atweight control and increased physicalactivity, if appropriate. If target bloodpressure is not reached with 3–6months of lifestyle intervention,pharmacological treatment should beconsidered. E

c Pharmacological treatment ofhypertension (SBP or DBPconsistently above the 95thpercentile for age, sex, and height orconsistently .130/80 mmHg, if 95%exceeds that value) should beconsidered as soon as the diagnosis isconfirmed. E

c ACE inhibitors should be consideredfor the initial pharmacologicaltreatment of hypertension, followingappropriate reproductive counselingdue to its potential teratogeniceffects. E

c The goal of treatment is blood pressureconsistently,130/80 or below the90th percentile for age, sex, andheight, whichever is lower. E

DyslipidemiaScreeningc If there is a family history of

hypercholesterolemia or acardiovascular event before age 55years, or if family history is unknown,then consider obtaining a fasting lipidprofile in children .2 years of agesoon after the diagnosis (afterglucose control has beenestablished). If family history is not ofconcern, then consider the first lipidscreening at puberty ($10 years). Forchildren diagnosed with diabetes at

or after puberty, consider obtaining afasting lipid profile soon after thediagnosis (after glucose control hasbeen established). E

c For both age-groups, if lipids areabnormal, annual monitoring isreasonable. If LDL cholesterol values arewithin the accepted risk levels (,100mg/dL [2.6 mmol/L]), a lipid profilerepeated every 5 years is reasonable. E

Treatmentc Initial therapy may consist of

optimization of glucose control andMNT using a Step 2 American HeartAssociation (AHA) diet aimed at adecrease in the amount of saturatedfat in the diet. E

c After the age of 10 years, theaddition 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 oneor more CVD risk factors isreasonable. E

c The goal of therapy is an LDLcholesterol value ,100 mg/dL(2.6 mmol/L). E

Retinopathyc An initial dilated and comprehensive

eye examination should beconsidered for the child at the start ofpuberty or at age $10 years,whichever is earlier, once the youthhas had diabetes for 3–5 years. B

c After the initial examination, annualroutine follow-up is generallyrecommended. Less frequentexaminationsmay be acceptable on theadvice of an eye care professional. E

Celiac Diseasec Consider screening children with

type 1 diabetes for celiac disease bymeasuring IgA antitissuetransglutaminase or antiendomysialantibodies, with documentationof normal total serum IgA levels,soon after the diagnosis ofdiabetes. E

c Testing should be considered inchildren with a positive family historyof celiac disease, growth failure,failure to gain weight, weight loss,diarrhea, flatulence, abdominal pain,or signs ofmalabsorption or in childrenwith frequent unexplainedhypoglycemia or deterioration inglycemic control. E






c Consider referral to agastroenterologist for evaluationwith possible endoscopy and biopsyfor confirmation of celiac disease inasymptomatic children with positiveantibodies. E

c Children with biopsy-confirmedceliac disease should be placed on agluten-free diet and haveconsultation with a dietitianexperienced in managing bothdiabetes and celiac disease. B

Hypothyroidismc Consider screening children with type

1 diabetes for antithyroid peroxidaseand antithyroglobulin antibodiessoon after diagnosis. E

c Measuring thyroid-stimulatinghormone (TSH) concentrations soonafter diagnosis of type 1 diabetes, aftermetabolic control has beenestablished, is reasonable. If normal,consider rechecking every 1–2 years,especially if the patient developssymptoms of thyroid dysfunction,thyromegaly, an abnormal growthrate, or unusual glycemic variation. E

TRANSITION FROM PEDIATRIC TOADULT CARE

c As teens transition into emergingadulthood, health care providersand families must recognize theirmany vulnerabilities B andprepare the developing teen,beginning in early to midadolescence and at least 1 year priorto the transition. E

c Both pediatricians and adult health careproviders should assist in providingsupport and links to resources for theteen and emerging adult. B

PRECONCEPTION CARE

c A1C levels should be as close tonormal as possible (,7%) in anindividual patient before conceptionis attempted. B

c Starting at puberty, preconceptioncounseling should be incorporated inthe routine diabetes clinic visit for allwomen of childbearing potential. B

c Women with diabetes who arecontemplating pregnancy should beevaluated and, if indicated, treated fordiabetic retinopathy, nephropathy,neuropathy, and CVD. B

c Medications used by such womenshould be evaluated prior to

conception, since drugs commonlyused to treat diabetes and itscomplications may becontraindicated or not recommendedin pregnancy, including statins, ACEinhibitors, ARBs, and most noninsulintherapies. E

c Since many pregnancies areunplanned, consider the potentialrisks and benefits of medications thatare contraindicated in pregnancy inall women of childbearing potentialand counsel women using suchmedications accordingly. E

OLDER ADULTS

c Older adults who are functional,cognitively intact, and havesignificant life expectancy shouldreceive diabetes care with goalssimilar to those developed foryounger adults. E

c Glycemic goals for some older adultsmight reasonably be relaxed, usingindividual criteria, but hyperglycemialeading to symptoms or risk of acutehyperglycemic complications shouldbe avoided in all patients. E

c Other cardiovascular risk factorsshould be treated in older adults withconsideration of the time frame ofbenefit and the individual patient.Treatment of hypertension is indicatedin virtually all older adults, and lipidand aspirin therapy may benefit thosewith life expectancy at least equal tothe time frameof primary or secondaryprevention trials. E

c Screening for diabetes complicationsshould be individualized in olderadults, but particular attention shouldbe paid to complications that wouldlead to functional impairment. E

CYSTIC FIBROSIS–RELATEDDIABETES

c Annual screening for cystic fibrosis–related diabetes (CFRD) with OGTTshould begin by age 10 years in allpatients with cystic fibrosis who donot have CFRD. B A1C as ascreening test for CFRD is notrecommended. B

c During a period of stable health, thediagnosis of CFRD can be made incystic fibrosis patients according tousual glucose criteria. E

c Patients with CFRD should be treatedwith insulin to attain individualizedglycemic goals. A

c Annual monitoring for complicationsof diabetes is recommended,beginning 5 years after the diagnosisof CFRD. E

DIABETES CARE IN THE HOSPITAL

c Diabetes discharge planning shouldstart at hospital admission, and cleardiabetes management instructionsshould be provided at discharge. E

c The sole use of sliding scale insulin inthe inpatient hospital setting isdiscouraged. E

c All patients with diabetes admitted tothe hospital should have theirdiabetes clearly identified in themedical record. E

c All patients with diabetes should havean order for blood glucose monitoring,with results available to all members ofthe health care team. E

c Goals for blood glucose levels:

c Critically ill patients: Insulin therapyshould be initiated for treatment ofpersistent hyperglycemia startingat a threshold of no greater than 180mg/dL (10 mmol/L). Once insulintherapy is started, a glucose rangeof 140–180 mg/dL (7.8–10 mmol/L)is recommended for the majority ofcritically ill patients. A

cMore stringent goals, such as 110–140mg/dL (6.1–7.8 mmol/L) may beappropriate for selected patients, aslong as this can be achieved withoutsignificant hypoglycemia. C

c Critically ill patients require anintravenous insulin protocol thathas demonstrated efficacy andsafety in achieving the desiredglucose range without increasingrisk for severe hypoglycemia. E

c Non–critically ill patients: There isno clear evidence for specific bloodglucose goals. If treated with insulin,the premeal blood glucose targetsgenerally ,140 mg/dL (7.8 mmol/L)with random blood glucose,180mg/dL (10.0mmol/L) are reasonable,provided these targets can be safelyachieved. More stringent targetsmay be appropriate in stable patientswith previous tight glycemic control.Less stringent targets may beappropriate in those with severecomorbidities. E

c Scheduled subcutaneous insulinwith basal, nutritional, and





correctional components is thepreferred method for achieving andmaintaining glucose control in non–critically ill patients. C

c Glucose monitoring should beinitiated in any patient not knownto be diabetic who receivestherapy associated with high riskfor hyperglycemia, including high-dose glucocorticoid therapy,initiation of enteral or parenteralnutrition, or other medicationssuch as octreotide orimmunosuppressive medications. BIf hyperglycemia is documentedand persistent, consider treatingsuch patients to the same glycemicgoals as in patients with knowndiabetes. E

c A hypoglycemia managementprotocol should be adopted andimplemented by each hospital orhospital system. A plan for

preventing and treatinghypoglycemia should beestablished for each patient.Episodes of hypoglycemia in thehospital should be documentedin the medical record andtracked. E

c Consider obtaining an A1C inpatients with diabetes admitted tothe hospital if the result of testing inthe previous 2–3 months is notavailable. E

c Consider obtaining an A1C inpatients with risk factors forundiagnosed diabetes whoexhibit hyperglycemia in thehospital. E

c Patients with hyperglycemia in thehospital who do not have a priordiagnosis of diabetes should haveappropriate plans for follow-uptesting and care documented atdischarge. E

STRATEGIES FOR IMPROVINGDIABETES CARE

c Care should be aligned withcomponents of the Chronic CareModel (CCM) to ensure productiveinteractions between a preparedproactive practice team and aninformed activated patient. A

c When feasible, care systems shouldsupport team-based care, communityinvolvement, patient registries, andembedded decision support tools tomeet patient needs. B

c Treatment decisions should be timelyand based on evidence-basedguidelines that are tailored toindividual patient preferences,prognoses, and comorbidities. B

c A patient-centered communicationstyle should be used that incorporatespatient preferences, assesses literacyand numeracy, and addresses culturalbarriers to care. B




