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Special Communication  |   July 2017
Highlights From the American Diabetes Association's 2017 Standards of Medical Care in Diabetes for Osteopathic Physicians
Author Notes
  • From the University of North Dakota School of Medicine and Health Sciences in Grand Forks (Dr Johnson); the Touro University College of Osteopathic Medicine in Vallejo, California (Drs Pfotenhauer and Shubrook); the American Diabetes Association (Ms Bradley); and the Johns Hopkins University School of Medicine in Baltimore, Maryland (Dr Kalyani).  
  • Disclaimer: Dr Shubrook, a JAOA associate editor, was not involved in the editorial review or decision to publish this article.  
  • Financial Disclosures: Dr Johnson serves on the Novo Nordisk and Medtronic Speakers’ Bureau and on an advisory panel for Novo Nordisk and Sanofi. Dr Shubrook has received research support from Sanofi, Eli Lilly, Astra Zeneca and Takeda. He has served as a consultant for Novo Nordisk and Eli Lilly. Dr Pfotenhauer, Ms Bradley, and Dr Kalyani have no financial disclosures.  
  • Support: None reported.  
  •  *Address correspondence to Eric L. Johnson, MD, Associate Professor, Family and Community Medicine, University of North Dakota School of Medicine and Health Sciences, 1301 N Columbia Rd, Grand Forks, ND 58202-9037. E-mail: eric.l.johnson@med.und.edu
     
Article Information
Endocrinology / Diabetes
Special Communication   |   July 2017
Highlights From the American Diabetes Association's 2017 Standards of Medical Care in Diabetes for Osteopathic Physicians
The Journal of the American Osteopathic Association, July 2017, Vol. 117, 457-472. doi:10.7556/jaoa.2017.086
The Journal of the American Osteopathic Association, July 2017, Vol. 117, 457-472. doi:10.7556/jaoa.2017.086
Abstract

The American Diabetes Association (ADA) updates its Standards of Medical Care (SOMC) in Diabetes annually. These ADA standards make up a comprehensive document that serves as an excellent resource for clinical care. The current article comes from the ADA's Primary Care Advisory Group. This article highlights key aspects of the SOMC that are relevant to the day-to-day practice of osteopathic primary care physicians. It is not intended to replace the full SOMC but will refer to the master document for further explanation and evidence-based support.

The American Diabetes Association (ADA) updates and publishes its Standards of Medical Care in Diabetes annually in a supplement to the January issue of Diabetes Care. This annual update comprises evidence-based guidelines (Table 1) to be used in the treatment of patients with diabetes. In the present article, we summarize key recommendations relevant to osteopathic physicians. Recommendations are provided as bulleted items throughout this article, with levels of evidence provided within brackets. The full updated recommendations are available at http://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf.1 
Table 1.
Evidence Grading System
Level of Evidence Description
A
■ Clear evidence from well-conducted, generalizable RCTs that are adequately powered, including evidence from well-conducted multicenter trials or meta-analyses that incorporate quality ratings in the analyses
■ Compelling nonexperimental evidence
■ Supportive evidence from well-conducted RCTs that are adequately powered
B
■ Supportive evidence from well-conducted cohort studies or case-control studies
C
■ Supportive evidence from poorly controlled or uncontrolled studies
■ Conflicting evidence with the weight of evidence supporting the recommendation
E
■ Expert consensus or clinical experience

Source: Adapted from Table 1 in the Standards of Medical Care in Diabetes—2017.1

Table 1.
Evidence Grading System
Level of Evidence Description
A
■ Clear evidence from well-conducted, generalizable RCTs that are adequately powered, including evidence from well-conducted multicenter trials or meta-analyses that incorporate quality ratings in the analyses
■ Compelling nonexperimental evidence
■ Supportive evidence from well-conducted RCTs that are adequately powered
B
■ Supportive evidence from well-conducted cohort studies or case-control studies
C
■ Supportive evidence from poorly controlled or uncontrolled studies
■ Conflicting evidence with the weight of evidence supporting the recommendation
E
■ Expert consensus or clinical experience

Source: Adapted from Table 1 in the Standards of Medical Care in Diabetes—2017.1

×
1. Promoting Health and Reducing Disparities in Populations
Although diabetes treatment should be individualized, system-level population health should be integrated to improve patient self-management, optimize provider and team behavior, and provide high-quality care. The Chronic Care Model serves as a framework.2 
  • ■ Treatment decisions should be timely, rely on evidence-based guidelines, and be made collaboratively with patients based on individual preferences, prognoses, and comorbidities. [B]
  • ■ Providers should assess social context, including potential food insecurity, housing stability, and financial barriers, and apply that information to treatment decisions. [A]
The National Diabetes Education Program has an online resource (http://www.betterdiabetescare.nih.gov) to assist in the design and implementation of successful health care delivery systems for those with diabetes. 
2. Classification and Diagnosis of Diabetes
Diabetes can be classified into type 1 (due to autoimmune β-cell destruction), type 2 (progressive loss of β-cell insulin secretion frequently on the background of insulin resistance), gestational diabetes mellitus (GDM, diabetes that is first diagnosed in the second or third trimester of pregnancy), and other specific types of diabetes due to other causes (eg, monogenic syndromes).3 
  • ■ Screening for prediabetes and testing for type 2 diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (body mass index [BMI] ≥25, or ≥23 in Asian Americans) and who have 1 or more additional risk factors for diabetes. [B]
  • ■ For all people, testing should begin at age 45 years. [B]
  • ■ To test for prediabetes or type 2 diabetes, fasting plasma glucose, 2-hour plasma glucose after 75-g oral glucose tolerance test, and hemoglobin A1c (HbA1c) are equally appropriate. [B]
  • ■ In patients with prediabetes or type 2 diabetes, identify and treat other cardiovascular disease risk factors. [B]
  • ■ Testing for prediabetes or type 2 diabetes should be considered in children and adolescents who are overweight or obese and who have 2 or more additional risk factors for diabetes. [E]
Type 1 Diabetes
Widespread screening in asymptomatic, low-risk persons is not recommended because of a lack of approved interventions. Screening for antibodies in relatives of persons with type 1 diabetes for risk assessment is generally only done in research centers. Type 1 diabetes may be more common in people with other autoimmune disorders and thus may raise the physician's index of suspicion, but it does not change screening recommendations (Table 2). 
Table 2.
Criteria for the Diagnosis of Diabetesa
Measure Value Notes
FPG ≥126 mg/dL (7.0 mmol/L) Fasting is defined as no caloric intake for at least 8 h.b
OR
2-h PG ≥200 mg/dL (11.1 mmol/L) Measure during an OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.b
OR
HbA1c ≥6.5% (48 mmol/mol) The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.b
OR
Random PG ≥200 mg/dL (11.1 mmol/L) Used with a patient with classic symptoms of hyperglycemia or hyperglycemic crisis.

a See section 13 for gestational diabetes mellitus information.

b In the absence of unequivocal hyperglycemia, results should be confirmed by repeated testing.

Abbreviations: HbA1c, hemoglobin A1c; DCCT, Diabetes Control and Complications Trial; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose; WHO, World Health Organization.

Source: Adapted from Table 2.2 in the Standards of Medical Care in Diabetes—2017.1

Table 2.
Criteria for the Diagnosis of Diabetesa
Measure Value Notes
FPG ≥126 mg/dL (7.0 mmol/L) Fasting is defined as no caloric intake for at least 8 h.b
OR
2-h PG ≥200 mg/dL (11.1 mmol/L) Measure during an OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.b
OR
HbA1c ≥6.5% (48 mmol/mol) The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.b
OR
Random PG ≥200 mg/dL (11.1 mmol/L) Used with a patient with classic symptoms of hyperglycemia or hyperglycemic crisis.

a See section 13 for gestational diabetes mellitus information.

b In the absence of unequivocal hyperglycemia, results should be confirmed by repeated testing.

Abbreviations: HbA1c, hemoglobin A1c; DCCT, Diabetes Control and Complications Trial; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose; WHO, World Health Organization.

Source: Adapted from Table 2.2 in the Standards of Medical Care in Diabetes—2017.1

×
3. Comprehensive Medical Evaluation and Assessment of Comorbidities
Treatment goals and plans should be created with patients based on their individual preferences, values, and goals. 
  • ■ A patient-centered communication style that uses active listening, elicits patient preferences and beliefs, and assesses literacy, numeracy, and potential barriers to care should be used to optimize patient health outcomes and health-related quality of life. [B]
The initial medical evaluation should confirm and classify the diagnosis of diabetes, screen for any existing or potential complications, and engage the patient in the care management plan (Figure 1). 
Figure 1.
Components of the comprehensive diabetes medical evaluation, which should ideally be done on the initial visit, although different components can be done as appropriate on follow-up visits. aRefer to the ADA position statement Psychosocial Care for People With Diabetes for additional details on diabetes-specific screening measures.4 Reprinted from Table 3.1 in the Standards of Medical Care in Diabetes—2017.1 Abbreviations: HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; LDL, low-density lipoprotein.
Figure 1.
Components of the comprehensive diabetes medical evaluation, which should ideally be done on the initial visit, although different components can be done as appropriate on follow-up visits. aRefer to the ADA position statement Psychosocial Care for People With Diabetes for additional details on diabetes-specific screening measures.4 Reprinted from Table 3.1 in the Standards of Medical Care in Diabetes—2017.1 Abbreviations: HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; LDL, low-density lipoprotein.
In addition to complications directly from diabetes, patients should be screened for additional conditions that may complicate diabetes management. People with diabetes are at a higher risk for cognitive impairment/dementia, fatty liver disease, fractures, hearing impairment, low testosterone, obstructive sleep apnea, and periodontal disease. Physicians should also consider annual screening for anxiety, depression, disordered eating behavior, and serious mental illness. 
Immunizations should be assessed and updated as appropriate per patient age and status. 
4. Lifestyle Management
Diabetes self-management education and support, nutrition therapy, physical activity, smoking cessation counseling, and psychosocial care are pertinent to the management of diabetes. 
Self-Management Education and Support
  • ■ In accordance with the national standards for diabetes self-management education and support, all people with diabetes should participate in diabetes self-management education to facilitate the knowledge, skills, and ability necessary for diabetes self-care and in diabetes self-management support to assist with implementing and sustaining skills and behaviors needed for ongoing self-management, both at diagnosis and as needed thereafter. [B]
  • ■ Diabetes self-management education and support programs have the necessary elements in their curricula to delay or prevent the development of type 2 diabetes. Diabetes self-management education and support programs should therefore be able to tailor their content when prevention of diabetes is the desired goal. [B]
Nutrition Therapy
For people with diabetes, there is no one-size-fits-all eating plan. Nutrition therapy should be individualized to fit the needs of each patient. A modest weight loss of 5% in those that are overweight or obese and have type 2 diabetes has been shown to improve glycemic control and reduce medications.5-7 
Goals of nutrition therapy for patients with diabetes promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes, to improve overall health and specifically to: 
  • 1. achieve and maintain body weight goals
  • 2. attain individualized glycemic, blood pressure (BP), and lipid goals
  • 3. delay or prevent the complications of diabetes
Physical Activity
  • ■ Children and adolescents with type 1 or type 2 diabetes or prediabetes should engage in 60 minutes or more of moderate- or vigorous-intensity aerobic activity per day, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days per week. [C]
  • ■ Most adults with type 1 [C] and type 2 [B] diabetes should engage in 150 minutes or more of moderate to vigorous intensity physical activity per week, spread over at least 3 days per week, with no more than 2 consecutive days without activity. Shorter durations (minimum 75 min/wk) of vigorous-intensity or interval training may be sufficient for younger and more physically fit individuals.
  • ■ All adults, and particularly those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior. [B] Prolonged sitting should be interrupted every 30 minutes for blood glucose benefits, particularly in adults with type 2 diabetes. [C]
Smoking Cessation
  • ■ Advise all patients not to use cigarettes and other tobacco products [A] or e-cigarettes. [E]
Psychosocial Issues
  • ■ Psychosocial care should be integrated with a collaborative, patient-centered approach and provided to all people with diabetes, with the goals of optimizing health outcomes and health-related quality of life. [A]
  • ■ Routinely monitor patients for diabetes distress, particularly when treatment targets are not met or are at the onset of diabetes complications. [B]
5. Prevention or Delay of Type 2 Diabetes
The Diabetes Prevention Program (DPP) demonstrated that an intensive lifestyle intervention could reduce the incidence of type 2 diabetes by 58% over 3 years.8 Several other studies of lifestyle intervention for diabetes prevention have also shown a sustained decreased rate up to 20 years later.9-11 
  • ■ Patients with prediabetes should be referred to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program to achieve and maintain 7% loss of initial body weight and increase moderate-intensity physical activity (such as brisk walking) to at least 150 minutes per week. [A]
  • ■ Metformin therapy for prevention of type 2 diabetes should be considered in persons with prediabetes, especially for those with a BMI of 35 or greater, those older than 60 years, women with prior gestational diabetes mellitus, or those with rising HbA1c despite lifestyle intervention. [A]
  • ■ Diabetes self-management education and support programs may be appropriate venues for people with prediabetes to receive education and support to develop and maintain behaviors that can prevent or delay the development of diabetes. [B]
  • ■ Screening for and management of modifiable risk factors for cardiovascular disease is also suggested for those with prediabetes. [B]
6. Glycemic Targets
Self-monitored blood glucose (SMBG) frequency and timing should be dictated by the patient's specific needs and goals. Self-monitored blood glucose is especially important for patients treated with insulin. Providers should 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. Table 3 outlines glycemic recommendations for nonpregnant adults with diabetes. 
Table 3.
Glycemic Recommendations for Many Nonpregnant Adults With Diabetes
Glycemic Measure Recommended Value
HbA1c <7.0% (53 mmol/mol)a
Preprandial capillary plasma glucose 80-130 mg/dLa (4.4-7.2 mmol/L)
Peak postprandial capillary plasma glucoseb <180 mg/dLa (10.0 mmol/L)

a More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on duration of diabetes, age/life expectancy, comorbidities, known cardiovascular disease or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.

b Postprandial glucose may be targeted if hemoglobin A1c (HbA1c) goals are not met despite reaching preprandial glucose goals. Measurements should be made 1-2 h after the beginning of the meal, generally peak levels in patients with diabetes.

Source: Adapted from Table 6.2 in the Standards of Medical Care in Diabetes—2017.1

Table 3.
Glycemic Recommendations for Many Nonpregnant Adults With Diabetes
Glycemic Measure Recommended Value
HbA1c <7.0% (53 mmol/mol)a
Preprandial capillary plasma glucose 80-130 mg/dLa (4.4-7.2 mmol/L)
Peak postprandial capillary plasma glucoseb <180 mg/dLa (10.0 mmol/L)

a More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on duration of diabetes, age/life expectancy, comorbidities, known cardiovascular disease or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.

b Postprandial glucose may be targeted if hemoglobin A1c (HbA1c) goals are not met despite reaching preprandial glucose goals. Measurements should be made 1-2 h after the beginning of the meal, generally peak levels in patients with diabetes.

Source: Adapted from Table 6.2 in the Standards of Medical Care in Diabetes—2017.1

×
HbA1c Testing
  • ■ Perform the HbA1c test at least twice per year in patients who are meeting treatment goals (and who have stable glycemic control). [E]
  • ■ Perform the HbA1c test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. [E]
Hypoglycemia Considerations
In the Standards of Medical Care in Diabetes—2017, clinically significant hypoglycemia is now defined as a serum glucose level of less than 54 mg/dL and should be included in reports of clinical trials of glucose-lowering drugs. A glucose alert value of 70 mg/dL or lower is sufficiently low for clinical treatment with fast-acting carbohydrate and dose adjustment of glucose-lowering therapy. Severe hypoglycemia is defined as any hypoglycemia associated with severe cognitive impairment and requiring external assistance. 
  • ■ 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 a conscious person with hypoglycemia (glucose alert value ≤70 mg/dL), although any carbohydrate 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 increased risk of clinically significant hypoglycemia so it is available should it be needed. Caregivers, school personnel, or family members of these individuals should know where it is and when and how to administer it. Glucagon administration is not limited to health care professionals. [E]
7. Obesity Management in Type 2 Diabetes
Obesity management can delay progression from prediabetes to type 2 diabetes8,12 and may be beneficial in the management of type 2 diabetes.3,5,6,13-15 In overweight and obese patients with type 2 diabetes, modest and sustained weight loss has been shown to improve glycemic control and to reduce the need for glucose-lowering medications.5-7 
Assessment
  • ■ At each patient encounter, BMI should be calculated and documented in the medical record. [B]
Diet, Physical Activity, and Behavioral Therapy
  • ■ Diet, physical activity, and behavioral therapy designed to achieve more than a 5% weight loss should be prescribed for overweight and obese patients with type 2 diabetes ready to achieve weight loss. [A]
  • ■ Such interventions should be high intensity (≥16 sessions in 6 months) and focus on diet, physical activity, and behavioral strategies to achieve a 500 to 750 kcal/d energy deficit. [A]
  • ■ Diets should be individualized, as those that provide the same caloric restriction but differ in protein, carbohydrate, and fat content are equally effective in achieving weight loss. [A]
Pharmacotherapy
  • ■ Weight loss medications may be effective as adjuncts to diet, physical activity, and behavioral counseling for selected patients with type 2 diabetes and BMI of 27 or higher. Potential benefits must be weighed against the potential risks of the medications. [A]
  • ■ If a patient's response to weight loss medications is less than 5% after 3 months or if there are any safety or tolerability issues at any time, the medication should be discontinued. [A]
Metabolic Surgery
  • ■ Metabolic surgery should be recommended to manage type 2 diabetes in appropriate surgical candidates with BMI of 40 or higher (BMI ≥37.5 in Asian Americans), regardless of the level of glycemic control or complexity of glucose-lowering regimens. It should also be recommended in patients with BMI 35.0 to 39.9 (32.5-37.4 in Asian Americans) when hyperglycemia is inadequately controlled despite lifestyle and optimal medical therapy [A] and should be considered in adults with type 2 diabetes and BMI of 30.0 to 34.9 (27.5-32.4 in Asian Americans) if hyperglycemia is inadequately controlled despite optimal medical control either by oral or injectable medications (including insulin). [B]
  • ■ Metabolic surgery should be performed in high-volume centers with multidisciplinary teams that understand and are experienced in the management of diabetes and gastrointestinal surgery. [C]
  • ■ Long-term lifestyle support and routine monitoring of micronutrient and nutritional status must be provided to patients after surgery. [C]
  • ■ Persons presenting for metabolic surgery should receive a comprehensive mental health assessment. [B]
Metabolic surgery is most successful in younger patients, those with shorter duration of diabetes (eg, <8 years),16 non-insulin users, and those with better baseline glycemic control.16-18 
8. Pharmacologic Approaches to Glycemic Therapy
Pharmacologic Therapy for Type 1 Diabetes
  • ■ Most people with type 1 diabetes should be treated with multiple daily injections of prandial insulin and basal insulin, or continuous subcutaneous insulin infusion. [A]
  • ■ Most individuals with type 1 diabetes should use rapid acting analogs to reduce hypoglycemia risk. [A]
Pharmacologic Therapy for Type 2 Diabetes
  • ■ Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacologic agent for the management of type 2 diabetes. [A]
  • ■ Long-term use of metformin may be associated with biochemical vitamin B12 deficiency, and periodic measurement of vitamin B12 levels should be considered in metformin-treated patients, especially in those with anemia or peripheral neuropathy. [B]
  • ■ If noninsulin monotherapy at maximum tolerated dose does not achieve or maintain the HbA1c target after 3 months, add a second oral agent, a glucagon-like peptide-1 receptor agonist, or basal insulin. [A]
  • ■ For patients with type 2 diabetes who are not achieving glycemic goals, insulin therapy should not be delayed. [B]
  • ■ Consider initiating insulin therapy (with or without additional agents) in patients with newly diagnosed type 2 diabetes who are symptomatic, have HbA1c of 10% or higher, or have blood glucose levels of 300 mg/dL or higher. [E]
  • ■ In patients with long-standing suboptimally controlled type 2 diabetes and established atherosclerotic cardiovascular disease (ASCVD), empagliflozin or liraglutide should be considered as they have been shown to reduce cardiovascular and all-cause mortality when added to standard care. [B]
The price of insulin has substantially increased over the past decade, and the cost-effectiveness of different antihyperglycemic agents is an important consideration when selecting therapies. Figure 2 outlines general recommendations for antihyperglycemic therapy. Figure 3 identifies combination injectable therapy for patients with type 2 diabetes. 
Figure 2.
Antihyperglycemic therapy in type 2 diabetes: general recommendations. 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). *See Inzucchi et al19 for description of efficacy categorization. §Usually a basal insulin (neutral protamine Hagedorn, glargine, detemir, degludec). Reprinted from Figure 8.1 in the Standards of Medical Care in Diabetes—2017.1 Adapted with permission from Inzucchi et al.19 Abbreviations: A1C, hemoglobin A1c; DPP-4-i, dipeptidyl peptidase-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1-RA, glucagon-like peptide-1 receptor agonist; GU, genitourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, sodium-glucose cotransporter-2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione.
Figure 2.
Antihyperglycemic therapy in type 2 diabetes: general recommendations. 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). *See Inzucchi et al19 for description of efficacy categorization. §Usually a basal insulin (neutral protamine Hagedorn, glargine, detemir, degludec). Reprinted from Figure 8.1 in the Standards of Medical Care in Diabetes—2017.1 Adapted with permission from Inzucchi et al.19 Abbreviations: A1C, hemoglobin A1c; DPP-4-i, dipeptidyl peptidase-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1-RA, glucagon-like peptide-1 receptor agonist; GU, genitourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, sodium-glucose cotransporter-2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione.
Figure 3.
Combination injectable therapy for patients with type 2 diabetes. Reprinted from Figure 8.2 in the Standards of Medical Care in Diabetes—2017.1 Adapted with permission from Inzucchi et al.19 Abbreviations: A1C, hemoglobin A1c; FBG, fasting blood glucose; GLP-1 RA, glucagon-like peptide-1 receptor agonist; hypo, hypoglycemia; SMBG, self-monitored blood glucose.
Figure 3.
Combination injectable therapy for patients with type 2 diabetes. Reprinted from Figure 8.2 in the Standards of Medical Care in Diabetes—2017.1 Adapted with permission from Inzucchi et al.19 Abbreviations: A1C, hemoglobin A1c; FBG, fasting blood glucose; GLP-1 RA, glucagon-like peptide-1 receptor agonist; hypo, hypoglycemia; SMBG, self-monitored blood glucose.
9. Cardiovascular Disease and Risk Management
For persons with diabetes, ASCVD is the leading cause of morbidity and mortality and is the largest contributor to the direct and indirect costs of diabetes. In all patients with diabetes, cardiovascular risk factors should be systematically assessed at least annually. Morbidity and mortality from ASCVD have decreased significantly over the past 10 years.20-22 
BP Control
  • ■ Most patients with diabetes and hypertension should be treated to achieve BP levels of less than 140/90 mm Hg. [A]
  • ■ Treatment for patients with hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes (angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], thiazide-like diuretics, or dihydropyridine calcium channel blockers). Multiple drug therapy is generally required to achieve BP targets (but not a combination of ACE inhibitors and ARBs). [A]
  • ■ An ACE inhibitor or an ARB, at the maximum tolerated dose indicated for BP management, is recommended first-line management for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio of 300 mg/g creatinine or higher [A] or 30 to 299 mg/g creatinine. [B] If one class is not tolerated, the other should be substituted. [B]
Lipid Management
  • ■ In adults not taking statins, it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter, or more frequently if indicated. [E]
  • ■ Obtain a lipid profile at initiation of statin therapy and periodically thereafter as it may help to monitor the response to therapy and inform adherence. [E]
  • ■ Lifestyle modification focusing on weight loss (if indicated); reduced saturated fat, trans fat, and cholesterol intake; increased omega-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity should be recommended to improve lipid profiles in patients. [A]
Table 4 outlines the need for most adults older than 40 years with ASCVD or ASCVD risk factors to be taking statin therapy. 
Table 4.
Recommendations for Statin and Combination Treatment in People With Diabetes
Age, y Risk Factors Recommended Statin Intensitya
<40
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ None
■ Moderate or high
■ High
40-75
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ ACS and LDL-C ≥50 mg/dL (1.3 mmol/L) or in patients with a history of ASCVD who cannot tolerate high-dose statins
■ Moderate
■ High
■ High
■ Moderate plus ezetimibe
>75
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ ACS and LDL-C ≥50 mg/dL (1.3 mmol/L) or in patients with a history of ASCVD who cannot tolerate high-dose statins
■ Moderate
■ Moderate or high
■ High
■ Moderate plus ezetimibe

a In addition to lifestyle therapy.

b Atherosclerotic cardiovascular disease (ASCVD) risk factors include low-density lipoprotein cholesterol (LDL-C) ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, chronic kidney disease, albuminuria, and family history of premature ASCVD.

Abbreviation: ACS, acute coronary syndrome.

Source: Reprinted from Table 9.1 in the Standards of Medical Care in Diabetes—2017.1

Table 4.
Recommendations for Statin and Combination Treatment in People With Diabetes
Age, y Risk Factors Recommended Statin Intensitya
<40
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ None
■ Moderate or high
■ High
40-75
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ ACS and LDL-C ≥50 mg/dL (1.3 mmol/L) or in patients with a history of ASCVD who cannot tolerate high-dose statins
■ Moderate
■ High
■ High
■ Moderate plus ezetimibe
>75
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ ACS and LDL-C ≥50 mg/dL (1.3 mmol/L) or in patients with a history of ASCVD who cannot tolerate high-dose statins
■ Moderate
■ Moderate or high
■ High
■ Moderate plus ezetimibe

a In addition to lifestyle therapy.

b Atherosclerotic cardiovascular disease (ASCVD) risk factors include low-density lipoprotein cholesterol (LDL-C) ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, chronic kidney disease, albuminuria, and family history of premature ASCVD.

Abbreviation: ACS, acute coronary syndrome.

Source: Reprinted from Table 9.1 in the Standards of Medical Care in Diabetes—2017.1

×
Antiplatelet Therapy
  • ■ Consider aspirin therapy (75-162 mg/d) as a primary prevention strategy in those with type 1 or type 2 diabetes who are at increased cardiovascular risk. Those at risk include most men or women with diabetes aged 50 years or older who have at least 1 additional major risk factor (family history of premature ASCVD, hypertension, smoking, dyslipidemia, or albuminuria) and are not at increased risk of bleeding. [C]
  • ■ Use aspirin therapy (75-162 mg/d) as a secondary prevention strategy in those with diabetes and a history of ASCVD. [A]
  • ■ For patients with ASCVD and documented aspirin allergy, clopidogrel (75 mg/d) should be used. [B]
Coronary Heart Disease
  • ■ In asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as ASCVD risk factors are treated. [A]
  • ■ In patients with known ASCVD, use aspirin and statin therapy (if not contraindicated) [A] and consider ACE inhibitor therapy [C] to reduce the risk of cardiovascular events.
  • ■ In patients with symptomatic heart failure, thiazolidinedione treatment should not be used. [A]
  • ■ In patients with type 2 diabetes with stable congestive heart failure, metformin may be used if estimated glomerular filtration rate (eGFR) remains greater than 30 mL/min but should be avoided in unstable or hospitalized patients with congestive heart failure. [B]
10. Microvascular Disease and Foot Care
More intensive glucose control has been shown in large prospective studies to be beneficial in reducing both the onset and progression of microvascular complications in diabetes.23-29 Promptly refer patients to a specialist in cases of uncertainty, difficult management issues, or rapidly deteriorating function. 
Diabetic Kidney Disease
Diabetic kidney disease occurs in 20% to 40% of persons with diabetes and is the leading cause of end-stage kidney disease.30 It is characterized by elevated albumin excretion rate (albuminuria), low eGFR, or other markers. Typically, it develops after 10 years (or at least 5 years) of type 1 diabetes, but it may be present at diagnosis for those with type 2 diabetes. Blood pressure levels of 140/90 mm Hg or lower in patients with diabetes are recommended to slow chronic kidney disease progression and to reduce cardiovascular mortality. 
  • ■ At least once per year, assess urinary albumin (eg, spot urinary albumin-to-creatinine ratio) and eGFR in patients with type 1 diabetes with duration of 5 or more years, in all patients with type 2 diabetes, and in all patients with comorbid hypertension. [B]
  • ■ For nonpregnant adults, an ACE inhibitor or ARB is recommended for an elevated urinary albumin-to-creatinine ratio [B] or an eGFR of lower than 60 mL/min/1.73 m2 [A] (not recommended for persons with diabetes who have normal BP, normal albumin-to-creatinine ratio, and normal eGFR) [B]. Monitor potassium and serum creatinine for changes, as well as urine albumin-to-creatinine ratio for response. [E]
Diabetic Retinopathy
Diabetic retinopathy is strongly related to both diabetes duration and level of glucose control. Screening for diabetic retinopathy should include a comprehensive dilated eye examination by an ophthalmologist or optometrist within 5 years of diagnosis for those with type 1 diabetes and at the time of diagnosis for those with type 2 diabetes. Screening should be repeated annually, perhaps every 2 years if glycemia is well controlled and there is no evidence of retinopathy on 1 or more eye examinations. Pregnancy may be associated with a rapid progression of diabetic retinopathy, and eye examinations should occur before pregnancy or in the first trimester in patients with preexisting type 1 or type 2 diabetes, and then patients should be monitored every trimester. 
  • ■ Optimize BP and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy. [A]
  • ■ The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage. [A]
Neuropathy
Patients with diabetic peripheral neuropathy (DPN) have a risk of foot problems. Symptoms of DPN may include pain, burning, tingling, or numbness. Autonomic neuropathy can include cardiac, gastrointestinal issues, neurogenic bladder, erectile dysfunction, hypoglycemia unawareness, and sudomotor dysfunction. 
  • ■ All patients should be assessed for DPN starting at diagnosis of type 2 diabetes and 5 years after diagnosis of type 1 diabetes, and at least annually thereafter. [B]
  • ■ Assessment for distal symmetric polyneuropathy should include a careful history and assessment of either temperature or pinprick sensation and vibration sensation using a 128-Hz tuning fork. All patients should have annual 10-g monofilament testing to identify feet at risk for ulceration and amputation. [B]
  • ■ Either pregabalin or duloxetine, are recommended as initial pharmacologic treatments for patients with neuropathic pain in diabetes. [A]
Foot Care
Diabetic neuropathy and peripheral vascular disease are the main contributors to diabetic foot ulcers and amputation, in addition to other risk factors such as cigarette smoking. A comprehensive foot examination along with appropriate risk factor–oriented history to include neuropathic (see above) and vascular components (pulses, claudication) should be performed annually. Home foot care and footwear should be discussed. Further assessments, interventions, and referrals should be provided as appropriate. 
  • ■ All patients with diabetes should have their feet inspected at every visit. [C]
11. Older Adults
Providers caring for older adults with diabetes must recognize the heterogeneity of this population when setting and prioritizing treatment goals. Individualization of goals should be considered in light of other comorbidities such as renal disease. Cognitive status assessment and depression screening should be part of the routine care plan. Cardiovascular risk factor treatment is likely to benefit many older adults, particularly treatment for hypertension to individualized target levels. 
Metformin can still be a first line agent for many older adults with type 2 diabetes, with consideration to renal status31 and congestive heart failure. Thiazolidinediones (heart failure, fractures) and sulfonylureas (hypoglycemia) may not be ideal in this population; if the latter is used, shorter-duration glipizide is preferred. Single injection basal insulin may be appropriate for many with ease of use and efficacy. Patients who take oral dipeptidyl peptidase-4 inhibitors have few side effects and minimal hypoglycemia; however, cost may be a barrier. Injectable glucagon-like peptide-1 receptor agonists may be more complex for some older patients, and gastrointestinal side effects (nausea, vomiting, weight loss) may be problematic. Oral sodium-glucose cotransporter-2 inhibitors may have a role in older patients, but evidence supporting long-term use is limited. Hypotension and genitourinary infection risk should be considered. 
In long-term care settings, hypoglycemia avoidance and management, nutritional considerations, and end-of-life care should receive special attention. Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. Reasonable relaxation of diabetes goals may be considered in appropriate patients. 
12. Children and Adolescents
Type 1 diabetes in this population warrants management by a multidisciplinary team of specialists trained in pediatric diabetes care to include the needs of patients and their families. Developmental changes and ability for shared decision making should be accounted for in diabetes self-management education and support, medical nutrition therapy, and psychosocial support. Multiple daily injection regimens or continuous subcutaneous insulin infusion (insulin pump) with continuous glucose monitoring are considerations for blood glucose management. Care in school and daycare settings require appropriate planning. 
Screening for retinopathy, diabetic kidney disease, and neuropathy for children and adolescents with type 1 or type 2 diabetes are the same as for adults with diabetes. Lipids should be obtained at diagnosis of type 2 diabetes because of the increased likelihood of comorbidities. 
  • ■ An HbA1c goal of 7.5% (58 mmol/ mol) or less is recommended across all pediatric age groups. [E] Blood pressure should be measured at each routine visit. Children found to have high-normal BP (systolic BP or diastolic BP ≥90th percentile for age, sex, and height) or hypertension (systolic BP or diastolic BP ≥95th percentile for age, sex, and height) should have elevated BP confirmed on 3 separate days. [B]
  • ■ For the initial pharmacologic management of hypertension, ACE inhibitors or ARBs should be considered after reproductive counseling and implementation of effective birth control due to potential teratogenic effects of both drug classes. [E]
  • ■ Obtain a fasting lipid profile for children aged 10 years or older soon after diabetes diagnosis (after glucose control has been established). [E]
  • ■ If lipids are abnormal, annual monitoring is reasonable. If LDL cholesterol values are within accepted risk levels (<100 mg/dL [2.6 mmol/L]), a lipid profile repeated every 3 to 5 years is reasonable. [E]
Because of the increased frequency of other autoimmune diseases in type 1 diabetes, screening for thyroid dysfunction and celiac disease should be considered, particularly in the settings of appropriate signs and symptoms or glycemic control changes. 
13. Management of Diabetes in Pregnancy
Type 2 diabetes and GDM are increasing in prevalence consistent with the rise in obesity. 
  • ■ Test for undiagnosed diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria. [B]
  • ■ Test for GDM at 24 to 28 weeks of gestation in pregnant women not previously known to have diabetes (Figure 4). [A]
Insulin is the drug of choice in GDM and preexisting diabetes in pregnancy. Long-term safety data are not available for other diabetes agents. Teratogenic agents such as angiotensin converter enzyme inhibitors and statins should not be used in pregnancy. 
Figure 4.
Screening for and diagnosis of gestational diabetes mellitus (GDM). aThe American Congress of Obstetricians and Gynecologists recommends either 135 mg/dL (7.5 mmol/L) or 140 mg/dL (7.8 mmol/L). A systematic review determined that a cutoff of 130 mg/dL (7.2 mmol/L) was more sensitive but less specific than 140 mg/dL (7.8 mmol/L).34 Reprinted from Table 2.6 in the Standards of Medical Care in Diabetes—2017.1 Abbreviations: GLT, glucose loading test; NDDG, National Diabetes Data Group; OGTT, oral glucose tolerance test.
Figure 4.
Screening for and diagnosis of gestational diabetes mellitus (GDM). aThe American Congress of Obstetricians and Gynecologists recommends either 135 mg/dL (7.5 mmol/L) or 140 mg/dL (7.8 mmol/L). A systematic review determined that a cutoff of 130 mg/dL (7.2 mmol/L) was more sensitive but less specific than 140 mg/dL (7.8 mmol/L).34 Reprinted from Table 2.6 in the Standards of Medical Care in Diabetes—2017.1 Abbreviations: GLT, glucose loading test; NDDG, National Diabetes Data Group; OGTT, oral glucose tolerance test.
For preexisting diabetes and GDM, combined targets are now a fasting plasma glucose level of ≤95 mg/dL (5.3 mmol/L) and either (1) a 1-hour postprandial glucose level ≤140 mg/dL (7.8 mmol/L) or (2) a 2-hour postprandial glucose level of ≤120 mg/dL (6.7 mmol/L). 
For patients with preexisting type 1 or type 2 diabetes, a preconception HbA1c of 6.5 or less is optimal. Tighter glycemic control during pregnancy is desirable if goals can be achieved safely. 
  • ■ Test women with GDM for persistent diabetes at 4 to 12 weeks’ postpartum, using the oral glucose tolerance test 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]
14. Diabetes Care in the Hospital
The type of diabetes should be identified upon admission. Further, if HbA1c has not been obtained in the previous 3 months, it should be ordered as an inpatient. 
The ADA recommends that insulin be the primary treatment of inpatient hyperglycemia: 
  • ■ Insulin therapy should be initiated for management of persistent hyperglycemia, starting at a threshold of 180 mg/dL (10.0 mmol/L) or higher. Once insulin therapy is started, a target glucose range of 140 to 180 mg/dL (7.8-10.0 mmol/L) is recommended for the majority of critically ill patients [A] and noncritically ill patients. [C]
  • ■ Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. [E]
  • ■ Basal insulin or a basal plus bolus correction insulin is the preferrred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake. [A]
Sole use of a sliding scale is strongly discouraged. More stringent goals may be appropriate for some patients, if hypoglycemia can be avoided. A hypoglycemia protocol should be in place. Self-managment may be appropriate for select patients who perform comprehensive self-managment at home and have cognitive and physical skills to administer insulin in the hospital if agreed upon by the patient, nursing staff, and physician. 
Transition from the acute care setting should involve team care, including both diabetes eduation and nutritonal counseling, with discharge planning that begins upon admission to include durable medical equipment needs, supplies, and medications. Outpatient follow-up visits should be scheduled within 1 month. 
Refer to the full Standards1 for guidance on perioperative care, enteral/parenteral feedings, glucocorticoid therapy, diabetic ketoacidosis, and hyperosmolar hyperglycemic state. 
Acknowledgments
The full Standards of Medical Care in Diabetes—2017 was developed by the ADA's Professional Practice Committee: William H. Herman, MD, MPH (co-chair); Rita R. Kalyani, MD, MHS (co-chair); Andrea L. Cherrington, MD, MPH; Donald R. Coustan, MD; Ian de Boer, MD, MS; Robert James Dudl, MD; Hope Feldman, CRNP, FNP-BC; Hermes J. Florez, MD, PhD, MPH; Suneil K. Koliwad, MD, PhD; Melinda Maryniuk, MEd, RD, CDE; Joshua J. Neumiller, PharmD, CDE; and Joseph I. Wolfsdorf, MB, BCh. 
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Figure 1.
Components of the comprehensive diabetes medical evaluation, which should ideally be done on the initial visit, although different components can be done as appropriate on follow-up visits. aRefer to the ADA position statement Psychosocial Care for People With Diabetes for additional details on diabetes-specific screening measures.4 Reprinted from Table 3.1 in the Standards of Medical Care in Diabetes—2017.1 Abbreviations: HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; LDL, low-density lipoprotein.
Figure 1.
Components of the comprehensive diabetes medical evaluation, which should ideally be done on the initial visit, although different components can be done as appropriate on follow-up visits. aRefer to the ADA position statement Psychosocial Care for People With Diabetes for additional details on diabetes-specific screening measures.4 Reprinted from Table 3.1 in the Standards of Medical Care in Diabetes—2017.1 Abbreviations: HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; LDL, low-density lipoprotein.
Figure 2.
Antihyperglycemic therapy in type 2 diabetes: general recommendations. 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). *See Inzucchi et al19 for description of efficacy categorization. §Usually a basal insulin (neutral protamine Hagedorn, glargine, detemir, degludec). Reprinted from Figure 8.1 in the Standards of Medical Care in Diabetes—2017.1 Adapted with permission from Inzucchi et al.19 Abbreviations: A1C, hemoglobin A1c; DPP-4-i, dipeptidyl peptidase-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1-RA, glucagon-like peptide-1 receptor agonist; GU, genitourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, sodium-glucose cotransporter-2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione.
Figure 2.
Antihyperglycemic therapy in type 2 diabetes: general recommendations. 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). *See Inzucchi et al19 for description of efficacy categorization. §Usually a basal insulin (neutral protamine Hagedorn, glargine, detemir, degludec). Reprinted from Figure 8.1 in the Standards of Medical Care in Diabetes—2017.1 Adapted with permission from Inzucchi et al.19 Abbreviations: A1C, hemoglobin A1c; DPP-4-i, dipeptidyl peptidase-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1-RA, glucagon-like peptide-1 receptor agonist; GU, genitourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, sodium-glucose cotransporter-2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione.
Figure 3.
Combination injectable therapy for patients with type 2 diabetes. Reprinted from Figure 8.2 in the Standards of Medical Care in Diabetes—2017.1 Adapted with permission from Inzucchi et al.19 Abbreviations: A1C, hemoglobin A1c; FBG, fasting blood glucose; GLP-1 RA, glucagon-like peptide-1 receptor agonist; hypo, hypoglycemia; SMBG, self-monitored blood glucose.
Figure 3.
Combination injectable therapy for patients with type 2 diabetes. Reprinted from Figure 8.2 in the Standards of Medical Care in Diabetes—2017.1 Adapted with permission from Inzucchi et al.19 Abbreviations: A1C, hemoglobin A1c; FBG, fasting blood glucose; GLP-1 RA, glucagon-like peptide-1 receptor agonist; hypo, hypoglycemia; SMBG, self-monitored blood glucose.
Figure 4.
Screening for and diagnosis of gestational diabetes mellitus (GDM). aThe American Congress of Obstetricians and Gynecologists recommends either 135 mg/dL (7.5 mmol/L) or 140 mg/dL (7.8 mmol/L). A systematic review determined that a cutoff of 130 mg/dL (7.2 mmol/L) was more sensitive but less specific than 140 mg/dL (7.8 mmol/L).34 Reprinted from Table 2.6 in the Standards of Medical Care in Diabetes—2017.1 Abbreviations: GLT, glucose loading test; NDDG, National Diabetes Data Group; OGTT, oral glucose tolerance test.
Figure 4.
Screening for and diagnosis of gestational diabetes mellitus (GDM). aThe American Congress of Obstetricians and Gynecologists recommends either 135 mg/dL (7.5 mmol/L) or 140 mg/dL (7.8 mmol/L). A systematic review determined that a cutoff of 130 mg/dL (7.2 mmol/L) was more sensitive but less specific than 140 mg/dL (7.8 mmol/L).34 Reprinted from Table 2.6 in the Standards of Medical Care in Diabetes—2017.1 Abbreviations: GLT, glucose loading test; NDDG, National Diabetes Data Group; OGTT, oral glucose tolerance test.
Table 1.
Evidence Grading System
Level of Evidence Description
A
■ Clear evidence from well-conducted, generalizable RCTs that are adequately powered, including evidence from well-conducted multicenter trials or meta-analyses that incorporate quality ratings in the analyses
■ Compelling nonexperimental evidence
■ Supportive evidence from well-conducted RCTs that are adequately powered
B
■ Supportive evidence from well-conducted cohort studies or case-control studies
C
■ Supportive evidence from poorly controlled or uncontrolled studies
■ Conflicting evidence with the weight of evidence supporting the recommendation
E
■ Expert consensus or clinical experience

Source: Adapted from Table 1 in the Standards of Medical Care in Diabetes—2017.1

Table 1.
Evidence Grading System
Level of Evidence Description
A
■ Clear evidence from well-conducted, generalizable RCTs that are adequately powered, including evidence from well-conducted multicenter trials or meta-analyses that incorporate quality ratings in the analyses
■ Compelling nonexperimental evidence
■ Supportive evidence from well-conducted RCTs that are adequately powered
B
■ Supportive evidence from well-conducted cohort studies or case-control studies
C
■ Supportive evidence from poorly controlled or uncontrolled studies
■ Conflicting evidence with the weight of evidence supporting the recommendation
E
■ Expert consensus or clinical experience

Source: Adapted from Table 1 in the Standards of Medical Care in Diabetes—2017.1

×
Table 2.
Criteria for the Diagnosis of Diabetesa
Measure Value Notes
FPG ≥126 mg/dL (7.0 mmol/L) Fasting is defined as no caloric intake for at least 8 h.b
OR
2-h PG ≥200 mg/dL (11.1 mmol/L) Measure during an OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.b
OR
HbA1c ≥6.5% (48 mmol/mol) The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.b
OR
Random PG ≥200 mg/dL (11.1 mmol/L) Used with a patient with classic symptoms of hyperglycemia or hyperglycemic crisis.

a See section 13 for gestational diabetes mellitus information.

b In the absence of unequivocal hyperglycemia, results should be confirmed by repeated testing.

Abbreviations: HbA1c, hemoglobin A1c; DCCT, Diabetes Control and Complications Trial; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose; WHO, World Health Organization.

Source: Adapted from Table 2.2 in the Standards of Medical Care in Diabetes—2017.1

Table 2.
Criteria for the Diagnosis of Diabetesa
Measure Value Notes
FPG ≥126 mg/dL (7.0 mmol/L) Fasting is defined as no caloric intake for at least 8 h.b
OR
2-h PG ≥200 mg/dL (11.1 mmol/L) Measure during an OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.b
OR
HbA1c ≥6.5% (48 mmol/mol) The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.b
OR
Random PG ≥200 mg/dL (11.1 mmol/L) Used with a patient with classic symptoms of hyperglycemia or hyperglycemic crisis.

a See section 13 for gestational diabetes mellitus information.

b In the absence of unequivocal hyperglycemia, results should be confirmed by repeated testing.

Abbreviations: HbA1c, hemoglobin A1c; DCCT, Diabetes Control and Complications Trial; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose; WHO, World Health Organization.

Source: Adapted from Table 2.2 in the Standards of Medical Care in Diabetes—2017.1

×
Table 3.
Glycemic Recommendations for Many Nonpregnant Adults With Diabetes
Glycemic Measure Recommended Value
HbA1c <7.0% (53 mmol/mol)a
Preprandial capillary plasma glucose 80-130 mg/dLa (4.4-7.2 mmol/L)
Peak postprandial capillary plasma glucoseb <180 mg/dLa (10.0 mmol/L)

a More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on duration of diabetes, age/life expectancy, comorbidities, known cardiovascular disease or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.

b Postprandial glucose may be targeted if hemoglobin A1c (HbA1c) goals are not met despite reaching preprandial glucose goals. Measurements should be made 1-2 h after the beginning of the meal, generally peak levels in patients with diabetes.

Source: Adapted from Table 6.2 in the Standards of Medical Care in Diabetes—2017.1

Table 3.
Glycemic Recommendations for Many Nonpregnant Adults With Diabetes
Glycemic Measure Recommended Value
HbA1c <7.0% (53 mmol/mol)a
Preprandial capillary plasma glucose 80-130 mg/dLa (4.4-7.2 mmol/L)
Peak postprandial capillary plasma glucoseb <180 mg/dLa (10.0 mmol/L)

a More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on duration of diabetes, age/life expectancy, comorbidities, known cardiovascular disease or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.

b Postprandial glucose may be targeted if hemoglobin A1c (HbA1c) goals are not met despite reaching preprandial glucose goals. Measurements should be made 1-2 h after the beginning of the meal, generally peak levels in patients with diabetes.

Source: Adapted from Table 6.2 in the Standards of Medical Care in Diabetes—2017.1

×
Table 4.
Recommendations for Statin and Combination Treatment in People With Diabetes
Age, y Risk Factors Recommended Statin Intensitya
<40
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ None
■ Moderate or high
■ High
40-75
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ ACS and LDL-C ≥50 mg/dL (1.3 mmol/L) or in patients with a history of ASCVD who cannot tolerate high-dose statins
■ Moderate
■ High
■ High
■ Moderate plus ezetimibe
>75
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ ACS and LDL-C ≥50 mg/dL (1.3 mmol/L) or in patients with a history of ASCVD who cannot tolerate high-dose statins
■ Moderate
■ Moderate or high
■ High
■ Moderate plus ezetimibe

a In addition to lifestyle therapy.

b Atherosclerotic cardiovascular disease (ASCVD) risk factors include low-density lipoprotein cholesterol (LDL-C) ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, chronic kidney disease, albuminuria, and family history of premature ASCVD.

Abbreviation: ACS, acute coronary syndrome.

Source: Reprinted from Table 9.1 in the Standards of Medical Care in Diabetes—2017.1

Table 4.
Recommendations for Statin and Combination Treatment in People With Diabetes
Age, y Risk Factors Recommended Statin Intensitya
<40
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ None
■ Moderate or high
■ High
40-75
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ ACS and LDL-C ≥50 mg/dL (1.3 mmol/L) or in patients with a history of ASCVD who cannot tolerate high-dose statins
■ Moderate
■ High
■ High
■ Moderate plus ezetimibe
>75
■ None
■ ASCVD risk factor(s)b
■ ASCVD
■ ACS and LDL-C ≥50 mg/dL (1.3 mmol/L) or in patients with a history of ASCVD who cannot tolerate high-dose statins
■ Moderate
■ Moderate or high
■ High
■ Moderate plus ezetimibe

a In addition to lifestyle therapy.

b Atherosclerotic cardiovascular disease (ASCVD) risk factors include low-density lipoprotein cholesterol (LDL-C) ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, chronic kidney disease, albuminuria, and family history of premature ASCVD.

Abbreviation: ACS, acute coronary syndrome.

Source: Reprinted from Table 9.1 in the Standards of Medical Care in Diabetes—2017.1

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