Chief’s Conference:Standards of Medical Care

in Diabetes - 2008

Sarah A. Bailey PGY3

Family Medicine

Emory University

Standards of Medical Care in Diabetes - 2008 Recommendations by the American Diabetes

Association. Include screening, diagnostic, and therapeutic

actions for patients with diabetes. Grading system developed by ADA to code the

evidence that forms basis for these recommendations.

Level of Evidence Level A – clear evidence from well-conducted,

generalizable, randomized control trials that are equally powered.

Level B – supportive evidence from well-documented cohort studies.

Level C – supportive evidence from poorly controlled or uncontrolled studies.

Level E – expert consensus or clinical experience.

Diagnosis of Diabetes To test for pre-diabetes or diabetes, either an

FPG test or 2 hour oral Glucose Tolerance Test (OGTT 75 gm glucose load), or both, is appropriate. (B)

An OGTT may be considered in patients with impaired fasting glucose (IFG). (E)

HbA1c level is not recommended at this time to diagnose diabetes. (E)

Diagnosis

Diagnosis of Pre- Diabetes IFG = FPG 100 mg/dl to 125 mg/dl IGT = 2 hour plasma glucose 140 mg/dl to

199 mg/dl.Diagnosis of Diabetes FPG > = 126 mg/dl OR Symptoms hyperglycemia (polyuria,

polydipsia, and weight loss) AND causal plasma glucose >= 200 mg/dl

OR 2 hour OGTT >= 200 mg/dl at 2 hours.

Screening Diabetes in Asymptomatic Adults Adults who are overweight (BMI >= 25) or

obese AND who have one or more risk factors for DM. Otherwise testing should begin at age 45. (B)

If tests are normal, repeat testing at least at 3-year intervals. (E)

In those identified with pre-diabetes, treat other CVD risk factors. (B)

Monitoring for development of DM in pre-diabetics is every year. (E)

Criteria for testing for pre-diabetes and diabetes in asymptomatic adult individuals1. Testing should be considered in all adults who are overweight (BMI _25 kg/m2*)

AND

have additional risk factors: physical inactivity first-degree relative with diabetes members of a high-risk ethnic population (e.g., African American, Latino,

Native

American, Asian American, and Pacific Islander) women who delivered a baby weighing > 9 lb or were diagnosed with GDM hypertension (>=140/90 mmHg or on therapy for hypertension) HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250

mg/dl (2.82 mmol/l) women with polycystic ovarian syndrome (PCOS) IGT or IFG on previous testing other clinical conditions associated with insulin resistance (e.g., severe obesity

and acanthosis nigricans) history of CVD

Screening for DM type II in Children Screen those who are overweight (BMI >85th

% for age and sex, weight for height >85%, or weight >120% if ideal for height)

AND 2 of the following risk factors: (E) Family hx of DM in 1st or 2nd degree relative. Race/ethnicity (Native American, African

American, Latino, Asian American, Pacific Islander) Signs of insulin resistance (acanthosis nigrans,

htn, dyslipidemia, or PCOS) Maternal h/o DM or GDM

Testing for DM type II in Children Testing should begin at age 10 years or at

onset of puberty, if puberty occurs at a younger age, and be repeated every 2 years (E).

The FPG is the preferred test (E).

Detection and Diagnosis of GDM Screen for GDM using risk factor analysis and,

if appropriate, use of an OGTT. (C) Women with GDM should be screened for DM

at 6-12 weeks postpartum and should be followed up with subsequent screening for the development of diabetes or pre-diabetes. (E)

Screening for GDM

Carry out GDM risk assessment at the first prenatal visit. Women at very high risk for GDM should be screened for

diabetes as soon as possible after the confirmation of pregnancy.

Criteria for very high risk are: Severe obesity Prior history of GDM or delivery of large-for-gestational-age

infant Presence of glycosuria Diagnosis of PCOS Strong family history of type 2 diabetes Screening/diagnosis at this stage of pregnancy should use

standard diagnostic testing (FPG, OGTT)

Screening for GDM All women of higher than low risk of GDM, including those

above not found to have diabetes early in pregnancy, should undergo GDM testing at 24–28 weeks of gestation.

Low risk status, which does not require GDM screening, is defined as women with ALL of the following characteristics:

Age <25 years Weight normal before pregnancy Member of an ethnic group with a low prevalence of

diabetes No known diabetes in first-degree relatives No history of abnormal glucose tolerance No history of poor obstetrical outcome

Diagnosis of GDM

Two approaches may be followed for GDM screening at 24–28 weeks:

1. Two-step approach: A. Perform initial screening by measuring plasma

or serum glucose 1 h after a 50-g oral glucose load. A glucose threshold after 50-g load of > =140 mg/dl identifies approx 80% of women with GDM, while the sensitivity is further increased to approx 90% by a threshold of > =130 mg/dl.

B. Perform a diagnostic 3 hr 100-g OGTT on a separate day in women who exceed the chosen threshold on 1 hr 50-g screening.

Diagnosis of GDM2. One-step approach (may be preferred in clinics

with high prevalence of GDM): Perform a diagnostic 100-g OGTT in all women to be tested at 24–28 weeks.

The 100-g OGTT should be performed in the morning after an overnight fast of at least 8 h.

A diagnosis of GDM requires at least two of the following plasma glucose values:

Fasting: >=95 mg/dl 1 h: >=180 mg/dl 2 h: >=155 mg/dl 3 h: >=140 mg/dl

Prevention and Delay of DM type II Patients with IGT (140 to 199 mg/dl after 2h) should

be given counseling on weight loss (5-10%) and increasing physical activity (150 min/week of moderate activity). (A)

Diet includes reduced calories, saturated fat (<7%) calories. (A) Increased whole grain dietary fiber. (B)

Follow-up counseling important for success. (B) Metformin, in addition to lifestyle, may be

considered for those patients with the following risk factors: (E) Obese AND Under 60 years of age AND Combined IFG and IGT PLUS Other risk factors for development of diabetes

Medical Nutrition Therapy (MNT) Individuals who have pre-DM or DM should

receive MNT, preferably provided by a registered dietician. (B)

Weight loss is recommended for all overweight or obese individuals with insulin resistance. (A)

Physical activity and behavioral modification are most helpful in maintenance of wt loss. (B)

People with DM should receive diabetes self-mgt educ (DSME) when their DM is diagnosed and as needed thereafter. (B)

Carbohydrate and other nutrition in diabetes managment Monitoring carbs remains key strategy in

glycemic control. (A) Use of glycemic index (B).

Sugar alcohols and nonnutritive sweeteners are safe when consumed within the acceptable FDA levels (A).

Do not advise routine supplementation w/ antioxidants (Vit E, Vit C, carotene). (A)

Monitor carbs by carb counting, exchanges, and experience estimations.

Self-Monitoring of Blood Glucose (SMBG) and A1C SMBG should be done 3 or more x per day for

patients using multiple insulin injections or insulin pump therapy. (A)

Patient on less frequent insulin dosing or noninsulin therapy then SMBG may be useful in achieving glycemic control. (E)

Point of Care testing A1C allowing timely decisions on therapy when needed. (E)

Perform A1C test at leat two times per year in patients who are meeting treatment goals with stable glycemic control. (E)

A1C test quarterly in patients whose therapy has changed or not meeting glycemic goals. (E)

Glycemic goals

The A1C goal for nonpregnant adults is <7%. (A)

A1C goal <6% is in select patients without significant hypoglycemia. (B)

Less stringent A1C goals may be appropriate for patients with severe hypoglycemia, limited life expectancy, children, comorbid conditions, longstanding DM. (E)

Glycemic Goals Pre-Prandial glucose 70 to 130 mg/dl Peak postprandial glucose < 180 mg/dl 1 to 2

hr after beginning of meal. A1C is the primary target for glycemic control. Postprandial glucose may be targeted if A1C

goals are not met despite reaching preprandial glucose goals.

Hypertension (HTN) and Blood Pressure Control in DM Hypertension defined as either systolic blood

pressure (SBP) >= 130 mmHg OR a diastolic blood pressure (DBP) >= 80 mmHg on two different days. (C)

DM patients treat to SBP < 130. (C) DM patietns treat to DBP < 80. (B) Severe HTN w/ SBP>=140 or DBP>= 90

should receive pharmacotherapy in addition to lifestyle modification. (A)

HTN and BP Control in DM Pharmacotherapy should include ACE inh or

angiotensin receptor blocker (ARB). Thiazide if needed for estimated GFR >=50 or loop diuretic w/ GFR <50. (E)

One or more agents at maximal dose is generally required to achieve blood pressure targets. (B)

Pregnant DM patients w/ chronic HTN BP goal 110-129/ 65-79 mmHg. (E)

Dyslipidemia and Lipid Management in DM Screening annually by fasting lipid profile in

most adult patients. Every 2 years in patients with low-risk lipid values. (E) LDL cholesterol < 100 mg/dl HDL cholesterol > 50 mg/dl Triglycerides < 150 mg/dl

Lifestyle modification (including reducation saturated fat, trans fat, weight loss, and increased physical activity) recommended to improve lipid profile in DM patients. (A)

Statin Therapy Statin therapy added to LTM regardless of

baseline lipid values for diabetic patients: With overt cardiovascular disease (CVD) (A)OR >40 yoa without CVD but one or more CVD risk

factors. (A) Consider adding statin in other patients (<40

yoa without overt CVD) if LDL>100 OR w/ mult CVD risk factors.(E)

CVD RF including dyslipidemia, hypertension, smoking, a positive family history of premature CAD, or presence of micro or macroalbuminuria.

Goals of Treatment Primary goal of LDL < 100 without overt CVD.

(A) Optional goal of LDL <70 with overt CVD using

high dose statin therapy (E). Alternative therapeutic goal of LDL reduction

of 40%, if above LDL goal not achieved with maximal therapy. (A)

LDL cholesterol targeted statin therapy remains the preferred strategy. (C)

Triglycerides and HDL Triglyceride levels < 150 mg/dl and HDL > 40

mg/dl in men and >50 in women are desirable. However, LDL cholesterol targeted stain therapy remains preferrd strategy. (C)

Combination therapy using statins and other lipid lowering agents may be considered to achieve lipid targets but has not been evaluated in outcome studies for either CVD outcomes or safety. (E)

Combined therapy w/ statin/fibrate or statin/niacin associated with increased risk of abnormal transaminases levels, myositis, or rhabdomyolysis.

Antiplatelet Agents Use Aspirin (ASA) 75-162 mg/day as a

secondary prevention in DM with h/o CVD. (A). Use ASA (75-162 mg/day) as a primary

prevention in those w/ type I or type II DM with increased CVD risk: (A) >40 years of age OR Fmhx CVD, hypertension, dyslipidemia, smoking,

or albuminuria.

Antiplatelet agents

Not recommended in people <30 yoa because lack of evidence of benefit(E)

Contraindicated in pateints <21 yoa because of risk of Reye Syndrome(E)

Combination therapy, such as clopidrogel in addition to ASA should be used in patients with severe and progressive CVD. (C)

Advise all patients to stop smoking. (A) Include counseling or other treatment as part of diabetes care. (B)

Coronary Heart Disease (CHD) Screen asymptomatic patients by evaluating

risk factors to stratify patients by 10-year risk, and treat risk factors accordingly. (B)

In patients with known CVD, ACE inh, ASA, and statin therapy should be used to reduce the risk CVD events. (A)

In patients with prior MI, add beta blockers to reduce mortality. (A)

Candidates for further cardiac testing:1. Typical or atypical cardiac symptoms AND2. Abnormal resting EKG

Coronary Heart Disease Patients > 40 yoa w/ addition CVD risk factors

(hyperlipidemia, fmhx, dyslipidemia, microalbuminuria, cardiac autonomic neuropathy, or smoking) ACE inh, ASA, and statin therapy should be used to reduce CVD events. (B)

In patients with treated CHF, metformin and thiazolidinedione (TZD) use are contraindicated. (C)

Nephropathy Screening and Treatment To reduce the risk or slow progression of

nephropathy, optimize glucose and blood pressure control. (A)

Perform an annual test to assess urine albumin excretion in Type I DM after 5 years of DM onset, and annually in type II DM patients. (E)

Measure serum creatinine at least annually to estimate GFR in all adults with DM regardless of degree of urine albumin excretion. (E)

Treatment of Nephropathy: ACE inh and ARBS In patients with type I DM, hypertension, and

any degree of albuminuria, ACE inh have been shown to delay progression of nephropathy. (A)

In patients with type 2 DM, hypertension, and microalbuminuria both ACE inh and ARBs have been shown to delay progression to macroalbuminuria. (A)

In type 2 DM, HTN, macroalbuminuria, and renal insufficiency (Cr>1.5), ARBs have been shown to delay progression of nephropathy. (A)

If one class is not tolerated then the other should be substituted. (E)

Monitor serum Cr and K levels for development of acute kidney disease and hyperkalemia. (E)

Nephropathy Treatment Reduction of protein intake to 0.8 to 1.0 grams x

kg body wt per day may improve measures of renal function (B).

Consider referral to nephrologist when there is uncertainty about the etiology of kidney disease, difficult mgt issues, or advanced kidney diseae. (B)

Monitor urine albumin excretion to asses both the response to therapy and progression of disease.

If active urine sediment, absence of retinopathy, or rapid delcine in GFR may not be DM nephropathy.

Retinopathy Screening and Treatment To reduce the risk and slow progression of

retinopathy, optimize glycemic and blood pressure control. (A)

Type 1 DM patients should have initial dilated and comprehensive eye exam within 5 years of onset of disease. (B)

Type 2 DM patients should have eye exam shortly after dx of DM. (B)

Subsequent exams for Type 1 and 2 DM patients should be annually. (B)

DM Retinopathy Promptly refer patients to opthalmology

with any level of macular edema, severe nonproliferative diabetic retinopathy (NPDR), or any proliferative diabetic retinopathy. (A)

Laser photocoagulation therapy indicated with high-risk PDR, sig macular edema, and severe NPDR. (A)

The presence of retinopathy is not CI to use of ASA and does not increase chance of retinal hemorrhage. (A)

Neuropathy All patients should be screened for DPN at dx of

DM at least annually there after, using clinical tests including pinprick sensation, temperature, vibration perception, 10 gram monofilament pressure sensation, and ankle reflexes. (A)

Combination of more than one of these tests has >87% sensitivity in detecting DPN.

Simple inspection of insensate feet should be performed at 3 to 6 month intervals. An abnormality should trigger referral for special footwear, preventative specialist, or podiatric care. (B)

DPN Reccomendations Provide general foot self-care education to all

patients with DM. (B) Refer patients who smoke, have loss of

protectlie sensation and structural abnormalities or have h/o prior LE complication to foot care specialists. (C)

Initial screening for PAD include h/o caludiacation, assessment of pedal pulses, and ABI. (C)

Screening ABI performed in patients >50 yoa and <50 yoa if PAD RF (smoking, HTN, HLD, or DM >10 Years)

Immunizations Annually provide influenza vaccine to all

diabetic patients >= 6 months of age. (C) Provide at least one lifetime pneumococcal

vaccine for adults with diabetes. A one-time revaccination recommended for adults 65 or older, who were previously immunized over 5 years ago. (C)

Components of the comprehensive diabetes evaluation

Medical history Age and characteristics of onset of diabetes (e.g., DKA,

asymptomatic laboratory finding) Eating patterns, nutritional status, and weight history;

growth and development in children and adolescents Diabetes education history Review of previous treatment regimens and response to

therapy (A1C records) Current treatment of diabetes, including medications, meal

plan, physical activity patterns, and results of glucose monitoring and patient’s use of data

DKA frequency, severity, and cause Hypoglycemic episodes and awareness Any severe hypoglycemia: frequency and cause

Diabetes Evaluation

History of diabetes-related complications Microvascular: retinopathy, nephropathy,

neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis)

Macrovascular: CHD, cerebrovascular disease, PAD

Other: psychosocial problems, dental disease

Diabetes Evaluation

Physical examination Height, weight, BMI Blood pressure determination, including orthostatic

measurements when indicated Fundoscopic examination Thyroid palpation Skin examination (for acanthosis nigricans and insulin injection

sites) Comprehensive foot examination: Inspection Palpation of dorsalis pedis and posterior tibial pulses Presence/absence of patellar and Achilles reflexes Determination of proprioception, vibration, and monofilament

sensation

Diabetes Evaluation Laboratory evaluation A1C, if results not available within past 2–3 months

If not performed/available within past year: Fasting lipid profile, including total, LDL, and HDL

cholesterol and triglycerides Liver function tests Test for urine albumin excretion with spot urine

albumin-to-creatinine ratio Serum creatinine and calculated GFR Thyroid-stimulating hormone in type 1 diabetes,

dyslipidemia or women over age 50

Diabetes Evaluation Referrals Annual dilated eye exam Family planning for women of reproductive

age Registered dietitian for MNT Diabetes self-management education Dental examination Mental health professional, if needed

ReferencesAmerican Diabetes Association. “Position Statement: Standards of Medical Care in Diabetes – 2008.” Diabetes Care. 31(1): S1-S54, 2008

http://care.diabetesjournals.org/cgi/reprint/31/Supplement_1/S12