1. American Diabetes Association (ADA) 2010
American College of Endocrinology (ACE) &
American Association of Clinical Endocrinologists
(AACE)Consensus Statement on DM2
2. Standardized A1C assay, Fasting atleast 8 hrs, GTT with 75 g of anhydrous glucose in
water, Symptoms of Hyperglycemis
* In the absence of unequivocal hyperglycemia, criteria 1-3 should be confirmed with
repeat assay.
3. For all three tests risk is continuous, exceeding below the lower limit of the
range and becoming disproportionately greater at higher end of the range.
4. Criteria for Diabetes Testing in
asymptomatic Adults
• Overweight BMI ≥25 kg/m2
• Physical Inactivity
• First degree relative with Diabetes
• Members of High risk ethnic populations
• HTN ≥140/90 or on HTN therapy
• HDL <35 and/or TG >250
• A1C ≥5.7%, IGT, IFG on previous testing
• History of CVD
• Women with baby >9lbs or H/O GDM
• Insulin resistance (acanthosis, obesity, PCOD)
• In absence of above at 45 yr of age
• If testing is normal repeat after 3 years*
5. Standardized A1C assay, Fasting atleast 8 hrs, GTT with 75 g of anhydrous glucose in
water, Symptoms of Hyperglycemis
* In the absence of unequivocal hyperglycemia, criteria 1-3 should be confirmed with
repeat assay.
6. Components of Comprehensive
Diabetes Evaluation
Medical history
• Age, onset & characteristics of onset of DM
• Eating patterns, Physical activity, weight history,
growth and developmental history.
• Diabetes education history
• Review of previous treatment regimens and response
to therapy (A1C records)
• Current treatment of diabetes
• DKA frequency, severity, and cause
• Hypoglycemia awareness and episodes
• History of diabetes-related complications
8. Components of Comprehensive
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/creatinine ratio
• Serum creatinine and calculated GFR
• TSH in type 1 diabetes, dyslipidemia, or women over
age 50 years
9. Components of Comprehensive
Diabetes Evaluation
Referrals
• Annual dilated eye exam
• Family planning for women of reproductive
age
• Registered dietitian for MNT
• DSME
• Dental examination
• Mental health professional, if needed
12. DSME
• People with diabetes should receive DSME
according to national standards when their
diabetes is diagnosed and as needed thereafter.
• Effective self-management and quality of life are
the key outcomes of DSME and should be
measured and monitored as part of care.
• DSME should address psychosocial issues, since
emotional well-being is associated with positive
diabetes outcomes.
• Because DSME can result in cost-savings and
improved outcomes, DSME should be reimbursed
13. Glucose Monitoring
• SMBG
• CGM (Continuous Glucose Monitoring)
• HbA1C & eAG
– Two Times a year if meeting goals & stable
Glycemia
– Quarterly if not meeting goals or Change in
Therapy
– eAG (estimated average glucose)
15. Glycemic Recommendations
• Postprandial Glucose may be targeted if A1C
are not met despite reaching preprandial goal.
• A1C is the primary target for glycemic control
• Goals should be induvidualized on
– Duration of diabetes
– Age/life expectancy
– Comorbid conditions
– Known CVD or advanced microvascular comp
– Hypoglycemic episodes and awareness
16. Medical Nutrition Therapy (MNT)
• Individuals who have pre-diabetes or diabetes should
receive individualized MNT as needed to achieve treatment
goals, preferably provided by a registered dietitian familiar
with the components of diabetes MNT
• For weight loss, either low carbohydrate or low-fat calorie-
restricted diets
• 14 g fiber/1,000 kcal and foods containing whole grains
• Saturated fat intake should be 7% of total calories
• Reducing intake of trans fat lowers LDL cholesterol and
increases HDL cholesterol
• Monitoring carbohydrate intake, whether by carbohydrate
counting, exchanges, or experience-based estimation,
remains a key strategy in achieving glycemic control
17. Physical Activity
• People with diabetes should be advised to
perform at least 150 min/week of moderate-
intensity aerobic physical activity (50–70% of
maximum heart rate)
• In the absence of contraindications, people with
type 2 diabetes should be encouraged to perform
resistance training three times per week.
• emphasizing lifestyle changes that include
moderate weight loss (7% body weight)
21. A1C 6.5% to 7.5%
• Monotherapy Metformin
• Dual Therapy :
– Metformin + Incretin Mimetic (GLP-1 agonist)/DPP-4
inhibitor/SU/Glitinides
*If metformin is contraindicated TZD may be used as foundation for the group
• Triple Therapy :
– Metformin+GLP-1+TZD/Glitinide/SU
– Metformin+DPP-4+TZD/Glitinide/SU
• Insulin Therapy
22. A1C 7.6% to 9%
• Dual Therapy :
– Metformin + Incretin Mimetic (GLP-1 agonist)/DPP-4
inhibitor/TZD/SU/Glitinides
• Triple Therapy :
– Metformin+GLP-1 agonist +TZD
– Metformin+DPP-4 inhibitor +TZD
– Metformin+GLP-1 agonist + SU
– Metformin+DPP-4 inhibitor +SU
– Metformin +TZD + SU
Glitinides/AGIs/Colesevelam are not considered in this group because of their limitied A1C
potential
• Insulin Therapy
23. A1C >9%
• For Drug-naïve patients with these A1C levels, it is unlikely that use of
1/2/3 agents (other than insulin) will achive A1C <6.5%. Drug therapy can
be used if patient is asymptomatic , recent onset and good probability
that some beta cell function exists.
• Combination Therapy:
– Metformin+GLP-1 agonist
– Metformin+GLP-1 agonist+SU
– Metformin+DPP-4 inhibitor
– Metformin+DPP-4 inhibitor+SU
– Metformin+TZD
– Metformin+TZD+SU
– Metformin+GLP-1 agonist+TZD
– Metformin+DPP-4 inhibitor+TZD
• Insulin Therapy
27. Basal Insulin
• Generally the initial choice for initiation of insulin
therapy
• Glargine and Detemir are preferred over NPH due
to peak-less activity, consistent effect and lower
chance of hypoglycemia.
• Started at 10 U at bedtime and titrated up 1 to 3
U every 2-3 days until the FBS levels are in
desired range
• Dose is reduced if FBS levels are lower than
Specified threshold.
28. Premixed Insulin
• Therapy is titrated with the major meal of the
day (typically dinner) and subsequently another
injection is added with the second largest meal.
• Dose before breakfastmeasure Pre dinner
• Dose before Dinner Measure FBS in am
• 2 injections in a day
• Patient must have a constant lifestyle
• Higher risk of hypoglycemia
29. Basal-Bolus Insulin Regimens
• 4 injections per day
• Long acting (glargine/detemir) Basal Once +short
acting (regular/lispro) Bolus with meals
• Greater flexibility, better for patients with variable
lifestyle.
• Before meal dose 5 U or 7% of total basal insulin dose.
• Bolus insulin titrated 2-3U every 2-3 days on basis of 2-
hr Postprandial Levels
• Titration should achieve good control in A1C levels, Pre
& postprandial Glycemia.
30.
31.
32. Prevention and management of
Diabetes Complications
• HTN/BP control
– BP measurement every routine visit
– If ≥130 / ≥80 should have a repeat measurement on
a separate day, if repeat same then HTN
– Target BP <130 systolic & <80 Diastolic
– Lifestyle modification, wt loss, ↓Na, ↑ K intake,
moderate alcohol intake and Physical activity.
– ACE/ARB +Thiazide/loop diuretic (GFR)/calcium
channel blocker/β blockers.
– Monitor K levels when above drugs are used.
33. Prevention and management of
Diabetes Complications
• Dyslipidemia/Lipid management
– FLP anually
– Target LDL<100 mg/dl, HDL >50 mg/dl, TGs<150
mg/dl
– If values as above FLP repeat in 2 years.
– Lifestyle modifications, ↓ Saturated fats, Trans fat,
cholesterol, ↑ Omega 3 FA, Fibers, Plant sterol, wt
loss.
– Statin therapy in pt with CVD and/or >40 yrs and/or
LDL >100 with lifestyle mod.
– LDL lowering is the main goal.
34. Prevention and management of
Diabetes Complications
• Antiplatelet Therapy
• Asprin 75-162 mg/day if :
– One additional risk factor e.g. (Smoking, HTN,
Dyslipidemia, Family history), >50 men, >60
women
– Secondary prevention in pt with h/o CVD
– If allergic to asprin and CVD use clopidogril
– Asprin+clopidogril for 1 year in patients after an
Acute Coronary Synd.
35. Prevention and management of
Diabetes Complications
• Smoking cessation
– Advise all not to smoke
– Include smoking cessation counseling and other
form of treatments as a routine component of
Diabetes care.
.
36. Prevention and management of
Diabetes Complications
• Coronary Heart disease screening and Rx
– In asymp pt evaluate risk factors by 10 yr risk
– In pt with known CVD : ACEi+Asprin+Statin should
be used if not contraindicated In pt with prior MI:
β blocker for 2 atleast 2 yrs
– Avoid TZD in pt with Symptomatic Heart faliure
– Metformin can be used in pt with stable CHF if
Renal func is normal
– Metformin shoul be avoided in Hospitalized or
Unstable pt with CHF.
37. Prevention and management of
Diabetes Complications
• Nephropathy Screening and Rx
– Annual Creatinine & Urine Microalbumin testing
– If Micro/Macro Albuminuria ACEi/ARB
– ACEi/ARB delay progression to Macroalbuminuria
– If DM 2 +HTN +Macroalbumin+Cr>1.5 ARB have
shown to delay progress ion of nephropathy.
– ↓ Protein to 0.8-1g/kg in pt with DM and early CKD
– Monitor CR and K when using ACEi/ARB
– Consider referral to a Nephrologist.
38. Prevention and management of
Diabetes Complications
Category Spot Collection (μg/mg creatinine)
Normal <30
Microalbuminuria 30-299
Macroalbuminuria (Clinical) ≥300
39. Prevention and management of
Diabetes Complications
• Retinopathy Screening & Rx
– Type 1 DM : Initial within 5 yrs of Onset
– Type 2 DM : at the time of Dx
– Then annually
– Less frequent (q 2-3 yrs) if 2-3 exams are normal
– Ophthalmology Referral
– Retinopathy is not a contraindication for Asprin
Therapy & doent ↑ the risk of Hemorrhage.
40. Prevention and management of
Diabetes Complications
• Neuropathy Screening & Rx
– All should be screened for Distal Symmetric
Polyneuropathy (DPN) at diagnosis & annually.
– Diabetic Autonomic Neuropathy
– Foot care
– Annual Foot exam
– General foot self care education
– LOPS, PAD
41. Prevention and management of
Diabetes Complications
• Risk of Ulcers or Amputation increases in pat who
have following
– Previous amputation
– Past foot ulcer history
– Peripheral Neuropathy
– PVD
– Foot deformity
– Visual Impairment
– Diabetic Nephropathy (specially pt on Dialysis)
– Poor glycemic control
– Cigarette smoking
