American Diabetes Association clinical practice recommendations 2012

1. AMERICAN DIABETES ASSOCIATION NEW
CLINICAL PRACTICE RECOMMENDATIONS
2012
http://crisbertcualteros.page.tl

2. CURRENT CRITERIA FOR THE DIAGNOSIS OF
DIABETES
 HbA1C ≥6.5%
 (FPG) ≥126 mg/dL (7.0 mmol/l)
 2-h plasma glucose ≥200 mg/dL (11.1 mmol/l)/ 2-h
75-g OGTT
 random plasma glucose ≥200 mg/dL (11.1 mmol/l)

3. TESTING FOR DIABETES IN ASYMPTOMATIC
PATIENTS
 adults who are overweight/obese (BMI ≥25 kg/m2)
 have one or more additional risk factors for
diabetes
 those without these risk factors, testing should
begin at age 45 years.
 If normal, repeat at least at 3-year intervals
 increased risk for future DM, identify /treat other
(CVD) risk factors

4. DETECTION AND DIAGNOSIS OF (GDM)
 Screen for undiagnosed T2DM at the 1st PNC in
those with risk factors
 not known to have DM, screen at 24-28 wks AOG
(75-g 2-h OGTT)
 Screen for persistent GDM at 6–12 wks
postpartum, using a test other than A1C
 Hx of GDM – test every 3 years
 Hx of GDM found prediabetic – lifestyle
interventions OR Metformin

5. PREVENTION/DELAY OF TYPE 2 DM
 IGT, IFG, or A1C 5.7–6.4%:
1. wt loss 7% body wt
2. increase physical activity atleast 150 min/week of
moderate activity (ex. Walking)
 Metformin tx: for prevention of T2DM in those w/
IGT, IFG, A1C 5.7-6.4%, BMI>35, <60 yo & prior
GDM
 Annual monitoring for prediabetes

6. GLUCOSE MONITORING
 Self-monitoring of blood glucose (SMBG) should be
3 or more times daily for pt w/ multiple insulin
injections or insulin pump therapy
 To achieve postprandial glucose targets,
postprandial SMBG may be appropriate

7. HBA1C
 at least 2x a year in patients who are meeting
treatment goals (and who have stable glycemic
control)
 quarterly in patients whose therapy has changed or
who are not meeting glycemic goals

8. GLYCEMIC GOALS IN ADULTS
 Lower A1C to <7% to reduce microvascular
complications
 reasonable A1C goal for nonpregnant adults is <7%
 More stringent A1C goals (<6.5%) if achieved w/o
significant hypoglycemia or other adverse effects
 Less stringent A1C goals (<8%) for pt w/ hx of
severe hypoglycemia, limited life expectancy,
advanced micro/macrovascular complications,
extensive comorbid conditions and longstanding
DM in whom the goal is difficult to attain

9. THERAPY FOR TYPE 2 DM
 initiate Metformin with lifestyle interventions, unless
contraindicated
 markedly symptomatic and/or elevated blood
glucose levels or A1C, consider insulin therapy, with
or without additional agents
 If noninsulin monotherapy at maximal tolerated
dose does not achieve/maintain the A1C target over
3–6 months, add a second oral agent, a GLP-1
receptor agonist, or insulin.

10. RECOMMENDATIONS FOR ENERGY BALANCE,
OVERWEIGHT, AND OBESITY
 Wt loss is for all overweight/obese
 For wt loss: low-carbohydrate, low-fat calorie-
restricted, or Mediterranean diets may be effective
in the short term (up to 2 years)
 For pt on low-carbohydrate diets: monitor lipid
profiles, renal function, and protein intake

11. PRIMARY PREVENTION OF DIABETES
1. moderate weight loss (7% body weight)
2. regular physical activity (150 min/week)
3. dietary strategies that include reduced calories
and reduced intake of dietary fat
4. dietary fiber (14 g fiber/1,000 kcal) & foods
containing whole grains (one-half of grain intake)
5. limit their intake of sugar-sweetened beverages.

12. OTHER NUTRITION RECOMMENDATIONS
Alcohol:
 one drink per day or less for adult women
 two drinks per day or less for adult men
 should take extra precautions to prevent
hypoglycemia
Not advised: routine supplementation:
antioxidants(vitamins E and C and carotene)

13. PHYSICAL ACTIVITY
 at least 150 min/week, moderate-intensity aerobic
physical activity(50–70% of max heart rate), spread
over at least 3 days/wk with no >2 consecutive days
w/o exercise
 In the absence of contraindications, people with
type 2 DM: encouraged to perform resistance
training at least twice/week

14. HYPOGLYCEMIA
 Glucose (15–20 g) is the preferred treatment for the
conscious individual with hypoglycemia, although
any form of carbohydrate that contains glucose may
be used
 If SMBG 15 min after treatment shows continued
hypoglycemia, repeat treatment
 Once glucose returns to normal, pt should consume
a meal or snack to prevent recurrence of
hypoglycemia

15. HYPOGLYCEMIA
 Glucagon should be prescribed for all individuals at
risk of severe hypoglycemia, & caregivers
instructed for administration.
 Individuals with hypoglycemia unawareness or one
or more episodes of severe hypoglycemia should
be advised to raise their glycemic targets to strictly
avoid further hypoglycemia for at least several
weeks

16. IMMUNIZATION
 Annually: influenza vaccine to all DM pts ≥6 months
of age
 Pneumococcal vaccine to all DM pts ≥2 yo. A one-
time revaccination is recommended for individuals
>64 yo previously immunized when they were <65
yo if the vaccine was administered >5 years ago.
 Administer hep B vaccination to adults with DM as
per (CDC) recommendations

17. HPN/BP CONTROL SCREENING AND
DIAGNOSIS
 Goal systolic BP <130 mmHg is appropriate for
most patients with diabetes
 Pts with DM should be treated to a DBP<80 mmHg

18. HPN TX
 either an ACE inhibitor or an ARB
 Administer one or more antihypertensive
medications at bedtime
 If ACE inhibitors (Ramipril), ARBs(Losartan), or
diuretics(HCTZ) are used, kidney function and
serum potassium levels should be monitored.

19. LIPID MANAGEMENT SCREENING
low-risk lipid values:
1. LDL cholesterol <100 mg/dL
2. HDL cholesterol >50 mg/dL
3. triglycerides <150 mg/dL)
 lipid assessments may be repeated every 2 years

20. TREATMENT RECOMMENDATIONS AND GOALS
 Lifestyle modification: reduction of saturated fat,
trans fat, and cholesterol intake
 increase of n-3 fatty acids, viscous fiber and plant
stanols/sterols
 weight loss
 increased physical activity

21.  Statin therapy should be added to lifestyle therapy,
regardless of baseline lipid levels for diabetic
patients:
 w/ overt CVD
 w/o CVD who are > 40 years and have one or more
other CVD risk factors
 Lower-risk pts: statin should be considered in
addition to lifestyle therapy if LDL cholesterol
remains >100 mg/dL or in those with multiple CVD
risk factors

22.  w/o overt CVD, the primary goal is LDL cholesterol
<100 mg/dL
 w/ overt CVD, a lower LDL cholesterol goal of <70
mg/dL, using a high dose of a statin
 If pts do not reach the targets on maximal tolerated
statin therapy, a reduction in LDL cholesterol of
∼30–40% from baseline is an alternative
therapeutic goal

23.  TG <150 mg/dL & HDL >40 mg/dL in men
 HDL>50 mg/dL in women are desirable.
 LDL cholesterol–targeted statin therapy remains the
preferred strategy
 If targets are not reached on maximally tolerated
doses of statins, combination therapy W/ statins
and other lipid-lowering agents may be
considered

24. ANTIPLATELET AGENTS
 Aspirin 75–162 mg/day: primary prevention for DM
at high cardiovascular risk: men >50 or women >60
w/ atleast 1 additional major risk factor (family w/
CVD, HPN, smoking, dyslipidemia, albuminuria)
 Aspirin not be recommended for CVD prevention
for DM at low CVD risk
 Aspirin: 2ndary prevention in DM with Hx of CVD
 Aspirin allergy: Clopidogrel (75 mg/day)
 Combination: ASA & clopidogrel for 1 year after
an acute coronary syndrome

25. CORONARY HEART DISEASE SCREENING AND
TREATMENT
 w/ CVD: ACE inhibitor, aspirin and statin therapy (if
not contraindicated) to reduce the risk of
cardiovascular event
 prior myocardial infarction: β-blockers should be
continued for at least 2 years after the event.
 Avoid TZD in symptomatic heart failure
 Metformin may be used in stable (CHF) if renal
function is normal.

26. NEPHROPATHY SCREENING AND TREATMENT
 To slow the progression of nephropathy, optimize
glucose control & blood pressure control
 Screening:
1. Annual urine albumin excretion
2. Annual serum creatinine regardless of degree of
UAE
 Treatment: nonpregnant w/ micro/macroalbuminuria
- either ACE inh or ARBs
 Continued monitoring of UAE to assess both
response to therapy and progression of disease

27. RETINOPATHY SCREENING AND TREATMENT
 To slow the progression of retinopathy, optimize
glycemic & BP control
Screening:
 Adults & children aged 10 yo or older with type 1
DM should have an initial dilated and
comprehensive eye examination within 5 years
after the onset of diabetes

28.  T2DM pts should have initial dilated and
comprehensive eye examination shortly after the
diagnosis
 Subsequent examinations for type 1 and type 2 DM
patients should be repeated annually
 Every 2–3 years: may be considered following one
or more normal eye exams.

29. Tx:
 Promptly refer pts w/ any level of macular
edema, severe nonproliferative diabetic retinopathy
(NPDR), or any PDR to an ophthalmologist
 Laser photocoagulation therapy is indicated to
reduce the risk of vision loss in high-risk
PDR, clinically significant macular edema, and
some cases of severe NPDR

30. NEUROPATHY SCREENING AND TREATMENT
 should be screened for distal symmetric
polyneuropathy (DPN) starting at diagnosis & 5
years after the diagnosis & annually thereafter
 Meds for the relief of specific symptoms related to
painful DPN & autonomic neuropathy are
recommended

31. FOOT CARE
 For all DM: annual comprehensive foot examination
to identify risk factors predictive of ulcers &
amputations
 The foot examination include: inspection,
assessment of foot pulses, and testing for loss of
protective sensation (10-g monofilament plus
testing any one of the following: vibration using
128-Hz tuning fork, pinprick sensation, ankle
reflexes, or vibration perception threshold)

32.  Refer pts who smoke, loss of protective sensation &
structural abnormalities, or w/ history of prior lower-
extremity complications to foot care specialists for
preventive care and life-long surveillance
 Initial screening for peripheral arterial disease
(PAD) include: history for claudication and an
assessment of the pedal pulses. Consider obtaining
an ankle-brachial index (ABI), as many patients
with PAD are asymptomatic

33. http://crisbertcualteros.page.tl