Standards of Medical Care in Diabetes—2013
- American Diabetes Association
Article Figures & Tables
Tables
- Table 1
ADA evidence grading system for clinical practice recommendations
Level of evidence Description A Clear evidence from well-conducted, generalizable RCTs that are adequately powered, including:
• Evidence from a well-conducted multicenter trial
• Evidence from a meta-analysis that incorporated quality ratings in the analysis
Compelling nonexperimental evidence, i.e., “all or none” rule
developed by the Centre for Evidence-Based Medicine at the University of Oxford
Supportive evidence from well-conducted RCTs that are adequately powered, including:
• Evidence from a well-conducted trial at one or more institutions
• Evidence from a meta-analysis that incorporated quality ratings in the analysisB Supportive evidence from well-conducted cohort studies
• Evidence from a well-conducted prospective cohort study or registry
• Evidence from a well-conducted meta-analysis of cohort studies
Supportive evidence from a well-conducted case-control studyC Supportive evidence from poorly controlled or uncontrolled studies
• Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results
• Evidence from observational studies with high potential for bias (such as case series with comparison with historical controls)
• Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendationE Expert consensus or clinical experience - Table 4
Criteria for testing for diabetes in asymptomatic adult individuals
1. 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
• high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, 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 ovary syndrome
• A1C ≥5.7%, IGT, or IFG on previous testing
• other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
• history of CVD2. In the absence of the above criteria, testing for diabetes should begin at age 45 years. 3. If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results (e.g., those with prediabetes should be tested yearly) and risk status. ↵* At-risk BMI may be lower in some ethnic groups.
- Table 5
Testing for type 2 diabetes in asymptomatic children*
Criteria • Overweight (BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height) Plus any two of the following risk factors: • Family history of type 2 diabetes in first- or second-degree relative • Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) • Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight) • Maternal history of diabetes or GDM during the child’s gestation Age of initiation: age 10 years or at onset of puberty, if puberty occurs at a younger age Frequency: every 3 years ↵* Persons aged 18 years and younger.
- Table 6
Screening for and diagnosis of GDM
Perform a 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24–28 weeks of gestation in women not previously diagnosed with overt diabetes. The OGTT should be performed in the morning after an overnight fast of at least 8 h. The diagnosis of GDM is made when any of the following plasma glucose values are exceeded:
• Fasting: ≥92 mg/dL (5.1 mmol/L)
• 1 h: ≥180 mg/dL (10.0 mmol/L)
• 2 h: ≥153 mg/dL (8.5 mmol/L) - Table 7
Components of the comprehensive diabetes evaluation
Medical history • Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding) • Eating patterns, physical activity habits, 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, medication adherence and barriers thereto, meal plan, physical activity patterns, and readiness for behavior change • Results of glucose monitoring and patient’s use of data • DKA frequency, severity, and cause • Hypoglycemic episodes Hypoglycemia awareness Any severe hypoglycemia: frequency and cause • 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, and PAD Other: psychosocial problems*, dental disease* 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 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 • TSH in type 1 diabetes, dyslipidemia or women over age 50 years Referrals • Eye care professional for annual dilated eye exam • Family planning for women of reproductive age • Registered dietitian for MNT • DSME • Dentist for comprehensive periodontal examination • Mental health professional, if needed ↵* See appropriate referrals for these categories.
- Table 9
Summary of glycemic recommendations for many nonpregnant adults with diabetes
A1C <7.0%* Preprandial capillary plasma glucose 70–130 mg/dL* (3.9–7.2 mmol/L) Peak postprandial capillary plasma glucose† <180 mg/dL* (<10.0 mmol/L) •*Goals should be individualized based on: duration of diabetes age/life expectancy comorbid conditions known CVD or advanced microvascular complications hypoglycemia unawareness individual patient considerations • More or less stringent glycemic goals may be appropriate for individual patients • Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals ↵†Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.
- Table 10
Summary of recommendations for glycemic, blood pressure, and lipid control for most adults with diabetes
A1C <7.0%* Blood pressure <140/80 mmHg** Lipids LDL cholesterol <100 mg/dL (<2.6 mmol/L)† Statin therapy for those with history of MI or age over 40+ other risk factors ↵* More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.
**Based on patient characteristics and response to therapy, lower systolic blood pressure targets may be appropriate.
†In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dL (1.8 mmol/L), using a high dose of a statin, is an option.
- Table 11
Definitions of abnormalities in albumin excretion
Category Spot collection (μg/mg creatinine) Normal <30 Increased urinary albumin excretion* ≥30 ↵* Historically, ratios between 30 and 299 have been called microalbuminuria and those 300 or greater have been called macroalbuminuria (or clinical albuminuria).
- Table 12
Stages of CKD
Stage Description GFR (mL/min/1.73 m2 body surface area) 1 Kidney damage* with normal or increased GFR ≥90 2 Kidney damage* with mildly decreased GFR 60–89 3 Moderately decreased GFR 30–59 4 Severely decreased GFR 15–29 5 Kidney failure <15 or dialysis ↵* Kidney damage defined as abnormalities on pathological, urine, blood, or imaging tests. Adapted from ref. 359.
- Table 13
Management of CKD in diabetes
GFR Recommended All patients Yearly measurement of creatinine, urinary albumin excretion, potassium 45–60 Referral to nephrology if possibility for nondiabetic kidney disease exists (duration of type 1 diabetes <10 years, heavy proteinuria, abnormal findings on renal ultrasound, resistant hypertension, rapid fall in GFR, or active urinary sediment on ultrasound) Consider need for dose adjustment of medications Monitor eGFR every 6 months Monitor electrolytes, bicarbonate, hemoglobin, calcium, phosphorus, parathyroid hormone at least yearly Assure vitamin D sufficiency Consider bone density testing Referral for dietary counseling 30–44 Monitor eGFR every 3 months Monitor electrolytes, bicarbonate, calcium, phosphorus, parathyroid hormone, hemoglobin, albumin, weight every 3–6 months Consider need for dose adjustment of medications <30 Referral to nephrologist - Table 14
Common comorbidities for which increased risk is associated with diabetes
Hearing impairment Obstructive sleep apnea Fatty liver disease Low testosterone in men Periodontal disease Certain cancers Fractures Cognitive impairment Depression - Table 15
Plasma blood glucose and A1C goals for type 1 diabetes by age-group
Values by age (years) Plasma blood glucose goal range (mg/dL) A1C Rationale Before meals Bedtime/overnight Toddlers and preschoolers (0–6) 100–180 110–200 <8.5% • Vulnerability to hypoglycemia • Insulin sensitivity • Unpredictability in dietary intake and physical activity • A lower goal (<8.0%) is reasonable if it can be achieved without excessive hypoglycemia School age (6–12) 90–180 100–180 <8% • Vulnerability of hypoglycemia • A lower goal (<7.5%) is reasonable if it can be achieved without excessive hypoglycemia Adolescents and young adults (13–19) 90–130 90–150 <7.5% • A lower goal (<7.0%) is reasonable if it can be achieved without excessive hypoglycemia Key concepts in setting glycemic goals: • Goals should be individualized and lower goals may be reasonable based on benefit-risk assessment. • Blood glucose goals should be modified in children with frequent hypoglycemia or hypoglycemia unawareness. • Postprandial blood glucose values should be measured when there is a discrepancy between preprandial blood glucose values and A1C levels and to help assess glycemia in those on basal/bolus regimens.