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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Diabetes and Endocrinology,Related

Diabetes - 2017 Summary Document

Diabetes - 2017 Summary Document - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Diabetes and Endocrinology, Related


2017 Diabetes Guideline: Key Practice Recommendations
(New recommendations/key revisions in green)
When to Screen - Adults
As
ym
pt
o
ma
tic

Ad
u
lt
s

Patients of any age with BMI
> 25 kg/m2 (or > 23 kg/m2 in
Asian Americans) AND one
or more additional risk
factors. (UW Health Moderate
quality evidence, weak/conditional
recommendation)
If results are normal, do
not repeat testing more
frequently than every 3
years (UW Health Low quality
evidence, weak/conditional
recommendation)
Adult Risk Factors
ξ A1C > 5.7%, IGT, or IFG on previous testing
ξ First-degree relative with diabetes
ξ High risk race/ethnicity (e.g., African American, Latino,
Native American, Asian American, Pacific Islander)
ξ Women diagnosed with GDM
ξ History of CVD
ξ HTN (> 140/90 mmHg or on HTN therapy)
ξ HDL < 35 mg/dL and/or TG level > 250 mg/dL
ξ Women with polycystic ovary syndrome
ξ Physical inactivity
ξ Chronic glucocorticosteroid exposure
ξ Atypical antipsychotic use
ξ Sleep disorders, including OSA, chronic sleep
deprivation, and night-shift work
ξ Other clinical conditions associated with insulin
resistance (e.g., severe obesity, acanthosis nigricans)
Pr
eg
n
a
nt
W
o
me
n In pregnant
women with risk
factors, test for
undiagnosed
type 2 diabetes
at first prenatal
visit.
(ADA Grade B)
Test for
GDM at
24-28
wks. using
OGTT.
(ADA Grade
E)
Screen women with GDM
for persistent diabetes at
4-12 wks. postpartum
using the OGTT. (ADA
Grade E)
Women with a history of
GDM should have lifelong
screening at least every 3
yrs. (ADA Grade B)
Co
mo
rb
id

Co
n
d
it
io
n
Annually screen
patients on
atypical
antipsychotic
therapy. (ADA
Grade B)
Patients with HIV should be screened with fasting glucose every 6-12 months before staring
antiretroviral therapy and 3 months after starting or changing antiretroviral therapy. If normal,
recheck every year. If prediabetes, recheck every 3-6 months.
(ADA Grade E)
When to Screen- Pediatrics
As
ym
pt
o
ma
tic

Ch
il
dr
en
Patients > 10 yrs. (or at onset of puberty if
earlier) with BMI > 85th percentile for age and
sex, weight for height > 85th percentile, or
weight > 120% of ideal for height AND two or
more additional risk factors. (ADA Grade E)
If results
normal,
repeat testing
every 3 years.
(ADA Grade C)
Pediatric Risk Factors
ξ First or second-degree relative with type 2
diabetes
ξ High risk race/ethnicity (e.g., Native American,
African American, Latino, Asian American,
Pacific Islander)
ξ Signs of insulin resistance or conditions
associated with insulin resistance (acanthosis
nigricans, HTN, dyslipidemia, polycystic
ovarian syndrome, or small-for-gestational-age
birth weight)
ξ Maternal history of diabetes or GDM during
pregnancy
C
hi
ld
re
n

w
it
h
C
ys
t
i
c
F
ib
ro
si
s Annually screen for cystic-fibrosis related diabetes (CFRD)
with OGTT by age 10 yrs. (ADA Grade B)
A1C is not a recommended test. (ADA Grade B)
Testing Options/Results (ADA Grade B)
(Test should be repeated if abnormal result) Post-Diagnosis Testing for Prediabetes or Diabetes
A1C
5.7- 6.4% Prediabetes
Perform A1C at
least twice a year
if meeting
treatment goals
(i.e., stable
glycemic control).
(ADA Grade E)
Perform A1C
quarterly if
therapy
changes or
when not
meeting
glycemic
goals.
(ADA Grade E)
Consider
obtaining A1C in
patients
admitted to the
hospital if result
not available in
the previous 3
months.
(ADA Grade E)
Prediabetics
should be
tested at least
annually.
(ADA Grade E)
> 6.5% Diagnosis
Fasting
Plasma
Glucose*
100- 125 mg/dL Prediabetes
> 126 mg/dL Diagnosis
2-h PG
on 75-g
OGTT
140- 199 mg/dL Prediabetes
> 200 mg/dL Diagnosis
*Blood glucose rather than A1C should be used to
diagnose acute onset of type 1 if symptoms of
hyperglycemia present. (ADA Grade E)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

2017 Diabetes Guideline: Key Practice Recommendations
(New recommendations/key revisions in green)

Glycemic Targets (should be individualized)
Adults
A1C < 7.0% (ADA Grade A) ξ 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.
ξ Postprandial values may be targeted if A1C goals not met despite reaching
premeal glucose targets. Postprandial glucose measurements should be
made 1-2 hours after beginning the meal.
Preprandial
glucose
80-130 mg/dL
Post-prandial
glucose
< 180 mg/dL
Pediatrics
A1C < 7.5% (ADA Grade E) ξ Goals should be individualized, and lower goals may be reasonable based
on a benefit-risk assessment (e.g., achieved w/o excessive hypoglycemia).
ξ Blood glucose goals should be modified in patients with frequent
hypoglycemia or hypoglycemia unawareness.
ξ Postprandial blood glucose values should be measured when there is a
discrepancy between preprandial values and A1C levels and to help assess
preprandial insulin doses in those on basal-bolus or pump regimens.
Before meals 90-130 mg/dL
Bedtime/overnight 90-150 mg/dL
Pregnant
Women
Gestational Diabetes (GDM) Preexisting type 1 or type 2
A1C < 6-6.5% (ADA Grade B)
Fasting glucose < 95 mg/dL < 95 mg/dL
Post-prandial
glucose
< 140 mg/dL (1-hr.)
< 120 mg/dL (2-hr.)
< 140 mg/dL (1-hr.)
< 120 mg/dL (2-hr.)
Alternative targets may be considered if optimal ranges cannot be achieved without significant hypoglycemia.
Individualization
of Goals

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

2017 Diabetes Guideline: Key Practice Recommendations
(New recommendations/key revisions in green)


Adults Pregnant Women Pediatrics
Physical
Activity &
Medical
Nutrition
Therapy
Most adults with type 1 (ADA Grade C) and type 2 (ADA Grade B) should
engage in at least 150 min. per week of moderate-to-vigorous intensity
physical activity, spread over at least 3 days/week with no more than 2
consecutive days without exercise. Adults with type 1 (ADA Grade C)
and type 2 (ADA Grade A) should engage in 2-3 sessions/week of
resistance exercise on non-consecutive days.
Children with diabetes or
prediabetes should be
encouraged to engage in at
least 60 min. of daily physical
activity. (ADA Grade B)
An individualized medical nutrition therapy program, preferably by a registered dietitian, is
recommended for all patients with type 1 or 2 diabetes. (ADA Grade A)

Patients prescribed a flexible insulin therapy program, education on how to use carbohydrate counting
and in some cases fat and protein gram estimation to determine mealtime insulin dosing can
improve glycemic control. (ADA Grade A)

Patients with impaired glucose tolerance (IGT) (ADA Grade A), impaired fasting glucose (IGF) (ADA Grade
E), or A1C 5.7-6.4% (ADA Grade E) should be referred to a dietitian for intensive nutrition and physical
activity counseling, targeting loss of 7% of body weight and increasing physical activity.

Diabetes Prevention Programs & Resources:
ξ UW Health Classes Offered by Health and Nutrition Education
ξ UW Health Preventive Cardiology (Active Living and Learning “ALL” class)
ξ YMCA
ξ Wisconsin Institute for Healthy Aging
ξ Illinois Department of Public Health Diabetes Prevention and Control
ξ Centers for Disease Control and Prevention (National Programs)
Metformin
Metformin therapy for type 2 prevention should be
considered in patients with prediabetes, especially
those with BMI > 35 kg/m2, age < 60 years,
women with prior GDM, and/or those with rising
A1C despite lifestyle interventions. (ADA Grade A)

Metformin may be safely used in patients with
eGFR > 30 mL/min/1.73 m2. Patients should be
advised to stop in cases of nausea, vomiting, or
dehydration. Metformin is contraindicated in
patients with advanced renal insufficiency or
significant heart failure.

Long-term metformin use (> 5 years1) may be
associated with vitamin B12 deficiency;
therefore periodic measurement should be
considered, especially in patients with anemia or
peripheral neuropathy. (ADA Grade B)
Insulin is the
preferred
treatment for
hyperglycemia
in GDM (ADA
Grade A), due to
concerns about
the concentration
of metformin on
the fetal side of
the placenta. All
oral agents lack
long-term safety
data.
When insulin treatment is not
required, initiation of
metformin is recommended.
Self-
Management
& Education
All should participate in diabetes self-management education (DSME) to facilitate knowledge, skills,
and ability necessary for diabetes self-care and in diabetes self-management and support (DSMS) to
assist with implementing and sustaining skills and behaviors needed for ongoing self-management,
both at diagnosis and as needed thereafter. (ADA Grade B)
Note:
Compliance
Reminder
Definition of diabetes per Medicare for DSMT and MNT ELIGIBILITY- must meet one of the below:
- Fasting blood sugar > 126 mg/dL on two different occasions
- Random glucose test over 200 mg/dL for a person with symptoms of uncontrolled diabetes
- 2 hour post-glucose challenge > 200 mg/dL on two different occasions
Medicare does not recognize an A1C test to diagnose a patient with diabetes.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

2017 Diabetes Guideline: Key Practice Recommendations
(New recommendations/key revisions in green)


Adults Pregnant Women Pediatrics
Psychosocial
Issues2
Consider annual depression screening in all patients with diabetes
and/or a self-reported history of depression or depressive symptoms.
(ADA Grade B) Consider assessment for depression beginning at
diagnosis of diabetes complications or when there are significant
changes in medical status. (ADA Grade B) Patients can be screened for
depression using the PHQ-2 and PHQ-9.
Patients with comorbid diabetes and depression should receive a
stepwise collaborative care approach for depression management.
(ADA Grade A)

Consider screening for anxiety in patients exhibiting anxiety or worry
regarding diabetes complications, insulin injections or infusions,
taking medications, and/or hypoglycemia that interfere with self-
management behaviors and those who express fear, dread, or
irrational thoughts and/or show anxiety symptoms such as avoidance
behaviors, excessive repetitive behaviors, or social withdrawal. Refer
for treatment if anxiety is present. (ADA Grade B) Patients can be
screened using the Generalized Anxiety Disorders-7 (GAD-7).

Consider screening for disordered or disrupted eating using validated
screening measures when hyperglycemia and weight loss are
unexplained based on self-reported behaviors related to medication
dosing, meal plan, and physical activity. A review of the medical
regimen is recommended to identify potential treatment-related
effects on hunger/calorie intake. (ADA Grade B)

Routinely monitor patients for diabetes distress, particularly when
treatment targets are not met and/or at the onset of diabetes
complications. (ADA Grade B) If identified, the patient should be referred
for diabetes education to address areas of diabetes self-care.
Patients can be screened using the Diabetes Distress Scale (DDS).
Assess psychosocial issues
and family stresses at
diagnosis and routine follow-up
care. Provide appropriate
referrals to mental health
professionals and consider
them as members of team.
(ADA Grade E)

Patients can be screened for
depression using the PHQ-2
and PHQ-9 or PHQ-A.

Patients can be screened for
anxiety using the Screen for
Child Anxiety Related
Disorders (SCARED).

Patients age 8-17 years with
Type 1 diabetes can be
screened for diabetes distress
using the Diabetes Distress
Scale (DDS) scale.
Tobacco Use All patients should be advised not to use tobacco products (ADA Grade A) or e-cigarettes (ADA Grade E).
Eye Exam
Patients should have an initial dilated eye exam
within 5 yrs. or diagnosis if type 1, or shortly after
diagnosis if type 2. (ADA Grade B)

If no indication of retinopathy, repeat every 2
years. If retinopathy, repeat at least annually.
(ADA Grade B)
Women with
pre-existing
diabetes should
have eye exam
in 1st trimester,
with follow-up 1
yr. postpartum.
(ADA Grade B)
Dilated eye exam at age > 10
or after puberty, whichever is
earlier, once diagnosed with
type 1 for 3-5 yrs. (ADA Grade B)

Repeat every 1-2 yrs. per eye
care professional.
(ADA Grade E)
Foot Exam
Perform a comprehensive foot evaluation at least annually to identify
risk factors for ulcers and amputations. (ADA Grade B)

All patients should have their feet inspected at every visit.
(ADA Grade C)
Consider annual foot exam
puberty or age > 10 yrs. once
diagnosed with type 1 for 5 yrs.
(ADA Grade E)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

2017 Diabetes Guideline: Key Practice Recommendations
(New recommendations/key revisions in green)


Adults Pregnant Women Pediatrics
Blood
Pressure
Goals
Target blood pressure < 140/90 mmHg
(ADA Grade A)

Lower targets, such as <130/80 mmHg, may be
appropriate for patients at high risk of CVD, if
achieved without undue treatment burden.
(ADA Grade C)
120-160/80-105
mmHg
(ADA Grade E)
< 90th percentile for age, sex
and height (ADA Grade E)
Lipids
Screen at first diagnosis, initial medical
evaluation, and every 5 years thereafter, or
more frequently if indicated (ADA Grade E)

Intensify lifestyle therapy and optimize glycemic
control if triglyceride levels > 150 mg/dL and/or
low HDL < 40 mg/dL (men), < 50 mg/dL (women).
(ADA Grade C)

Ezetimibe in addition to moderate-intensity statin
may be considered in patients with recent acute
coronary syndrome and LDL > 50 mg/dL (ADA
Grade A) or in patients with history of ASCVD who
cannot tolerate high-intensity statins. (ADA Grade E)
Potentially
teratogenic
medications
(ACE inhibitors,
statins, etc.)
should be
avoided.
(ADA Grade B)
Screen using fasting lipid
profile if > 10 yrs. of age soon
after diagnosis (after glucose
control has been established).
(ADA Grade E)
If abnormal, annual monitoring
is reasonable. If LDL within
accepted risk level (< 100
mg/dL), a lipid profile repeated
every 3-5 yrs. is reasonable.
(ADA Grade E)


After age 10, addition of statin
is reasonable (after MNT and
lifestyle changes) if LDL > 160
mg/dL or LDL > 130 mg/dL
and one or more CVD risk
factors, following
reproductive counseling and
implementation of effective
birth control due to the
potential teratogenic effects
of statins.
(ADA Grade E)
Age Risk Statin Dose**
< 40
yrs.
At Risk* Moderate or High (ADA Grade C)
ASCVD High (ADA Grade A)
40-75
yrs.
None Moderate (ADA Grade A)
At Risk* High (ADA Grade B)
ASCVD High (ADA Grade A)
> 75
yrs.
None Moderate (ADA Grade B)
At Risk* Moderate or High (ADA Grade B)
ASCVD High (ADA Grade A)
*ASCVD Risk Factors: LDL > 100 mg/dL, high BP, smoking,
overweight/obesity, family history of premature ASCVD.

**In addition to lifestyle therapy.
Aspirin
Consider aspirin therapy for primary prevention in those with type 1 or
type 2 diabetes at increased cardiovascular risk (10-year risk > 10%)
and are not at increased risk of bleeding. (ADA Grade C)

Aspirin is not recommended for ASCVD prevention in patients at low
ASCVD risk, such as patients age < 50 years with no other major
ASCVD risk factors. (ADA Grade C)

Aspirin therapy is recommended for secondary prevention in patients
with diabetes and a history of ASCVD. (ADA Grade A)


References
1. Aroda VR, Edelstein SL, Goldberg RB, et al. Long-term Metformin Use and Vitamin B12 Deficiency in the Diabetes Prevention Program Outcomes
Study. J Clin Endocrinol Metab. 2016;101(4):1754-1761.
2. Young-Hyman D, de Groot M, Hill-Briggs F, Gonzalez JS, Hood K, Peyrot M. Psychosocial Care for People With Diabetes: A Position Statement of
the American Diabetes Association. Diabetes Care. 2016;39(12):2126-2140.
3. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2017. Diabetes Care. 2017;40(Suppl 1):S1-135.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org