Diabetes Care - Montefiore Care Management

Diabetes Care
Summary of Revisions for the 2014
Clinical Practice Recommendations
Copied from: http://diabetesjournals.org/content/36/Supplement_1/S3.extract
Types of Diabetes
Type 1
- Beta cell destruction
Type 2
- progressive decrease in insulin secretion /
secretory defect
Other Specific Types of Diabetes
- Genetic defects in beta cell function/insulin action
- Disease of the exocrine pancreas
- Drug-or Chemical induced
Gestational
Criteria for Diagnosis of Diabetes
• A1C> 6.5 or
• Fasting Plasma Glucose > 126
mg/dl or
• 2 hour plasma glucose >200 or
• A Random Plasma glucose >200
with symptoms of hyperglycemia
Prediabetes
• Fasting Plasma Glucose 100 – 125
mg/dl or
• 2 hour plasma glucose 140 -199
mg/dl or
• A1C 5.7 – 6.4
Testing Asymptomatic
Patients
Test Overweight / Obese patients
with one or more additional risk
factor
Age 45 years with no risk factor
If normal, Test every 3 years
Screening for Type 2 Diabetes in
Children
Should be considered in children
who are overweight or have 2 or more
additional risk factors for diabetes
Test should start at age 10 years or
onset of puberty
Frequency every 3 years thereafter
BMI >85%for age sex, wt and ht
Nigricans
Mother with GDM
Type 1
Consider referring relatives of
those with type 1 diabetes for
testing for risk assessment in
the setting of a clinical
research study. (E)
Section IV. Prevention/Delay of
Type 2 Diabetes
A1C 5.7 to 6.4
– Refer to ongoing support system
targeting weight loss and
increase physical activity
- Follow up counseling
- Enroll in a Diabetes Prevention
Program
Prevention and Delay Type 2 DM
Continued
• Consider metformin – Especially
for those with BMI over 35
• Age <60 years and women with
prior history of gestational diabetes
• Monitor for diabetes annually
• Screen and treat CVD’s
Components of
Comprehensive Care







Age
DKA
Symptoms
Labs
Diet – Nutritional and eating patterns
Weight
Growth and development in children and
adolescents
 Diabetes education
 Past response to therapy
Components of Comprehensive
Care continued
•
•
•
•
•
•
•
•
Current treatment
Adherence
Barriers
Physical activities (make sure pre-exercise
blood glucose >100)
Readiness for behavioral change
Glucose monitoring and use of data
Hypoglycemia – Awareness, severity, frequency
and cause
Diabetes related complications such as
Microvascular disease, Macrovascular disease,
Psychosocial and dental
Components of Comprehensive
Care continued
• Lab evaluation – A1C 2 times a year if at
goal and quarterly if not controlled, Fasting
Lipids, LFT, spot urine albumin, serum
creatinine and TSH
• Refer for annual dilated eye exam
• Registered Dietician
• Diabetes Self Management education –
Ongoing diabetes support
• Comprehensive periodontal exam
• Mental health if needed
• People with diabetes should receive DSME and
diabetes self-management support (DSMS)
according to National Standards for Diabetes
Self-Management Education and Support when
their diabetes is diagnosed and as needed
thereafter. (B)
• Effective self-management and quality of life are
the key outcomes of DSME and DSMS and
should be measured and monitored as part of
care. (C)
• DSME and DSMS should address psychosocial
issues, since emotional well-being is associated
with positive diabetes outcomes. (C)
Glycemic Control
Self monitoring of blood glucose
• Use as a tool to help guide treatment decision
for patients using less frequent insulin injections
/ noninsulin therapies
• Ongoing instructions and regular evaluation of
technique and results and patient ability to use
data to adjust therapy
• Reasonable A1C below 7% for non pregnant
individuals to reduce microvascular
complications and if early in the disease
process reduces long term macrovascular
complications
Glycemic Control Continued
• A1C < 6.5% if possible without
significant hypoglycemia
• Less stringent goal <8% for people
with severe hypoglycemia and
advanced microvascular /
macrovascular complications and
extensive comorbids
Patients on multiple-dose insulin
(MDI) or insulin pump therapy
should do SMBG at least prior to
meals and snacks, occasionally
postprandially, at bedtime, prior to
exercise, when they suspect low
blood glucose, after treating low
blood glucose until they are
normoglycemic, and prior to critical
tasks such as driving. (B)
Approach to Management of Hyperglycemia
Section V.D. Pharmacological
and
Overall Approaches to
Treatment has been revised to
add a section with more
specific recommendations for
insulin therapy in type 1
diabetes 2013
• Most people with type 1 diabetes should be
treated with MDI injections (three to four
injections per day of basal and prandial insulin)
or continuous subcutaneous insulin infusion
(CSII). (A)
• Most people with type 1 diabetes should be
educated in how to match prandial insulin dose
to carbohydrate intake, premeal blood glucose,
and anticipated activity. (E)
• Most people with type 1 diabetes should use
insulin analogs to reduce hypoglycemia risk. (A)
• Consider screening those with type 1 diabetes
for other autoimmune diseases (thyroid, vitamin
B12 deficiency, celiac) as appropriate. (B)
Section V.K. Hypoglycemia
has been revised to
emphasize the need to
assess hypoglycemia and
cognitive function when
indicated.
• Individuals at risk for hypoglycemia should be
asked about symptomatic and asymptomatic
hypoglycemia at each encounter. (C)
• 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, the
treatment should be repeated. Once SMBG
glucose returns to normal, the individual should
consume a meal or snack to prevent recurrence
of hypoglycemia. (E)
• Glucagon should be prescribed for all
individuals at significant risk of severe
hypoglycemia, and caregivers or family
members of these individuals should be
instructed on its administration. Glucagon
administration is not limited to health care
professionals. (E)
• Hypoglycemia unawareness or one or more
episodes of severe hypoglycemia should
trigger re-evaluation of the treatment
regimen. (E)
• Insulin-treated patients with hypoglycemia
unawareness or an episode of severe
hypoglycemia should be advised to raise
their glycemic targets to strictly avoid further
hypoglycemia for at least several weeks, to
partially reverse hypoglycemia unawareness,
and to reduce risk of future episodes. (A)
• Ongoing assessment of cognitive function is
suggested with increased vigilance for
hypoglycemia by the clinician, patient, and
caregivers if low cognition and/or declining
cognition is found. (B)
Section V.M. Immunization has
been updated to include the
new Centers for Disease
Control and Prevention (CDC)
recommendations for hepatitis
B vaccination for people with
diabetes
• Administer hepatitis B
vaccination to unvaccinated
adults with diabetes who are
aged 19 through 59 years. (C)
• Consider administering hepatitis
B vaccination to unvaccinated
adults with diabetes who are
aged ≥60 years. (C)
Section VI.A.1. Hypertension/Blood
Pressure Control has been revised
to suggest that the systolic blood
pressure goal for many people with
diabetes and hypertension should
be 140 mmHg, but that lower
systolic targets (such as,130 mmHg)
may be appropriate for certain
individuals, such as younger
patients, if it can be achieved
without undue treatment burden.
2013
Section VI.A.2.
Dyslipidemia/Lipid
Management and Table 10
have been revised to
emphasize the importance of
statin therapy over particular
LDL cholesterol goals in highrisk patients.
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
 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 (1.8mmol/L), using a high
dose of a statin, is an option.
Section VI.B. Nephropathy
Screening and Treatment and
Table 11 have been revised to
highlight increased urinary
albumin excretion >30 over
the terms micro- and
macroalbuminuria, other than
when discussion of past
studies requires the
distinction.
Table 11 - Definitions of abnormalities in albumin
excretion
Category
Spot collection
(mg/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).
Section VI.C. Retinopathy
Screening and Treatment has
been revised to include anti–
vascular endothelial growth
factor therapy for diabetic
macular edema. 2013
Section IX.A. Diabetes Care in
the Hospital has been revised
to include a recommendation
to consider obtaining an A1C
in patients with risk factors for
undiagnosed diabetes who
exhibit hyperglycemia in the
hospital. 2013
Changes in Aspirin Therapy
• Aspirin has been shown to be effective
in reducing cardiovascular morbidity
and mortality in high-risk patients with previous MI
or stroke
• Men aged >50 years or women aged >60
• Aspirin should not be recommended
for CVD prevention for adults with diabetes at
low CVD risk
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