Self-monitoring of blood glucose (SMBG) may help with self-management and medication adjustment, particularly in individuals taking insulin. There is strong evidence that treating obesity can delay the progression from prediabetes to type 2 diabetes. B, 4.6 The 10-year risk of a first atherosclerotic cardiovascular disease (ASCVD) event should be assessed using the race- and sex-specific Pooled Cohort Equations to better stratify ASCVD risk. Practical guidance is needed for medical providers as well as LTC staff and caregivers. 11.12 Optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy. Approximately one-quarter of people over the age of 65 years have diabetes and one-half of older adults have prediabetes. In patients who are eating, glucose monitoring should be performed before meals; in those not eating, glucose monitoring is advised every 4–6 h. Testing every 30 min to every 2 h is required for intravenous insulin infusion. The diagnostic criteria for diabetes and prediabetes are shown in Table 2.2/2.5. B, 11.34 The examination should include inspection of the skin, assessment of foot deformities, neurological assessment (10-g monofilament testing with at least one other assessment: pinprick, temperature, vibration), and vascular assessment including pulses in the legs and feet. B. The ADA guidelines still recommend Metformin as the first drug for patients with diabetes type 2 (DM2). The ADA position statement “Psychosocial Care for People With Diabetes” provides a list of assessment tools and additional details. A, 3.3 A variety of eating patterns are acceptable for persons with prediabetes. An earlier appointment (in 1–2 weeks) is preferred, and frequent contact may be needed. Table 14.1 in the complete 2020 Standards of Care provides details on preconception care.

The Standards of Medical Care in Diabetes is updated annually, or more frequently online if new evidence or regulatory changes merit immediate incorporation, and is published in Diabetes Care. B, 10.37 Aspirin therapy (75–162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased CV risk, after a comprehensive discussion with the patient on the benefits versus the comparable increased risk of bleeding. Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. B Prolonged sitting should be interrupted every 30 min for blood glucose benefits. “Refer” indicates that nephrology services are recommended. The abridged version does not include references. 10.1 Blood pressure should be measured at every routine clinical visit. Potential adverse effects of antihypertensive therapy (e.g., hypotension, syncope, falls, acute kidney injury, and electrolyte abnormalities) should also be taken into account. B, 8.20 People who undergo metabolic surgery should routinely be evaluated to assess the need for ongoing mental health services to help with the adjustment to medical and psychosocial changes after surgery. Comprehensive Medical Evaluation and Assessment of Comorbidities”, “Physical Activity/Exercise and Diabetes”, “Psychosocial Care for People With Diabetes”, “14. Microvascular Complications and Foot Care” in the complete 2020 Standards of Care provides further details on appropriate screening. B, 11.39 The use of specialized therapeutic footwear is recommended for high-risk patients with diabetes including those with severe neuropathy, foot deformities, ulcers, callous formation, poor peripheral circulation, or history of amputation. E, 8.4 Diet, physical activity, and behavioral therapy designed to achieve and maintain ≥5% weight loss is recommended for patients with type 2 diabetes who have overweight or obesity and are ready to achieve weight loss.

CREDENCE, Evaluation of the Effects of Canagliflozin on Renal and Cardiovascular Outcomes in Participants With Diabetic Nephropathy. Diabetes Care in the Hospital” in the complete 2020 Standards of Care for guidance on enteral/parenteral feedings, glucocorticoid therapy, perioperative care, and diabetic ketoacidosis and hyperosmolar hyperglycemic state. B, 13.67 If glycemic targets are no longer met with metformin (with or without basal insulin), liraglutide (a GLP-1 receptor agonist) therapy should be considered in children 10 years of age or older if they have no past medical history or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2.

Sign In to Email Alerts with your Email Address. In the critical care setting, continuous intravenous insulin infusion is the best method for achieving glycemic targets. Sample AGP report. The degree of albuminuria is associated with CKD progression, CVD, and mortality. E, 5.3 Clinical outcomes, health status, and well-being are key goals of DSMES that should be measured as part of routine care. *Referring clinicians may wish to discuss with their nephrology service, depending on local arrangements regarding treating or referring. B, 4.4 A follow-up visit should include most components of the initial comprehensive medical evaluation, including interval medical history, assessment of medication-taking behavior and intolerance/side effects, physical examination, laboratory evaluation as appropriate to assess attainment of A1C and metabolic targets, and assessment of risk for complications, diabetes self-management behaviors, nutrition, psychosocial health, and the need for referrals, immunizations, or other routine health maintenance screening. A.
A. The patient’s medications must be cross-checked to ensure that no chronic medications were stopped and to ensure the safety of new prescriptions. C, 11.4 Optimize blood pressure control to reduce the risk or slow the progression of CKD. CGM has emerged as a complementary method for the assessment of glucose levels. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked.

Several inpatient studies have shown that CGM use did not improve glucose control but detected a greater number of hypoglycemic events than point-of-care glucose testing. FPG, fasting plasma glucose; FRC, fixed-ratio combination; GLP-1 RA, GLP-1 receptor agonist; iDegLira, insulin degludec/liraglutide; iGlarLixi, insulin glargine/lixisenatide; max, maximum; PPG, postprandial glucose; Table 9.3 appears in the complete 2020 Standards of Care. Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated. B, 8.11 When choosing glucose-lowering medications for patients with type 2 diabetes and overweight or obesity, consider a medication’s effect on weight. Risk of CKD progression, frequency of visits, and referral to nephrology according to GFR and albuminuria. A 5-year effectiveness study of the CCM in 53,436 primary care patients with type 2 diabetes suggested that the use of this model of care delivery reduced the cumulative incidence of diabetes-related complications and all-cause mortality. 13.59 A reasonable A1C target for most children and adolescents with type 2 diabetes treated with oral agents alone is <7% (53 mmol/mol). PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT, 11. A, 6.7 On the basis of provider judgment and patient preference, achievement of lower A1C levels (such as <6.5%) may be acceptable if this can be achieved safely without significant hypoglycemia or other adverse effects of treatment. Improving Care and Promoting Health in

For patients with complications and reduced functionality, it is reasonable to set less intensive glycemic goals. Patients with type 1 diabetes are living longer, and the population of these patients >65 years of age is growing. Treatment with metformin should be reassessed for patients with an eGFR <45 mL/min/1.73 m2 and should be temporarily discontinued at the time of or before iodinated contrast imaging procedures in patients with eGFR 30–60 mL/min/1.73 m2. Therefore, the combined use of an ACE inhibitor and an ARB should be avoided. Essential to achieving these goals are DSMES, medical nutrition therapy (MNT), routine physical activity, smoking cessation counseling when needed, and psychosocial care. A, 11.24 The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage. It is important to prevent hypoglycemia to reduce the risk of cognitive decline and other major adverse outcomes. Different patient categories have been proposed for diabetes management in those with advanced disease. Any of the following agents could be fourth line therapies; sulfonylurea, basal insulin, DDP4 inhibitor, or TZD if heart failure is absent. The ADA recommends the following drugs as the third line option: GLP1 agonist if already on Metformin + SGLT2 inhibitor and SGLT2 inhibitor if the patient is taking Metformin + GLP1 agonist.
This population has unique challenges and requires distinct treatment considerations. A, 10.32 Statin plus fibrate combination therapy has not been shown to improve ASCVD outcomes and is generally not recommended. Caregivers, school personnel, or family members of these individuals should know where it is and when and how to administer it. The American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes is updated and published annually in a supplement to the January issue of Diabetes Care.

Although no drugs have been approved by the U.S. Food and Drug Administration (FDA) for diabetes prevention, several have shown promise in research studies. A plan for preventing and treating hypoglycemia should be established for each patient. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. The above drug algorithmic guidance is general. E. Glucose monitoring is key for the achievement of glycemic targets for many people with diabetes. Diabetes Advocacy” in the complete 2020 Standards of Care. C, 10.5 For individuals with diabetes and hypertension at lower risk for CVD (10-year ASCVD risk <15%), treat to a blood pressure target of <140/90 mmHg. Readers may link to the version of record of this work on professional.diabetes.org/standards, but ADA permission is required to post this work on any third-party website or platform. Health inequities related to diabetes and its complications are well documented and are heavily influenced by social determinants of health (SDoH).


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