Source: American Diabetes Association, Standards of medical care in dabetes~2016, Diabetes Care 2016;35(suppl 1)S1-S105, Avalble hee. Refer to source document for fl recomeensations, nding level of evidence rating, 1. Diabetes Diagnosis FPG 2126 mg/dl (7.0 mmol/L) Fasting defined a no clr nak for 28 hours ‘Bihr PG 2200 mg/d. (11.1 mmol/L) during OGTT (75-3)* Using a uci oad canting the equvalert of 759 anhydrous lucse dasoved in water ‘AIC 26.5% (48 mmal/mol)* Performed ina lab using NGSP-certfed method and standardized to OCCT assay ‘Random PG =200 mg/d (11.1 mmol/L) nba ty amps hyperemia ois “nthe absence of unequvocal hyperglyceia resus shouldbe confirmed using repeat tesing No dear cincal diagnos? Inmediaty repeat the se test sng anew blood sample Same test with same or snr results? lagna canted. 1 Dierent tess above agnostic tveshol? Disgross confirmed. {+ Discordant ress from wo separate tests? Repent the test wth areut above diagnostic cut point. “Type 2 davetes screening should be performed in aduts of any age who are overweight or obese, and who have one or more diabetes risk factor (See Diabetes Rsk Factors) ‘+ Testing should begin at age 45, ‘+ IF testis normal? Repeat tat least every 3 years (See Diabetes Rsk Factors): Screening for prediabetes can be done using AIC, FPG, or2-hr PG after 75-g OGTT criteria ‘© CVD risk factors should be identified and treated ‘Testing may be considered in children and adolescents who are overweight or obese and have two or more risk factors for diabetes (See Diabetes Risk Factors) ‘Type 2 Diabetes Risk Factors ‘= Physical inactivity « First-degree relative with diabetes «High-risk race/ethnicity ‘Women who delivered a baby >9 Ib or were diagnosed with GDM 4+ HOL-C <35 mg/dl * TG >250 mg/dl. «+ Hypertension (2140/90 mm Hg or on therapy) ‘= AIC 25.7%, IGT, oF IFG on previous testing ‘= Conditions associated with insulin resistance: severe obesity, acanthosis nigricans, PCOS. «History of CVDti i 2-hr PG ALC 700-125 mara, 140-199 mg/dl 57-64% (566. mmol/L) (78-110 mov) (39-46 mmoy/mot) Impeired fasting glucose (166) Impaired glucose tolerance (IGT) For al tests, rik is continuous, extending below lower limit of range ‘and becoming disproportonately greater at higher ends of renge I gl ‘and have two or more ofthe fallowing risk factors: ‘+ Family history of type 2 dabetes in afirst- or second-degree relative + Native American, African American, Latino, Asian American, or Pacific Islander descent + Signs of insulin resistance or conditions associated with insuin resistance’ + Maternal history of dabetes or GDM during the child's gestation “Test every 3 years using AIC beginning at age 10 or onset of puberty “BMI >85th percentile forage and sex, weight for height >85th percentile, or weight >120% ideal weight ‘tacanthoss nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, or smal-forgestational-age birth weight Children defined as age <18 years Pregnant women with risk factors “Test for undiagnosed type 2 at frst prenatal vst using stansard diagnostic crteria Pregnant women without known prior diabetes | Test for GDM at 24-28 weeks ‘Women with GDM Screen for persistent dabetes 6-12 wks postpartum using OGTT and standard diagnostic criteria ‘Women witha history of GOM Lifelong screening for diabetes or prediabetes every 23 ‘Women with a history of GDM and prediabetes | Lfestye interventions or metformin for dabetes prevention ‘= Women with diabetes in the first trimester have type 2 dabetes ‘= GDM is diagnosed in the second or third trimester and not clearly associated with type 1 or type 2 diabetes Screeni di with overt diabetes One-step diagnosis strategy ‘= Perform 75-9 OGTT with plasma glucose Step 1: measurement «= Teatin the moring after the patient has fasted for |* Perform a 50-9 nonfasting GLT with plasma measurement at 28 hous, hour ‘+ Repeat test at 1 and 2 hours ater intial + IFPG measured 1 hour after the load is measurement 2140 mg/dl. (7.8 mmol/L), proceed to 100-9 OGTT Diagnosis is confirmed when PG levels mest or | Step 2: exceed: + Perform 100-9 OGTT while patient is fasting + Fasting 92 may. (5.1 mmol/L) Diagnosis is confirmed when two or more PG levels meet or 1 180 mg/dl. (10.0 mmol) exceed: 2 153 mg/d (8.5 mmo/L) Fasting: 95 mg/dl or 105 mgyAl. (5.3/5.8) be: 180 ma/at oF 190 mg/Al. (10.0/10:6) 2 he: 155 mg/dL or 165 ma/aL (8.6/9.2) 3 he: 140 mg/dl or 145 maya (7.8/8.0) [Sereening for Type 1 Diabetes "There are two manifestations of type 1 dlabetes: + Immune mediated diabetes, previously called “insulin dependent diabetes" or "juvenile-onset diabetes", is due to celular-mediated autoimmune destruction of beta-cell, + Idiopathic type 1 diabetes largely has no known cause with no evidence of beta-cell autoimmunity. ‘Blood glucose is preferred over AIC to diagnose acute onset of type 1 diabetes with symptoms ofhyperalycemia Inform relatives of individuals with type 1 diabetes ofthe opportunity to be tested «Testing should occur only in the setting of a clinical research study.Ask at-risk patents about symptomatic and asymptomatic hypoglycemia at each encounter ‘Glucose (15-20 g) isthe preferred treatment of hypoglycemia for conscious patients ‘+15 minutes after treatment, repeat f SHBG shows continued hypoglycemia «When SMAG is normal, the patient should consume a meal or snack to prevent hypoglycemia recurrence ‘Glucagon may be prescribed for al individuals who are at risk for severe hypoalycemia TF an individual has hypoglycemia unawareness or an episode of severe hypoglycemia ‘+ Re-evaluate the treatment regimen + In patients treated with insulin, raise alycemic targets for several weeks to partially reverse hypoglycemia unawareness, and reduce the recurrence of hyponlycemia For individuals with low or decning cognition, continually asse35 cognitive Function with increased wglance for 3. Type 2 Diabetes Prevention Tndviduas with prediabetes: IGT, TFG, or AIC 57-64% Refer these individuals to a behaworal counseling program targeting Intensive det end physical activity to achive: ‘+ 73% of body weight oss ‘+ Increased physical activity, targeting atleast 150 minutes per week — {moderate acy. Consider metformin’ rap for type 2 dabetes prevention in individuals with predabetes, especialy inthe presence of 335 kg {ge <60 years ‘Women who have had gestational dabetes ‘anton at least once er yea recommenced fr alindviduals with predibetes ‘Stren for and eat modiable CVD sk factors Obesity Hypertension + Dyslipidemia Diabetes slf-vanagorent education (OSHE) and diabetes sa management support (OSM) are appropriate for al Individuals wth prediabetes fo type 2 diabetes preventon or delay ‘Netforin not FDA approved nthe United tates for type 2 dabets preveion ‘I=body mass index; CVD=cardiovascular isease; IFG=Impaired fasting glucose; IGT=impared glucose tolerance 4, Pharmacologic Therapy for Type 2 Diabetes Management Lifestyle changes should be the fis-ine therapy for most individuals with type 2 diabetes ‘When lifestyle changes alone have not achieved or maintained glycemic goals ‘© Add metformin + Preferred initial pharmacologic therapy if tolerated and not contraindicated” For newily diagnosed individuals who are markedly ‘symptomatic and/or have elevated glucese levels or AIC ‘= Consider insulin therapy with or without other ‘agents Tf noninsuin monotherapy (OAD) at maximal tolerated dose(s) does not achieve or maintain AIC target over 3 months = Aad: ‘A second oral agent or ‘A GLP-1 receptor agonist or = Basal insulin ‘Due to the progressive nature of type 2 diabetes, insulin is eventually needed Insulin therapy should not be delayed+ Potential side effects fects on went + Renal disease or renal dysfunction (e.g, a5 suggested by serum creatinine levels 21.5 mg/dl (males), 21.4 mg/dL (females) or abnormal creatinine clearance) which may also resut from conditions such as cardovescular collapse (shock), acute myocardial infarction, and septiceria + Known hypersensitivity to Metformin hydrochloride ‘+ Acute or conic metabolic acidosis, including diabetic ketoacidosis, with or without coma, Diabetic ketoacidosis should be treated with inulin 5. Pharmacologic Therapy for Type 1 Diabetes Insulin therapy isthe mainstay for indviduas with type 1 diabetes + Treat with multiple dase insulin injections” or continuous subcutaneous insulin infusion (CSI) ‘+ Match praia insulin to carbohydrate intake, premeal glucose, and antispate physical activity ‘Use insula analogs to reduce the risk of hypoglycemia ‘+ Consider using sensor-augmented low glucose suspend threshold pumpin patients with frequent noctural hypoglycemia and/or hypoglycemia unawareness Non ineuln aaects Towestoational agen + Praline (amin ealoa) + Metformin + insuin + Delays gastne emptying ‘May reduce insulin requirements and improve {Blunts parereatic secreton of glucagon metabolic contol nabesefoverweght with poor {enhances satiety ‘ycemic control { tnduces weight loss sincretins + Lowers insulin dose ‘+ GLP-1 receptor agonists + Use oniyin ads PP intors 2 SGLT2 inhibitors "5-4 injecons/day of basal and prandial insulin) ‘Not FDA approved forthe treatment of type 1 dlabetes inthe United States. 6. Insulin & Glucose Monitoring “Encourage individuals receiving multiple dose insulin or insulin pump therapy to perform SMEG: «= Prior to meals and snacks 1 Occasionally after meat (postprandaly) + At bedtime Prior to exercise ‘When low blood glucose is suspected “= After treating low blood glucose until normoglycemia is achieved «= rir to critical tasks, such as driving 'SMBG results may be useful for guiding treatment and/or self-management for individuals using less frequent insulin Injections or noninsulin therapies ‘Its important to provide ongoing instruction and reguiar evaluation of SMBG technique, results, and the patent's ability to.use the data to adjust therapy ‘CGM is useful for AIC lowering in select aduits (aged 225 yrs) with type 1 dabetes wo require intensive insulin: «The technique may be useful among children, teens, and younger adults” ‘Success i elated with adherence to ongoing use ‘CGM may be a useful supplement to SHBG among individuals with hypoglycemia unawareness andjor Frequent Inypoalycemic episodes ‘Evidence for AIC lowering is less strong in these populations7. Lifestyle Changes ‘The ADA acknowledges that there is no one-size-itsal eating patter for individuals with type 2 dabetes.. "MNT Is recommenced for all incviduals with type 1 and type 2 clabetes as part ofan overall treatment plan preferably provided by a registred dietitian skiled in diabetes MNT Goals of MNT: ‘healthful eating patter to improve overall health, specifically: ‘Achievernent and maintenance of weight goals ‘Type 2 diabetes prevention or delay ‘= Ata indvidvalzed glycemic, blood pressure, and lipid goats ‘+ Achieve and maintain body weight goals daysjik with no more than 2 consecutive days without exercise Resistance training 22 times/wk (in absence of contrainications” Reduce sedentary time = break up 290 minutes spent sting valuate patients for contraindication prohibiting certan types of exercise before recommending exercise program ‘protocol 7 | ‘Advantages of bariatric surgery Disadvantages of bariatric surgery + Achieves near or complete normalization of glycemia | « Costly 2 years after surgery “|e Outcomes are variable based onthe procedure and experience ‘Consider age and previous level of physical activity Children with diabetes or prediabetes ‘= 260 min physical actvty/day ‘Adults with type 2 diabetes "Eg, uncontrolied hypertension, severe autonomic or peripheral neuropathy, history of foot lesions, unstable proliferative retinopathy + If an individual staking insulin and/or insulin secretagogues, physical activty can cause hypoglycemia if medication ‘dose of carb consumption isnot altered + Added carbohydrate should be ingested when pre-evercse glucose is <100 mg/dl. (5.6 mmol/L) Retinopathy “= Proliferative diabetic retinopathy ar severe nonprolferative dabetic retinopathy «Vigorous aerobic or resistance exercise may be contraindicated ‘Autonomic neuropathy | «Can increase the risk for exercise-induced injury ‘Al individuals with autonomic neuropathy should undergo cardiac investigation before beginning more-intense-than-usual physical activity Peripheral neuropathy | Decreased pain sensation and a higher pain threshold in the extremities CAUSE increased ‘isk of skin breakaown and infection “All individuals with neuropathy should wear proper footwear and examine feet dally for civduals with foo injury or open sores are restricted to non-weight-bearing activity ‘Nburninura and sical activity can acutely increase urinary protein excretion nephropaty| ‘+ There is no evidence that vigorous-intensity exercise increases the progression of diabetic kidney disease No restrictions are necessary for individuals with dabetic kidney disease