CHAPTER 1. Clinical Guideline for Adults With Diabetes

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Evidence-Based Diabetes Management, June 2018, Volume 24, Issue 7

From the Adult Diabetes and Clinical Research sections, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts.

1.1.0 APPROACH TO CARE

1.1.1 Individualizing patient care:

The Joslin Clinical Guideline for Adults With Diabetes is designed to assist primary care physicians and specialists as they individualize the care of and set goals for nonpregnant adults with diabetes. This guideline focuses on the unique needs of the patient with diabetes. It is not intended to replace sound medical judgment or clinical decision making and may need to be adapted for certain patient care situations in which more or less stringent interventions may be necessary. This guideline was approved May 17, 2017, and updated May 25, 2018.

The needs and goals of each patient are unique. A treatment plan must be based on a thorough assessment and requires an understanding of not only the patient’s medical needs, but also other factors that may influence the treatment plan such as social history, race, cultural issues, ethnicity, education needs (including literacy and numeracy), comorbidities, and barriers to care. The patient’s diabetes management plan should include medical treatment, interventions, follow-up, and ongoing support. Use of the electronic medical record may help facilitate care, by enabling the team to track progress, ensuring goals are met, and facilitating communication flow among team members and the patient.

1.1.2 The patient-centered approach:

Diabetes is a condition that requires considerable selfmanagement. A collaborative counseling model that involves the patient in decisions and goal-setting helps promote behavioral change. Whenever appropriate, with the patient’s consent, involving family members and nonclinical caregivers in medical visits and education is valuable.

1.1.3 Working in a team:

Diabetes is best managed by a team, which may include clinicians, diabetes educators (DEs), dieticians, exercise physiologists, and behavioral health specialists. The patient should be informed and fully aware of what roles the various team members play. If access to a team is not possible within the office practice, it is useful to identify community resources.

Clear communication among all providers is critical to ensure patients’ needs are being met.

1.1.4 Frequency of medical visits:

While the frequency of visits for ongoing care should be individualized, monitoring the patient’s progress through medical visits is recommended at least 2 to 4 times/year. Special attention should be given to patients who do not keep scheduled appointments, have frequent hospitalizations, or miss days of work/school. Since many factors contribute to patients’ ability to manage their care, the provider should:

• Engage patients in identifying and resolving contributing factors or barriers to underutilization or overutilization of healthcare services. Patients with challenging care may benefit from consultation with endocrinologists focused on diabetes care.

• Refer to a DE, registered dietician (RD), social service professional, or behavioral health professional to address possible barriers and/or psychosocial issues

1.2.0 DIAGNOSIS OF DIABETES MELLITUS

1.2.1 General criteria for diagnosis:

• Establish a process of follow-up communication regarding adherence to the treatment plan and sustaining behaviors

The diagnosis of diabetes mellitus can be made based upon:

• Random plasma glucose ≥200 mg/dl (11.1 mmol/L) and symptoms of diabetes (polyuria, polydipsia, ketoacidosis, or unexplained weight loss) OR

• Fasting plasma glucose* ≥126 mg/dl (6.9 mmol/L) OR

• Results of a 2-hour 75-gram oral glucose tolerance test*

≥200 mg/dl (11.1 mmol/L) OR

• Glycated hemoglobin* (A1C) ≥6.5% (46 mmol/mol)**

*These tests should be confirmed by a repeat test, on a different day, unless unequivocally high.

**An A1C level of ≥6.5% on 2 separate days is acceptable for diagnosis of diabetes [1B]. However, some individuals may have an A1C <6.5% with diabetes diagnosed by previously established blood glucose criteria. Therefore, presence of either criterion is acceptable for diagnosis. Those with an A1C of 5.7%-6.4% (39-46 mmol/mol) are considered to have prediabetes, and they are at high risk for developing diabetes. These patients should be treated with lifestyle changes and followed more frequently.

The A1C test should be performed in a laboratory using a method that is certified by the National Glycohemoglobin Standardization Program and standardized to the Diabetes Control and Complications Trial assay.

A point-of-care (POC) A1C is not acceptable for diagnosis of diabetes.

1.2.2 Hemoglobin A1C (A1C)

Diagnosis:

See above section on Diagnosis of Diabetes Mellitus.

1.2.2a Goals:

The A1C target goal should be individualized for each patient. A goal of <7.0% (53 mmol/mol) is chosen as a practical level for most patients to reduce the risk of long-term complications of diabetes. Achieving this goal is recommended if it can be done safely and practically [1B].

Alternative A1C goals may be set, based upon presence or absence of microvascular and/or cardiovascular complications, hypoglycemic unawareness, cognitive status, and life expectancy [1A]. For patients with longstanding type 2 diabetes (T2D) with preexisting cardiovascular disease (CVD), or high coronary artery disease (CAD) risk (diabetes plus 2

or more additional risk factors), consider revising A1C goals to avoid adverse consequences of tight glycemic control, eg hypoglycemia [1A].

Some clinicians may translate patients’ A1C level into their estimated average glucose level, based upon the work of the A1C Derived Average Glucose Study. This metric is also a valid tool that may be used to assess the response of patients to their diabetes treatment plan [1C].

Joslin’s A1C target goal for most patients is consistent with that of the American Diabetes Association (ADA). Other expert panels, such as the American Association of Clinical Endocrinologists, suggest that the A1C target goal should be <6.5% in those newly diagnosed with diabetes and without comorbidities. Recent recommendation of 7% to 8% for most individuals with T2D by the Ameican College of Physicians are not endorsed by us ( see caveats above).

1.2.2b Caveats:

The A1C may not reflect glycemic control in special patient populations, including pediatric and geriatric populations, patients with anemia or other blood disorders resulting in rapid turnover of red blood cells, in chronic liver and renal disease, following recent blood transfusions, or while patients are hospitalized. It is therefore important to interpret

A1C results accordingly when determining treatment plans and goals.

1.2.2c Monitoring:

Monitor the A1C 2-4 times a year as part of the scheduled medical visit [1C] to evaluate efficacy of the treatment plan. The A1C may be checked more frequently if the treatment program requires revision, or the advice regarding behavior changes needs reinforcement. Having the A1C result at the time of the visit can be useful in making timely treatment decisions [1C].

Alternatively, the A1C may be performed prior to the medical visit POC method.

1.2.2d Treatment:

If A1C is ≥7% and <8%, or above the individualized goal, for 6 or more months:

• Review and clarify the management plan with the patient with special attention given to address:

-- nutrition and meal planning

--physical activity

-- medication administration,

schedule, and technique

-- self-monitoring blood glucose (SMBG) schedule and technique

-- treatment of hypoglycemia and hyperglycemia

-- sick day management practices

• Reassess goals and adjust medication as needed [1A]

• Establish and reinforce individualized glycemic goals with patient

• Refer patient to a certified diabetes educator (CDE) for evaluation, diabetes self-management education (DSME), and support for ongoing consultation [1C]

• Consider referral to RD for medical nutrition therapy (MNT) [1B]

• Schedule follow-up appointment within 3-4 months or more frequently as the situation may dictate

If A1C is ≥8%:

• Review and clarify the plan as previously noted

• Assess for psychosocial stress as a potential barrier to adequate response to treatment [1C]

• Establish and reinforce individualized glycemic goals with the patient

• Intensify therapy

• Refer patient to DE for evaluation, DSME, and support for ongoing consultation. Document reason if no referral initiated

• Refer patient to RD for MNT [1C]

If the patient has a history of severe recurrent hypoglycemia or hypoglycemia unawareness (a condition in which the patient is unable to recognize symptomsof hypoglycemia):

• Assess for changes in daily routine such as reduced food intake or increased physical activity [1C]

• Refer to DE for evaluation, DSME, and hypoglycemia prevention; encourage family/friend attendance

• Review use of glucagon

• Consider revising A1C goal

• Discuss and reinforce goals with patient

• Adjust medications to minimize hypoglycemia risk [1B]

• If insulin-treated, consider use of a more physiologic insulin replacement program, such as basal/bolus therapy

• Consider and screen for other medical causes

• Consider referral for blood glucose awareness training, if available

• Consider use of continuous glucose monitoring [2B]

1.3.0 SELF-MONITORING OF BLOOD GLUCOSE

• Schedule follow-up appointment within 1-2 months. If history of recent, severe hypoglycemia, or change in pattern of hypoglycemia, recommend increase in frequency of communicating blood glucose levels to provider or DE.SMBG is an important element of the treatment program for all individuals with diabetes. Its benefits are: to gauge treatment efficacy, to help in treatment design, to provide

feedback on the impact of nutritional intake and activity, to provide patterns that assist in medication selection, and, for those on insulin, to assist in daily dose adjustments [1B].

1.3.1 Goals:

Goals for glycemic control for most individuals with diabetes are:

• Fasting glucose: 80 to130 mg/dl (4.4-7.2 mmol/L)

• 2-hour postprandial glucose: <180 mg/dl (9.9 mmol/L)

• Bedtime glucose: 90 to 150 mg/dl (4.9-8.3 mmol/L)

1.3.2 Frequency:

The frequency of SMBG should be individualized, based on factors such as glucose goals, medication changes, and patient motivation. Most patients with type 1 diabetes (T1D)

should monitor 4 to 6 times per day. Some patients may need to monitor even more frequently.

Most patients using intensive insulin therapy should ideally monitor before meals and bedtime, prior to exercise, when they suspect hypoglycemia, after treating hypoglycemia, and prior to driving. In patients with T1D, there is a correlation between increased SMBG frequency and lower A1C. For patients with T2D, the frequency of monitoring is dependent upon such factors as mode of treatment and level of glycemic control [1C].

1.3.3 Postprandial monitoring:

To obtain meaningful data for treatment decisions, it is helpful for the patient to monitor for several consecutive days (eg, 2-4 days). In addition to obtaining fasting and preprandial glucose levels, consider obtaining glucose readings 2 to 3 hours postprandial, as postprandial hyperglycemia has been implicated as an additional cardiovascular risk factor [1B].

Postprandial monitoring is particularly recommended for patients who:

• Have an elevated A1C but fasting glucose is at target

• Are initiating intensive (physiologic) insulin treatment programs

• Are experiencing problems with glycemic control

• Are using glucose-lowering agents targeted at postprandial glucose levels

• Are making meal planning or activity adjustments

One-hour postprandial glucose monitoring should be considered:

• During pregnancy [1A]

• For those patients using alpha-glucosidase inhibitors

Encourage the patient to provide SMBG results (written records or meter for downloading) to each visit for review with provider/educator.

1.3.4 Using alternate sites to monitor:

Blood glucose levels from sites such as the upper arm, forearm, and thigh may lag behind those taken from the fingertips, particularly when glucose levels are changing

rapidly. Glucose levels may change rapidly with exercise, eating, or hypoglycemia, or after insulin administration. For this reason, alternate site monitoring is not recommended in

the following situations:

• When the blood glucose may be changing rapidly

• For patients using intensive insulin treatment programs

• If hypoglycemia is suspected

• In patients with hypoglycemia unawareness

1.3.5 Continuous glucose monitoring (CGM):

CGM measures interstitial glucose levels and correlates with plasma glucose levels. CGM requires calibration with SMBG at least twice daily. Use of CGM technology has been shown to decrease A1C in adults aged 25 years older using intensive insulin therapy along with CGM, compared with those using intensive insulin therapy with SMBG. The best predictor of A1C lowering was increased frequency of sensor use. CGM can be helpful in insulin-treated patients with hypoglycemia unawareness and/or frequent severe hypoglycemic episodes. The FDA has approved the use of properly calibrated CGM devices (ie, Medtronic 670G pump/sensor and Dexcom G6 sensor) to help make treatment decisions.

1.4.0 HYPOGLYCEMIA

1.4.1 Classification:

Patients with insulin-treated diabetes aged more than 65 years who would benefit from CGM should have access to it with insurance coverage. Intensive diabetes education and support are essential for optimal CGM implementation and ongoing use.

Prompt action is recommended for the treatment of hypoglycemia. When possible, the patient should confirm symptoms with SMBG to document hypoglycemia. All patients with T1D should ensure that a family member/companion/caregiver knows how to administer a glucagon injection in the event that the patient is unable or unwilling to take carbohydrate orally [1C].

The International Hypoglycemia Study Group recently recommended that hypoglycemia be classified as:

Level 1 (glucose alert level) with glucose less than 70 mg/dL (3.8 mmol/L), which is considered sufficiently low for treatment with fast-acting carbohydrates

Level 2 (clinically significant hypoglycemia) with glucose less than 54 mg/dL (2.9 mmol/L), which is considered serious and clinically important hypoglycemia

Level 3 (severe hypoglycemia) with no specific glucose threshold but associated with cognitive impairment requiring external assistance.

1.4.2 Treatment:

• Caution patient to avoid alternate site monitoring with blood glucose meter when hypoglycemic

• Treat as mild-to-moderate hypoglycemia if patient is symptomatic or unable to confirm hypoglycemia with SMBG, or if blood glucose levels are >54 mg/dl (2.9 mmol/L) and <70 mg/dL (3.8 mmol/L) and are <90 mg/dL (4.9 mmol/L) at bedtime or overnight

• To treat mild-to-moderate hypoglycemia (plasma glucose 54-70 mg/dL [3.8-2.9 mol/L] most times of the day and <90 mg/ dL (4.9 mmol/L) at bedtime or overnight), begin with 15-20 grams of carbohydrate (1/2 cup juice or regular soft drink; 3-4 glucose tabs) [1C]

• If glucose level is ≤54 mg/dl (2.9 mmol/L), consume 20-30 grams of carbohydrate [1C]

• Recheck blood glucose after 15 minutes [1B]

• Repeat hypoglycemia treatment if blood glucose does not return to normal range after 15 minutes [1C]

• Follow with additional carbohydrates if next meal is more than 1 hour away [1C]

• If hypoglycemia persists after 2 to 3 treatments, patient or companion should be instructed to contact their healthcare provider or seek emergency care

• In event of severe hypoglycemia (altered consciousness, unable to take carbohydrate orally, or requiring the assistance of another person) treat with glucagon and/or intravenous glucose [1C]

• For patients with hypoglycemia unawareness, the threshold for treatment of hypoglycemia needs to be individualized [1C]

• For patients using real-time CGM, check 15 minutes post treatment using a finger stick and not the sensor reading. Due to the physiologic lag between blood and interstitial glucose, the sensor will yield a lower result and can lead to overtreatment [1B]

• For patients with gastroparesis, treat hypoglycemia with oral glucose gel

• The patient’s treatment plan should be revised if hypoglycemic events are frequent, or if they have hypoglycemia unawareness

1.4.3 Education:

• Instruct the patient to obtain and wear or carry diabetes identification

• Instruct patient to carry treatment for hypoglycemia at all times

• Instruct all patients with T1D, and patients with T2D who are at risk for hypoglycemia, to check blood glucose before operating a motor vehicle or other potentially dangerous equipment. In addition, advise them to check blood glucose regularly if driving for 1 or more hours. Hypoglycemia should be treated immediately, and patients should not drive until their blood glucose has reached and remained at a safe range for at least 30 minutes and/or until cognitive function is restored [1B]

• Identify potential causes of hypoglycemia to prevent its occurrence [1C]

• Be clear in communicating modified treatment goals in individuals with hypoglycemia unawareness

• Glucagon injections should be prescribed to all patients with severe hypoglycemia. Education on its use should be provided to the patient and to their

1.5.0 DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT (DSME/S)

caregivers/family members if possible

Everyone with diabetes should receive DSME/S according to the National Standards for Diabetes Self-Management Education and Support, to facilitate knowledge and to implement

and sustain self-care skills and problem-solving [1B].

Critical time points recommended for DSME/S are:

• At diagnosis

• Annually for assessment of education, nutrition and emotional needs

• When new complicating factors arise

• When transitions in care occur

Multiple visits with a DE are recommended to evaluate progress toward goals [1B].

1.6.0 MEDICAL NUTRITION THERAPY (MNT)

Group education sessions are encouraged for cost effectiveness and efficiency of staff utilization. Group education is a benefit to patients as it allows them to share ideas and concerns and enables them to learn from one another [1B].

No one-size-fits-all eating pattern exists for individuals with diabetes. Patients with newly diagnosed diabetes should receive either individualized or group MNT, preferably by a

registered dietitian nutritionist who is knowledgeable and skilled in providing diabetes-specific MNT. MNT delivered by a registered dietitian is associated with an A1C decrease

of 0.3%-1% for those with T1D and 0.5%-2% for patients with T2D [1A]. Goals of MNT are to promote healthy eating patterns while addressing the unique nutrition needs of

each patient based on their personal preferences, cultural background, health literacy, barriers to change, and ability to make changes in their eating habits.

Weight management is important for overweight and obese individuals living with T1D and T2D. There is strong evidence that modest and persistent weight loss is beneficial to the management of T2D and can delay the progression from prediabetes to T2D.

1.7.0 PHYSICAL ACTIVITY

For further details please refer to Chapter 2.All adults should consult their healthcare provider and/or see an exercise physiologist to discuss a safe exercise program that is appropriate to their abilities [1C].

1.7.1 Physical activity for healthy adults:

• Physical activity should be an integral component of the diabetes care plan to optimize glucose control, decrease cardiovascular risk factors, and achieve or maintain optimal body weight [1A]

• A moderate-intensity aerobic (endurance) physical activity minimum of 30 minutes 5 days per week or vigorous-intensity aerobic physical activity for a minimum of 20 minutes 3 days per week should be achieved unless contraindicated. Activity can be accumulated toward the 30-minute minimum by performing bouts, each lasting 10 or more minutes [1A]

• All adults, and particularly those with T2D, should decrease the amount of time spent in daily sedentary behavior. Prolonged sitting should be interrupted every 30 minutes for blood glucose benefits, particularly in adults with T2D.

• A target of 60 to 90 minutes of activity, 6 to 7 days per week, is encouraged for weight loss if overweight or obese [1A]

• To increase lean body mass, full body resistance training should be incorporated into the activity plan 3 to 4 days per week. It should include upper-body, core, and lower-body strengthening exercises using free weights, resistance machines, or resistance bands [1B]. Beginning training intensity should be moderate, involving 10 to 15 repetitions per set, with

increases in weight or resistance undertaken with a lower number of repetitions (8-10) only after the target number of repetitions per set can consistently be exceeded; increase in resistance can be followed by a greater number of sets and, lastly, by increased training frequency

• Stretching exercises should be done when muscles are warm or at the end of the activity plan to loosen muscles and prevent soreness [1B]

1.7.2 Physical activity for adults with medical or physical limitations:

• A moderate-intensity aerobic (endurance) physical activity minimum of 30 minutes, 5 days per week, or vigorous-intensity aerobic physical activity for a

minimum of 20 minutes, 3 days per week, should be achieved, as feasible, unless contraindicated. Activity can be accumulated toward the 30-minute

minimum by performing bouts each lasting 10 or more minutes [1A]

• To increase lean body mass, resistance training should be incorporated into the activity plan 3 to 4 days per week, as feasible. It should include upper-body, core,

and lower-body strengthening exercises using free weights, resistance machines, or resistance bands [1B]

• Incorporate balance exercises to prevent falling and injury

• Functional Fitness Testing is useful to assess patients’ functionality and track their progress. Testing such as the 6-Minute Walk Test, 2-Minute Step Test, Balance

Assessment, and Hand Strength should be included at baseline and post intervention [1C]

1.8.0 CARDIOVASCULAR HEALTH

• See section on Ocular Health.(Also see sections on Lipids, Blood Pressure, Physical Activity, and Smoking)

1.8.1 Antiplatelet therapy:

A daily enteric-coated aspirin (ASA) (75-162 mg) unless contraindicated* as a primary prevention strategy for men aged ≥50 years [1C] and for women ≥60 years of age [1C] with

1 or more of the following risk factors:

• Family history of premature** CAD or stroke

• Hypertension (HTN)

• Current cigarette smoker

• Albuminuria

• Hyperlipidemia

Recommend a daily enteric-coated ASA (75-162 mg), or clopidogrel (75 mg, if aspirin-intolerant), or another agent of the class as a secondary prevention strategy for anyone with

1 or more of the following [1A]:

• History of myocardial infarction (MI), angina, or documented CAD

• Vascular revascularization

• Nonhemorrhagic stroke

• Transient ischemic attack

• Peripheral artery disease (PAD)

*Possible contraindications for antiplatelet therapy may include allergy, bleeding tendency, anticoagulant therapy, recent gastrointestinal bleeding, and clinically active hepatic disease.

Eye disease is usually not a contraindication for ASA therapy.

**Premature: 1st-degree male relative aged less than 55 years; 1st-degree female relative aged less than 65 years.

1.8.2 Other therapeutic considerations:

Consider using beta-blockers in all patients with a history of MI or with documented CAD unless contraindicated [1A]. Consider using angiotensin-converting-enzyme (ACE)

inhibitors (or angiotensin receptor blockers [ARBs] if ACE inhibitors not tolerated) in patients with known CAD or cardiovascular risk factors and aged ≥55 years [1B].

Thiazolidinediones (TZDs) (ie, pioglitazone, rosiglitazone) are contraindicated in patients with heart failure defined as New York Heart Association (NYHA) classes III and IV [and conditions of fluid overload (ie, congestive heart failure). See Clinical Guideline for Pharmacological Management of Adults With Type 2 Diabetes (Chapter 5) for additional caveats on TZDs [1A].

Consider recommending aerobic activity if not clinically contraindicated, and a weight-loss program if patient is overweight or obese. [1A]

1.8.3 When to conduct a stress test:

Based on current research and understanding of CAD in diabetes, it is reasonable to screen patients with diabetes who [1C]:

• Complain of typical or atypical chest pain

• Have an abnormal electrocardiogram (ECG)

• Have a diagnosis of PAD or carotid artery disease

• Are aged >35 years with sedentary lifestyle about to start a rigorous exercise program

Currently, no strong evidence supports screening asymptomatic patients with T2D for silent myocardial ischemia [1C].

Patients with autonomic neuropathy may have increased risk of asymptomatic ischemia and therefore warrant careful attention [1B].

If stress testing is performed, either nuclear imaging or echocardiography with ECG monitoring is recommended. An exercise stress test is preferred, if resting ECG is normal and

patient is able to exercise, because the response to exercise is an important prognostic factor. If the patient cannot adequately exercise, pharmacologic stress testing is warranted.

1.8.4 Lipid management:

1.8.4a Screening for lipid disorders:

Adults should be screened annually for lipid disorders with measurements of serum cholesterol, triglycerides, and low-density lipoprotein cholesterol (LDL-C) and high-density

lipoprotein cholesterol (HDL-C), preferably fasting [1B].

1.8.4b Treatment:

All patients should receive information about a meal plan designed to improve glycemic and lipid control, physical activity recommendations, and cardiovascular risk reduction

strategies (with an emphasis on smoking cessation and blood pressure control). Consultation with appropriate education discipline is preferred [1A].

Institute therapy after abnormal values are confirmed.

• All patients with any form of clinical diagnosis of atherosclerotic cardiovascular disease (ASCVD), or with LDL-C ≥190 mg/dl: Treat with statin to reduce

LDL-C ≥50% [1A]

• Patients aged 40 to 75 years without clinical evidence of ASCVD, with LDL-C 70-189 mg/dl: Treat with statin to reduce LDL-C by 30% to 49%. Consider reduction of ≥50% if 1 or more of the following additional major risk factors are present:

-- Calculated 10-year risk of ASCVD ≥7.5% using the American College of Cardiology/American Heart Association risk equation calculator (my.americanheart.org/cvriskcalculator) [1B]

-- Family history of premature ASCVD

-- High blood pressure

-- Tobacco use

-- AlbuminuriaIn patients aged <40 years, consider statin if LDL-C ≥100 mg/dl and multiple ASCVD risk factors are present [2B]

• In patients aged >75 years, no clear evidence exists for benefits of initiating statin therapy in the absence of ASCVD or multiple CV risk factors [2C]

• Recheck lipids after drug initiation or dose escalation in 6 to 12 weeks. Thereafter, check lipids every 3 to 12 months to monitor adherence. May down-titrate statin

dose if LDL-C <40 mg/dl

• No evidence exists for benefits of statin therapy in patients on hemodialysis or those with heart failure (NYHA class II-IV) [1B]

• If adequate reduction in LDL-C as described above has been achieved, a specific LDL-C goal (<70 and <100 mg/dl) or non-HDL-C goal (<100 and <130 respectively)

for those with or without ASCVD, respectively, is not recommended

• In patients with ASCVD or with familial hypercholesterolemia, who are unable to achieve LDL-C goal with maximum tolerated statin therapy, add ezetimibe and

consider a PCSK9 inhibitor

• For primary prevention of ASCVD, consider use of ezetimibe or bile acid sequestrant or niacin (alone, or in combination therapy) for patients intolerant

to multiple statins or who have unacceptable adverse events [2B]

• Statins are contraindicated during pregnancy or if contemplating pregnancy

Patients with LDL-C at goal and fasting triglycerides ≥150 mg/dl or HDL-C ≤40 mg/dl:

• Optimize glycemic control [1A]

• Refer to RD for dietary modification and therapeutic lifestyle changes [1A]

• Consider referral to an exercise specialist for an appropriate exercise regimen

• Recheck lipids within 6 to 12 weeks

• In patients with fasting triglyceride levels 200 to 499 mg/dl and/or HDL-C ≤35 mg/dl after optimal statin therapy; calculate non-HDL-C, intensify statin if

non-HDL-C not in goal before considering addition of fibrate [2B]

• If triglycerides are persistently ≥500 mg/dl, secondary causes of hypertriglyceridemia should be considered and managed appropriately.

Initiate treatment with a very low-fat meal plan and with a fibrate for prophylaxis against acute pancreatitis; reassess lipid status when triglycerides <500 mg/dl [1A]

• If fasting triglycerides remain ≥ 500 mg/dl after initiation of fibrate, consider the addition of fish oil (to provide 2 to 4 grams omega-3 fatty acids

daily) or niacin [2B]

1.8.5 Blood pressure management:

1.8.5a Blood pressure measurement:

• Check blood pressure (BP) at all routine visits after patient has been seated for at least 5 minutes. Use proper-size cuff and arm position. Postural BP (sitting, then standing) should be checked initially, and as clinically indicated:

-- In cases of known or suspected orthostatic hypotension (defined as a fall in systolic BP [SBP] of >20 mmHg or diastolic BP [DBP] of >10 mmHg or an increase in heart rate by more than 20 beats per minute after 3 minutes of standing)

-- In cases where standing upright is associated with lightheadedness, syncope, or signs of brain hypoperfusion [1C]

• Initiate lifestyle changes if BP >130/80 mm/Hg

• Consider initiating pharmacologic therapy if the average of 3 blood pressure measurements is >140/90 mmHg

• Schedule for follow-up blood pressure check within 1 month [1B]

1.8.5b Blood pressure targets:

• BP goal for each patient aged >18 years is ≤140/90 mmHg [1B] The recent recommendation for achieving BP target of < 130/80 by the American College of Cardiology and others is controversial in patients with diabetes and not endorsed by the Joslin Clinical Oversight Committee or the ADA.

• SBP <130 mmHg may be appropriate for individuals without CVD or without multiple risk factors [1B]

• No clear evidence exists for significant benefits to be gained by lowering SBP to <120 mmHg in those with coronary heart disease or multiple risk factors [1B]

• BP goal for patients with albuminuria ≥300mcg/mg is <130/80 mmHg, if tolerated [1C]

• Initial goal for patients with isolated systolic HTN (SBP >180 mmHg and DBP <80 mmHg) is a SBP <160 mmHg [2B] or < 140 mmHg if safely achieved.

• Initial goal for patients with SBP 160-179 mmHg is to lower SBP by 20 mmHg. If well tolerated, lower BP goals may be indicated [1B]

1.8.5c Treatment:

If SBP ≥140 mmHg or DBP ≥90 mmHg, a 3-month trial of lifestyle modification is warranted as follows [1C]:

• Counsel about meal plans, use of Dietary Approaches to Stop Hypertension (DASH), the DASH low-sodium diet, and sodium reduction in general. Also, counsel about activity, weight loss, alcohol use, and stress reduction

• Consider referral to RD for MNT

• Encourage home BP self-monitoring and providing documentation during clinic visits

• Instruct patient to have BP checked 2 times a week prior to the next appointment

• Follow-up with healthcare provider within 2 to 4 weeks

• Initiate or adjust therapy with antihypertensive agents as clinically indicated if BP remains above goal

Studies have shown that aggressive management and control of BP may result in long-term benefits.

• Pharmacotherapy:

Efficaciousness is the most important consideration in choosing an initial antihypertensive drug. In that sense, any available antihypertensive drug can be an appropriate

choice. However, other considerations (eg, presence of albuminuria, coexisting CAD, cost) may dictate a preference for an ACE inhibitor, ARB, calcium channel

blocker, or thiazide-type diuretic [1A]. In general, ACE inhibitors and ARBs should not be used in combination.

Consider ACE inhibitors or ARBs for patients with persistent urine albumin/creatinine ratio ≥30 mcg/mg. These drugs require monitoring of serum creatinine and K+ within 1 week of

starting therapy and periodically thereafter [1A]. (See section on Renal Health.)

1.9.0 RENAL HEALTH

1.9.1 Screening for renal health:

ACE inhibitors/ARBs are contraindicated during pregnancy or if contemplating pregnancy.

Measure serum creatinine at least annually to estimate glomerular filtration rate (eGFR) regardless of degree of urine albumin excretion.) [1C]

Measure eGFR using chronic kidney disease epidemiology (CKD-EPI) calculation.

If eGFR is <60 ml/min, evaluate for complications of kidney disease (anemia, hyperparathyroidism, and vitamin D deficiency).

Screen for albuminuria by checking urine albumin/creatinine (A/C) ratio as follows:

• Patients with T1D within 5 years after diagnosis and then yearly [1C]

• Patients with T2D at diagnosis (after glucose has been stabilized) and then yearly [1C]

• Annually in all patients up to age 70 years [2C]

• As clinically indicated in patients aged >70 years

Albuminuria is recognized as a major independent risk factor for CAD in patients with diabetes. Albuminuria may be measured with a spot or timed urine collection. Spot urine is

preferred for simplicity.

Continue use of routine urinalysis as clinically indicated [2C].

Patients should be advised that BP control, glycemic control, and management of albuminuria may slow the progression of CKD.

1.9.2 Evaluation and treatment of diabetes kidney disease (DKD)

If A/C ratio <30 mcg/mg or timed urine albumin <30 mg/24 hours:

• recheck in 1 year

If A/C ratio 30-299 mcg/mg or timed urine albumin 30-299 mg/24 hours:

• Confirm presence of albuminuria with at least 2 of 3 positive collections done within 3-6 months. In the process, rule out confounding factors that cause a false

positive, such as urinary tract infection, pregnancy, excessive exercise, menses, or severe hypoglycemic event [1C]

• Consider testing first morning urine

• Consider consult with nephrologist for blood pressure control, successive increases in albumin, and other issues (ie, eGFR <60 ml/min) [2C]

Once DKD confirmed:

• Evaluate BP and initiate/modify aggressive blood pressure treatment to achieve a BP of <130/80 mmHg [2B]

• Recommend that patient self-monitor BP with portable cuff and maintain a record/log. The monitoring schedule should be determined with the healthcare provider and is based on patient circumstance

• Strive to improve glycemic control with an optimal goal A1C of <7% or as otherwise clinically indicated [1A]

• Refer to DE for glucose management

• Initiate/modify ACE inhibitor or ARB treatment if albuminuria persists. Check K+ and creatinine about 1 week after making these medication changes [1A]

• Repeat A/C ratio at least every 6 months. Consider increase in frequency when changes in medication are made [2C]

If A/C ratio ≥300 mcg/mg (≥300 mg/24 hours) or persistent albuminuria presents (positive dipstick for protein or ≥30 mg/dl):

• Follow all guidelines as stated for A/C ratio 30-300 mcg/mg

• Consider BP goal of <130/80 mmHg [2B]

• Evaluate for patient adherence, with emphasis on avoidance of high sodium and of very high protein intake

• Consider referral to RD for MNT

• Consider referral to nephrologist to:

• Assess cause(s) of impaired kidney function, including assessing for DKD

• Maximize therapies aimed at slowing progression

of kidney disease (eg, BP control; reduction of

urine protein level)

• Treat complications of kidney disease (hyperphosphatemia,

anemia, etc)

• Evaluate any rapid rise in serum creatinine, abnormal sediment, or concomitant hematuria, or sudden increase in albuminuria

• Assess problems with ACE inhibitor use and difficulties in management of high BP or hyperkalemia

Manage resistant hypertension, defined as BP that remains above goal despite concurrent use of 3 antihypertensive agents of different classes (1 of which should

1.10.0 OCULAR HEALTH

1.10.1 Screening for eye disease:

be a diuretic. All should be at maximum dose tolerated)

Refer patient for comprehensive dilated eye exam or validated retinal imaging to determine level of retinopathy.

• T1D: initial eye exam at start of puberty or once patient is 10 years of age or older, whichever is earlier, within 3 to 5 years of diagnosis. Annual eye exam thereafter [1A]

• T2D: at diagnosis and annually thereafter [1A]

• Pregnancy in woman with preexisting diabetes: several exams, including prior to conception; during first trimester; follow-up during pregnancy as determined by first-trimester exam; and 6 to 12 weeks postpartum [1B]

• For physiologic insulin therapy (pump therapy or multiple daily injections): Consult with patient’s eye care provider or evaluate retinal status with validated retinal imaging to determine level of retinopathy and appropriate follow-up care prior to initiating physiologic insulin therapy [1A]

1.10.2 Treatment:

Aggressively treat known medical risk factors for onset and progression of retinopathy:

• Strive to improve glycemic control with optimal A1C goal of <7% [1A]

• Monitor eye disease carefully when intensifying glycemic control [1A]

• Strive for BP <130/80 mmHg [1B]

• Treat albuminuria [1B]

• Strive to maintain total cholesterol, LDL-C, HDL-C, and triglyceride levels as per the recommendations outlined in the Lipids section of this guideline [1A]

• Treat anemia [1B]

Activity programs that involve strenuous lifting; harsh, high-impact components; or activities that place the head in an inverted position for extended periods of time may need

to be revised depending on the level of retinopathy.

Reinforce follow-up with eye-care provider for any level of retinopathy, including no apparent retinopathy. The frequency of follow-up is dependent upon the level

of retinopathy and presence of risk factors for onset and progression of retinopathy and is determined by the eye care provider.

• For high-risk proliferative diabetic retinopathy, prompt scatter (panretinal) laser photocoagulation and/or intravitreal anti—vascular endothelial growth factor

(VEGF) injection is indicated [1A]

• For clinically significant macular edema (CSME) or center-involved macular edema, focal laser and/or intravitreal anti-VEGF injection is generally indicated

regardless of level of retinopathy [1A]

• The level of diabetic retinopathy and diabetic macular edema (DME) generally determines follow-up* [1A].

See suggested follow-up time spans below:

If No Diabetic Retinopathy:

• 12 months

If Mild Nonproliferative Diabetic Retinopathy:

• Without DME, 12 months

• With DME,** monthly if undergoing anti-VEGF treatment, otherwise 3 to 4 months

If Moderate Nonproliferative Diabetic Retinopathy:

• Without DME, 6 to 9 months

• With DME,** monthly if undergoing anti-VEGF treatment, otherwise 3 to 4 months

If Severe-to-Very Severe Nonproliferative Diabetic Retinopathy:

• Without DME,*** 3 to 4 months

• With DME,** monthly if undergoing anti-VEGF treatment, otherwise 3 to 4 months

If Proliferative Diabetic Retinopathy Less Than High-Risk:

• Without DME,*** 1 week to 3 to 4 months

• With DME,** 1 week to 1 month if undergoing anti-VEGF treatment, otherwise 3 to 4 months

If High-Risk Proliferative Diabetic Retinopathy:

• With or without DME: scatter (panretinal) laser photocoagulation and/or intravitreal anti-VEGF injection with follow-up in 3 months, or 1 month and monthly thereafter if undergoing anti-VEGF treatment

*The presence of known risk factors for onset and progression of retinopathy may suggest follow-up at shorter intervals for all levels of retinopathy.

**Focal laser surgery and/or intravitreal anti-VEGF injection is generally indicated for CSME or center-involved macular edema. If receiving anti-VEGF treatment, follow-up

is generally monthly.

1.11.0 NERVOUS SYSTEM HEALTH

1.11.1 Screening for neuropathy

1.11.1a Methods:

***Scatter laser surgery may be indicated, especially for T2D or T1D of long duration

• Ask patient about loss of sensation in the limbs, symptoms of pain, tingling, paresthesia, weakness, or gait instability.

• Evaluate feet for sensation using a 128 Hz tuning fork and Semmes-Weinstein 5.07 monofilament [1B]

• Evaluate reflexes

• Laboratory screening with complete blood count, lipid panel, thyroid panel, B12 level (methylmalonic acid and/or homocysteine if low-normal B12),

and serum and urine protein electrophoresis, as clinically indicated

Neurophysiologic testing (electromyogram, nerve conduction studies, or skin biopsy analysis of intra-epidermal nerve fiber density) should be considered in atypical cases

• Assess for symptoms of autonomic neuropathy such as erectile dysfunction, gastroparesis, or postural hypotension. If symptoms of autonomic neuropathy are present, refer for evaluation by formal autonomic testing (including heart rate variability testing, blood maneuver, and the blood pressure response to upright tilt table testing or standing) [1B]

1.11.1b Frequency:

• For patients with T1D and T2D without complications, conduct symptom and examination screen at time of diagnosis and at least annually [1C]

• For “at-risk patients,”* conduct symptom and examination screen at all routine interval visits [1C]

• Laboratory screening at the time of diagnosis of diabetes or with change in symptoms or examination [1C]

• Screen for cardiovascular autonomic neuropathy at the time of diagnosis of T2D, or 5 years after diagnosis of T1D. Screening should be repeated yearly or

with development of symptoms [1C]. If symptoms of autonomic neuropathy are present, refer for evaluation by formal autonomic testing (including

heart rate variability testing, blood pressure and heart rate response to a Valsalva maneuver, and the blood pressure response to upright tilt table testing

or standing) [1B]

• Neurophysiologic testing only for atypical cases [1C] *“At-risk patients” include patients who smoke; who have vascular insufficiency, neuropathy, retinopathy, nephropathy,

structural deformities, infections, skin/nail abnormalities, or a history of ulcers or amputations; who are on anticoagulation therapy; or who cannot see, feel, or reach their feet.

1.11.2 Treatment:

For patients with acute problems or who are “at risk”:

• Consider referral to neurologist for:

-- atypical neuropathy

-- rapidly progressive symptoms

-- severe pain unresponsive to first-line therapy

-- weakness suggestive of diabetic amyotrophy

For patients with symptoms related to diabetic peripheral or autonomic neuropathy:

• Consider medications, because they improve quality of life [1A]

1.12.0 FOOT HEALTH

1.12.1 Screening

1.12.1a Methods:

Screening should include:

• Questions about loss of sensation in the limbs, or symptoms of pain, including claudication, tingling, or other paresthesia

• Foot evaluation for sensory function (Semmes-Weinstein 5.07 monofilament and 128 Hz tunic fork) [1B]

• Evaluation of reflexes, skin and soft-tissue integrity, nail condition, callous formation, vascular sufficiency (pedal pulses), and biomechanical integrity

• Examination of shoes for wear and appropriateness

1.12.1b Frequency:

• For patients with T1D and T2D without complications or significant risk factors, conduct foot screen at time of diagnosis and at least annually thereafter [1C]

• For “at-risk patients,”* check feet at all routine interval visits [1C]

*“At-risk patients” include patients who smoke; who have vascular insufficiency, neuropathy, retinopathy, nephropathy, structural deformities, infections, skin/nail abnormalities, or a

history of ulcers or amputations; who are on anticoagulation therapy; or who cannot see, feel, or reach their feet.

1.12.2 Treatment:

For patients with acute problems or who are “at risk”:

• Refer to podiatric physician for routine care and evaluation [1B]

• Refer to DE for foot care training** [1C]

• Consider referral to neurologist for:

-- atypical neuropathy

-- rapidly progressive symptoms

-- severe pain unresponsive to first-line therapy

-- weakness suggestive of diabetic amyotrophy

For mild current ulcer or infection** [1C]

** Mild ulcer or infection is characterized by: (a) superficial lesion (no foul odor), (b) no significant ischemia, (c) no bone or joint involvement, (d) no systemic toxicity, (e) minimal or no cellulitis (<2 cm)

• Instruct patient in nonweight-bearing, if appropriate

• Apply local dressings with topical antiseptic

• Consider baseline x-ray to evaluate for bone integrity

and possible osteomyelitis

• Consider systemic antibiotic therapy

• Refer to podiatric physician for evaluation

and treatment

• Refer to DE for foot-care training

• Ensure follow-up appointments are kept

For limb-threatening*** ulcer or infection [1C]:

***Limb-threatening ulcer or infection is characterized by (a) deep ulcer, (b) bone or joint involvement, (c) gangrene, (d) lymphangitis, (e) cellulitis (>2 cm), (f) systemic toxicity, (g) significant ischemia, (h) no social support system, (i) immunocompromised, (j) foul odor in ulcer.

Osteomyelitis is presumed to be present if able to probe through the ulcer to the bone.

• Urgent hospitalization

• Consult a podiatric physician and vascular surgeon for immediate evaluation and treatment

• Foot care training should address:

-- Avoidance of foot trauma

-- Daily foot inspection

-- Nail care

-- Callous formation

-- Proper footwear

-- Impact of loss of protective sensation on morbidity

-- Need for smoking cessation

-- Action to take when problems arise

1.13.0 ORAL HEALTH

-- Importance of glucose control on disease progression• Periodontal disease is associated with suboptimal diabetes control and may be a risk factor for cardiovascular disease. There is mixed evidence on the impact of treatment of periodontal disease on glycemic control

• Referral to a dentist should be considered an essential component of a comprehensive diabetes care plan

• At initial visit and annually, discuss need for dental cleaning at least every 6 months [1C]

• Refer to dental specialist for oral symptoms and findings such as sore, swollen, or bleeding gums, loose teeth, or persistent mouth ulcers [1C]

1.14.0 BEHAVIORAL HEALTH

• If edentulous, refer to dental specialist for restoration of functional dentitionA psychosocial evaluation should be an integrated component of the initial assessment and the ongoing care of all patients with diabetes and should be strongly considered in

the following situations:

Newly diagnosed diabetes:

• Assess at least the following [1C]:

• Ability to cope with the emotional impact and lifestyle changes of diabetes

• Level of social support

• Barriers to treatment and self-management

• Type and degree of nondiabetes-related life stress

During hospitalizations or any intensification in treatment, significant life change, problems with self-management, or metabolic stability. Key areas to assess:

• Diabetes distress: consider using Problem Areas in Diabetes as a screening tool.

• Depression: consider using Patient Health Questionnaire (PHQ)-2 or PHQ-9 as a screening tool

• Anxiety (eg, compulsive SMBG fear of injections).

• Exaggerated fear of hypoglycemia: Consider referral for blood glucose awareness training.

• Disordered eating: Consider inquiry about insulin omission or bingeing if A1C >9% or diabetic ketoacidosis is recurrent

• Family conflict related to diabetes

• Substance abuse: Consider use of the CAGE alcohol screening tool

Newly diagnosed complications from diabetes. Assess at least the following:

• Emotional impact (diabetes distress, depression,

anxiety) and lifestyle changes for patient and family

• Barriers to treatment and self-management

• Level of social support

• Type and quantity of nondiabetes-related life stress

1.15.0 WOMEN’S HEALTH

Patients using second-generation or atypical antipsychotic medications should be monitored for weight gain with resulting increases in glucose, lipid, and blood pressure levels.(Refer to Joslin Guideline for Detection and Management of Diabetes in Pregnancy [Chapter 3]).

• All women of reproductive age should be assessed for the possibility of pregnancy prior to initiating new medications, and they should be counseled on potential risks to the developing fetus.

• Counsel women with the potential for conception about contraception use and relationship of blood glucose control to fetal development and pregnancy outcomes [1C]

• At initial and annual visit, discuss sexual function -- Assess for infectious, hormonal, psychological, or structural etiologies if dysfunction exists

-- Refer to specialist as indicated [1C]

• Follow appropriate guidelines for pap/pelvic and mammography screening for primary care patients [1B]

• Individualize approach to bone health for women with risk factors for osteoporosis, including surgical and natural menopause [1B]

1.16.0 MEN’S HEALTH

-- Ensure adequate intake of calcium and vitamin D• At initial and annual visit, discuss sexual function and any fertility concerns -- Assess for hormonal, psychological, or structural etiologies if dysfunction exists [1C]

• For men with type 2 diabetes, consider screening for low testosterone [1B]

-- Screen for total testosterone and sexhormone—binding globulin

1.17.0 ADDITIONAL CONSIDERATIONS

1.17.1 Tobacco dependence:

• Refer to specialist as indicated

Screen: Assess patient’s use of tobacco and e-cigarettes at initial and follow-up visits.

Treatment (if patient smokes)

• Discuss rationale for and strongly recommend smoking cessation [1A]

• Review options available to assist in smoking cessation, including medications and cessation programs [1B]

1.17.2 Identifying sleep disorders:

• At initial visit and annually, inquire about sleep quality, level of fatigue, and symptoms such as snoring and restless sleep [1C]

• Obstructive sleep apnea is more frequent in the setting of central obesity and is a risk factor for ASCVD

• Refer for sleep study if indicated

• The evidence surrounding the impact of sleep apnea treatment on diabetes control has been so far inconclusive

• Pay special attention to shift workers. An individualized care plan should be tailored to their schedules, and the effect of shift work on glycemic control should

be assessed at each visit

1.17.3 Immunizations:

Recommend the following vaccines:

• Influenza vaccine: yearly for all adult patients with diabetes [1B]

• Pneumococcal vaccine with pneumococcal polysaccharide vaccine (PPSV23): once for all patients with diabetes [1B]

-- Patients ≥65 years of age should receive pneumococcal conjugate vaccine (PCV13) at least 1 year after vaccination with PPSV23, followed by a 1-time revaccination

if they received the previous dose ≥5 years earlier [1C]

-- Repeat vaccination should be considered for those with nephrotic syndrome, chronic renal disease, and other immunocompromised states

-- Hepatitis B Vaccine 3-dose series: for unvaccinated adult patients with diabetes (age 19-59 years) [1C]. May also consider for unvaccinated adults ≥60 years [2C]

Address Correspondence to:

Om P. Ganda, MD

1 Joslin Place

Boston, MA 02215

Phone: 617-309-2645

Email: om.ganda@joslin.harvard.eduReferences

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