Diabetes Care

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Diabetes Care

• Summary of Revisions for the 2013Clinical
  Practice Recommendations

Copied from http//diabetesjournals.org/content/3
6/Supplement_1/S3.extract
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• Section II.C. Screening for Type 1
• Diabetes has been revised to include
• more specific recommendations.

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• Consider referring relatives of those with type 1
  diabetes for antibody testing for risk assessment
  in the setting of a clinical research study. (E)

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• Section IV. Prevention/Delay of Type 2 Diabetes
  has been revised to reflect the importance of
  screening for and treating other cardiovascular
  risk factors

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• People with prediabetes often have other
  cardiovascular risk factors, such as obesity,
  hypertension, and dyslipidemia. Assessing and
  treating these risk factors is an important
  aspect of reducing cardiometabolic risk. In the
  DPP and DPPOS, cardiovascular event rates have
  been very low, perhaps due to appropriate
  management of cardiovascular risk factors in all
  arms of the study (56).

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• Section V.C.a. Glucose Monitoring has been
  revised to highlight the need for patients on
  intensive insulin regimens to do frequent
  self-monitoring of blood glucose

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• 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)

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• 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

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• 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)

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• Section V.F. Diabetes Self-Management Education
  and Support has been revised to be National
  Standards for Diabetes Self-Management Education
  and Support consistent with the newly revised.

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• 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)

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• DSME and DSMS programs are appropriate venues for
  people with prediabetes to receive education and
  support to develop and maintain behaviors that
  can prevent or delay the onset of diabetes. (C)
• Because DSME and DSMS can result in cost-savings
  and improved outcomes (B), DSME and DSMS should
  be adequately reimbursed by third-party payers.
  (E)

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• Section V.K. Hypoglycemia has been revised to
  emphasize the need to assess hypoglycemia and
  cognitive function when indicated.

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• Individuals at risk for hypoglycemia should be
  asked about symptomatic and asymptomatic
  hypoglycemia at each encounter. (C)
• Glucose (1520 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)

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• 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)

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• 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

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• 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)

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• 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.

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• 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 high-risk patients.

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• 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.

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• Section VI.B. Nephropathy Screening
• and Treatment and Table 11 have been revised to
  highlight increased urinary albumin excretion
  over the terms micro- and macroalbuminuria, other
  than when discussion of past studies requires the
  distinction.

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• Table 11 - Definitions of abnormalities in
  albumin excretion
• Category Spot collection
• (mg/mg creatinine)
• _____________________________________________
• Normal 30
• Increased urinary
• albumin excretion
  gt/30
• _____________________________________________
• Historically, ratios between 30 and 299 have
  been called microalbuminuria and those 300 or
  greater have been called macroalbuminuria (or
  clinical albuminuria).

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• Section VI.C. Retinopathy Screening and Treatment
  has been revised to include antivascular
  endothelial growth factor therapy for diabetic
  macular edema

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• 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.