Diabetes Care Summary of Revisions for the 2014 Clinical Practice Recommendations Copied from:

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 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 high- risk 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 CategorySpot 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