ADA-Standard of Medical Care-2017 Updates to standards of medical care in diabetes 2016 Diabetes Care 2017;40(Suppl. 1):S1–S138.

ADA-Standard of Medical Care-2017 Updates to standards of medical care in diabetes 2016
Diabetes Care 2017;40(Suppl. 1):S1–S138

Background The ADA/EASD joint position statement on the management of hyperglycaemia in patients with diabetes mellitus was first published in 2012 and focused on proper selection and sequence of available antihyperglycaemic drugs1 The 2015 standards of medical care revision reflected the evidence generated after the ADA Position statement 20122 Current update to the 2016 standards of care focuses on psychosocial care in the treatment of diabetes and provides updates on several recommendations in approach, education, prevention, diagnosis and management of diabetes based on levels of new evidence generated3 ADA, American Diabetes association 1. Diabetes Care 2012;35(Suppl. 1):S11–S63 ; 2. Diabetes Care 2015;38(Suppl. 1):S1–S94 ; 3. Diabetes Care 2016;39(Suppl. 1):S1–S119 Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 1. Promoting Health and Reducing Disparities in Populations
Focuses on improving outcomes and reducing disparities in populations with diabetes Recommendations Treatment decisions should be timely, rely on evidence-based guidelines, and be made collaboratively with patients based on individual preferences, prognoses and comorbidities Treatment plans should align with the Chronic Care Model, emphasizing productive interactions between a prepared proactive practice team and an informed activated patient Providers should assess social context, including potential food insecurity, housing stability, and financial barriers, and apply that information to treatment decisions Patients should be referred to local community resources when available Patients should be provided with self-management support from lay health coaches, navigators, or community health workers when available Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 2. Classification and Diagnosis of Diabetes
Updated to include a new consensus on the staging of type 1 diabetes Stage 1 Stage 2 Stage 3 Stage Autoimmunity Normoglycaemia Presymptomatic Dysglycemia New-onset hyperglycemia Symptomatic Diagnostic criteria Multiple autoantibodies No IGT or IFG Dysglycemia: IFG and/or IGT FPG 100–125 mg/dL (5.6–6.9 mmol/L) 2-h PG 140–199 mg/dL (7.8–11.0 mmol/L) A1C 5.7–6.4% (39–47 mmol/mol) or ≥10% increase in A1C Clinical symptoms Diabetes by standard criteria Recommendation on Type 1 diabetes Persistence of two or more autoantibodies in screening predicts clinical type 1 diabetes and may serve as an indication for intervention in the setting of a clinical trial. Outcomes may include reversion of autoantibody status, prevention of glycemic progression within the normal or prediabetes range, prevention of clinical diabetes, or preservation of residual C-peptide secretion FPG, fasting plasma glucose; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; A1C, glycated hemoglobin Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 2. Classification and Diagnosis of Diabetes (Contd.)
Recommendation on Type 2 diabetes Screening for type 2 diabetes with an informal assessment of risk factors or validated tools should be considered in asymptomatic adults The ADA diabetes risk test for T2DM is an additional option for screening which is recommended to guide providers on need for a diagnostic test (a new template in this edition) ADA, American Diabetes association; T2DM, Type 2 diabetes mellitus Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 3. Comprehensive Medical Evaluation and Assessment of Comorbidities
Highlights the importance of assessing comorbidities in the context of patient-centered comprehensive medical evaluation Recommends assessment of sleep pattern and duration Recent meta-analysis indicates poor sleep quality, short sleep and long sleep associated with higher A1C in T2DM Recommendations for comprehensive medical evaluation Confirm the diagnosis and classify diabetes Detect diabetes complications and potential comorbid conditions Review previous treatment and risk factor control in patients with established diabetes Begin patient engagement in the formulation of a care management plan Develop a plan for continuing care Includes an expanded list of diabetes co-morbidities Autoimmune diseases, HIV, anxiety disorders, depression, disordered eating behavior and serious mental illness A1C, glycated hemoglobin; T2DM, Type 2 diabetes mellitus Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 4. Lifestyle Management
This section, previously entitled “Foundations of Care and Comprehensive Medical Evaluation,” was refocused on lifestyle management Recommendations Dietary factors influence insulin dosing and blood glucose levels. Nutrition therapy in flexible insulin therapy program should include education on how to use carbohydrate counting and in some cases fat and protein gram estimation to determine mealtime insulin dosing to improve glycemic control Prolonged sitting should be interrupted every 30 min with bouts of physical activity for blood glucose benefits, particularly in adults with T2DM Flexibility training and balance training are recommended 2–3 times/week for older adults with diabetes. Yoga and Tai Chi may be included based on individual preferences to increase flexibility, muscular strength, and balance T2DM, Type 2 diabetes mellitus Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 5. Prevention or delay of type 2 diabetes
Emphasizes on importance of screening for prediabetes using an informal assessment of risk factors and performing a diagnostic test when appropriate Recommendations Long-term use of metformin may be associated with biochemical vitamin B12 deficiency Periodic measurement of vitamin B12 levels should be considered in metformin-treated patients, especially in those with anemia or peripheral neuropathy Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 6. Glycemic targets
Update of this section is based on the recommendations of International Hypoglycemia Study Group Classification of Hypoglycemia Level Glycemic criteria Recommended treatment Description Glucose alert value (level 1) ≤70 mg/dL (3.9 mmol/L) Glucose (15–20 g) is the preferred treatment Sufficiently low for treatment with fast-acting carbohydrate and dose adjustment of glucose-lowering therapy Clinically significant hypoglycemia (level 2) ≤54 mg/dL (3.0 mmol/L) Glucagon should be prescribed Sufficiently low to indicate serious, clinically important hypoglycemia Severe hypoglycemia (level 3) No specific glucose threshold Hypoglycemia associated with severe cognitive impairment requiring external assistance for recovery Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 8. Pharmacological approaches to Glycemic treatment
This section has been renamed to highlight that this section focuses on Pharmacotherapy and includes updates on injectable insulin therapy, addition of cardiovascular risk reduction evidence and newly available biosimilar insulins Recommendations on Pharmacotherapy of type 2 diabetes Long-term use of metformin may be associated with biochemical vitamin B12 deficiency, and periodic measurement of vitamin B12 levels should be considered in metformin-treated patients, especially in those with anemia or peripheral neuropathy The algorithm for combination injectable therapy has been changed to reflect studies demonstrating The non-inferiority of basal + GLP-1 receptor agonist vs basal insulin plus rapid acting insulin vs two daily injections of premixed insulin The non-inferiority of multiple dose premixed insulin regimen vs basal bolus therapy T2DM, Type 2 diabetes mellitus; GLP-1 Glucagon like peptide 1 Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 8. Pharmacological approaches to Glycemic treatment (contd.)
Recommendations on Pharmacotherapy of type 2 diabetes Consider initiating insulin therapy (with or without additional agents) in patients with newly diagnosed type 2 diabetes who are symptomatic and/or have A1C ≥10% (86 mmol/mol) and/or blood glucose levels ≥300 mg/dL (16.7 mmol/L) If noninsulin monotherapy at maximum tolerated dose does not achieve or maintain the A1C target after 3 months, add a second oral agent, a glucagon-like peptide 1 receptor agonist, or basal insulin A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include efficacy, hypoglycemia risk, impact on weight, potential side effects, cost, and patient preferences FDA approved once-daily combination products containing basal insulin plus a GLP-1 receptor agonist have been included: Insulin glargine plus lixisenatide - Insulin degludec plus liraglutide A1C, glycated hemoglobin; GLP-1 Glucagon like peptide 1 Diabetes Care 2017;40(Suppl. 1):S1–S138

Start with monotherapy unless:
A1c is greater than or equal to 9%, consider dual therapy A1c is greater than or equal to 10 %, blood glucose is greater than or equal to 300 mg/dL or patient is markedly symptomatic, consider combination injectable therapy Monotherapy Metformin Lifestyle Management EFFICACY* high HYPO RISK low risk WEIGHT neutral/loss SIDE EFFECTS GI/lactic acidosis COSTS* low If A1c is not achieved approximately after 3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference- choice dependent on variety of patient- & disease-specific factors) Dual Therapy Metformin + Lifestyle Management Sulfonylurea Thiazolidinedione DPP-4 inhibitor SGLT2 inhibitor GLP-1 receptor agonist Insulin (Basal) EFFICACY* high intermediate highest HYPO RISK moderate risk low risk high risk WEIGHT gain neutral loss SIDE EFFECTS hypoglycemia Edema, HF, fxs rare GU, dehydration, fxs GI COSTS* low If A1c is not achieved approximately after 3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference- choice dependent on variety of patient- & disease-specific factors) Diabetes Care 2017;40(Suppl. 1):S1–S138

Contd. Dual Therapy Triple Therapy Metformin + Lifestyle Management
Sulfonylurea + Thiazolidinedione + DPP-4 inhibitor + SGLT2 inhibitor + GLP-1 receptor agonist + Insulin (Basal) + or If A1c is not achieved approximately after 3 months of triple therapy, and patient (1) on oral combination, move to basal insulin or GLP-1 RA, (2) on GLP-1 RA, add basal insulin or (3) on optimally titrated basal insulin, addaGLP-1 RA or meal time insulin. Metformin therapy should be maintained, while other oral agents may be discontinued on an individual basis to avoid unnecessary complex or costly regimens. (i.e. adding fourth antihyperglycemic agent). TZD SU SU SU SU TZD DPP-4-i DPP-4-i TZD TZD TZD DPP-4-i SGLT2-i SGLT2-i SGLT2-i DPP-4-i SGLT2-i SGLT2-i GLP-1-RA GLP-1-RA Insulin $ GLP-1-RA Insulin $ GLP-1-RA Insulin $ Insulin $ Insulin $ Combination Injectable Therapy Fig.8.1: Antihyperglycemic therapy in type 2 diabetes: general recommendations. The order in the chart is determined by historical availability and the route of administration, with injectables to the right; it is not meant to denote any specific preference. Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, with the usual transition moving vertically from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). DPP-4-i, DPP-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1 RA, GLP-1 receptor agonist; GU, genitourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, SGLT2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione. $ Usually a basal insulin (NPH, glargine, detemir, degludec). Adapted with permission from Inzucchi et al 2015 *Inzucchi SE, Bergenstal RM, Buse JB, et al.Management of hyperglycemia in type 2 diabetes,2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Studyof Diabetes. Diabetes Care 2015;38:140–149 Diabetes Care 2017;40(Suppl. 1):S1–S138

FBG, Fasting blood glucose; SMBG, Self monitored blood glucose
Fig. 8.2 Combination injectable therapy for type 2 diabetes Adapted with permission from Inzucchi et al. Initiate basal Insulin Usually with metformin +/- other noninsulin agent Start: 10U/day or U/Kg/day Adjust: 10-15% or 2-4 units once or twice weekly to reach FBG target For Hypo: Determine & address cause; if no clear reason for hypo, dose by 4 units or 10-20% If A1c not controlled, consider combination injectable therapy Add 1 rapid-acting insulin injection before largest meal Start: 4 units, 0.1 U/Kg/day or 10% basal dose. If A1c <8%,consider basal by same amount Adjust: dose by 1-2 units or 10-15% once or twice weekly until SMBG target reached For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% Change to premixed insulin twice daily (before breakfast and supper) Add GLP-1 RA If not tolerated or A1C target not reached, change to 2 insulin injection regimen If goals are not met, consider changing to alternative insulin regimen If A1c is not controlled, advance to basal bolus If A1c is not controlled, advance to 3rd injection Add ≥ 2 rapid-acting insulin injection before meals (‘basal-bolus’) Start: 4 units, 0.1 U/Kg/day or 10% basal dose. If A1c <8%, consider basal by same amount Adjust: dose(s) by 1-2 units or 10-15% once or twice weekly to achieve SMBG target. For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% Change to premixed analog insulin 3 times daily (breakfast, lunch, supper) Start: Add additional injection before lunch Adjust: dose(s) by 1-2 units or 10-15% once or twice weekly to achieve SMBG target. For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% If goals are not met, consider changing to alternative insulin regimen FBG, Fasting blood glucose; SMBG, Self monitored blood glucose Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 8. Pharmacological approaches to Glycemic treatment (contd.)
Recommendations for combination injectable therapy Recommendations at the level of 2 injections per day Either 1 rapid acting insulin, or GLP-1RA can be added to basal insulin Dotted line removed and Premix BID is an option for intensification from basal insulin If one regimen is not effective, switching to the alternative insulin regimen may be considered (Premix BID, Basal+ Prandial, Basal+GLP-1 RA) Recommendations at the level of 3 injections per day Premix TID is included as an intensification option when patients fail to achieve targets on Premix BID regimens Patients can be considered to switch from one regimen to another (i.e., premixed analog insulin three times daily to basal bolus regimen or vice-versa) if A1C targets are not being met and/or depending on other patient considerations Recommendations for combination injectable therapy BID, twice daily; TID, thrice daily; GLP-1 RA, Glucagon like peptide 1 receptor agonist; A1C, glycated hemoglobin Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 10. Microvascular Complications and Foot Care
Recommendations for Diabetic retinopathy Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who are pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy Recommendations for Diabetic neuropathy Either Pregabalin or Duloxetine are recommended as initial pharmacologic treatments for neuropathic pain in diabetes Recommendations for Diabetic foot care The use of specialized therapeutic footwear is recommended for high-risk patients with diabetes including those with severe neuropathy, foot deformities, or history of amputation Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 11. Older Adults Recommendations
Emphasizes on importance of assessment of medical, mental, functional and social geriatric domains in older adults to determine targets and therapeutic approaches for diabetes management Recommendations Annual screening for early detection of mild cognitive impairment or dementia is indicated for adults 65 years of age or older Treatment of hypertension to individualized target levels is indicated in most older adults Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 12. Children and adolescents
Updated to highlight the importance of assessment and referral for psychosocial issues in youth Recommendations for Psychosocial issues Mental health professionals should be considered integral members of the pediatric diabetes multidisciplinary team Providers should assess children’s and adolescents’ diabetes distress, social adjustment (peer relationships), and school performance to determine whether further intervention is needed In youth and families with behavioral self-care difficulties, repeated hospitalizations for diabetic ketoacidosis, or significant distress, consider referral to a mental health provider for evaluation and treatment Adolescents should have time by themselves with their care provider(s)starting at age 12 years Starting at puberty, preconception counselling should be incorporated into routine diabetes care for all girls of childbearing potential Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 13. Management of Diabetes in Pregnancy
Recommendations for Gestational diabetes mellitus Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus, as it does not cross the placenta to a measurable extent Metformin and glyburide may be used, but both cross the placenta to the fetus, with metformin likely crossing to a greater extent than glyburide. All oral agents lack long-term safety data Recommendations for targets in both type 1, type 2 & GDM * Fasting ≤95 mg/dL (5.3 mmol/L) and either One hour postprandial ≤140 mg/dL (7.8 mmol/L) or Two hour postprandial ≤120 mg/dL (7.8 mmol/L) * Based on available data, preprandial self-monitoring of blood glucose is deemphasized in the management of diabetes in pregnancy Diabetes Care 2017;40(Suppl. 1):S1–S138

Section 14. Diabetes care in the Hospital
This section is updated and reorganized to provide more clarity of diabetes management in hospital setup Recommendations Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for non-critically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for non-critically ill hospitalized patients with good nutritional intake Recommendations for insulin dosing for enteral/parenteral feedings were expanded to provide greater detail on insulin type, timing, dosage, correctional and nutritional considerations This section is updated and reorganized to provide more clarity of diabetes management in hospital setup Diabetes Care 2017;40(Suppl. 1):S1–S138

Standards of Medical Care in Diabetes ADA-2017
Updates on Premix Insulin Diabetes Care 2017;40(Suppl. 1):S1–S138

FBG, Fasting blood glucose; SMBG, Self monitored blood glucose.
Fig. 8.2 Combination injectable therapy for type 2 diabetes Adapted with permission from Inzucchi et al. Initiate basal Insulin Usually with metformin +/- other noninsulin agent Start: 10U/day or U/Kg/day Adjust: 10-15% or 2-4 units once or twice weekly to reach FBG target For Hypo: Determine & address cause; if no clear reason for hypo, dose by 4 units or 10-20% If A1c not controlled, consider combination injectable therapy Add 1 rapid-acting insulin injection before largest meal Start: 4 units, 0.1U/Kg/day or 10% basal dose. If A1c <8%,consider basal by same amount Adjust: dose by 1-2 units or 10-15% once or twice weekly until SMBG target reached For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% Change to premixed insulin twice daily (before breakfast and supper) Add GLP-1 RA If not tolerated or A1C target not reached, change to 2 insulin injection regimen If goals are not met, consider changing to alternative insulin regimen If A1c is not controlled, advance to basal bolus If A1c is not controlled, advance to 3rd injection Add ≥ 2 rapid-acting insulin injection before meals (‘basal-bolus’) Start: 4 units, 0.1 U/Kg/day or 10% basal dose. If A1c <8%, consider basal by same amount Adjust: dose(s) by 1-2 units or 10-15% once or twice weekly to achieve SMBG target. For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% Change to premixed analog insulin 3 times daily (breakfast, lunch, supper) Start: Add additional injection before lunch Adjust: dose(s) by 1-2 units or 10-15% once or twice weekly to achieve SMBG target. For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% If goals are not met, consider changing to alternative insulin regimen FBG, Fasting blood glucose; SMBG, Self monitored blood glucose. Diabetes Care 2017;40(Suppl. 1):S1–S138

Recommendations for combination injectable therapy: Level of 2 injections per day Previous version Considered intensification with premix insulin twice daily as a less preferred alternative when intensifying insulin therapy from basal insulin compared to adding a mealtime insulin and the option to switch to premix insulin twice daily was presented as a dotted line The algorithm also did not include an option to switch to an alternative insulin regimen ( Basal+ prandial to Premix/ Premix to Basal + Prandial) when treatment goals were not met Changes in the current guidelines Dotted line removed and Premix BID is an option for intensification from basal insulin If one regimen is not effective, switching to the alternative insulin regimen may be considered (Basal+prandial ,Premix BID, Basal + GLP 1 RA) Each approach has its advantages and disadvantages and health care providers may choose the most appropriate regimen for their patients Recommendations for combination injectable therapy BID, twice daily; GLP-1 RA, Glucagon like peptide 1 receptor agonist Diabetes Care 2017;40(Suppl. 1):S1–S138

Fig. 8.2 Combination injectable therapy for type 2 diabetes Adapted with permission from Inzucchi et al. Initiate basal Insulin Usually with metformin +/- other noninsulin agent Start: 10U/day or U/Kg/day Adjust: 10-15% or 2-4 units once or twice weekly to reach FBG target For Hypo: Determine & address cause; if no clear reason for hypo, dose by 4 units or 10-20% If A1c not controlled, consider combination injectable therapy Add 1 rapid-acting insulin injection before largest meal Start: 4 units, 0.1U/Kg/day or 10% basal dose. If A1c <8%,consider basal by same amount Adjust: dose by 1-2 units or 10-15% once or twice weekly until SMBG target reached For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% Change to premixed insulin twice daily (before breakfast and supper) Add GLP-1 RA If not tolerated or A1C target not reached, change to 2 insulin injection regimen If goals are not met, consider changing to alternative insulin regimen If A1c is not controlled, advance to basal bolus If A1c is not controlled, advance to 3rd injection new inclusion Add ≥ 2 rapid-acting insulin injection before meals (‘basal-bolus’) Start: 4 units, 0.1 U/Kg/day or 10% basal dose. If A1c <8%, consider basal by same amount Adjust: dose(s) by 1-2 units or 10-15% once or twice weekly to achieve SMBG target. For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% Change to premixed analog insulin 3 times daily (breakfast, lunch, supper) Start: Add additional injection before lunch Adjust: dose(s) by 1-2 units or 10-15% once or twice weekly to achieve SMBG target. For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% If goals are not met, consider changing to alternative insulin regimen FBG, Fasting blood glucose; SMBG, Self monitored blood glucose. Diabetes Care 2017;40(Suppl. 1):S1–S138

Recommendations for combination injectable therapy: Level of 3+ injections per day Previous version Considered intensification only with a basal bolus regimen when patients did not achieve glycaemic targets with either a Basal+ prandial or Premix BID regimen The algorithm did not include an option to intensify with Premix TID The algorithm did not include a recommendation for patients who fail to achieve targets on a fully intensified Basal Bolus regimen Changes in the current guidelines Premix TID is included as an intensification option when patients fail to achieve targets on Premix BID regimens Patients can be considered to be switched from one regimen to another (i.e., premixed analog insulin three times daily to basal bolus regimen or vice-versa) if A1C targets are not being met and/or depending on other patient considerations Recommendations for combination injectable therapy BID, twice daily; TID, thrice daily; A1C, glycated hemoglobin Diabetes Care 2017;40(Suppl. 1):S1–S138

Fig. 8.2 Combination injectable therapy for type 2 diabetes Adapted with permission from Inzucchi et al. Initiate basal Insulin Usually with metformin +/- other noninsulin agent Start: 10U/day or U/Kg/day Adjust: 10-15% or 2-4 units once or twice weekly to reach FBG target For Hypo: Determine & address cause; if no clear reason for hypo, dose by 4 units or 10-20% If A1c not controlled, consider combination injectable therapy Add 1 rapid-acting insulin injection before largest meal Start: 4 units, 0.1U/Kg/day or 10% basal dose. If A1c <8%,consider basal by same amount Adjust: dose by 1-2 units or 10-15% once or twice weekly until SMBG target reached For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% Change to premixed insulin twice daily (before breakfast and supper) Add GLP-1 RA If not tolerated or A1C target not reached, change to 2 insulin injection regimen If goals are not met, consider changing to alternative insulin regimen Inclusion of premix TID as an intensification option If A1c is not controlled, advance to basal bolus If A1c is not controlled, advance to 3rd injection Switching between fully intensified regimens when treatment goals are not met Add ≥ 2 rapid-acting insulin injection before meals (‘basal-bolus’) Start: 4 units, 0.1 U/Kg/day or 10% basal dose. If A1c <8%, consider basal by same amount Adjust: dose(s) by 1-2 units or 10-15% once or twice weekly to achieve SMBG target. For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% Change to premixed analog insulin 3 times daily (breakfast, lunch, supper) Start: Add additional injection before lunch Adjust: dose(s) by 1-2 units or 10-15% once or twice weekly to achieve SMBG target. For Hypo: Determine & address cause; if no clear reason for hypo, dose by 2-4 units or 10-20% If goals are not met, consider changing to alternative insulin regimen FBG, Fasting blood glucose; SMBG, Self monitored blood glucose. Diabetes Care 2017;40(Suppl. 1):S1–S138

ADA-Standard of Medical Care-2017 Updates to standards of medical care in diabetes 2016 Diabetes Care 2017;40(Suppl. 1):S1–S138.

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ADA-Standard of Medical Care-2017 Updates to standards of medical care in diabetes 2016 Diabetes Care 2017;40(Suppl. 1):S1–S138.

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Presentation on theme: "ADA-Standard of Medical Care-2017 Updates to standards of medical care in diabetes 2016 Diabetes Care 2017;40(Suppl. 1):S1–S138."— Presentation transcript:

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