Standards of Medical Care in Diabetes—2018 …

1 P O S I T I O N ES D. TAI TTO. EMR IEANL T. Standards of Medical care in Diabetes 2018. Abridged for Primary care Providers American Diabetes Association T. he American Diabetes Associ- document, including all supporting ation's (ADA's) Standards of references, is available at professional. Medical care in Diabetes are published each year in a supplement IMPROVING care AND. to the January issue of Diabetes care . PROMOTING HEALTH IN. The ADA's Professional Practice POPULATIONS. Committee develops the Standards Over the past 10 years, the proportion and updates them annually, or more of patients with diabetes who achieve frequently online should it determine recommended A1C, blood pressure, that new evidence or regulatory chang- and LDL cholesterol levels has in- es ( , drug approvals, label changes). creased. The mean A1C nationally merit immediate incorporation.

2 The among people with diabetes has de- Standards include the most current clined from (60 mmol/mol) in evidence-based recommendations for 1999 2002 to (55 mmol/mol). diagnosing and treating adults and in 2007 2010 based on the National children with diabetes. ADA's grad- Health and Nutrition Examination ing system uses A, B, C, or E to show Survey, with younger adults less likely the evidence level that supports each to meet treatment targets than older recommendation. adults. This has been accompanied A Clear evidence from well- by improvements in cardiovascular conducted, generalizable random- outcomes and has led to substantial ized controlled trials that are ade- reductions in end-stage microvascular quately powered complications. Nevertheless, 33 49%. B Supportive evidence from of patients still do not meet targets for well-conducted cohort studies glycemic, blood pressure, or cholester- C Supportive evidence from ol control, and only 14% meet targets poorly controlled or uncontrolled for all three measures while also avoid- studies ing smoking.

3 This is an abridged version of the American E Expert consensus or clinical Optimal diabetes management Diabetes Association's Standards of experience requires an organized, systematic Medical care in Diabetes 2018. Diabetes care 2018;41(Suppl. 1):S1 S159. This is an abridged version of approach and the involvement of a The complete 2018 Standards supplement, the Standards containing the evi- coordinated team of dedicated health including all supporting references, is dence-based recommendations most care professionals working in an available at Standards . pertinent to primary care . The tables environment where patient-centered high-quality care is a priority. and figures have been renumbered from the original document to match Recommendations 2018 by the American Diabetes Association. Readers may use this article as long as the work is this version. All of the recommenda- Ensure treatment decisions are properly cited, the use is educational and not for tions (bulleted text) are precisely the timely, rely on evidence-based profit, and the work is not altered.

4 See http://. same as in the full Standards of care . guidelines, and are made collab- for details. The complete 2018 Standards of care oratively with patients based on C L I N I C A L D I A B E T E S 1. Clinical Diabetes Online Ahead of Print, published online December 8, 2017. P O S I T I O N S TAT E M E N T. individual preferences, prognoses, mune -cell destruction, usually small percentage of patients have and comorbidities. B leading to absolute insulin defi- conditions such as sickle cell trait or Align approaches to diabetes ciency) hemoglobinopathies that skew A1C. management with the Chronic 2. Type 2 diabetes (due to a pro- results. See the full 2018 Standards care Model, emphasizing pro- gressive loss of -cell insulin of care for conditions causing dis- ductive interactions between a secretion frequently on the back- crepancies. Unless there is a clear prepared proactive care team and ground of insulin resistance) clinical diagnosis based on overt an informed activated patient.

5 A 3. Gestational diabetes mellitus signs of hyperglycemia, a second test care systems should facilitate (GDM) (diabetes diagnosed in is required for confirmation, either team-based care , patient regis- the second or third trimester of repeating the same test used initially tries, decision support tools, and pregnancy that was not clearly or a different test. If patients have community involvement to meet overt diabetes prior to gestation) test results near the margins of the patient needs. B 4. Specific types of diabetes due diagnostic threshold, the health care Efforts to assess the quality of to other causes, , monogenic professional should follow the patient diabetes care and create quality diabetes syndromes (such as neo- closely and repeat the test in 3 6. improvement strategies should natal diabetes and maturity-onset months. incorporate reliable data metrics, diabetes of the young), diseases of the exocrine pancreas (such as Categories of Increased Risk to promote improved processes of cystic fibrosis and pancreatitis), for Diabetes (Prediabetes).

6 care and health outcomes, with and drug- or chemical-induced Prediabetes is the term used for in- simultaneous emphasis on costs. E. diabetes (such as with gluco- dividuals whose glucose levels do not Tailoring Treatment for Social corticoid use, in the treatment meet the criteria for diabetes but are Context of HIV/AIDS, or after organ too high to be considered normal (see Health inequities related to diabetes transplantation) Table 1). Prediabetes should not be and its complications are well docu- viewed as a clinical entity in its own mented and are heavily influenced by Diagnostic Tests for Diabetes right but rather as an increased risk social determinants of health. Social Diabetes and prediabetes may be for diabetes and cardiovascular disease determinants of health are defined as screened based on plasma glucose cri- (CVD). the economic, environmental, polit- teria, either the fasting plasma glucose (FPG) or the 2-h plasma glucose (2-h Recommendations ical, and social conditions in which Screening for prediabetes and risk people live and are responsible for a PG) value during a 75-g oral glucose tolerance test (OGTT), or A1C cri- for future diabetes with an infor- major part of health inequality world- mal assessment of risk factors or teria (Table 1).

7 Wide. The ADA recognizes the associ- validated tools should be consid- There is incomplete concordance ation between social and environmen- ered in asymptomatic adults. B. between A1C, FPG, and 2-h PG, and tal factors and risk for diabetes and its Testing for prediabetes and risk the 2-h PG diagnoses more people complications. for future diabetes in asymptom- with diabetes than the FPG or A1C. Recommendations Marked discrepancies between mea- atic people should be considered Providers should assess social sured A1C and plasma glucose levels in adults of any age who are over- context, including potential food should prompt consideration that weight or obese (BMI 25 kg/m2. insecurity, housing stability, the A1C assay may not be reliable or 23 kg/m2 in Asian Americans). and financial barriers, and apply for that individual, since a relatively and who have one or more addi- that information to treatment decisions.

8 A TABLE 1. Criteria for the Screening and Diagnosis of Diabetes Refer patients to local community Prediabetes Diabetes resources when available. B A1C * . Provide patients with self-man- FPG 100 125 mg/dL ( mmol/L)* 126 mg/dL ( mmol/L) . agement support from lay health OGTT 140 199 mg/dL ( mmol/L)* 200 mg/dL ( mmol/L) . coaches, navigators, or community health workers when available. A RPG 200 mg/dL ( mmol/L) . *For all three tests, risk is continuous, extending below the lower limit of the CLASSIFICATION AND. range and becoming disproportionately greater at the higher end of the range. DIAGNOSIS OF DIABETES. In the absence of unequivocal hyperglycemia, results should be confirmed Diabetes can be classified into the by repeat testing. Only diagnostic in a patient with classic symptoms of following general categories: hyperglycemia or hyperglycemic crisis.

9 RPG, random plasma glucose. 1. Type 1 diabetes (due to autoim- 2 Clinical Diabetes Online Ahead of Print, published online December 8, 2017. a b r i d g e d s ta n d a r d s o f c a r e 2 0 1 8. ideal for height) and who have TABLE 2. Criteria for Testing for Diabetes or Prediabetes in Asymptomatic Adults additional risk factors for diabetes (Table 3). E. 1. Testing should be considered in overweight or obese (BMI 25 kg/m2. or 23 kg/m2 in Asian Americans) adults who have one or more of the COMPREHENSIVE. following risk factors: Medical EVALUATION. First-degree relative with diabetes AND ASSESSMENT OF. High-risk race/ethnicity ( , African American, Latino, Native COMORBIDITIES. American, Asian American, Pacific Islander). Patient-Centered Collaborative History of CVD. care Hypertension ( 140/90 mmHg or on therapy for hypertension). Recommendation HDL cholesterol level <35 mg/dL ( mmol/L) and/or a triglyceride level >250 mg/dL ( mmol/L) A patient-centered communication style that uses person-centered and Women with polycystic ovary syndrome strength-based language, active lis- Physical inactivity tening, elicits patient preferences Other clinical conditions associated with insulin resistance ( , and beliefs, and assesses literacy, severe obesity, acanthosis nigricans) numeracy, and potential barriers 2.

10 Patients with prediabetes (A1C [39 mmol/mol], IGT, or IFG) to care should be used to opti- should be tested yearly. mize patient health outcomes and 3. Women who were diagnosed with GDM should have lifelong testing health-related quality of life. B. at least every 3 years. 4. For all other patients, testing should begin at age 45 years. Comprehensive Medical Evaluation 5. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on Recommendations initial results and risk status. A complete Medical evaluation should be performed at the initial TABLE 3. Risk-Based Screening for Type 2 Diabetes visit to: or Prediabetes in Asymptomatic Children and Adolescents Confirm the diagnosis and classify in a Clinical Setting* diabetes. B. Criteria Evaluate for diabetes complica- Overweight (BMI >85th percentile for age and sex, weight for height tions and potential comorbid >85th percentile, or weight >120% of ideal for height) A conditions.