Executive Summary: Standards of Medical Care in Diabetes2012

 

## (a)
Psychosocial assessment and care c It is reasonable to include assessment of the patient's psychological and social situation as an ongoing part of the medical management of diabetes. (E) c Psychosocial screening and follow-up may include, but is not limited to, attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional), and psychiatric history. (E) c Consider screening for psychosocial problems such as depression and diabetesrelated distress, anxiety, eating disorders, and cognitive impairment when selfmanagement is poor. (C) Antiplatelet agents c Consider aspirin therapy (75-162 mg/ day) as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk .10%). This includes most men .50 years of age or women .60 years of age who have at least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). (C) c Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (10-year CVD risk ,5%, such as in men ,50 years and women ,60 years of age with no major additional CVD risk factors), since the potential adverse effects from bleeding likely offset the potential benefits. (C) c In patients in these age-groups with multiple other risk factors (e.g., 10-year risk 5-10%), clinical judgment is required. (E) c Use aspirin therapy (75-162 mg/day) as a secondary prevention strategy in those with diabetes with a history of CVD. and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist. Less-frequent exams (every 2-3 years) may be considered following one or more normal eye exams. Foot care c For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation (10-g monofilament plus testing any one of the following: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold). (B) c Provide general foot self-care education to all patients with diabetes. (B) c A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet, especially those with a history of prior ulcer or amputation. (B) c Refer patients who smoke, have loss of protective sensation and structural abnormalities, or have history of prior lower-extremity complications to foot care specialists for ongoing preventive care and life-long surveillance. (C) c Initial screening for peripheral arterial disease (PAD) should include a history for claudication and an assessment of the pedal pulses. Consider obtaining an ankle-brachial index (ABI), as many patients with PAD are asymptomatic. (C) c Refer patients with significant claudication or a positive ABI for further vascular assessment and consider exercise, medications, and surgical options. (C)
Assessment of common comorbid conditions c For patients with risk factors, signs or symptoms, consider assessment and treatment for common diabetes-associated conditions (see of the "Standards of Medical Care in Diabetesd 2012"). (B)
Children and adolescents Glycemic control c Consider age when setting glycemic goals in children and adolescents with type 1 diabetes. (E)
Screening and management of chronic complications in children and adolescents with type 1 diabetes Nephropathy c Annual screening for microalbuminuria, with a random spot urine sample for albumin-to-creatinine ratio (ACR), should be considered once the child is 10 years of age and has had diabetes for 5 years. (B) c Treatment with an ACE inhibitor, titrated to normalization of albumin excretion, should be considered when elevated ACR is subsequently confirmed on two additional specimens from different days. (E)
Hypertension c Initial treatment of high-normal blood pressure (systolic or diastolic blood pressure consistently above the 90th percentile for age, sex, and height) includes dietary intervention and exercise, aimed at weight control and increased physical activity, if appropriate. If target blood pressure is not reached with 3-6 months of lifestyle intervention, pharmacologic treatment should be considered. (E) c Pharmacologic treatment of hypertension (systolic or diastolic blood pressure consistently above the 95th percentile for age, sex, and height or consistently .130/80 mmHg, if 95% exceeds that value) should be considered as soon as the diagnosis is confirmed. (E) c ACE inhibitors should be considered for the initial treatment of hypertension, following appropriate reproductive counseling due to the potential teratogenic effects. (E) c The goal of treatment is a blood pressure consistently ,130/80 or below the 90th percentile for age, sex, and height, whichever is lower. (E)

## Dyslipidemia
Screening c If there is a family history of hypercholesterolemia or a cardiovascular event before age 55 years, or if family history is unknown, then consider obtaining a fasting lipid profile on children .2 years of age soon after diagnosis (after glucose control has been established). If family history is not of concern, then consider the first lipid screening at puberty ($10 years  Critically ill patients: Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of no greater than 180 mg/dL (10 mmol/L). Once insulin therapy is started, a glucose range of 140-180 mg/dL (7.8 to 10 mmol/L) is recommended for the majority of critically ill patients. (A)  More stringent goals, such as 110-140 mg/dL (6.1-7.8 mmol/l) may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia. (C)  Critically ill patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia. (E)  Non-critically ill patients: There is no clear evidence for specific blood glucose goals. If treated with insulin, premeal blood glucose targets generally ,140 mg/dL (7.8 mmol/l) with random blood glucose ,180 mg/dL (10.0 mmol/l) are reasonable, provided these targets can be safely achieved. More stringent targets may be appropriate in stable patients with previous tight glycemic control. Less stringent targets may be appropriate in those with severe comorbidites. (E) c Scheduled subcutaneous insulin with basal, nutritional, and correction components is the preferred method for achieving and maintaining glucose control in noncritically ill patients. c Glucose monitoring should be initiated in any patient not known to be diabetic who receives therapy associated with high-risk for hyperglycemia, including high-dose glucocorticoid therapy, initiation of enteral or parenteral nutrition, or other medications such as