Standards of Medical Care in Diabetes—2017 Evidence Table Recommendation Reason for Change 2016 references that support recommendation (list citation #) New Evidence for 2017 (hyperlinked reference title/s) Strategies for improving Care A patient-centered communication style patient preferences assess literacy numeracy, and cultural barriers . B Now provides recommendation on a skill that can help providers get the information from patients that they need to inform treatment. Do we want to say anything goal setting here? (reference 10) and also could just say overcoming barriers (since literacy/numeracy covered later) 13, 14-17, 55 Treatment decisions should be timely based on evidence-based guidelines individual preferences, prognoses, and comorbidities. B Should include mention of collaboration/shared decision making 6, 10, 12 (timely), 18-20, 34 Care should be aligned with components of the Chronic Care to ensure productive interactions between a prepared proactive practice team and an 7,8 (CCM) 29, 30 (activated patients) New review article (2015) in Journal of Evaluation in Clinical Practice (IF 1.05), but current references are in higher tier journal and conclusions are similar Trial
considered in children and adolescents who are overweight or obese and who have two or more additional risk factors for diabetes. E . American Diabetes Association. Diabetes Care Blood glucose rather than A1C should be used to diagnose acute onset of type 1 diabetes in individuals with symptoms of hyperglycemia. E Inform the relatives of patients with type 1 diabetes of the opportunity to be tested for type 1 diabetes risk, but only in the setting of a clinical research study. E Testing to detect type 2 diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and who have one or more additional risk factors for diabetes. B For Discussion: Wang B, Zhuang R, Luo X, et al. . Horm Metab Res 2015;47:839-845 LA, Abbasi A, Sharp SJ, et al. . Diabetes Care 2015;38(11):2177-2187 Lee SH, Yang HK, Ha HS, et al. . Medicine (Baltimore) 2015;94(40):e1705. Dental Clinic Screening References: E, Kunzel C, Burkett S, et al. . J Dent Res 2011;90(7):855-860 Trial
In accordance with the national standards for diabetes education (DSME) and support (DSMS), all people with diabetes should participate in DSME to facilitate the knowledge, skills, and ability necessary for diabetes self-care and in DSMS to assist with implementing and sustaining skills and behaviors needed for ongoing both at diagnosis and as needed thereafter. B OK (note undergoing revision starting in Sept; for publication next year. 4, 5, 6, 7 Somewhere in the text we should acknowledge the emerging evidence that internet based diabetes education may be helpful: 2015 Jan;17(1):55-63. doi: 10.1089/dia.2014.0155. Internet delivered diabetes education: a review. 1, , , . And article by Sepah et al (including Anne Peters) on 2 yr online DM prevention program. Effective improved clinical outcomes, health status, and quality of life are key outcomes of DSME and DSMS and should be measured and monitored as part of care. C 4, 6, 9, 10, 11, 12, 10, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 DSME and DSMS should be patient centered, respectful, and responsive to individual patient preferences, needs, and values, which should guide clinical decisions. A 20, 21, 22, 23, 12, 26, 2016 Mar 21. doi: 10.1111/dme.13120. [Epub ahead of print] Reasons why patients referred to diabetes education programmes choose not to attend: a systematic review. 1, 2, 3, 3, 1. DSME and DSMS programs should have the necessary elements in their curricula that are needed to prevent the onset of diabetes. Ok – or this could be part of the “prevention” section. It may be misplaced here. management
DSME and DSMS programs should therefore tailor their content specifically when prevention of diabetes is the desired goal. B 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 The section on reimbursement only references #4 – but I think should include 16, B Psychosocial positon statement B . B E An individualized MNT program, preferably provided by a registered dietitian, is recommended for all people with type 1 or type 2 diabetes. A ok 34, 35 Add 2015 EAL citations for T1 and T2 For people with type 1 diabetes or those with type 2 diabetes who are prescribed a flexible insulin therapy program, education on how to use carbohydrate counting or estimation to determine mealtime insulin dosing can improve glycemic control. A For type 1, insulin dosing should also take into account fat content of the meal. (especially larger quantiries – over 40 gm) 37 2016 Jul 7. pii: dc152855. [Epub ahead of print] Optimized Mealtime Insulin Dosing for Fat and Protein in Type 1 Diabetes: Application of a Approach to Derive Insulin Doses for Diabetes Management. 1, 2, 3, 4. For individuals whose daily insulin dosing is
[Ann Intern Med. 2015]. Patients with prediabetes should be referred to an intensive diet and physical activity behavioral counseling program adhering to the tenets of the Diabetes Prevention Program (DPP) targeting a loss of 7% of body weight and should increase their moderate-intensity physical activity (such as brisk walking) to at least 150 min/week. A Follow-up counseling and maintenance programs should be offered for long-term success in preventing diabetes. B Replace old references with more comprehensive ones replace (8) with et al. 2014 Jun;2(6):474-80. doi: Epub 2014 Apr 3. Replace (9) with et al. Diabetologia. Feb;56(2):284-93. doi: Epub 2012 Oct 24. Replace 13 with on the of diabetes prevention, such programs should May cite CMS announcement and on which it was based for DPP, and use Medicare's intensive
management in older adults to provide a framework to determine targets and therapeutic approaches. E Screening for geriatric syndromes may be appropriate in older adults experiencing limitations in their basic and instrumental activities of daily living, as they may affect diabetes E Additional relevant evidence Citation #3 (Chapter 10) Laiteerapong N, Karter AJ, Liu JY, et al. Correlates of quality of life in adults with diabetes: the Diabetes & Aging Study. Diabetes Care adults (65 years of age) with diabetes should be considered a high-priority population for depression screening and treatment. B Citation # 2 (Chapter 10) Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacological interventions. B Citation #3 (Chapter 10) adults who are functional and cognitively intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults. E Additional relevant reference Citation #3 (Chapter 10) Blaum C, Cigolle CT, Boyd C, et al. Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study. Med Care 2010; 48:327–334 Glycemic goals for some older adults might Additional relevant reference Citation #3 (Chapter 10) Blaum C, Cigolle CT, Boyd C, et al.
reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. E Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study. Med Care 2010; 48:327–334 Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. E Citation #3 (Chapter 10) Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. E Additional relevant reference Citation #3 (Chapter 10) Blaum C, Cigolle CT, Boyd C, et al. Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study. Med Care 2010; 48:327–334 When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. Similarly, the of lipid management can be relaxed, and withdrawal of lipid-lowering Updating reference Munshi M, Florez H, Huang ES et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care. 2016;39(2):308-18
therapy may be appropriate. E Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. E Updating reference Munshi M, Florez H, Huang ES et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care. 2016;39(2):308-18 Patients with diabetes residing in long-term care facilities need careful assessment to establish a glycemic goal and to make appropriate choices of glucose-lowering agents based on their clinical and functional status. E Updating reference Munshi M, Florez H, Huang ES et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care. 2016;39(2):308-18 Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. E Updating reference Munshi M, Florez H, Huang ES et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care. 2016;39(2):308-18 Children and Adolescents New from psychosocial statement New from psychosocial statement New from psychosocial statement
New from psychosocial statement E Youth with type 1 diabetes and parents/caregivers (for patients aged <18 years) should receive culturally sensitive and developmentally appropriate individualized diabetes self-management education and support according to national standards at diagnosis and routinely thereafter. B Citation #6 (Chapter 11) At diagnosis and during routine follow-up care, assess psychosocial issues and family stresses that impact adherence to diabetes management and provide appropriate referrals to trained mental health professionals, preferably experi enced in childhood diabetes. E Additional evidence: Pediatric Diabetes Consortium T1D and T2D registries: Symptoms of depression were identified in 13% of T1D and 22% of T2D participants Add comment: “Depressive symptoms are more frequent than diagnosed depression in youth with T1D or T2D and underscore the need for regular depression screening and appropriate referral for youth with diabetes.” Citation #7 (Chapter 11) Citation #8 (Chapter 11) Citation #9 (Chapter 11) Citation #10 (Chapter 11) Citation #11 (Chapter 11) Citation #12 (Chapter 11) Citation #13 (Chapter 11) Silverstein J, Cheng P, Ruedy KJ Depressive Symptoms in Youth With Type 1 or Type 2 Diabetes: Results of the Pediatric Diabetes Consortium Screening Assessment of Depression in Diabetes Study. 2015; 38(12):2341-3.
Encourage developmentally appropriate family involvement in diabetes management tasks for children and adolescents, recognizing that premature transfer of diabetes care to the child can result in nonadherence and deterioration in glycemic control. B N/A Citation #15 (Chapter 11) Citation #16 (Chapter 11) Citation #17 (Chapter 11) Consider mental health professionals as integral members of the pediatric diabetes multidisciplinary team. E N/A Citation #14 (Chapter 11) An A1C goal of <7.5% (58 mmol/mol) is recommended across all pediatric age-groups. E Citation #20 Blasetti: Meta-analysis confirms that recurrent severe hypoglycemia has a selective negative effect on the children's cognitive functions. Caution with small sample sizes, the different definitions of severe hypoglycemia, and variety of neuropsychological tests used. Data from T1D Exchange: Children with excellent glycemic control tend to exhibit markedly different diabetes techniques than with poor control. Old Citation #18 (Chapter 11) 2013 doi: Epub 2013 Apr 15. Omit this citation. Citation # 19 (Chapter 11) Citation # 21 (Chapter 11) Citation #22 (Chapter 11) Citation #23 (Chapter 11) Citation #24 (Chapter 11) New Citation #18? (Chapter 11) Campbell MS, Schatz DA, Chen V, et al. A contrast between children and adolescents with excellent and poor control: the T1D Exchange clinic registry experience. 2014; 15(2):110-7. doi: 10.1111/pedi.12067.
years or sooner if the patient develops symptoms suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or an unexplained glycemic variation. E Consider screening with type 1 diabetes for celiac disease by measuring either tissue transglutaminase or deamidated gliadin antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes. E Additional reference - proposal to upgrade recommendation to C. Meta-analysis/ systematic review of studies with at least 100 individuals with type 1 diabetes screened for coeliac disease: More than one in twenty patients with type 1 diabetes have coeliac disease. Citation #33 (Chapter 11) Citation #34 (Chapter 11) Citation #35 (Chapter 11) Citation #36 (Chapter 11) Citation #37 (Chapter 11) Citation #38 (Chapter 11) Elfström P1, Sundström J, Ludvigsson JF. Systematic review with meta-analysis: associations between coeliac disease and type 1 diabetes. Aliment Pharmacol Ther. 2014 Nov;40(10):1123-32. Consider screening in who have a first-degree relative with celiac disease, growth failure, weight loss, failure to gain weight, diarrhea, flatulence, abdominal pain, or signs of malabsorption or in children with frequent unexplained hypoglycemia or deterioration in glycemic control. E See with biopsy-confirmed celiac disease should be See above
Elicit a smoking history at initial and follow-up diabetes visits and discourage smoking in youth who do not smoke and encourage smoking cessation in those who do smoke. B Citation #56 (Chapter 11) Annual screening for albuminuria with a random spot urine sample for ratio should be considered once the child has had diabetes for 5 years. B Citation #57 (Chapter 11) Estimate glomerular filtration rate at initial evaluation and then based on age, diabetes duration, and treatment. E Citation #58 (Chapter 11) Treatment with an ACE inhibitor, titrated to normalization of albumin excretion, should be considered when elevated urinary albumin–to–creatinine ratio (>30 mg/g) is documented with at least two of three urine samples. These should be obtained over a interval following efforts to improve glycemic control and normalize blood pressure. Only small studies (no RCT). Consider changing recommendation to C (or E) Citation #59 (Chapter 11) . An initial dilated and comprehensive eye examination is recommended at age 10 years or after puberty has started, whichever is earlier, once the youth has had Citation #60 (Chapter 11)
NEJM 361:1339-48, 2009 Clarify that insulin is treatment of choice. This proposed modification is based on Concentration of metformin on the fetal side of the placenta to levels similar to or twice those in the maternal circulation. Glyburide levels in cord blood have been shown to be approximately 70% of simultaneous maternal level. Citation #23 (Chapter 12) Since this systematic review suggested that metformin has a more favorable short term outcome profile than glibenclamide, but metformin appears to be concentrated on the fetal side of the placenta, it may be better (prudent) to be non-directive about the choice between the two when patients decline to take insulin injections. Vanky E, Zahlsen K, Spigset O, Carlsen SM: Placental passage of metformin in women with polycystic ovary syndrome. Fertility Sterility Charles B, Norris R, Xiao X, Hague W. Population pharmacokinetics of metformin in late pregnancy. Ther Drug Monit 2006; 28: 67-72. Hebert MF et al: Are we optimizing gestational diabetes treatment with glyburide? Clinical Pharmacology & Therapeutics 2009 Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. B Citations about statin, ACE-inhibitors and ARBs use in pregnancy Taguchi N, Rubin ET, Hosokawa A, Choi J, Ying AY, Moretti ME, et al. Prenatal exposure to HMG-CoA reductase inhibitors: effects on fetal and neonatal outcomes. Reprod Toxicol 2008;26:175–7. Bateman BT, Hernandez-Diaz S, Fischer MA et al. Statins and congenital malformations: cohort study. BMJ. 2015 Mar 17;350:h1035
J, Koren G. The fetal safety of statins: a systematic review and meta-analysis. J Obstet Gynaecol Can. 2014; 36(6):506-9. Bullo M1, Tschumi S, Bucher BS, et al. Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: a systematic review. Hypertension. 2012; 60(2): 444-50. PMID: 22753220 Fasting, and postprandial of blood glucose are recommended in both gestational diabetes mellitus anddiabetes in pregnancy to achieve glycemic control. B While preprandial glucose monitoring is standard in nonpregnant individuals with type 1 or type 2 diabetes, available data do not support its use in pregnancy (with regard to improving pregnancy outcomes) and most caregivers in the field do not ask their patients to monitor blood sugars preprandially. This would be even more true with gestational diabetes. RCT of preprandial vs postprandial glucose testing in GDM: De Veciana M, Major CA, Morgan MA et al. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy. NEJM 1995; 333: 1237-41. Ancillary analysis from DIEP observational study showing that postprandial glucose values are more predictive of fetal macrosomia than fasting values:
Jovanovic-Peterson L, Peterson CM, Reed GF, et al. Maternal postprandial glucose levels and infant weight: the Diabetes in Early Pregnancy Study. The National Institute of Child Health and Human Development--Diabetes in Early Pregnancy Study. Am J Obstet Gynecol. 1991; PMID: 1986596 Due to increased red cell turnover, A1C is lower in normal pregnancy than in normal nonpregnant women. The A1C target in pregnancy is 6–6.5% (42–48 mmol/mol); <6% (42 mmol/mol) may be optimal if this can be achieved without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia. B N/A There is an additional reference with a larger sample size (445 non diabetic pregnant women) who were tested at between 15 and 36 weeks and compared to 384 controls. It provides standards for various gestational intervals. Citations #3, #4 #12 (Chapter 12) Citation #12 is a study of 100 pregnant women without diabetes and supports the assertion that A1c is lower in early and later pregnancy than in the non-pregnant state. Mosca A, Paleari R, Dalfra MG, DiCianni G et al. Reference intervals for hemoglobin A1c in pregnant women: data from an Italian multicenter study. Clinical Chemistry 2006; 52(6): 1138-1143. Diabetes Care in the Hospital Consider performing an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months. C New evidence that supports use of A1C But still a C recommendation Pasquel FJ, R, Anzola L et al. Predictive Value of Admission Hemoglobin A1c on Inpatient Glycemic Control and Response to Insulin Therapy in Medicine and Surgery Patients With Type 2 Diabetes. Diabetes Care 2015 Dec; 38(12): e202-e203