Standards and Guidelines: Myths and Truths
The Diagnostic Standard for Diabetes Mellitus is Fixed and Immutable
ADA Criteria for Diagnosis of Diabetes A1C ≥ 6.5% FPG ≥ 126 mg/dl 2 ‐ hour PG ≥ 200 mg/dl during OGTT Classic symptoms and random PG ≥ 200 American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care 2013; 36 (Suppl. 1)
The ADA standard for A1C is the same as the AACE standard.
ADA Guidelines: A1C Target < 7.0% “… for selected individual patients, providers might reasonably suggest even lower A1C goals than the general goal of <7%, if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Such patients might include those with short duration of diabetes, long life expectancy, and no significant CVD….Conversely, less stringent goals may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, or advanced complications. ” AACE Guidelines: A1C Target < 6.5% “… if it can be achieved safely. In patients with a history of severe hypoglycemia, limited life expectancy, advance micro ‐ or macrovascular complications, extensive co ‐ morbid conditions, or long ‐ standing DM where the general goal has been difficult to obtain, a goal of 7 ‐ 8% may be considered.” American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care 2013; 36 (Suppl. 1) American Association of Clinical Endocrinologists. Medical Guidelines for Clinical Practice for Developing a Diabetes Mellitus Comprehensive Care Plan. Endocr Pract. 2011; 17(suppl. 2)
Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print] (Adapted with permission from: Ismail-Beigi F, et al. Ann Intern Med 2011;154:554)
The ADA and AACE Guidelines for SECTION A TITLE OPTION 2 screening of risk factors are the same.
ADA Guidelines: Screening • Screen for diabetes at age 45 and every 3 yrs after, or adults of any age with BMI > 25 kg.M 2 and one or more additional risk factors AACE Guidelines: Screening • Screen all at risk individuals. Persons with prediabetes should have at least annual measure of FPG or OGTT American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care 2013; 36 (Suppl. 1) American Association of Clinical Endocrinologists. Medical Guidelines for Clinical Practice for Developing a Diabetes Mellitus Comprehensive Care Plan. Endocr Pract. 2011; 17(suppl. 2)
ADA Guidelines: Additional Risk Factors for Screening (AACE too) • Physically inactive • First ‐ degree relative with diabetes • Members of a high risk ethnic population • Delivered baby > 9 lbs or GDM • Hypertensive (BP> 140/90 mmHg) • HDL cholesterol <35 mg/dL and/or triglyceride levels >250 mg/dL • Women with polycystic ovary syndrome • A1c > 5.7% or IGT or IFG on previous testing • Other conditions associated with diabetes (PCOS, (severe obesity, acanthosis nigricans) • History of vascular disease American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care 2013; 36 (Suppl. 1) American Association of Clinical Endocrinologists. Medical Guidelines for Clinical Practice for Developing a Diabetes Mellitus Comprehensive Care Plan. Endocr Pract. 2011; 17(suppl. 2)
Postprandial glucose control levels are the same in the AACE guidelines as they are in the IDF Postmeal Guidelines
ADA Guidelines < 180 mg/dL peak postprandial capillary plasma glucose AACE Guidelines < 140mg/dL 2-hr post meal American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care 2013; 36 (Suppl. 1) American Association of Clinical Endocrinologists. Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus. Endocr Pract. 2007; 13(suppl 1).
IDF Guidelines • Target PPG levels should seldom rise above 140mg/dL – PPG levels should return to basal 3 hrs post meal – SMBG is currently the optimal method for assessing plasma glucose levels • Two hour PPG should not exceed 140mg/dL as long as hypoglycemia is avoided International Diabetes Federation. Guidelines for Management of Postmeal Glucose. Available at www.idf.org.
The new ADA Guidelines provide additional new recommendations on laboratory evaluation.
ADA Initial Evaluation for Labs & Referrals • Laboratory evaluation – A1c – Fasting lipid profile – Test for urine albumin excretion – Serum creatinine and calculated (GFR) – TSH in T1, dyslipidemia, or women >50 – Liver function tests (LFT) – Screen for Celiac Disease in Children with type 1 diabetes • Referrals – Annual dilated Eye Exam – Family planning for women of reproductive age – Registered Dietitian for MNT – Diabetes Self Management Education – Dental Examination – Mental Health Professional (if needed) American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care 2013; 36 (Suppl. 1)
The AACE Guidelines are more detailed on SMBG testing than ADA guidelines
SMBG Guidelines For Patients on Insulin AACE Guidelines � SMBG should be performed by all patients using insulin (minimum of twice daily and ideally at least before any injection of insulin) � More frequent SMBG after meals or in the middle of the night may be required for patients with frequent hypoglycemia, patients not at A1C target, or those with symptoms ADA Guidelines � Patients using multiple insulin injections 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 � For patients using less-frequent insulin injections, SMBG may be useful as a guide to management. American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care 2013; 36 (Suppl. 1) American Association of Clinical Endocrinologists. Medical Guidelines for Clinical Practice for Developing a Diabetes Mellitus Comprehensive Care Plan. Endocr Pract. 2011; 17(suppl. 2)
SMBG Guidelines For Patients NOT on Insulin AACE Guidelines � Patients not requiring insulin therapy may benefit from SMBG, especially to provide feedback about effects of their lifestyle and pharmacologic therapy � Testing must be personalized ADA Guidelines � When prescribed as part of a broader educational context, SMBG results may be helpful to guide treatment decisions and/or patient self- management for patients using less frequent insulin injections or noninsulin therapies American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care 2013; 36 (Suppl. 1) American Association of Clinical Endocrinologists. Medical Guidelines for Clinical Practice for Developing a Diabetes Mellitus Comprehensive Care Plan. Endocr Pract. 2011; 17(suppl. 2)
AACE General Guidelines • Instruct patients to obtain comprehensive pre ‐ prandial and 2 ‐ hour postprandial glucose measurements to create a weekly profile periodically and before clinic visits to guide nutrition and physical activity, to detect postprandial hyperglycemia, and to prevent hypoglycemia • Instruct patients to monitor glucose levels anytime there is suspected (or risk of) low glucose level and/or before driving • Instruct patients to monitor glucose levels more frequently during illness American Association of Clinical Endocrinologists. Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus. Endocrine Practice 2007; 13(suppl 1).
ADA General Guidelines • For individuals who have premeal glucose values within target but have A1C values above target, monitoring postprandial plasma glucose (PPG) 1 ‐ 2 hours after the start of the meal and treatment aimed at reducing PPG values to <180 mg/dL may help lower A1C • When prescribing SMBG, ensure that patients receive initial instruction in, and routine follow ‐ up evaluation of, SMBG technique and their ability to use data to adjust therapy American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care 2013; 36 (Suppl. 1)
Both AACE and ADA have treatment algorithms for type 2 diabetes in their guidelines
Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]
AACE and ADA have similar recommendations for blood pressure and lipid control
AACE and ADA Guidelines Hypertension • AACE Target BP <130/80 • ADA Target BP <140/80 New in 2013 • First line therapy ACE inhibitor or ARB, if necessary in combination with other drug classes, along with lifestyle modification • Individualize treatment according to specific comorbidities (ACE inhibitors and ARBs are contraindicated in pregnancy) American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care 2013; 36 (Suppl. 1) American Association of Clinical Endocrinologists. Medical Guidelines for Clinical Practice for Developing a Diabetes Mellitus Comprehensive Care Plan. Endocr Pract. 2011; 17(suppl. 2)
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