American Diabetes Association releases Standards of Medical Care in Diabetes 2017- Part 4: Glycemic Control

This is the fourth and last article in a series of posts describing the latest standards of medical care in diabetes released by the American Diabetes Association recently.

Key Messages:

Assessment of Glycemic Control

Recommendations

Most patients using intensive insulin regimens (multiple-dose insulin or insulin pump therapy) should perform Self-monitoring of blood glucose (SMBG)

  • prior to meals and snacks,
  • at bedtime,
  • occasionally postprandially,
  • 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

A1C Testing

Recommendations

Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control).

Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals.

Point-of-care testing for A1C provides the opportunity for more timely treatment changes.

A1C Goals

Recommendations

A reasonable A1C goal for many nonpregnant adults is <7% (53 mmol/mol).

Providers might reasonably suggest more stringent A1C goals (such as <6.5% [48 mmol/mol]) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment (i.e., polypharmacy). Appropriate patients might include those with

  • a short duration of diabetes,
  • type 2 diabetes treated with lifestyle or metformin only,
  • long life expectancy, or
  • no significant CVD.

Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients

  • with a history of severe hypoglycemia,
  • limited life expectancy,
  • advanced microvascular or macrovascular complications,
  • extensive comorbid conditions, or
  • long-standing diabetes in whom the goal is difficult to achieve despite DSME, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents, including insulin.

table-6-summary-of-glycemic-recommendations-for-nonpregnant-adults-with-diabetes

figure-1-approach-to-the-management-of-hyperglycemia

PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT

Pharmacologic Therapy for Type 1 Diabetes

Recommendations

Most people with type 1 diabetes should be treated with multiple daily injection (MDI) therapy including prandial and basal insulin or continuous subcutaneous insulin infusion (CSII; insulin pump therapy).

Most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk.

Consider educating individuals with type 1 diabetes on matching prandial insulin doses to carbohydrate intake, premeal blood glucose levels, and anticipated physical activity.

Individuals with type 1 diabetes who have been successfully using CSII should have continued access to this therapy after they turn 65 years of age.

Pharmacologic Therapy for Type 2 Diabetes

Recommendations

Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacologic agent for the treatment 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.

Consider initiating insulin therapy (with or without additional agents) in patients with newly diagnosed type 2 diabetes who are symptomatic and/or have an 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 second oral agent, a GLP-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.

For patients with type 2 diabetes who are not achieving glycemic goals, insulin therapy should not be delayed.

In patients with long-standing suboptimally controlled type 2 diabetes and established atherosclerotic cardiovascular disease (ASCVD), empagliflozin or liraglutide should be considered because they have been shown to reduce cardiovascular and all-cause mortality when added to standard care.

figure-2-antihyperglycemic-therapy-in-type-2-diabetes-general-recommendations

figure-3-combination-injectable-therapy-for-type-2-diabetes

In addition to the above, the Standards also provide guidance on the management of chronic kidney disease, neuropathy, lipid management, coronary heart disease, diabetic retinopathy, foot care, management of diabetes in older adults; children and adolescents, and the management of diabetes in pregnancy.

Useful Links:

Link to the new Standards of Medical Care in Diabetes 2017:

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf

Link to the news release:

http://www.diabetes.org/newsroom/press-releases/2016/american-diabetes-2017-standards-of-care.html?referrer=https://www.google.co.in/?referrer=http://www.diabetes.org/newsroom/press-releases/2016/american-diabetes-2017-standards-of-care.html

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s