2016 Standards Of Medical Care In Diabetes
STANDARDS OF MEDICALCARE IN DIABETES 2016Armand Krikorian, MD, FACEAssociate Professor of MedicineIM Residency Program DirectorUniversity of Illinois at ChicagoAdvocate Christ Medical Center
STANDARDS OF CARE Funded out Association’s general revenues and doesnot use industry support. Slides correspond with sections within the Standards ofMedical Care in Diabetes—2016. Reviewed and approved by the Executive Committeeof the Association’s Board of Directors.
PROCESS ADA’s Professional Practice Committee (PPC)conducts annual review & revision. Searched Medline for human studies related to eachsubsection and published since January 1, 2015. Recommendations revised per new evidence, forclarity, or to better match text to strength ofevidence.Professional.diabetes.org/SOC
CLINICAL PRACTICE RECOMMENDATIONS EVIDENCEGRADING SYSTEMABCE Clear evidence from adequately-powered, well-conducted,generalizable RCTs, including evidence from a multicenter trial ormeta-analysis that incorporated quality ratings in the analysis; Compelling nonexperimental evidence; Supportive evidence from adequately-powered, well-conductedRCTs. Supportive evidence from a well-conducted cohort studies Supportive evidence from a well-conducted case-control study Supportive evidence from poorly controlled or uncontrolled studiesor evidence from observational studies with high potential for bias Evidence from case series or case reports Conflicting evidence with the weight of evidence supporting therecommendation Expert consensus or clinical experienceAmerican Diabetes Association Standards of Medical Care in Diabetes.Introduction. Diabetes Care 2016; 39 (Suppl. 1): S1-S2
TRENDS IN THE NUMBER AND PROPORTION OF HIGHER ANDLOWER LEVEL RECOMMENDATIONS Higher level recommendations defined as A or B evidence grades Lower level recommendationsdefined as C or E evidence gradesGrant R W , and Kirkman M S Dia Care 2015;38:6-8
TERMINOLOGY No longer using the term “diabetic.” Diabetes does not define people. People with diabetes are individuals withdiabetes, not “diabetics.” “Diabetic” will continue to be usedrelated to complications, e.g., “diabeticretinopathy.”American Diabetes Association Standards of Medical Care in Diabetes.Introduction. Diabetes Care 2016; 39 (Suppl. 1): S1-S2
1. STRATEGIESFOR IMPROVINGDIABETES CARE
CARE DELIVERY SYSTEMS 33-49% of patients still do not meet targets forA1C, blood pressure, or lipids. 14% meet targets for all A1C, BP, lipids, andnonsmoking status. Progress in CVD control is slowing. Substantial system-level improvements areneeded. Delivery system is fragmented, lacks clinicalinformation capabilities, duplicates services &is poorly designed.American Diabetes Association Standards of Medical Care in Diabetes.Strategies for improving diabetes care. Diabetes Care 2016; 39 (Suppl. 1): S6-S12
CHRONIC CARE MODELSix Components:1.Delivery system design2.Self-management support3.Decision support4.Clinical information systems5.Community resources & policies6.Health systemswww.BetterDiabetesCare.nih.govAmerican Diabetes Association Standards of Medical Care in Diabetes.Strategies for improving diabetes care. Diabetes Care 2016; 39 (Suppl. 1): S6-S12
WHEN TREATMENT GOALS AREN’T MET Seek evidence-based approaches that improveclinical outcomes and quality of life. Recent reviews of quality improvement strategies havenot identified one approach that’s more effective thanothers. Translating Research Into Actions for Diabetes (TRIAD)study provided objective data.American Diabetes Association Standards of Medical Care in Diabetes.Strategies for improving diabetes care. Diabetes Care 2016; 39 (Suppl. 1): S6-S12
HEALTH DISPARITIES Lack of health insurance Food insecurity (FI) Carefully evaluate hyperglycemia and hypoglycemiaand propose solutions A Recognize that homelessness, poor literacy, and poornumeracy often occur with food insecurity; appropriateresources should be made available for patients withdiabetes. AAmerican Diabetes Association Standards of Medical Care in Diabetes.Strategies for improving diabetes care. Diabetes Care 2016; 39 (Suppl. 1): S6-S12
2. Classificationand Diagnosisof Diabetes
CLASSIFICATION OF DIABETES1.Type 1 diabetes β-cell destruction2.Type 2 diabetes Progressive insulin secretory defect3.Gestational Diabetes Mellitus (GDM)4.Other specific types of diabetes Monogenic diabetes syndromes Diseases of the exocrine pancreas, e.g., cystic fibrosis Drug- or chemical-induced diabetesAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
CRITERIA FOR THE DIAGNOSIS OF DIABETESFasting plasma glucose (FPG) 126 mg/dL (7.0 mmol/L)OR2-h plasma glucose 200 mg/dL(11.1 mmol/L) during an OGTTORA1C 6.5%ORRandom plasma glucose 200 mg/dL (11.1 mmol/L)American Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
CRITERIA FOR THE DIAGNOSIS OF PREDIABETESFPG 100–125 mg/dL(5.6–6.9 mmol/L): IFGOR2-h plasma glucose 140–199 mg/dL(7.8–11.0 mmol/L): IGTORA1C 5.7–6.4%* For all three tests, risk is continuous, extending below the lower limit of arange and becoming disproportionately greater at higher ends of the range.American Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
A1C 6.5% Performed in a laboratory using a method that isNGSP certified and standardized to the DCCTassay –www.ngsp.org POC testing not recommended Greater convenience, preanalytical stability,and less day-to-day perturbations than FPG andOGTT Consider cost, age, race/ethnicity, anemia, etc.American Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
RECOMMENDATIONS: SCREENINGFOR TYPE 2 DIABETES Consider testing in asymptomatic adults of any agewith BMI 25 kg/m2 or 23 kg/m2 in Asian Americanswho have 1 or more add’l dm risk factors. B For all patients, testing should begin at age 45 years. B If tests are normal, repeat testing carried out at aminimum of 3-year intervals is reasonable. CAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
RECOMMENDATIONS: SCREENINGFOR TYPE 2 DIABETES (2) FPG, 2-h PG after 75-g OGTT, and the A1C are equallyappropriate. B In patients with diabetes, identify and, if appropriate,treat other CVD risk factors. B Consider testing for T2DM in overweight/obese childrenand adolescents with 2 or more add’l diabetes riskfactors. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
RECOMMENDATIONS: PREDIABETES Testing should begin at age 45 for all patients,particularly those who are overweight or obese. B Consider testing for prediabetes in asymptomaticadults of any age w/ BMI 25 kg/m2 or 23 kg/m2 (inAsian Americans) who have 1 or more add’l risk factorsfor diabetes. B If tests are normal, repeat at a minimum of 3-yearintervals. CAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
RECOMMENDATIONS: PREDIABETES (2) FPG, 2-h PG after 75-g OGTT, and A1C, are equallyappropriate for prediabetes testing. B In patients with prediabetes, identify and, ifappropriate, treat other CVD risk factors. B Consider prediabetes testing in overweight/obesechildren and adolescents with 2 or more add’l diabetesrisk factors. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
CRITERIA FOR TESTING FORT2DM IN CHILDREN & ADOLESCENTS Overweight plus any 2 : Family history of type 2 diabetes in 1st or 2nd degreerelative Race/ethnicity Signs of insulin resistance or conditions associated withinsulin resistance Maternal history of diabetes or GDM Age of initiation 10 years or at onset of puberty Frequency: every 3 years Screen with A1CAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
RECOMMENDATIONS: DETECTIONAND DIAGNOSIS OF GDM Test for undiagnosed T2DM at the 1st prenatal visit inthose with risk factors. B Test for GDM at 24–28 weeks of gestation in women notpreviously known to have diabetes. A Screen women with GDM for persistent diabetes at 6–12 weeks postpartum, using the OGTT. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
RECOMMENDATIONS: DETECTION ANDDIAGNOSIS OF GDM (2) Women with GDM history should have lifelongscreening for development of diabetes or prediabetesat least every 3 years. B Women with GDM history found to have prediabetesshould receive lifestyle interventions or metformin toprevent diabetes. AAmerican Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
BASIS FOR INITIAL CARE Diabetes Self-Management Education (DSME) Diabetes Self-Management Support (DSMS) Medical Nutrition Therapy (MNT) Physical activity education Smoking cessation counseling Guidance on routine immunizations Psychosocial careAmerican Diabetes Association Standards of Medical Care in Diabetes. Foundations of careand the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
RECOMMENDATIONS: DIABETES SELFMANAGEMENT EDUCATION & SUPPORT All people with diabetes should participate inDSME and DSMS both at diagnosis and as neededthereafter. B Effective self-management, improved clinicaloutcomes, health status, and quality-of-life are keyoutcomes of DSME and DSMS and should bemeasured and monitored as part of care. C DSME/S should be patient-centered, respectful,and responsive to individual patient preferences,needs, and values that should guide clinicaldecisions. AAmerican Diabetes Association Standards of Medical Care in Diabetes. Foundations of careand the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
RECOMMENDATIONS: NUTRITIONEffectiveness of Nutrition Therapy: An individualized MNT program is recommended forall people with type 1 and type 2 diabetes. A For people with T1DM or those with T2D who are ona flexible insulin program, education on carbcounting or estimation. A For patients on a fixed insulin program, having aconsistent pattern of carbohydrate intake withrespect to time and amount can result in improvedglycemic control and a reduced risk ofhypoglycemia. BAmerican Diabetes Association Standards of Medical Care in Diabetes. Foundations of careand the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
RECOMMENDATIONS:PHYSICAL ACTIVITY Children with diabetes/prediabetes: at least 60min/day physical activity B Adults with diabetes: at least 150 min/wk ofmoderate-intensity aerobic activity over at least 3days/week with no more than 2 consecutive dayswithout exercise A All individuals, including those with diabetes,should reduce sedentary time, particularly bybreaking up extended amounts of time ( 90 min)spent sitting. B Adults with type 2 diabetes should performresistance training at least twice weekly AAmerican Diabetes Association Standards of Medical Care in Diabetes. Foundations of careand the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
RECOMMENDATIONS:SMOKING CESSATION Advise all patients not to use cigarettes, other tobaccoproducts, or e-cigarettes. A Include smoking cessation counseling and other forms oftreatment as a routine component of diabetes care. BAmerican Diabetes Association Standards of Medical Care in Diabetes. Foundations of careand the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
RECOMMENDATIONS:PSYCHOSOCIAL CARE Routinely screen for depression, diabetesrelated distress, anxiety, eating disorders &cognitive impairment. B Adults aged 65 years with DM should beconsidered for evaluation of cognitivefunction, depression screening andtreatment. B Patients with diabetes and depression shouldreceive a collaborative care approach fordepression mgmt. AAmerican Diabetes Association Standards of Medical Care in Diabetes. Foundations of careand the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35
3. Glycemic Targets
DIABETES CARE: GLYCEMIC CONTROL Two primary techniques available for health providersand patients to assess effectiveness of managementplan on glycemic control1.2.Patient self-monitoring of blood glucose (SMBG)A1C CGM or interstitial glucose may be a useful adjunct toSMBG in selected patients.American Diabetes Association Standards of Medical Care in Diabetes.Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
RECOMMENDATIONS:GLUCOSE MONITORING When prescribed as part of a broader educationalcontext, SMBG results may be helpful to guidetreatment decisions and/or patient selfmanagement for patients using less frequent insulininjections B or noninsulin therapies. E When prescribing SMBG, ensure that patientsreceive ongoing instruction and regular evaluationof SMBG technique and SMBG results, and theirability to use SMBG data to adjust therapy. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
RECOMMENDATIONS: A1C TESTING Perform the A1C test at least 2x annually inpatients that meet treatment goals (andhave stable glycemic control). E Perform the A1C test quarterly in patientswhose therapy has changed or who are notmeeting glycemic goals. E Use of point-of-care (POC) testing for A1Cprovides the opportunity for more timelytreatment changes. EAmerican Diabetes Association Standards of Medical Care in Diabetes.Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
RECOMMENDATIONS:GLYCEMIC GOALS IN ADULTS Lowering A1C to 7% has been shown to reducemicrovascular complications and, if implementedsoon after the diagnosis of diabetes, is associatedwith long-term reduction in macrovasculardisease. B Consider more stringent goals (e.g. 6.5%) forselect patients if achievable without significanthypos or other adverse effects. C Consider less stringent goals (e.g. 8%) for patientswith a hx of severe hypoglycemia, limited lifeexpectancy, or other conditions that make 7%difficult to attain. BAmerican Diabetes Association Standards of Medical Care in Diabetes.Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
APPROACH TO THE MANAGEMENTOF HYPERGLYCEMIARisks associated with hypoglycemia& other drug adverse se Durationnewly diagnosedlong-standingLife expectancyImportant comorbiditieslongshortabsentFew/mildsev ereabsentFew/mildsev ereUsually notmodifiablePatient/Disease FeaturesPatient attitude & expected treatmenteffortshighly motiv ated, adherent,excellent self-care capabilitiesless motiv ated, nonadherent,poor self-care capabilitiesResources & support systemreadily av ailablePotentiallymodifiableEstablished vascular complicationslimitedAmerican Diabetes Association Standards of Medical Care in Diabetes.Glycemic targets. Diabetes Care 2016; 39 (Suppl. 1): S39-S46
4. Approachesto Glycemic Treatment
RECOMMENDATIONS: PHARMACOLOGICALTHERAPY FOR TYPE 1 DIABETES Most people with T1DM should be treated with multipledose insulin (MDI) injections (3–4 injections /day of basal& prandial insulin) or continuous subcutaneous insulininfusion (CSII). A Individuals who have been successfully using CSIIshould have continued access after they turn 65 yearsold. EAmerican Diabetes Association Standards of Medical Care in Diabetes. Approaches toglycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S59
RECOMMENDATIONS: PHARMACOLOGICALTHERAPY FOR TYPE 1 DIABETES (2) Consider educating individuals with T1DM on matchingprandial insulin dose to carbohydrate intake, premealblood glucose, and anticipated activity. E Most individuals with T1DM should use insulin analogs toreduce hypoglycemia risk. AAmerican Diabetes Association Standards of Medical Care in Diabetes. Approaches toglycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S59
RECOMMENDATIONS:PHARMACOLOGICAL THERAPY FOR T2DM Metformin, if not contraindicated andif tolerated, is the preferred initial pharmacologicalagent for T2DM. A In patients with newly dx’d T2DM and markedlysymptomatic and/or elevated blood glucose levels orA1C, consider insulin therapy (with or without additionalagents). EAmerican Diabetes Association Standards of Medical Care in Diabetes. Approaches toglycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S59
RECOMMENDATIONS:PHARMACOLOGICAL THERAPY FOR T2DM (2) If noninsulin monotherapy at maximal tolerated dose doesnot achieve or maintain the A1C target over 3 months, adda second oral agent, a GLP-1 receptor agonist, or insulin. A Use a patient-centered approach to treatment. E Don’t delay insulin initiation in patients not achievingglycemic goals. BAmerican Diabetes Association Standards of Medical Care in Diabetes. Approaches toglycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S59
5. Cardiovascular Diseaseand Risk Management
CARDIOVASCULAR DISEASE CVD is the leading cause of morbidity & mortality forthose with diabetes. Largest contributor to direct/indirect costs Common conditions coexisting with type 2 diabetes(e.g., hypertension, dyslipidemia) are clear risk factorsfor ASCVD. Diabetes itself confers independent risk Control individual cardiovascular risk factors toprevent/slow CVD in people with diabetes. Systematically assess all patients with diabetes forcardiovascular risk factors.American Diabetes Association Standards of Medical Care in Diabetes. Cardiovasculardisease and risk management. Diabet es Care 2016; 39 (Suppl. 1): S60-S71
RECOMMENDATIONS: HYPERTENSION/ BLOODPRESSURE CONTROLSystolic Targets: People with diabetes and hypertension should betreated to a systolic blood pressure goal of 140 mmHg.A Lower systolic targets, such as 130 mmHg, may beappropriate for certain individuals, such as youngerpatients, if it can be achieved without undue treatmentburden. CAmerican Diabetes Association Standards of Medical Care in Diabetes. Cardiovasculardisease and risk management. Diabet es Care 2016; 39 (Suppl. 1): S60-S71
RECOMMENDATIONS: HYPERTENSION/BLOOD PRESSURE CONTROL (2)Diastolic Targets: Patients with diabetes should be treated to a diastolicblood pressure 90 mmHg. A Lower diastolic targets, such as 80 mmHg, may beappropriate for certain individuals, such as youngerpatients, if it can be achieved without undue treatmentburden. BAmerican Diabetes Association Standards of Medical Care in Diabetes. Cardiovasculardisease and risk management. Diabet es Care 2016; 39 (Suppl. 1): S60-S71
RECOMMENDATIONS FOR STATIN TREATMENT INPEOPLE WITH DIABETESAge 40 years40–75years 75 yearsRisk FactorsStatin Intensity*NoneNoneASCVD risk factor(s)**Moderate or highASCVDHighNoneModerateASCVD risk factorsHighACS & LDL 50 who can’ttolerate high dose statinModerate ezetimibeNoneModerateASCVD risk factorsModerate or highASCVDHighACS & LDL 50 who can’ttolerate high dose statinModerate ezetimibe* In addition to lifestyle therapy. ** ASCVD risk factors include LDL cholesterol 100 mg/dL (2.6 mmol/L),high blood pressure, smoking, overweight and obesity, and family history of premature ASCVD.American Diabetes Association Standards of Medical Care in Diabetes. Cardiovasculardisease and risk management. Diabet es Care 2016; 39 (Suppl. 1): S60-S71
RECOMMENDATIONS:ANTIPLATELET AGENTSConsider aspirin therapy (75–162 mg/day) C As a primary prevention strategy in those with type1 or type 2 diabetes at increased cardiovascularrisk (10-year risk 10%) Includes most men or women with diabetes age 50 years who have at least one additional majorrisk factor, including: Family history of premature rican Diabetes Association Standards of Medical Care in Diabetes. Cardiovasculardisease and risk management. Diabet es Care 2016; 39 (Suppl. 1): S60-S71
RECOMMENDATIONS:CORONARY HEART DISEASEScreening In asymptomatic patients, routine screening forCAD isn’t recommended & doesn’t improveoutcomes provided ASCVD risk factors are treated.A Consider investigations for CAD with: Atypical cardiac symptoms (e.g. unexplained dyspnea,chest discomfort) Signs or symptoms of associated vascular disease incl.carotid bruits, transient ischemic attack, stroke,claudication or PAD EKG abnormalities (e.g. Q waves) EAmerican Diabetes Association Standards of Medical Care in Diabetes. Cardiovasculardisease and risk management. Diabet es Care 2016; 39 (Suppl. 1): S60-S71
6. MicrovascularComplicationsand Foot Care
RECOMMENDATIONS:DIABETIC KIDNEY DISEASETreatment Optimize glucose control to reduce risk or slowprogression of diabetic kidney disease. A Optimize blood pressure control ( 140/90 mmHg) toreduce risk or slow progression of diabetic kidneydisease. AAmerican Diabetes Association Standards of Medical Care in Diabetes. Microvascularcomplications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
MANAGEMENT OF CKD IN DIABETESGFRRecommendedAll patientsYearly measurement of creatinine, urinaryalbumin excretion, potassium45-60Referral to a nephrologist if possibility fornondiabetic kidney disease existsConsider dose adjustment of medicationsMonitor eGFR every 6 monthsMonitor electrolytes, bicarbonate, hemoglobin,calcium, phosphorus, parathyroid hormone atleast yearlyAssure vitamin D sufficiencyConsider bone density testingReferral for dietary counsellingAmerican Diabetes Association Standards of Medical Care in Diabetes. Microvascularcomplications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
MANAGEMENT OF CKD IN DIABETES (2)GFR30-44RecommendedMonitor eGFR every 3 monthsMonitor electrolytes, bicarbonate,calcium, phosphorus, parathyroidhormone, hemoglobin, albuminweight every 3–6 monthsConsider need for dose adjustment ofmedications 30Referral to a nephrologistAmerican Diabetes Association Standards of Medical Care in Diabetes. Microvascularcomplications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
RECOMMENDATIONS:DIABETIC RETINOPATHY To reduce the risk or slow the progression of retinopathy Optimize glycemic control A Optimize blood pressure control AAmerican Diabetes Association Standards of Medical Care in Diabetes. Microvascularcomplications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
RECOMMENDATIONS:DIABETIC RETINOPATHY (2)Screening: Initial dilated and comprehensive eye examination byan ophthalmologist or optometrist: Adults with type 1 diabetes, within 5 years of diabetesonset. B Patients with type 2 diabetes at the time of diabetesdiagnosis. BAmerican Diabetes Association Standards of Medical Care in Diabetes. Microvascularcomplications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
RECOMMENDATIONS:DIABETIC RETINOPATHY (3)Screening (2): If no evidence of retinopathy for one or more eyeexam, exams every 2 years may be considered. B If diabetic retinopathy if present subsequentexaminations for type 1 and type 2 diabeticpatients should be repeated annually by anophthalmologist or optometrist. B If retinopathy is progressing or sight-threatening,more frequent examsrequired. BAmerican Diabetes Association Standards of Medical Care in Diabetes. Microvascularcomplications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
RECOMMENDATIONS:NEUROPATHYEarly recognition & management is important because:1.DN is a diagnosis of exclusion.2.Numerous treatment options exist.3.Up to 50% of DPN may be asymptomatic.4.Recognition & treatment may improve symptoms,reduce seqeullae, and improve quality-of-life.American Diabetes Association Standards of Medical Care in Diabetes. Microvascularcomplications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
RECOMMENDATIONS: NEUROPATHY (2)Screening: Assess all patients for DPN at dx for T2DM, 5 yearsafter dx for T1DM, and at least annually thereafter.B Assessment should include history & 10gmonofilament testing, and at least one of thefollowing: pinprick, temperature, and vibrationsensation. B Symptoms of autonomic neuropathy should beassessed in patients with microvascular &neuropathic complications. EAmerican Diabetes Association Standards of Medical Care in Diabetes. Microvascularcomplications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
RECOMMENDATIONS: NEUROPATHY (3)Treatment: Optimize glucose control to prevent or delay thedevelopment of neuropathy in patients with T1DM A &to slow progression in patients with T2DM. B Assess & treat patients to reduce pain related to DPN Band symptoms of autonomic neuropathy and toimprove quality of life. EAmerican Diabetes Association Standards of Medical Care in Diabetes. Microvascularcomplications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
RECOMMENDATIONS: FOOT CARE Perform a comprehensive foot evaluation annually toidentify risk factors for ulcers & amputations. B History should contain prior hx of ulceration,amputation, Charcot foot, angioplasty or vascularsurgery, cigarette smoking, retinopathy & renal disease;and should assess current symptoms of neuropathy andvascular disease. BAmerican Diabetes Association Standards of Medical Care in Diabetes. Microvascularcomplications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
RECOMMENDATIONS: FOOT CARE (2) Exam should include inspection of the skin, assessmentof foot deformities, neurologic assessment & vascularassessment including pulses in the legs and feet. B Patients with history of ulcers or amputations, footdeformities, insensate feet & PAD are at increased riskfor ulcers and amputations and should have their feetexamined at every visit. CAmerican Diabetes Association Standards of Medical Care in Diabetes. Microvascularcomplications and foot care. Diabetes Care 2016; 39 (Suppl. 1): S72-S80
TRENDS IN THE PROPORTION OF HIGHER LEVELRECOMMENDATIONS BY CATEGORYGrant R W , and Kirkman M S Dia Care 2015;38:6-8
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STANDARDS OF MEDICAL CARE IN DIABETES 2016 . Armand Krikorian, MD, FACE . . Classification and diagnosis of diabetes. Diabetes Care . 2016; 39 (Suppl. 1): S13-S22 . minimum of 3 -year intervals is reasonable. C . American Diabetes Association Standards of Medical Care in Diabetes.
4 Current Drivers of Home-Based Medical Care Models 5 The Opportunity 6 The Spectrum of Home-Based Medical Care Models Table 1. Longitudinal Home-Based Medical Care Models Table 2. Episodic Home-Based Medical Care Models The Bottom Line 12 Case Studies 15 Looking Ahead: An Integrated Home- and Community-Based Health Care Ecosystem 16 Endnotes .
Dec 21, 2015 · AMERICAN DIABETES ASSOCIATION STANDARDS OF MEDICAL CARE IN DIABETES—2016 S U P P L E M E N 1 T. American Diabetes Association Standards of Medical Care in . EDITORIAL BOARD Nicola Abate, MD Silva Arslanian, MD Angelo Avogaro, MD, PhD Ana
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