Diabetes Clinical Guideline
Every January the American Diabetes Association updates and publishes the Standards of Medical Care for Diabetes. This guideline provides the basis for Paramount’s management of diabetes. Each year, Paramount’s Medical Advisory Council (MAC) reviews and adopts the American Diabetes Association’s Standards of Medical Care In Diabetes. The most recent adoption occurred at the March 13, 2018 meeting. A sincere thank you goes out to Jeff Lewis, MD, Associate Medical Director at Paramount, Srini Hejeebu, DO, Associate Medical Director at Paramount, and Richard Beham, MD, a Paramount provider specializing in endocrinology, for providing their time to review and support of the adoption of the 2018 ADA Standards of Medical Care in Diabetes. It should be noted that the Standards of Care will now become the ADA’s sole source of clinical practice recommendations, superseding all prior position and scientific statements. Listed below are corresponding chapters and noteworthy changes in each, if any:
- Improving Care and Promoting Health in Populations: – Align approaches to diabetes management with the Chronic Care Model (CCM), emphasizing productive interactions between a prepared proactive care team and an informed activated patient. Level of Evidence (LOE) A.
- Classification and Diagnosis of Diabetes – For all people, testing should begin at age 45 years (LOE B). Testing for Type 2 Diabetes should be considered in adults of any age who are overweight or obese (BMI ≥25kg/m2 or ≥23kg/m2 in Asian Americans) and who have one or more additional risk factors for diabetes (LOE B) (Please see Fig.2.1- Diabetes Risk Test). Please see Table 2.5 – Risk based screening for type 2 diabetes or prediabetes in asymptomatic children and adolescents in a clinical setting.
- Comprehensive Medical Evaluation and Assessment of Comorbidities – This chapter highlights the importance of assessing comorbidities in the context of a patient–centered comprehensive Medical Evaluation. In people with a history of cognitive impairment/dementia, intensive glucose control cannot be expected to remediate deficits. Treatment should be tailored to avoid significant hypoglycemia. LOE B. Referrals for treatment of depression should be made to mental health providers with experience using cognitive behavioral therapy, interpersonal therapy, or other evidence-based treatment approach in conjunction with collaborative care with the patient’s diabetes treatment team. LOE A.
- Lifestyle Management – Lifestyle management is a fundamental aspect of diabetes care and includes diabetes self-management education and support (DSMES), medical nutrition therapy (MNT), physical activity, smoking cessation counseling, and psychosocial care. Please see Table 4.2 –Situations that warrant referral of a person with diabetes to a mental health provider for evaluation and treatment.
- Prevention or Delay of Type 2 Diabetes– The strongest evidence for diabetes prevention comes from the Diabetes Prevention Program (DPP), which demonstrated that an intensive lifestyle intervention could reduce the incidence of type 2 diabetes by 58% over 3 years. The CDC helps to coordinate the National Diabetes Prevention Program (National DPP), and on July 7, 2016 Centers for Medicare and Medicaid Services (CMS) proposed expanded Medicare reimbursement coverage for DPP programs in an effort to expand preventive services using a cost effective model with proposed implementation in 2018.
- Glycemic Targets – Recommendation: Less stringent A1C goals (such as <8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. LOE B.
- Obesity Management for the Treatment of Type 2 Diabetes – The U.S. Food and Drug Administration (FDA) has approved medications for both short term (1 medication) and long term (5 medications) weight management (see Table 7.2). Special note: None of the Medications are covered by Paramount, data is not there for long term maintenance of weight loss once drugs are stopped. The rationale for weight loss medications is to help patients to more consistently adhere to low-calorie diets and to reinforce lifestyle changes including physical activity.
- Pharmacologic Approaches to Glycemic Treatment – Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacologic agent for the treatment of type 2 diabetes. LOE A.
- Cardiovascular Disease and Risk Management – A new recommendation was added that all hypertensive patients with diabetes should monitor their blood pressure at home to help identify masked or white coat hypertension, as well as to improve medication-taking behavior. LOE B. Based on the EMPA-REG OUTCOME trial (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients), the FDA recently added a new indication for empagliflozin, to reduce the risk of major adverse cardiovascular death in adults with type 2 diabetes and cardiovascular disease.
- Microvascular Complications and Foot Care – At least once a year, assess urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and estimated glomerular filtration rate in patients with type 1 diabetes with duration of ≥5 years, in all patients with type 2 diabetes, and in all patients with comorbid hypertension. Perform a comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputations. LOE B.
- Older Adults – Screening for early detection of mild cognitive impairment or dementia and depression is indicated for adults 65 years of age or older at the initial visit and annually as appropriate. LOE B. See Table 11.1 – Framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes.
- Children and Adolescents – See Table 12.1-Blood glucose and A1C goals for children and adolescents with type 1 diabetes.
- Management of Diabetes in Pregnancy – Insulin is the preferred agent for management of both type 1 diabetes and type 2 diabetes in pregnancy because it does not cross the placenta, and because oral agents are generally insufficient to overcome the insulin resistance in type 2 diabetes and are ineffective in type 1 diabetes. LOE E.
- Diabetes Care in the Hospital – Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180mg/dl. Once insulin therapy is started, a target glucose range of 140-180 mg/dl is recommended for the majority of critically ill patients and noncritically ill patients. LOE A.
- Diabetes Advocacy – Unchanged.
Please see the Standards of Medical Care in Diabetes-2018 Abridged for Primary Care Providers and the complete guideline.