Diabetes Management Guidelines

American Diabetes Association (ADA) 2012 Clinical Practice Recommendations

 

The ADA 2013 guidelines are available. Click here. 

Source: American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.  

Topic Recommendations Slides

Detection and Diagnosis 

Recommendations for Nonpregnant Adults 

A1C ≥6.5%; or 

FPG ≥126 mg/dL (≥7.0 mmol/L); or 

 

2-hour plasma glucose ≥200 mg/dL
(≥11.1 mmol/L) during an OGTT; 75-g glucose load should be used; or
 

 

Random plasma glucose concentration ≥200 mg/dL (≥11.1 mmol/L) in persons with symptoms of hyperglycemia/hyperglycemic crisis 

 

Pregnant Adults/Gestational 

  • Among those with risk factors, screen for undiagnosed type 2 diabetes at first prenatal visit using standard diagnostic criteria 
  • In pregnant women not known to have diabetes, screen for GDM at 24–28 weeks using a 75-g 2-hour OGTT and the following cut points: 
    • Fasting: ≥92 mg/dL 
    • 1-hour: ≥180 mg/dL 
    • 2-hour: ≥153 mg/dL 
     
  • Screen those with GDM for persistent diabetes
    6–12 weeks postpartum using a test other than A1C
     
  • Continue to screen women with history of GDM for diabetes or prediabetes at least every 3 years 
  • Women with GDM history and prediabetes should receive lifestyle interventions or metformin for diabetes prevention 
 

ADA Criteria for the Diagnosis of Diabetes 

 

ADA Criteria for Testing for Prediabetes and Diabetes in Asymptomatic Adults 

 

 

 

 

 

ADA Recommendations for Detection and Diagnosis of Gestational Diabetes Mellitus 

Special Populations  Children and Adolescents 
  • Test children for type 2 diabetes every 3 years from age 10 years or at onset of puberty if overweight and have two or more risk factors: 
    • Positive family history, signs of, or conditions associated with, insulin resistance, member of high-risk race/ethnic group, maternal history of diabetes or GDM during the child’s gestation 
     
  • Establish normal blood glucose and A1C values as goals  
  • Begin self-management education at diagnosis 
  • Initiate medical nutrition therapy and exercise if no illness present 
  • If goals are not met by lifestyle changes, pharmacotherapy is indicated 

 

Older Adults 

  • Treatment goals developed for younger adults are also appropriate for older adults who are 
    • Functional and cognitively intact 
    • Expected to live long enough to reap benefits 
    • Able to undertake self-management 
     
  • Relax glycemic goals if not met using individual criteria, but avoid hyperglycemic complications 
  • Treating CV risk factors in older adults may have greater impact on reducing morbidity and mortality than tight glycemic control alone 
  • Treat older adults with same drug regimens as younger patients, using special care in prescribing and monitoring 
  • Individualize screening for complications, paying particular attention to complications that may lead to functional impairment  
 

ADA Guidelines for Type 2 Diabetes in Children and Adolescents: Screening and Treatment 

 

 

 

 

 

ADA Guidelines for Treatment of Older Adults With Diabetes 

Glycemic, Blood Pressure, and Lipid Control  Goals for Glycemia, Blood Pressure, and Lipids 

A1C: <7.0% 

Blood Pressure: <130/80 mm Hg 

Lipids: LDL-C <100 mg/dL 

 

A1C Recommendations 

  • A1C test should be performed: 
    • At least 2 times/year in patients who are meeting treatment goals and have stable glycemic control 
    •  Quarterly in patients whose therapy has changed or who are not meeting glycemic goals 
     
  • Use of point-of-care (POC) testing for A1C allows for more timely changes in treatment 

 

Glycemic Recommendations for Nonpregnant Adults 

  • A1C <7.0% 
  • Preprandial capillary plasma glucose
    70–130 mg/dL
     
  • Peak postprandial capillary plasma glucose <180 mg/dL 
 

ADA: Goals for Glycemic, Blood Pressure, and Lipid Control 

 

 

 

ADA Guidelines: A1C Recommendations 

 

 

 

 

 

ADA Guidelines: Glycemic Recommendations for Nonpregnant Adults With Diabetes 

 

Pharmacologic Therapy 

 
 
  • Initiate metformin therapy along with lifestyle changes at diagnosis (unless metformin contraindicated) 
  • Consider insulin therapy (with or without other agents) at outset of treatment in newly diagnosed patients with markedly symptomatic and/or elevated blood glucose levels or A1C 
  • Add second oral agent, GLP-1 receptor agonist, or insulin if noninsulin monotherapy at maximal tolerated dose does not achieve or maintain A1C target over 3–6 months 
 

Recommendations for Type 2 Diabetes Therapy 

 

ADA Guidelines: Noninsulin Therapies for Hyperglycemia in Type 2 Diabetes (1 of 2) 

 

 

ADA Guidelines: Noninsulin Therapies for Hyperglycemia in Type 2 Diabetes (2 of 2) 

 

Medical Nutrition Therapy 

Recommendations for Weight Loss 
  • Weight loss recommended for all overweight or obese individuals at risk for, or with, diabetes 
  • Either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to 2 years) 
  • With low-carbohydrate diets: 
    • Monitor lipid profiles and renal function 
    • Monitor protein intake (in patients with nephropathy) 
    • Adjust hypoglycemic therapies as needed 
     

 

Recommendations for Medical Nutrition Therapy 

  • Encourage weight loss for all overweight/obese individuals; even modest weight loss reduces insulin resistance  
    • Physical activity and behavior modification are important for weight loss and maintenance 
     
  • Adjust mix of carbohydrates, protein, and fat to meet metabolic goals and preferences of person with diabetes 
    • Saturated fat should be <7% of total calories 
    • Minimize trans fat 
    • Monitor carbohydrate consumption to achieve glycemic control 
     
  • Customize nutrition counseling to each patient 
  • Limit alcohol intake 
  • Supplementation with antioxidants is not recommended 
  • Meal planning should include optimization of food choices to meet RDA/DRI for micronutrients 

 

Recommendations for Primary Prevention of Diabetes With Medical Nutrition Therapy 

  • Begin a structured program emphasizing lifestyle changes, including moderate weight loss (7% body weight) and regular physical activity (150 min/week) with dietary strategies, including reduced calories and reduced intake of dietary fat  
  • Achieve the USDA recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake)  
  • Limit intake of sugar-sweetened beverages 

 

Recommendations for Physical Activity/Exercise 

  • Exercise programs (absent contraindications) should include the following: 
    • 150 min/week moderate-intensity aerobic activity (50%–70% maximum heart rate), spread over ≥3 days/week with no more than 2 consecutive days without exercise 
    • Resistance training 2 times/week 
     
 

ADA Nutrition Strategies for Weight Loss 

 

 

 

 

 

ADA Recommendations for Medical Nutrition Therapy 

 

 

 

 

 

 

 

ADA Recommendations for Primary Prevention of Diabetes With Medical Nutrition Therapy 

 

 

 

 

ADA: Physical Activity/Exercise Recommendations for Patients With Type 2 Diabetes 

Diabetes Complications  

Recommendations for Nephropathy 
  • Optimize glucose and blood pressure control to reduce risk or slow progression of nephropathy 
    • Measure urine albumin excretion annually in type 1 patients with  5-year diabetes duration, and in all type 2 patients starting at diagnosis 
    • Measure serum creatinine annually 
     
  • Limit protein intake to 0.8–1.0 g/kg/day in patients with diabetes and early stages of CKD and to 0.8 g/kg/day in the later stages of CKD 
  • In patients with albuminuria, treatment with ACE inhibitor or ARB is indicated; if one class is not tolerated, substitute the other 
    • These treatments should not be used during pregnancy 
     
  • Monitor serum creatinine and potassium levels in all patients receiving ACE inhibitors, ARBs, or diuretics 

 

Recommendations for Neuropathy 

  • Screen all patients for distal symmetric polyneuropathy (DPN) using simple clinical tests 
    • Type 2 diabetes: at diagnosis 
    • Type 1 diabetes: 5 years after diagnosis and at least annually thereafter 
     
  • Institute screening for autonomic cardiovascular neuropathy  
    • Type 2 diabetes: at diagnosis  
    • Type 1 diabetes: 5 years after diagnosis 
     
  • Use of medications for the relief of DPN-related symptoms and autonomic neuropathy is recommended 

 

Recommendations for Retinopathy 

  • Optimal glycemic and blood pressure control can reduce risk or slow progression of diabetic retinopathy  
  • Comprehensive eye exam by an ophthalmologist or optometrist shortly after diagnosis (type 2) or within 5 years after onset of diabetes (type 1) 
  • Repeat eye exam annually, less frequently (every 2–3 years) following one or more normal exams 
  • Fundus photographs may be used to screen for retinopathy 
  • Pregnant women with preexisting diabetes should have eye exam in first trimester with close follow-up and 1 year postpartum 
  • Laser therapy indicated to reduce risk of vision loss among those with high-risk PDR, clinically significant macular edema, and some cases of severe NPDR 
  • Presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection 
 

ADA Treatment Recommendations for Nephropathy 

 

 

 

 

 

 

 

ADA Recommendations for Neuropathy Screening and Treatment 

 

 

 

 

 

 

ADA Guidelines for Retinopathy Management in Diabetes 

 

Foot Care  

 
  • Annual foot examination to identify high-risk conditions and risk factors predictive of ulcers and amputations 
    • Assess foot pulses and test for loss of protective sensation 
     
  • Risk of ulcers or amputations increased in those with risk factors including 
    • Peripheral neuropathy, history of ulcers or amputation, PVD, foot deformity, cigarette smoking, visual impairment, poor glycemic control, diabetic nephropathy 
     
 

ADA Guidelines for Foot Care in Patients With Diabetes (1 of 2) 

 

ADA Guidelines for Foot Care in Patients With Diabetes (2 of 2) 

 

Aspirin Therapy 

 
  • Aspirin 75–162 mg/day recommended as 
    • Primary prevention in type 1 or type 2 diabetes patients at increased CVD risk (10-year risk >10%) 
     
  • No sufficient evidence to recommend aspirin for primary prevention in lower risk individuals (10-year risk <5%; eg, men <50 years of age or women <60 years of age without other major risk factors) since potential adverse effects from bleeding likely offset potential benefits 
    • Clinical judgment recommended for treating patients in these age groups with other risk factors (10-year risk 5%–10%) 
     
  • Use aspirin therapy (75–162 mg/day) as secondary prevention strategy in those with diabetes with history of CVD 
  • Use clopidogrel (75 mg/day) for those with CVD and documented aspirin allergy 
  • Combination therapy with aspirin (75–162 mg/day) and clopidogrel (75 mg/day)  is reasonable for ≤1 year after ACS 
 

ADA Recommendations for Aspirin Therapy in Diabetes 

Care Settings 

 
  •  Diabetes should be clearly identified in the patient’s medical record 
  • Blood glucose monitoring should be ordered for all diabetes patients with results made available to healthcare team 
  • Goals for blood glucose levels 
    • Critically ill: initiate insulin for treatment of persistent hyperglycemia starting at ≤180 mg/dL; once insulin is started, 140–180 mg/dL is recommended range for most patients 
    • Non–critically ill: no clear evidence for specific goals; insulin-treated: premeal target <140 mg/dL with random blood glucose <180 mg/dL  
     
  • Preferred method for achieving/maintaining glucose control in non–critically ill patients: scheduled subcutaneous insulin with basal, nutritional, and correction components 
  • Monitor nondiabetic patients who receive therapy associated with high risk for hyperglycemia 
  • Create a plan for each patient for treating hypoglycemia and track episodes 
  • All patients with diabetes admitted to hospital should have A1C obtained if no previous test results from the last 2–3 months are available 
  • Patients with hyperglycemia in the hospital with no prior diabetes diagnosis should have plans for follow-up testing and care documented at discharge 
 

ADA Recommendations for Care in the Hospital (1 of 2) 

 

ADA Recommendations for Care in the Hospital (2 of 2) 

Smoking Cessation   
  • Advise patients with diabetes not to smoke 
  • Counsel on smoking prevention and cessation 
  •  Cessation counseling should be completed as a routine component of diabetes care 
  • Assess level of nicotine dependence 
  • Offer pharmacologic therapy as appropriate 
 

ADA Recommendations for Smoking Cessation in Diabetes 

 

 
Bariatric Surgery   
  • Bariatric surgery may be considered for adults with type 2 diabetes with BMI >35 kg/m2  
  • Not recommended for those with BMI <35 kg/m2 outside of a research protocol 
  • Lifelong lifestyle support and medical monitoring necessary post-surgery 
 

ADA Recommendations on Bariatric Surgery in Patients With Diabetes 

 

 
Immunizations   
  • Annual influenza vaccinations advised for all patients with diabetes aged ≥6 months  
  • Vaccination against pneumococcal polysaccharide advised for patients with diabetes aged ≥2 years  
    • One-time revaccination recommended for those aged >64 years previously immunized at age <65 years, if administered >5 years prior 
    •  Repeat vaccination for those with nephrotic syndrome, chronic renal disease, other immunocompromised states 
     
  • Hepatitis B vaccination should be administered to adults with diabetes as per CDC recommendations  
 

ADA Recommendations for Immunizations in Patients With Diabetes 

 

 

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Last Modified: 3/10/2014

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