P O S I T I O N SETD

ATI TEO
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ATL

Standards of Medical Care in Diabetes—2017

Abridged for Primary Care Providers
American Diabetes Association

T
he American Diabetes Associa- PROMOTING HEALTH AND
tion’s (ADA’s) Standards of Med- REDUCING DISPARITIES IN

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ical Care in Diabetes is updated POPULATIONS
and published annually in a supple-
Recommendations
ment to the January issue of Diabetes
• Treatment plans should align
Care. The ADA’s Professional Practice
with the Chronic Care Model,
Committee, comprised of physicians,
emphasizing productive interac-
diabetes educators, registered dieti-
tions between a prepared proactive
tians, and public health experts, de-
practice team and an informed
velops the Standards. Formerly called
Clinical Practice Recommendations, the activated patient. A
Standards includes the most current • When feasible, care systems
evidence-based recommendations for should support team-based care,
diagnosing and treating adults and community involvement, patient
children with all forms of diabetes. registries, and decision support
ADA’s grading system uses A, B, C, tools to meet patient needs. B
or E to show the evidence level that Diabetes and Population
supports each recommendation. Health
• A—Clear evidence from well-con- Clinical practice guidelines are key
ducted, generalizable randomized to improving population health;
controlled trials that are ade- however, for optimal outcomes, di-
quately powered abetes care must be individualized
• B —Supportive evidence from for each patient. Thus, efforts to im-
well-conducted cohort studies prove population health will require
• C —Supportive evidence from a combination of systems-level and
poorly controlled or uncontrolled patient-level approaches. With such
studies an integrated approach in mind, the
• E —Expert consensus or clinical ADA highlights the importance of
This is an abridged version of the experience
American Diabetes Association Position
patient-centered care, defined as care
Statement: Standards of Medical Care that is respectful of and responsive to
in Diabetes—2017. Diabetes Care This is an abridged version of the individual patient preferences, needs,
2017;40(Suppl. 1):S1–S135. current Standards containing the
and values and ensuring that patient
The complete 2017 Standards supplement, evidence-based recommendations
including all supporting references, is values guide all clinical decisions.
most pertinent to primary care. The
available at professional.diabetes.org/
standards. tables and figures have been renum- Care Delivery Systems
DOI: 10.2337/cd16-0067 bered from the original document Despite the many advances in diabe-
to match this version. The complete tes care, 33–49% of patients still do
©2017 by the American Diabetes Association.
Readers may use this article as long as the work
2017 Standards of Care document, not meet targets for glycemic, blood
is properly cited, the use is educational and not including all supporting references, pressure, or cholesterol control, and
for profit, and the work is not altered. See http://
creativecommons.org/licenses/by-nc-nd/3.0
is available at professional.diabetes. only 14% meet targets for all three
for details. org/standards. measures while also avoiding smok-

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P O S I T I O N S TAT E M E N T

ing. Certain segments of the popu- TABLE 1. Criteria for the Diagnosis of Diabetes
lation, such as young adults and pa-
FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at
tients with complex comorbidities, least 8 h.*
financial or other social hardships,
and/or limited English proficiency, OR
face particular challenges to care. 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT. The test
Even after adjusting for these factors, should be performed as described by the World Health Organization,
using a glucose load containing the equivalent of 75 g anhydrous glucose
the persistent variability in the quality dissolved in water.*
of diabetes care across providers and
OR
practice settings indicates that sub-
stantial system-level improvements A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory
using a method that is NGSP certified and standardized to the Diabetes
are still needed. Control and Complications Trial assay.*
Chronic Care Model OR
Numerous interventions to improve In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis,
adherence to the recommended a random plasma glucose ≥200 mg/dL (11.1 mmol/L).

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standards have been implemented. *In the absence of unequivocal hyperglycemia, results should be confirmed
However, a major barrier to optimal by repeat testing.
care is a delivery system that is often
fragmented, lacks clinical information mental to the successful implemen- and change the societal determinants
capabilities, duplicates services, and is tation of the CCM. Collaborative, of these problems.
poorly designed for the coordinated multidisciplinary teams are best
delivery of chronic care. The Chronic Recommendations
suited to provide care for people
Care Model (CCM) takes these fac- • Providers should assess social
with chronic conditions such as dia-
tors into consideration and is an ef- context, including potential food
betes and to facilitate patients’ self-
fective framework for improving the insecurity, housing stability, and
management.
quality of diabetes care. financial barriers, and apply that
Strategies for System-Level information to treatment deci-
Six Core Elements
Improvement sions. A
The CCM includes six core elements
Optimal diabetes management re- • Patients should be referred to local
to optimize the care of patients with
chronic disease: quires an organized, systematic ap- community resources when avail-
1. Delivery system design (moving
proach and the involvement of a co- able. B
from a reactive to a proactive care ordinated team of dedicated health • Patients should be provided with
delivery system where planned care professionals working in an en- self-management support from
visits are coordinated through a vironment where patient-centered, lay health coaches, navigators, or
team-based approach) high-quality care is a priority. Three community health workers when
2. Self-management support objectives to achieve this include: available. A
3. Decision support (basing care 1. Optimizing provider and team
CLASSIFICATION AND
on evidence-based, effective care behavior
DIAGNOSIS OF DIABETES
guidelines) 2. Supporting patient self-manage-
Diabetes can be classified into the fol-
4. Clinical information systems ment
lowing general categories:
(using registries that can provide 3. Changing the care system
1. Type 1 diabetes (due to auto-
patient-specific and popula- Tailoring Treatment to Reduce immune β-cell destruction,
tion-based support to the care Disparities usually leading to absolute insu-
team)
Social determinants of health can be lin deficiency)
5. Community resources and pol-
defined as the economic, environmen- 2. Type 2 diabetes (due to a pro-
icies (identifying or developing
tal, political, and social conditions in gressive loss of β-cell insulin
resources to support healthy
lifestyles) which people live and are responsible secretion frequently on the back-
6. Health systems (to create a qual-
for a major part of health inequality ground of insulin resistance)
ity-oriented culture) worldwide. Given the tremendous 3. Gestational diabetes mellitus
burden that obesity, unhealthy eat- (GDM) (diabetes diagnosed in
Redefining the roles of the health ing, physical inactivity, and smoking the second or third trimester
care delivery team and empowering place on the health of patients with of pregnancy that is not clearly
patient self-management are funda- diabetes, efforts are needed to address overt diabetes prior to gestation)

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TABLE 2. Criteria for Testing for Diabetes or Prediabetes in

The American Diabetes Association
Asymptomatic Adults
Risk Test is an additional option for
screening.
1. Testing should be considered in overweight or obese (BMI ≥25 kg/m2
or ≥23 kg/m2 in Asian Americans) adults who have one or more of the COMPREHENSIVE
following risk factors: MEDICAL EVALUATION
• A1C ≥5.7% (39 mmol/mol), impaired glucose tolerance, or impaired AND ASSESSMENT OF
fasting glucose on previous testing COMORBIDITIES
• First-degree relative with diabetes The comprehensive medical evalua-
• High-risk race/ethnicity (e.g., African American, Latino, Native tion includes the initial and ongoing
American, Asian American, Pacific Islander) evaluations, assessment of complica-
• Women who were diagnosed with GDM
tions, management of comorbid con-
ditions, and engagement of the pa-
• History of CVD
tient throughout the process. People
• Hypertension (≥140/90 mmHg or on therapy for hypertension) with diabetes should receive health
• HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglycer- care from a team that may include

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ide level >250 mg/dL (2.82 mmol/L) physicians, nurse practitioners, physi-
• Women with polycystic ovary syndrome cian assistants, nurses, dietitians, exer-
• Physical inactivity
cise specialists, pharmacists, dentists,
podiatrists, and mental health pro-
• Other clinical conditions associated with insulin resistance (e.g.,
severe obesity, acanthosis nigricans)
fessionals. Individuals with diabetes
must assume an active role in their
2. For all patients, testing should begin at age 45 years. care. The patient, family, physician,
3. If results are normal, testing should be repeated at a minimum of 3-year and health care team should formu-
intervals, with consideration of more frequent testing depending on late the management plan, which in-
initial results (e.g., those with prediabetes should be tested yearly) and
risk status.
cludes lifestyle management.
Lifestyle management and psy-
TABLE 3. Referrals for Initial Care Management chosocial care are the cornerstones of
diabetes management. Patients should
• Eye care professional for annual dilated eye exam
be referred for diabetes self-manage-
• Family planning for women of reproductive age ment education (DSME), diabetes
• Registered dietitian for MNT self-management support (DSMS),
• DSME and DSMS medical nutrition therapy (MNT),
• Dentist for comprehensive dental and periodontal examination
and psychosocial/emotional health
concerns if indicated. Additional
• Mental health professional, if indicated referrals should be arranged as neces-
sary (Table 3). Patients should receive
4. Other specific types, including Type 2 Diabetes and
recommended preventive care ser-
monogenic forms of diabetes Prediabetes
vices (e.g., immunizations and cancer
Diagnostic Tests for Diabetes Recommendations screening); smoking cessation coun-
Diabetes may be diagnosed based on • Screening to assess prediabetes seling; and ophthalmological, dental,
and risk for future diabetes with and podiatric referrals. Clinicians
plasma glucose criteria—either the
an informal assessment of risk should ensure that individuals with
fasting plasma glucose (FPG) or the diabetes are appropriately screened
2-h plasma glucose value after a 75-g factors or validated tools should
be considered in asymptomatic for complications and comorbidities.
oral glucose tolerance test (OGTT)
adults. B Comprehensive Medical
—or A1C (Table 1).
• To test for prediabetes, FPG, Evaluation
The same tests are used to screen OGTT, and A1C are equally The components of the comprehen-
for and diagnose diabetes and to appropriate. B sive diabetes medical evaluation are
detect individuals with prediabetes • Testing for prediabetes and type 2 listed in Table 4.
(Table 2). Prediabetes is defined as diabetes should be considered in Recommendations
FPG of 100–125 mg/dL (5.6–6.9 children and adolescents who are A complete medical evaluation should
mmol/L); 2-h OGTT of 140–199 overweight or obese and who have be performed at the initial visit to
mg/dL (7.8–11.0 mmol/L); or A1C two or more additional risk factors • Confirm the diagnosis and classify
of 5.7–6.4% (39–47 mmol/mol). for diabetes. E diabetes. B

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TABLE 4. Components of the Comprehensive Diabetes Medical Evaluation*

Medical history
• Age and characteristics of onset of diabetes (e.g., diabetic ketoacidosis [DKA], asymptomatic laboratory finding)
• Eating patterns, nutritional status, weight history, sleep behaviors (pattern and duration), and physical activity
habits; nutrition education and behavioral support history and needs
• Complementary and alternative medicine use
• Presence of common comorbidities and dental disease
• Screen for depression, anxiety, and disordered eating using validated and appropriate measures**
• Screen for diabetes distress using validated and appropriate measures**
• Screen for psychosocial problems and other barriers to diabetes self-management such as limited financial,
logistical, and support resources
• History of tobacco use, alcohol consumption, and substance use
• DSME and DSMS history and needs

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• Review of previous treatment regimens and response to therapy (A1C records)
• Assess medication-taking behaviors and barriers to medication adherence
• Results of glucose monitoring and patient’s use of data
• DKA frequency, severity, and cause
• Hypoglycemia episodes, awareness, frequency, and causes
• History of increased blood pressure and abnormal lipids
• Microvascular complications: retinopathy, nephropathy, and neuropathy (sensory, including history of foot
lesions; autonomic, including sexual dysfunction and gastroparesis)
• Macrovascular complications: coronary heart disease, cerebrovascular disease, and peripheral arterial disease
• For women with child-bearing capacity, review contraception and preconception planning
Physical examination
• Height, weight, and BMI; growth and pubertal development in children and adolescents
• Blood pressure determination, including orthostatic measurements when indicated
• Fundoscopic examination
• Thyroid palpation
• Skin examination (e.g., for acanthosis nigricans and insulin injection or infusion set insertion sites)
• Comprehensive foot examination:
❍❍ Inspection
❍❍ Palpation of dorsalis pedis and posterior tibial pulses
❍❍ Presence/absence of patellar and Achilles reflexes
❍❍ Determination of proprioception, vibration, and monofilament sensation
Laboratory evaluation
• A1C, if results not available within the past 3 months
• If not performed/available within the past year:
❍❍ Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides, as needed
❍❍ Liver function tests
❍❍ Spot urinary albumin–to–creatinine ratio
❍❍ Serum creatinine and eGFR
❍❍ Thyroid-stimulating hormone in patients with type 1 diabetes
*The comprehensive medical evaluation should all ideally be done on the initial visit, but if time is limited different
components can be done as appropriate on follow-up visits.
**Refer to the ADA position statement “Psychochsocial Care for People With Diabetes” for additional details on
diabetes-specific screening measures.

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• Detect diabetes complications and thyroid disease and celiac disease (relative risk 1.7) diabetes in both
potential comorbid conditions. E soon after diagnosis. E sexes. Type 1 diabetes is associated
• Review previous treatment and with osteoporosis, but in type 2 dia-
Cancer
risk factor control in patients with betes, an increased risk of hip fracture
Diabetes is associated with increased
established diabetes. E is seen despite higher bone mineral
risk of cancers of the liver, pancreas,
• Begin patient engagement in the endometrium, colon/rectum, breast, density.
formulation of a care management and bladder. The association may re- Hearing Impairment
plan. B sult from shared risk factors between Hearing impairment, both in high-
• Develop a plan for continuing diabetes and cancer (older age, obesi- frequency and low- to mid-frequen-
care. B ty, and physical inactivity) or diabe- cy ranges, is more common in peo-
Immunization tes-related factors such as underlying ple with diabetes than in those with-
disease physiology or diabetes treat- out, perhaps due to neuropathy and/
Recommendations ments, although evidence for these or vascular disease.
• Provide routine vaccinations for links is scarce. Patients with diabetes
children and adults with diabetes should be encouraged to undergo rec- Low Testosterone in Men
according to age-related recom- Mean levels of testosterone are lower

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ommended age- and sex-appropriate
mendations. C cancer screenings and to reduce their in men with diabetes compared with
• Annual vaccination against influ- modifiable cancer risk factors (obesity, age-matched men without diabetes,
enza is recommended for all physical inactivity, and smoking). but obesity is a major confounder.
people with diabetes ≥6 months Treatment in asymptomatic men is
Cognitive Impairment/ controversial. The evidence that tes-
of age. C Dementia
• Vaccination against pneumonia is tosterone replacement affects out-
Diabetes is associated with a signifi- comes is mixed, and recent guidelines
recommended for all people with cantly increased risk and rate of cog-
diabetes who are 2–64 years of age do not recommend testing or treating
nitive decline and an increased risk men without symptoms.
with pneumococcal polysaccha- of dementia. In a 15-year prospective
ride vaccine (PPSV23). At age ≥65 study of community-dwelling peo- Obstructive Sleep Apnea
years, administer the pneumococ- ple >60 years of age, the presence Age-adjusted rates of obstructive sleep
cal conjugate vaccine (PCV13) at of diabetes at baseline significantly apnea, a risk factor for cardiovascu-
least 1 year after vaccination with increased the age- and sex-adjust- lar disease (CVD), are significantly
PPSV23, followed by another dose ed incidence of all-cause dementia, higher (4- to 10-fold) with obesity,
of vaccine PPSV23 at least 1 year Alzheimer’s disease, and vascular de- and especially with central obesity.
after PCV13 and at least 5 years mentia compared with rates in those The prevalence of obstructive sleep
after the last dose of PPSV23. C with normal glucose tolerance. apnea in the population with type 2
• Administer three-dose series of diabetes may be as high as 23%, and
Fatty Liver Disease the prevalence of any sleep disordered
hepatitis B vaccine to unvacci-
Elevations of hepatic transaminase breathing may be as high as 58%.
nated adults with diabetes who
concentrations are associated with
are aged 19–59 years. C higher BMI, waist circumference, Periodontal Disease
• Consider administering three- and triglyceride levels and lower Periodontal disease is more severe
dose series of hepatitis B vaccine to HDL cholesterol levels. In a prospec- and may be more prevalent in people
unvaccinated adults with diabetes tive analysis, diabetes was significantly with diabetes than in those without.
who are ≥60 years of age. C associated with incident nonalcoholic Current evidence suggests that peri-
Comorbidities chronic liver disease and with hepato- odontal disease adversely affects di-
Besides assessing diabetes-related cellular carcinoma. Interventions that abetes outcomes, although evidence
complications, clinicians and their improve metabolic abnormalities in for treatment benefits on diabetes
patients need to be aware of com- patients with diabetes (weight loss, control remains unclear.
mon comorbidities that affect people glycemic control, and treatment with Psychosocial Disorders
with diabetes and may complicate specific drugs for hyperglycemia or Prevalence of clinically significant
management. dyslipidemia) are also beneficial for psychopathology in people with di-
fatty liver disease.
Autoimmune Diseases
abetes ranges across diagnostic cate-
Fractures gories, and some diagnoses are con-
Recommendations Age-specific hip fracture risk is signifi- siderably more common in people
• Consider screening patients with cantly increased in people with both with diabetes than for those without
type 1 diabetes for autoimmune type 1 (relative risk 6.3) and type 2 the disease. Symptoms, both clinical

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and subclinical, that interfere with a in conjunction with collaborative self-management, both at diagno-
person’s ability to carry out diabetes care with the patient’s diabetes sis and as needed thereafter. B
self-management must be addressed. treatment team. A • Effective self-management and
Diabetes distress is very common and improved clinical outcomes,
distinct from a psychological disorder. Disordered Eating Behavior
health status, and quality of
Anxiety Disorders Recommendations life are key goals of DSME and
• Providers should consider reeval- DSMS that should be measured
Recommendations uating the treatment regimen of and monitored as part of routine
• Consider screening for anxiety people with diabetes who present care. C
in people exhibiting anxiety or with symptoms of disordered eat- • DSME and DSMS should be
worries regarding diabetes com- ing behavior, an eating disorder, patient-centered, respectful, and
plications, insulin injections or or disrupted patterns of eating. B responsive to individual patient
infusion, taking medications, • Consider screening for disor- preferences, needs, and values
and/or hypoglycemia that interfere dered or disrupted eating using
with self-management behaviors and should help guide clinical
validated screening measures decisions. A
and those who express fear, dread, when hyperglycemia and weight

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or irrational thoughts and/or show • DSME and DSMS programs
loss are unexplained based on have the necessary elements in
anxiety symptoms such as avoid-
self-reported behaviors related to their curricula to delay or prevent
ance behaviors, excessive repetitive
medication dosing, meal plan, the development of type 2 diabe-
behaviors, or social withdrawal.
Refer for treatment if anxiety is and physical activity. In addition, tes. DSME and DSMS programs
present. B a review of the medical regimen is should therefore be able to tailor
• People with hypoglycemic recommended to identify poten- their content when prevention of
unawareness, which can co-occur tial treatment-related effects on diabetes is the desired goal. B
with fear of hypoglycemia, should hunger/caloric intake. B • Because DSME and DSMS can
be treated using Blood Glucose Serious Mental Illness improve outcomes and reduce
Awareness Training (or another costs B , DSME and DSMS
similar evidence-based interven- Recommendations
should be adequately reimbursed
tion) to help re-establish awareness • Annually screen people who are by third-party payers. E
of hypoglycemia and reduce fear prescribed atypical antipsychotic
of hyperglycemia. A medications for prediabetes or The overall objectives of DSME
diabetes. B and DSMS are to support informed
Depression • Incorporate monitoring of diabetes decision-making, self-care behaviors,
Recommendations self-care activities into treatment problem-solving, and active collabo-
• Providers should consider annual goals in people with diabetes and ration with the health care team to
screening of all patients with serious mental illness. B improve clinical outcomes, health
diabetes, especially those with a status, and quality of life in a cost-
LIFESTYLE MANAGEMENT
self-reported history of depres- effective manner.
Lifestyle management is a funda-
sion, for depressive symptoms Four critical time points have
with age-appropriate depression mental aspect of diabetes care and in-
cludes DSME and DSMS, nutrition, been defined when the need for
screening measures, recognizing DSME and DSMS should be eval-
that further evaluation will be physical activity, smoking cessation,
and psychosocial care. uated by the medical care provider
necessary for individuals who have
and/or multidisciplinary team, with
a positive screen. B DSME and DSMS
• Beginning at diagnosis of com- referrals made as needed:
Recommendations 1. At diagnosis
plications or when there are
significant changes in medical • In accordance with the national 2. Annually for assessment of edu-
status, consider assessment for standards for DSME and DSMS, cation, nutrition, and emotional
depression. B all people with diabetes should needs
• Referrals for treatment of depres- participate in DSME to facilitate 3. When new complicating factors
sion should be made to mental the knowledge, skills, and ability (health conditions, physical lim-
health providers with experience necessary for diabetes self-care itations, emotional factors, or
using cognitive behavioral therapy, and in DSMS to assist with imple- basic living needs) arise that influ-
interpersonal therapy, or other evi- menting and sustaining skills and ence self-management
dence-based treatment approaches behaviors needed for ongoing 4. When transitions in care occur

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TABLE 5. MNT Recommendations

Topic Recommendations Evidence Rating
Effectiveness of • An individualized MNT program, preferably provided by a registered A
nutrition therapy dietitian, is recommended for all people with type 1 or type 2 diabetes.
• For people with type 1 diabetes and those with type 2 diabetes who are A
prescribed a flexible insulin therapy program, education on how to use
carbohydrate counting and, in some cases, fat and protein gram
estimation to determine mealtime insulin dosing can improve glycemic
control.
• For individuals whose daily insulin dosing is fixed, having a consistent B
pattern of carbohydrate intake with respect to time and amount can
result in improved glycemic control and a reduced risk of hypoglycemia.
• A simple and effective approach to glycemia and weight management B
emphasizing portion control and healthy food choices may be more
helpful for those with type 2 diabetes who are not taking insulin, who
have limited health literacy or numeracy, or who are elderly and prone to

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hypoglycemia.
• Because diabetes nutrition therapy can result in cost savings B and B, A, E
improved outcomes (e.g., A1C reduction) A, MNT should be adequately
reimbursed by insurance and other payers. E
Energy balance • Modest weight loss achievable by the combination of reduction of A
caloric intake and lifestyle modification benefits overweight or
obese adults with type 2 diabetes and also those with prediabetes.
Intervention programs to facilitate this process are recommended.
Eating patterns • Because there is no single ideal dietary distribution of calories among E
and macronutrient carbohydrates, fats, and proteins for people with diabetes, macronutri-
distribution ent distribution should be individualized while keeping total caloric and
metabolic goals in mind.
• A variety of eating patterns are acceptable for the management of type B
2 diabetes and prediabetes including the Mediterranean diet, DASH,
and plant-based diets.
• Carbohydrate intake from whole grains, vegetables, fruits, legumes, and B
dairy products, with an emphasis on foods higher in fiber and lower in
glycemic load, should be advised over other sources, especially those
containing sugars.
• People with diabetes and those at risk should avoid sugar-sweetened B, A
beverages to control weight and reduce their risk for CVD and fatty liver
disease B and should minimize their consumption of foods with added
sugar that have the capacity to displace healthier, more nutrient-dense
food choices. A
Protein • In individuals with type 2 diabetes, ingested protein appears to increase B
insulin response without increasing plasma glucose concentrations.
Therefore, carbohydrate sources high in protein should not be used to
treat or prevent hypoglycemia.
Dietary fat • Whereas data on the ideal total dietary fat content for people with B
diabetes are inconclusive, an eating plan emphasizing elements of a
Mediterranean-style diet rich in monounsaturated fats may improve
glucose metabolism and lower CVD risk and can be an effective
alternative to a diet low in total fat but relatively high in carbohydrates.
• Eating foods rich in long-chain ω-3 fatty acids, such as fatty fish (EPA B, A
and DHA) and nuts and seeds (ALA) is recommended to prevent or treat
CVD B; however, evidence does not support a beneficial role for ω-3
dietary supplements. A

TABLE CONTINUED ON P. 12 →

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TABLE 5. MNT Recommendations,

TABLE continued from p. 11
5. MNT Recommendations
Topic Recommendations Evidence Rating
Micronutrients • There is no clear evidence that dietary supplementation with vitamins, C
and herbal minerals, herbs, or spices can improve outcomes in people with
supplements diabetes who do not have underlying deficiencies, and there may
be safety concerns regarding the long-term use of antioxidant
supplements such as vitamins E and C and carotene.
Alcohol • Adults with diabetes who drink alcohol should do so in moderation C
(no more than one drink per day for adult women and no more than
two drinks per day for adult men).
• Alcohol consumption may place people with diabetes at increased B
risk for hypoglycemia, especially if they are taking insulin or insulin
secretagogues. Education and awareness regarding the recognition
and management of delayed hypoglycemia are warranted.
Sodium • As for the general population, people with diabetes should limit sodium B
consumption to <2,300 mg/day, although further restriction may be

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indicated for those with both diabetes and hypertension.
Nonnutritive • The use of nonnutritive sweeteners has the potential to reduce overall B
Sweeteners caloric and carbohydrate intake if substituted for caloric sweeteners and
without compensation by intake of additional calories from other food
sources. Nonnutritive sweeteners are generally safe to use within the
defined acceptable daily intake levels.

Nutrition Therapy diabetes should engage in 60 times/week for older adults with
For many individuals with diabe- min/day or more of moderate or diabetes. Yoga and tai chi may
tes, the most challenging part of the vigorous intensity aerobic activity, be included based on individual
treatment plan is determining what with vigorous, muscle-strength- preferences to increase flexibility,
to eat and following a food plan. ening, and bone-strengthening muscular strength, and balance. C
There is not a one-size-fits-all eating activities included at least 3 days/
pattern for individuals with diabe- Exercise in the Presence
week. C
tes. The Mediterranean diet, Dietary • Most adults with with type 1 C or of Specific Long-Term
Approaches to Stop Hypertension type 2 B diabetes should engage Complications of Diabetes
(DASH) diet, and plant-based diets in 150 min or more of moder- Retinopathy
are all examples of healthful eating ate-to-vigorous intensity activity If proliferative diabetic retinopathy or
patterns. See Table 5 for specific nu- per week, spread over at least 3 severe nonproliferative diabetic reti-
trition recommendations. days/week, with no more than 2 nopathy is present, then vigorous-in-
In overweight and obese patients consecutive days without activity. tensity aerobic or resistance exercise
with type 2 diabetes, modest weight Shorter durations (minimum 75 may be contraindicated because of the
loss, defined as sustained reduc- min/week) of vigorous-intensity or risk of triggering vitreous hemorrhage
tion of 5% of initial body weight, interval training may be sufficient or retinal detachment. Consultation
has been shown to improve glyce- for younger and more physically with an ophthalmologist prior to en-
mic control and to reduce the need fit individuals. gaging in an intense exercise regimen
for glucose-lowering medications. • Adults with type 1 C or type 2 may be appropriate.
However, sustaining weight loss can B diabetes should engage in 2−3
be challenging. Weight loss can be sessions/week of resistance exercise Peripheral Neuropathy
attained with lifestyle programs that on nonconsecutive days. Decreased pain sensation and a high-
achieve a 500–750 kcal/day energy • All adults, and particularly those er pain threshold in the extremities
deficit or provide ~1,200–1,500 with type 2 diabetes, should result in an increased risk of skin
kcal/day for women and 1,500–1,800 decrease the amount of time spent breakdown, infection, and Charcot
kcal/day for men, adjusted for the in daily sedentary behavior. B joint destruction with some forms of
individual’s baseline body weight. Prolonged sitting should be inter- exercise. Therefore, a thorough assess-
rupted every 30 min for blood ment should be done to ensure that
Physical Activity
glucose benefits, particularly in neuropathy does not alter kinesthetic
Recommendations adults with type 2 diabetes. C or proprioceptive sensation during
• Children and adolescents with • Flexibility training and balance physical activity, particularly in those
type 1 or type 2 diabetes or pre- training are recommended 2−3 with more severe neuropathy.

12 CLINICAL.DIABETESJOURNALS.ORG
 a b r i d g e d s ta n d a r d s o f c a r e 2 0 1 7

Smoking Cessation: Tobacco be referred to an intensive behav- insulin or insulin pump therapy)
and e-Cigarettes ioral lifestyle intervention program should perform SMBG prior to
modelled on the Diabetes Pre- meals and snacks, at bedtime,
Recommendations
vention Program to achieve and occasionally postprandially, prior
• Advise all patients not to use ciga-
maintain 7% loss of initial body to exercise, when they suspect low
rettes and other tobacco products
weight and increase moderate-in- blood glucose, after treating low
A or e-cigarettes. E
tensity physical activity (such as blood glucose until they are nor-
• Include smoking cessation brisk walking) to at least 150 min/
counseling and other forms of moglycemic, and prior to critical
week. A tasks such as driving. B
treatment as a routine component • Metformin therapy for prevention
of diabetes care. B of type 2 diabetes should be con- SMBG allows patients to evaluate
Psychosocial Issues sidered in those with prediabetes, their individual responses to therapy
especially for those with a BMI and assess whether glycemic targets
Recommendations ≥35 kg/m 2 , those <60 years of are being achieved. Results of SMBG
• Psychosocial care should be age, and women with prior GDM, can be useful in preventing hypogly-
integrated with a collaborative, and/or those with rising A1C cemia and adjusting medications

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patient-centered approach and despite lifestyle intervention. A
provided to all people with diabe- (particularly prandial insulin doses),
• Screening for and treatment of MNT, and physical activity. Evidence
tes, with the goals of optimizing modifiable risk factors for CVD
health outcomes and health-re- also supports a correlation between
is suggested for those with predi- SMBG frequency and meeting A1C
lated quality of life. A abetes. B
• Psychosocial screening and fol- targets.
low-up may include, but are not Intensive lifestyle modification pro- SMBG accuracy is instrument-
limited to, attitudes about the grams have been shown to be very and user-dependent. Evaluate each
illness, expectations for medi- effective (∼58% risk reduction after patient’s monitoring technique, both
cal management and outcomes, 3 years). In addition, pharmacologic initially and at regular intervals
affect or mood, general and diabe- agents including metformin, α-glu- thereafter. The ongoing need for and
tes-related quality of life, available cosidase inhibitors, orlistat, gluca- frequency of SMBG should be reeval-
resources (financial, social, and gon-like peptide 1 (GLP-1) receptor uated at each routine visit.
emotional), and psychiatric his- agonists, and thiazolidinediones have A1C Testing
tory. E been shown to decrease incident dia-
• Providers should consider assess- betes to various degrees. Metformin Recommendations
ment for symptoms of diabetes has demonstrated long-term safety as • Perform the A1C test at least two
distress, depression, anxiety, and pharmacologic therapy for diabetes times a year in patients who are
disordered eating, as well as cog- prevention. meeting treatment goals (and who
nitive capacities, using patient- GLYCEMIC TARGETS have stable glycemic control). E
appropriate standardized and val- • Perform the A1C test quarterly
idated tools at the initial visit, at Assessment of Glycemic in patients whose therapy has
periodic intervals, and when there Control changed or who are not meeting
is a change in disease, treatment, Self-monitoring of blood glucose glycemic goals. E
or life circumstances. Including (SMBG) frequency and timing • Point-of-care testing for A1C pro-
caregivers and family members in should be dictated by patients’ spe- vides the opportunity for more
this assessment is recommended. B cific needs and goals. SMBG is es- timely treatment changes. E
• Consider screening older adults pecially important for patients treat-
(aged ≥65 years) with diabetes for ed with insulin to monitor for and For patients in whom A1C and
cognitive impairment and depres- prevent asymptomatic hypoglycemia measured blood glucose appear dis-
sion. B and hyperglycemia. For patients on crepant, clinicians should consider
nonintensive insulin regimens such as the possibilities of hemoglobinopathy
PREVENTION OR DELAY OF those with type 2 diabetes using bas- or altered red blood cell turnover and
TYPE 2 DIABETES al insulin, when to prescribe SMBG the options of more frequent and/or
Recommendations
and at what testing frequency are less different timing of SMBG or con-
• At least annual monitoring for the established. tinuous glucose monitoring. Other
development of diabetes in those Recommendation measures of chronic glycemia such
with prediabetes is suggested. E • Most patients using intensive as fructosamine are available, but
• Patients with prediabetes should insulin regimens (multiple-dose their linkage to average glucose and

VO LU M E 3 5 , N U M B ER 1, W I N T ER 2 017 13
P O S I T I O N S TAT E M E N T

their prognostic significance are not Approach to the Management of Hyperglycemia

as clear as for A1C. Patient / Disease Features More stringent A1C 7% Less stringent
A1C Goals Risks potentially associated
with hypoglycemia and
Recommendations other drug adverse effects low high
• A reasonable A1C goal for many
nonpregnant adults is <7% (53

Usually not modifiable

mmol/mol). A Disease duration newly diagnosed long-standing
• Providers might reasonably sug-
gest more stringent A1C goals
Life expectancy
(such as <6.5% [48 mmol/mol]) long short

for selected individual patients if

this can be achieved without sig- Relevant comorbidities
nificant hypoglycemia or other absent few / mild severe

adverse effects of treatment (i.e.,

Established vascular
polypharmacy). Appropriate pat-

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complications absent few / mild severe
ients might include those with a
short duration of diabetes, type 2

Potentially modifiable
diabetes treated with lifestyle or Patient attitude and highly motivated, adherent, less motivated, nonadherent,
metformin only, long life expec- expected treatment efforts excellent self-care capabilities poor self-care capabilities

tancy, or no significant CVD. C

• Less stringent A1C goals (such Resources and support
system
as <8% [64 mmol/mol]) may be readily available limited

appropriate for patients with a ■ FIGURE 1. Depicted are patient and disease factors used to determine optimal
history of severe hypoglycemia, A1C targets. Characteristics and predicaments toward the left justify more stringent
limited life expectancy, advanced efforts to lower A1C; those toward the right suggest less stringent efforts. Adapted
microvascular or macrovascular with permission from Inzucchi et al. Diabetes Care 2015;38:140–149.
complications, extensive comor-
bid conditions, or long-standing levels that appear to correlate with • Glucagon should be prescribed
diabetes in whom the goal is dif- achievement of an A1C of ≤7% for all individuals at increased
ficult to achieve despite DSME, (53 mmol/mol). risk of clinically significant hypo-
appropriate glucose monitoring, glycemia, defined as blood glucose
Hypoglycemia
and effective doses of multiple <54 mg/dL (3.0 mmol/L), so it is
The 2017 Standards of Care provides
glucose-lowering agents, including available should it be needed.
a new classification of hypoglycemia.
insulin. B Caregivers, school personnel, or
Recommendations family members of these individ-
The complete 2017 Standards of • Individuals at risk for hypogly- uals should know where it is and
Care includes additional goals for cemia should be asked about when and how to administer it.
children and pregnant women. symptomatic and asymptomatic The use of glucagon is indicated
Glycemic control achieved using hypoglycemia at each encounter. for the treatment of hypoglycemia
A1C targets of <7% (53 mmol/mol) C in people unable or unwilling to
has been shown to reduce micro- • Glucose (15–20 g) is the pre- consume carbohydrates by mouth.
vascular complications of diabetes, ferred treatment for conscious Glucagon administration is not
and, in type 1 diabetes, mortality. individuals with hypoglycemia limited to health care profession-
There is evidence for cardiovascular (glucose alert value of ≤70 mg/dL), als. E
benefit of intensive glycemic control although any form of carbohy- • Hypoglycemia unawareness or
after long-term follow-up of people drate that contains glucose may one or more episodes of severe
treated early in the course of type 1 be used. Fifteen minutes after hypoglycemia should trigger
and type 2 diabetes; however, optimal treatment, if SMBG shows contin- reevaluation of the treatment reg-
A1C targets should be individualized ued hypoglycemia, the treatment imen. E
based on several patient-specific and should be repeated. Once SMBG • Insulin-treated patients with
disease-specific factors (Figure 1). returns to normal, the individual hypoglycemia unawareness or an
Recommended glycemic targets are should consume a meal or snack episode of clinically significant
provided in Table 6. The recom- to prevent recurrence of hypogly- hypoglycemia should be advised
mendations include blood glucose cemia. E to raise their glycemic targets to

14 CLINICAL.DIABETESJOURNALS.ORG
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TABLE 6. Summary of Glycemic Recommendations for Many Nonpregnant Adults With Diabetes
A1C <7.0% (53 mmol/mol)*
Preprandial capillary plasma glucose 80–130 mg/dL* (4.4–7.2 mmol/L)
Peak postprandial capillary plasma glucose† <180 mg/dL* (10.0 mmol/L)
*More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized
based on duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular com-
plications, hypoglycemia unawareness, and individual patient considerations. †Postprandial glucose may be targeted
if A1C goals are not met despite reaching preprandial glucose goals. Postprandial glucose measurements should be
made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.

strictly avoid hypoglycemia for Diet, Physical Activity, and monitoring. To maintain weight
at least several weeks to partially Behavioral Therapy loss, such programs must incor-
reverse hypoglycemia unawareness porate long-term comprehensive
Recommendations
and reduce the risk of future epi- weight maintenance counseling. B
• Diet, physical activity, and behav-
sodes. A

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ioral therapy designed to achieve Pharmacotherapy
• Ongoing assessment of cogni- >5% weight loss should be pre-
tive function is suggested with Recommendations
scribed for overweight and obese
increased vigilance for hypoglyce- • When choosing glucose-lowering
patients with type 2 diabetes ready medications for overweight or
mia by the clinician, patient, and to achieve weight loss. A
caregivers if low cognition and/or obese patients with type 2 diabe-
• Such interventions should be tes, consider their effect on weight.
declining cognition is found. B high intensity (≥16 sessions in E
OBESITY MANAGEMENT FOR 6 months) and focus on diet, • Whenever possible, minimize the
THE TREATMENT OF TYPE 2
physical activity, and behavioral medications for comorbid con-
DIABETES
strategies to achieve a 500–750 ditions that are associated with
kcal/day energy deficit. A weight gain. E
Obesity management can delay pro-
• Diets should be individualized; • Weight loss medications may
gression from prediabetes to type 2
eating patterns that provide the be effective as adjuncts to diet,
diabetes and may be beneficial in the
same caloric restriction but differ physical activity, and behavioral
treatment of type 2 diabetes. In over- in protein, carbohydrate, and fat
weight and obese patients with type 2 counseling for selected patients
content are equally effective in with type 2 diabetes and a BMI
diabetes, modest and sustained weight achieving weight loss. A
loss has been shown to improve gly- ≥27 kg/m2. Potential benefits must
• For patients who achieve short- be weighed against the potential
cemic control and to reduce the need term weight loss goals, long-term risks of the medications. A
for glucose-lowering medications. (≥1-year) comprehensive weight • If a patient’s response to weight
Assessment maintenance programs should be loss medications is <5% weight
prescribed. Such programs should loss after 3 months or if there are
Recommendation provide at least monthly contact any safety or tolerability issues at
• At each patient encounter, BMI and encourage ongoing moni- any time, the medication should
should be calculated and docu- toring of body weight (weekly be discontinued and alterna-
mented in the medical record. B or more frequently), continued tive medications or treatment
consumption of a reduced-calorie approaches should be considered.
In Asian Americans, the BMI diet, and participation in high lev- A
cutoff points to define overweight els of physical activity (200–300
and obesity are lower than in other min/week). A Metabolic Surgery
populations. • To achieve weight loss of >5%, Recommendations
Providers should advise over- short-term (3-month) high-in- • Metabolic surgery should be rec-
weight and obese patients that higher tensity lifestyle interventions ommended to treat type 2 diabetes
BMIs increase the risk of CVD and that use very-low-calorie diets in appropriate surgical candidates
all-cause mortality. (≤800 kcal/day) or total meal with a BMI ≥40 kg/m 2 (BMI
Providers should assess each replacements may be prescribed ≥37.5 kg/m2 in Asian Americans)
patient’s readiness to achieve weight for carefully selected patients by regardless of the level of glycemic
loss and jointly determine weight loss trained practitioners in medical control or complexity of glu-
goals and intervention strategies. care settings with close medical cose-lowering regimens and in

VO LU M E 3 5 , N U M B ER 1, W I N T ER 2 017 15
P O S I T I O N S TAT E M E N T

adults with a BMI of 35.0–39.9 metabolic surgery has been shown to agents) in patients with newly
kg/m2 (32.5–37.4 kg/m2 in Asian confer additional health benefits in diagnosed type 2 diabetes who
Americans) when hyperglycemia randomized controlled trials, includ- are symptomatic and/or have an
is inadequately controlled despite ing greater reductions in CVD risk A1C ≥10% (86 mmol/mol) and/or
lifestyle and optimal medical ther- factors and enhancements in quality blood glucose levels ≥300 mg/dL
apy. A of life. (16.7 mmol/L). E
• Metabolic surgery should be con- • If noninsulin monotherapy at
PHARMACOLOGIC maximum tolerated dose does not
sidered for adults with type 2
APPROACHES TO achieve or maintain the A1C tar-
diabetes and a BMI of 30.0–34.9
GLYCEMIC TREATMENT get after 3 months, add a second
kg/m2 (27.5–32.4 kg/m2 in Asian
Americans) if hyperglycemia is Pharmacologic Therapy for oral agent, a GLP-1 receptor ago-
inadequately controlled despite Type 1 Diabetes nist, or basal insulin. A
optimal medical control by either • A patient-centered approach
Recommendations should be used to guide the
oral or injectable medications
(including insulin). B • Most people with type 1 diabetes choice of pharmacologic agents.
• Metabolic surgery should be per- should be treated with multiple Considerations include efficacy,

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formed in high-volume centers daily injection (MDI) therapy hypoglycemia risk, impact on
with multidisciplinary teams who including prandial and basal weight, potential side effects, cost,
understand and are experienced in insulin or continuous subcutane- and patient preferences. E
the management of diabetes and ous insulin infusion (CSII; insulin • For patients with type 2 diabetes
gastrointestinal (GI) surgery. C pump therapy). A who are not achieving glycemic
• Long-term lifestyle support and • Most individuals with type 1 goals, insulin therapy should not
routine monitoring of micronutri- diabetes should use rapid-acting be delayed. B
ent and nutritional status must be insulin analogs to reduce hypo- • In patients with long-standing
provided to patients after surgery, glycemia risk. A suboptimally controlled type 2
according to guidelines for postop- • Consider educating individuals diabetes and established athero-
erative management of metabolic with type 1 diabetes on matching sclerotic cardiovascular disease
surgery by national and interna- prandial insulin doses to carbo- (ASCVD), empaglif lozin or
tional professional societies. C hydrate intake, premeal blood liraglutide should be considered
• People presenting for metabolic glucose levels, and anticipated because they have been shown
surgery should receive a compre- physical activity. E to reduce cardiovascular and all-
hensive mental health assessment. • Individuals with type 1 diabetes cause mortality when added to
B Surgery should be postponed in who have been successfully using standard care. Ongoing studies
patients with a history of alcohol CSII should have continued access are investigating the cardiovascu-
or substance abuse, significant to this therapy after they turn 65 lar benefits of other agents in these
depression, suicidal ideation, or years of age. E drug classes. B
other mental health conditions Pharmacologic Therapy for Figure 2 and Figure 3 outline mono-
until these conditions have been Type 2 Diabetes therapy and combination therapy
fully addressed. E emphasizing drugs commonly used
• People who undergo metabolic Recommendations
• Metformin, if not contraindicated in the United States and/or Europe.
surgery should be evaluated to
assess their need for ongoing men- and if tolerated, is the preferred CVD AND RISK MANAGEMENT
tal health services to help them initial pharmacologic agent for ASCVD is the leading cause of mor-
adjust to medical and psychosocial the treatment of type 2 diabetes. bidity and mortality for individuals
changes after surgery. C A with diabetes and is the largest con-
• Long-term use of metformin may tributor to the direct and indirect
Several GI operations promote be associated with biochemical costs of diabetes. In all patients with
dramatic and durable improvement vitamin B12 deficiency, and peri- diabetes, cardiovascular risk factors
of type 2 diabetes. Younger age, odic measurement of vitamin B12 should be systematically assessed at
shorter duration of diabetes (e.g., <8 levels should be considered in met- least annually. These risk factors in-
years), nonuse of insulin, and better formin-treated patients, especially clude hypertension, dyslipidemia,
glycemic control are consistently asso- in those with anemia or peripheral smoking, family history of premature
ciated with higher rates of diabetes neuropathy. B coronary disease, and albuminuria.
remission and/or lower risk of recid- • Consider initiating insulin ther- Large benefits are seen when multiple
ivism. Beyond improving glycemia, apy (with or without additional risk factors are addressed simultane-

16 CLINICAL.DIABETESJOURNALS.ORG
 a b r i d g e d s ta n d a r d s o f c a r e 2 0 1 7

Start with Monotherapy unless:

A1C is greater than or equal to 9%, consider Dual Therapy.

A1C is greater than or equal to 10%, blood glucose is greater than or equal to 300 mg/dL,
or patient is markedly symptomatic, consider Combination Injectable Therapy (See Figure 3).

Monotherapy Metformin Lifestyle Management

EFFICACY* high
HYPO RISK low risk
WEIGHT neutral/loss
SIDE EFFECTS GI/lactic acidosis
COSTS* low
If A1C target not achieved after approximately 3 months of monotherapy, proceed to 2-drug combination (order not
meant to denote any specific preference — choice dependent on a variety of patient- & disease-specific factors):

Dual Therapy Metformin + Lifestyle Management

Sulfonylurea Thiazolidinedione DPP-4 inhibitor SGLT2 inhibitor GLP-1 receptor agonist Insulin (basal)

EFFICACY* high high intermediate intermediate high highest

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HYPO RISK moderate risk low risk low risk low risk low risk high risk
WEIGHT gain gain neutral loss loss gain
SIDE EFFECTS hypoglycemia edema, HF, fxs rare GU, dehydration, fxs GI hypoglycemia
COSTS* low low high high high high

If A1C target not achieved after approximately 3 months of dual therapy, proceed to 3-drug combination (order not
meant to denote any specific preference — choice dependent on a variety of patient- & disease-specific factors):

Triple Therapy Metformin + Lifestyle Management

Sulfonylurea + Thiazolidinedione + DPP-4 inhibitor + SGLT2 inhibitor + GLP-1 receptor agonist + Insulin (basal) +

TZD SU SU SU SU TZD

or DPP-4-i or DPP-4-i or TZD or TZD or TZD or DPP-4-i

or SGLT2-i or SGLT2-i or SGLT2-i or DPP-4-i or SGLT2-i or SGLT2-i

or GLP-1-RA or GLP-1-RA or Insulin§ or GLP-1-RA or Insulin§ or GLP-1-RA

or Insulin§ or Insulin§ or Insulin§

If A1C target not achieved after approximately 3 months of triple therapy and patient (1) on oral combination, move to
basal insulin or GLP-1 RA, (2) on GLP-1 RA, add basal insulin or (3) on optimally titrated basal insulin, add GLP-1 RA or
mealtime insulin. Metformin therapy should be maintained, while other oral agents may be discontinued on an individual
basis to avoid unnecessarily complex or costly regimens (i.e. adding a fourth antihyperglycemic agent).

Combination Injectable Therapy (See Figure 3)

■ FIGURE 2. Antihyperglycemic therapy in type 2 diabetes: general recommendations. The order in the chart was determined
by historical availability and the route of administration, with injectables to the right; it is not meant to denote any specific pref-
erence. Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, with the usual transition
moving vertically from top to bottom (although horizontal movement within therapy stages is also possible, depending on the
circumstances). DPP-4-i, DPP-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1 RA, GLP-1 receptor agonist; GU, geni-
tourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, SGLT2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione. *See
original source for description of efficacy categorization. §Usually a basal insulin (NPH, glargine, detemir, degludec). Adapted
with permission from Inzucchi et al. Diabetes Care 2015;38:140–149.

ously. There is evidence that measures pressure confirmed on a separate • Patients with confirmed office-
of 10-year coronary heart disease risk day. B based blood pressure >140/90
among U.S. adults with diabetes have • Most patients with diabetes and mmHg should, in addition to
improved significantly over the past hypertension should be treated to lifestyle therapy, have prompt
decade and that ASCVD morbidity a systolic blood pressure goal of initiation and timely titration of
and mortality have decreased. <140 mmHg and a diastolic blood pharmacologic therapy to achieve
pressure goal of 90 mmHg. A
Blood Pressure Control
• Lower systolic and diastolic blood blood pressure goals. A
Recommendations pressure targets, such as 130/80 • Patients with confirmed office-
• Blood pressure should be mea- mmHg, may be appropriate for based blood pressure >160/100
sured at every routine visit. individuals at high risk of CVD mmHg should, in addition to
Patients found to have elevated if they can be achieved without lifestyle therapy, have prompt ini-
blood pressure should have blood undue treatment burden. C tiation and timely titration of two

VO LU M E 3 5 , N U M B ER 1, W I N T ER 2 017 17
P O S I T I O N S TAT E M E N T

monitor the response to therapy

Initiate Basal Insulin
Usually with metformin +/- other noninsulin agent
and inform adherence. E
• Lifestyle modification focusing on
Start: 10 U/day or 0.1–0.2 U/kg/day
Adjust: 10–15% or 2–4 units once or twice weekly to reach FBG target weight loss (if indicated); reduc-
For hypo: Determine & address cause; if no clear reason for hypo, tion of saturated fat, trans fat,
ê dose by 4 units or 10–20%
and cholesterol intake; increase
If A1C not controlled, consider
combination injectable therapy
in omega-3 fatty acids, viscous
fiber, and plant stanols/sterols
intake; and increase in physical
Add 1 rapid-acting Change to premixed activity should be recommended
insulin injection before Add GLP-1 RA insulin twice daily (before
largest meal breakfast and supper) to improve the lipid profile in
Start: 4 units, 0.1 U/kg, or 10% If not tolerated or A1C Start: Divide current basal dose
patients with diabetes. A
basal dose. If A1C <8%, consider
ê basal by same amount
target not reached,
change to 2 injection
into ⅔ AM, ⅓ PM or ½ AM, ½ PM
Adjust: é dose by 1–2 units or
• Intensify lifestyle therapy and
Adjust: é dose by 1–2 units or insulin regimen 10–15% once or twice weekly optimize glycemic control for
10–15% once or twice weekly until SMBG target reached
until SMBG target reached
If goals not met, consider For hypo: Determine and patients with elevated triglyceride
For hypo: Determine and address cause; if no clear reason
levels (≥150 mg/dL [1.7 mmol/L])

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changing to alternative
address cause; if no clear reason insulin regimen for hypo, ê corresponding dose
for hypo, ê corresponding dose
by 2–4 units or 10–20%
by 2–4 units or 10–20%
and/or low HDL cholesterol (<40
If A1C not controlled, If A1C not controlled,
mg/dL [1.0 mmol/L] for men, <50
advance to basal-bolus advance to 3rd injection mg/dL [1.3 mmol/L] for women).
C
Add ≥2 rapid-acting Change to premixed • For patients with fasting tri-
insulin injections before analog insulin 3 times daily
meals (‘basal-bolus’) (breakfast, lunch, supper) glyceride levels ≥500 mg/dL (5.7
Start: 4 units, 0.1 U/kg, or 10% Start: Add additional injection
mmol/L), evaluate for secondary
basal dose/meal. If A1C <8%,
consider ê basal by same amount
before lunch
Adjust: é doses by 1–2 units or
causes of hypertriglyceridemia
If goals not met, consider
Adjust: é dose(s) by 1–2 units or changing to alternative 10–15% once or twice weekly to and consider medical therapy to
10–15% once or twice weekly to insulin regimen achieve SMBG target
achieve SMBG target For hypo: Determine and reduce the risk of pancreatitis. C
For hypo: Determine and
address cause; if no clear reason
address cause; if no clear reason
for hypo, ê corresponding dose • In clinical practice, providers may
for hypo, ê corresponding dose
by 2–4 units or 10–20%
by 2–4 units or 10–20%
need to adjust intensity of sta-
tin therapy based on individual
■ FIGURE 3. Combination injectable therapy for type 2 diabetes. FBG, fasting patient response to medication
blood glucose; GLP-1 RA, GLP-1 receptor agonist; hypo, hypoglycemia. Adapted (e.g., side effects, tolerability, LDL
with permission from Inzucchi et al. Diabetes Care 2015;38:140–149. cholesterol levels). E
• The addition of ezetimibe to mod-
erate-intensity statin therapy has
drugs to reduce CVD events in • For patients with blood pressure
been shown to provide additional
patients with diabetes. A >120/80 mmHg, lifestyle inter-
vention consists of weight loss, cardiovascular benefit compared
• An ACE inhibitor or an angioten-
if overweight or obese; a DASH- with moderate-intensity statin
sin receptor blocker (ARB) at the therapy alone for patients with
maximum tolerated dose indicated style dietary pattern, including
reduced sodium and increased recent acute coronary syndrome
for blood pressure treatment is the and LDL cholesterol ≥50 mg/dL
recomended first-line treatment potassium intake; moderation
of alcohol intake; and increased (1.3 mmol/L) and should be con-
for hyperytension in patients with sidered for these patients A and
diabetes and urine albumin–to– physical activity. B
also in patients with diabetes and
creatinine ratio (UACR) ≥300 Lipid Management history of ASCVD who cannot
mg/g creatinine A or UACR tolerate high-intensity statin ther-
Recommendations
30–299 mg/g creatinine. B If one • In adults not taking statins, it is apy. E
class is not tolerated, the other reasonable to obtain a lipid profile • Combination therapy (statin/
should be substituted. B at the time of diabetes diagnosis, fibrate) has not been shown to
• For patients treated with an ACE at an initial medical evaluation, improve ASCVD outcomes and
inhibitor, ARB, or diuretic, serum and every 5 years thereafter, or is generally not recommended. A
creatinine/estimated glomerular more frequently if indicated. E However, therapy with statin and
filtration rate (eGFR) and serum • Obtain a lipid profile at initiation fenofibrate may be considered for
potassium levels should be mon- of statin therapy and periodically men with both triglyceride level
itored. B thereafter because it may help to ≥204 mg/dL (2.3 mmol/L) and

18 CLINICAL.DIABETESJOURNALS.ORG
 a b r i d g e d s ta n d a r d s o f c a r e 2 0 1 7

TABLE 7. Recommendations for Statin and Combination Treatment in People With Diabetes
Age (years) Risk Factors Recommended Statin Intensity*
<40 None None
ASCVD risk factor(s)** Moderate or high
ASCVD High
40–75 None Moderate
ASCVD risk factors High
ASCVD High
ACS and LDL cholesterol ≥50 mg/dL (1.3 mmol/L) Moderate plus ezetimibe
or in patients with a history of ASCVD who cannot
tolerate high-dose statins
>75 None Moderate
ASCVD risk factors Moderate or high

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ASCVD High
ACS and LDL cholesterol ≥50 mg/dL (1.3 mmol/L) Moderate plus ezetimibe
or in patients with a history of ASCVD who cannot
tolerate high-dose statins
*In addition to lifestyle therapy.
**ASCVD risk factors include LDL cholesterol ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, chronic kidney
disease, albuminuria, and family history of premature ASCVD.

HDL cholesterol level ≤34 mg/dL tion strategy in those with type • In patients with symptomatic
(0.9 mmol/L). B 1 or type 2 diabetes who are at heart failure, thiazolidinedione
• Combination therapy (statin/nia- increased cardiovascular risk. This treatment should not be used. A
cin) has not been shown to provide includes most men or women with • In patients with type 2 diabetes
additional cardiovascular benefit diabetes aged ≥50 years who have with stable congestive heart fail-
above statin therapy alone and at least one additional major risk ure, metformin may be used if
may increase the risk of stroke and factor (family history of premature eGFR remains >30 mL/min but
is not generally recommended. A ASCVD, hypertension, smoking, should be avoided in unstable or
dyslipidemia, or albuminuria) and hospitalized patients with conges-
Table 7 provides recommendations
are not at increased risk of bleed- tive heart failure. B
for statin and combination therapy
ing. C
in people with diabetes. Table 8 out- MICROVASCULAR
lines high- and moderate-intensity Coronary Heart Disease COMPLICATIONS AND FOOT
statin therapy. CARE
Recommendations
Antiplatelet Agents • In asymptomatic patients, routine Intensive diabetes management with
screening for coronary artery dis- the goal of achieving near-normogly-
Recommendations
ease is not recommended because cemia has been shown in large, pro-
• Use aspirin therapy (75–162
it does not improve outcomes as spective, randomized studies to delay
mg/day) as a secondary prevention
strategy in those with diabetes and long as ASCVD risk factors are the onset and progression of micro-
a history of ASCVD. A treated. A vascular complications.
• For patients with ASCVD and • In patients with known ASCVD, Diabetic Kidney Disease
documented aspirin allergy, use aspirin and statin therapy (if
clopidogrel (75 mg/day) should not contraindicated) A, and con- Recommendations
be used. B sider ACE inhibitor therapy C to • At least once a year, assess uri-
• Dual antiplatelet therapy is rea- reduce the risk of cardiovascular nary albumin (e.g., spot UACR)
sonable for up to 1 year after an events. and eGFR in patients with type
acute coronary syndrome and may • In patients with prior myocardial 1 diabetes with a duration of ≥5
have benefits beyond this period. B infarction, β-blockers should be years, in all patients with type 2
• Consider aspirin therapy (75–162 continued for at least 2 years after diabetes, and in all patients with
mg/day) as a primary preven- the event. B comorbid hypertension. B

VO LU M E 3 5 , N U M B ER 1, W I N T ER 2 017 19
P O S I T I O N S TAT E M E N T

TABLE 8. High- and Moderate-Intensity Statin Therapy*

etrist at the time of the diabetes
diagnosis. B
High-Intensity Statin Therapy Moderate-Intensity Statin Therapy • If there is no evidence of retinop-
(Lowers LDL cholesterol by ≥50%) (Lowers LDL cholesterol by 30 to <50%) athy for one or more annual eye
• Atorvastatin 40–80 mg • Atorvastatin 10–20 mg exams and glycemia is well con-
• Rosuvastatin 20–40 mg • Rosuvastatin 5–10 mg trolled, then exams every 2 years
• Simvastatin 20–40 mg
may be considered. If any level of
diabetic retinopathy is present,
• Pravastatin 40–80 mg subsequent dilated retinal exam-
• Lovastatin 40 mg inations should be repeated at least
• Fluvastatin XL 80 mg annually by an ophthalmologist or
• Pitavastatin 2–4 mg optometrist. If retinopathy is pro-
*Once-daily dosing.
gressing or sight-threatening, then
examinations will be required
• Optimize glucose control to FDA guidance states that metformin more frequently B
reduce the risk or slow the progres- is contraindicated in patients with an

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Neuropathy
sion of diabetic kidney disease. A eGFR <30 mL/min/1.73 m2, eGFR
• Optimize blood pressure control should be monitored while taking Recommendations
to reduce the risk or slow the metformin, the benefits and risks • All patients should be assessed for
progression of diabetic kidney of continuing treatment should be diabetic peripheral neuropathy
disease. A reassessed when eGFR falls to <45 (DPN) starting at diagnosis of
• In nonpregnant patients with dia- mL/min/1.73 m2, metformin should type 2 diabetes and 5 years after
betes and hypertension, either an not be initiated for patients with an the diagnosis of type 1 diabetes
ACE inhibitor or an ARB is recom- eGFR <45 mL/min/1.73 m 2 , and and at least annually thereafter. B
mended for those with modestly metformin should be temporarily • Assessment for distal symmetric
elevated UACR (30–299 mg/g discontinued at the time of or before polyneuropathy should include
creatinine) B and is strongly rec- iodinated contrast imaging pro- a careful history and assessment
ommended for those with UACR cedures in patients with an eGFR of either temperature or pinprick
>300 mg/g creatinine and/or eGFR of 30–60 mL/min/1.73 m 2. Other sensation (for small-fiber function)
<60 mL/min/1.73 m2. A glucose-lowering medications also and vibration sensation using a
require dose adjustment or discon- 128-Hz tuning fork (for large-fi-
Screening for albuminuria can tinuation at low eGFR. ber function). All patients should
be most easily performed by UACR Recommendations for the man- have annual 10-g monofilament
in a random spot urine collection. agement of CKD in people with testing to identify feet at risk of
UACR determined for two of three diabetes are summarized in Table 9. ulceration and amputation. B
specimens collected within a 3- to • Optimize glucose control to pre-
6-month period should be abnormal Diabetic Retinopathy vent or delay the development of
before considering a patient to have Recommendations neuropathy in patients with type
albuminuria. • Optimize glycemic control to 1 diabetes A and to slow the pro-
Blood pressure levels <140/90 reduce the risk or slow the pro- gression of neuropathy in patients
mmHg in diabetes are recommended gression of diabetic retinopathy. A with type 2 diabetes. B
to reduce CVD mortality and slow • Optimize blood pressure and • Either pregabalin or duloxetine are
chronic kidney disease (CKD) serum lipid control to reduce the recommended as initial pharma-
progression. risk or slow the progression of dia- cologic treatments for neuropathic
With reduced eGFR, drug dos- betic retinopathy. A pain in diabetes. A
ing may require modification. The • Adults with type 1 diabetes should Foot Care
U.S. Food and Drug Administration have an initial dilated and com-
(FDA) revised guidance for the use prehensive eye examination by an Recommendations
of metformin in diabetic kidney dis- ophthalmologist or optometrist • Perform a comprehensive foot
ease in 2016, recommending use of within 5 years after the onset of evaluation each year to identify
eGFR instead of serum creatinine diabetes. B risk factors for ulcers and ampu-
to guide treatment and expanding • Patients with type 2 diabetes tations. B
the pool of patients with kidney dis- should have an initial dilated and • All patients with diabetes should
ease for whom metformin treatment comprehensive eye examination have their feet inspected at every
should be considered. The revised by an ophthalmologist or optom- visit. C

20 CLINICAL.DIABETESJOURNALS.ORG
 a b r i d g e d s ta n d a r d s o f c a r e 2 0 1 7

TABLE 9. Management of CKD in Diabetes

geriatric domains in older adults to
provide a framework to determine
eGFR Recommended Management targets and therapeutic approaches
(mL/min/1.73 m2)
for diabetes management. C
All patients • Yearly measurement of UACR, serum creatinine, • Screening for geriatric syndromes
and potassium
may be appropriate in older adults
45–60 • Refer to a nephrologist if possibility for nondiabetic experiencing limitations in their
kidney disease exists (duration of type 1 diabetes
<10 years, persistent albuminuria, abnormal find-
basic and instrumental activities
ings on renal ultrasound, resistant hypertension, of daily living because they may
rapid fall in eGFR, or active urinary sediment on affect diabetes self-management
urine microscopic examination) and be related to health-related
• Consider the need for dose adjustment of quality of life. C
medications • Annual screening for early detec-
• Monitor eGFR every 6 months tion of mild cognitive impairment
• Monitor electrolytes, bicarbonate, hemoglobin, or dementia is indicated for adults
calcium, phosphorus, and parathyroid hormone at ≥65 years of age. B

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least yearly • Older adults (≥65 years of age)
• Assure vitamin D sufficiency with diabetes should be consid-
• Vaccinate against hepatitis B virus
ered a high-priority population
for depression screening and treat-
• Consider bone density testing
ment. B
• Refer for dietary counseling • Hypoglycemia should be avoided
30–44 • Monitor eGFR every 3 months in older adults with diabetes. It
• Monitor electrolytes, bicarbonate, calcium, should be assessed and managed
phosphorus, parathyroid hormone, hemoglobin, by adjusting glycemic targets and
albumin, and weight every 3–6 months pharmacologic interventions. B
• Consider the need for dose adjustment of • Older adults who are cognitively
medications and functionally intact and have
<30 • Refer to a nephrologist significant life expectancy may
receive diabetes care with goals
• Obtain a history of ulceration, (e.g., dialysis patients and those similar to those developed for
amputation, Charcot foot, with Charcot foot, prior ulcers, or younger adults. C
angioplasty or vascular surgery, amputation). B • Glycemic goals for some older
cigarette smoking, retinopathy, • Refer patients who smoke or who adults might reasonably be
and renal disease and assess cur- have a history of prior lower-ex- relaxed using individual criteria,
rent symptoms of neuropathy tremity complications, loss of but hyperglycemia leading to
(pain, burning, numbness) and protective sensation, structural symptoms or risk of acute hyper-
vascular disease (leg fatigue, clau- abnormalities, or peripheral arte- glycemic complications should be
dication). B rial disease to foot care specialists avoided in all patients. C
• The examination should include for ongoing preventive care and • Screening for diabetes complica-
inspection of the skin, assessment lifelong surveillance. C tions should be individualized in
of foot deformities, neurological • Provide general preventive foot older adults. Particular attention
assessment (10-g monofilament self-care education to all patients should be paid to complications
testing), and vascular assessment, with diabetes. B that would lead to functional
including pulses in the legs and • The use of specialized therapeu- impairment. C
feet. B tic footwear is recommended for • Treatment of hypertension to indi-
• Patients who are ≥50 years of age high-risk patients with diabe- vidualized target levels is indicated
and any patients with symptoms tes, including those with severe in most older adults. C
of claudication or decreased or neuropathy, foot deformities, or • Treatment of other cardiovascular
absent pedal pulses should be history of amputation. B risk factors should be individual-
referred for further vascular assess- ized in older adults considering
OLDER ADULTS
ment as appropriate. C the time frame of benefit. Lipid-
• A multidisciplinary approach is Recommendations lowering therapy and aspirin
recommended for individuals • Consider the assessment of medi- therapy may benefit those with a
with foot ulcers and high-risk feet cal, mental, functional, and social life expectancy at least equal to the

VO LU M E 3 5 , N U M B ER 1, W I N T ER 2 017 21
P O S I T I O N S TAT E M E N T

time frame of primary prevention Older adults with diabetes in • At diagnosis and during routine
or secondary intervention trials. E LTC are especially vulnerable to follow-up care, assess psychoso-
• When palliative care is needed in hypoglycemia because of their dis- cial issues and family stresses that
older adults with diabetes, strict proportionately higher number of could affect adherence to diabetes
blood pressure control may not be complications and comorbidities. management and provide appro-
necessary, and withdrawal of ther- Alert strategies should be in place for priate referrals to trained mental
apy may be appropriate. Similarly, hypoglycemia (blood glucose ≤70 health professionals, preferably
the intensity of lipid management mg/dL [3.9 mmol/L]) and hypergly- experienced in childhood diabe-
can be relaxed, and withdrawal cemia (blood glucose >250 mg/dL tes. E
of lipid-lowering therapy may be [13.9 mmol/L]). • Starting at puberty, preconception
appropriate. E For patients in the LTC setting, counseling should be incorporated
• Consider diabetes education for special attention should be given to into routine diabetes care for all
the staff of long-term care facili- nutritional considerations, end-of-life girls of childbearing potential. A
ties to improve the management of care, and changes in diabetes man- Glycemic Control
older adults with diabetes. E agement with respect to advanced
disease. Acknowledging the limited Recommendations

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Treatment Goals
benefit of intensive glycemic control • An A1C goal of <7.5% (58 mmol/
The care of older adults with diabetes mol) is recommended across all
in people with advanced disease can
is complicated by their clinical and pediatric age-groups. E
guide A1C goals and determine the
functional heterogeneity. Providers
use or withdrawal of medications. For Autoimmune Conditions
caring for older adults with diabetes
more information, see ADA’s position
must take this heterogeneity into con- Recommendations
statement “Management of Diabetes
sideration when setting and prioritiz- • Assess for the presence of auto-
in Long-Term Care and Skilled
ing treatment goals (Table 10). immune conditions associated
Nursing Facilities.”
Older adults with diabetes are with type 1 diabetes soon after
likely to benefit from control of CHILDREN AND the diagnosis and if symptoms
other cardiovascular risk factors. ADOLESCENTS develop. E
Evidence is strong for treatment of Children and adolescents with diabe-
hypertension. There is less evidence tes have unique aspects of care such as Hypertension
for lipid-lowering and aspirin therapy, changes in insulin sensitivity related Recommendations
although the benefits of these inter- to physical growth and sexual mat- • Blood pressure should be measured
ventions are likely to apply to older uration, ability to provide self-care, at each routine visit. Children
adults whose life expectancies equal supervision in the child care and found to have high-normal blood
or exceed the time frames of clinical school environment, and neurologi- pressure (systolic or diastolic blood
prevention trials. cal vulnerability to hypoglycemia and pressure ≥90th percentile for age,
hyperglycemia (in young children), as sex, and height) or hypertension
Pharmacologic Therapy
well as possible adverse neurocogni- (systolic or diastolic blood pressure
Special care is required in prescribing
tive effects of diabetic ketoacidosis ≥95th percentile for age, sex, and
and monitoring pharmacologic ther-
(DKA). Attention to family dynam- height) should have elevated blood
apy in older adults. Factors include
ics, developmental stages, and physi- pressure confirmed on three sepa-
hypoglycemia, cost, and coexisting
ological differences related to sexual rate days. B
conditions (e.g., renal status). The
maturity are all essential in develop- • ACE inhibitors or ARBs should be
patient’s living situation must be con-
ing and implementing an optimal considered for the initial pharma-
sidered because it may affect diabetes
diabetes regimen. cologic treatment of hypertension,
management and support.
Support Services to be initiated after reproductive
Treatment in Skilled Nursing counseling and implementation
Facilities and Nursing Homes Recommendations of effective birth control due to
Management of diabetes is unique in • Youth with type 1 diabetes and the potential teratogenic effects of
the long-term care (LTC) setting (i.e., parents/caregivers (for patients <18 both drug classes. E
nursing homes and skilled nursing years of age) should receive cultur- • The goal of treatment is blood
facilities). Individualization of health ally sensitive and developmentally pressure consistently <90th per-
care is important for all patients. appropriate individualized DSME centile for age, sex, and height. E
However, practical guidance is needed and DSMS according to national
for both medical providers and LTC standards at diagnosis and rou- Blood pressure measurements
staff and caregivers. tinely thereafter. B should be determined using the

22 CLINICAL.DIABETESJOURNALS.ORG
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a b r i d g e d s ta n d a r d s o f c a r e 2 0 1 7

23
TABLE 10. Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older Adults
With Diabetes
Patient Rationale Reasonable A1C Fasting or Bedtime Glucose Blood Pressure Lipids
Characteristics/ Goal Preprandial (mg/dL [mmol/L]) (mmHg)
Health Status Glucose
(% [mmol/mol])‡
(mg/dL [mmol/L])
Healthy (few coexisting Longer remaining life <7.5 (58) 90–130 (5.0–7.2) 90–150 (5.0–8.3) <140/90 Statin unless con-
chronic illnesses, intact expectancy traindicated or not
cognitive and function- tolerated
al status)
Complex/intermediate Intermediate remain- <8.0 (64) 90–150 (5.0–8.3) 100–180 (5.6–10.0) <140/90 Statin unless con-
(multiple coexisting ing life expectancy, traindicated or not
chronic illnesses* high treatment burden, tolerated
or 2+ instrumental hypoglycemia vulnera-
ADL impairments or bility, fall risk
mild-to-moderate cog-
nitive impairment)
Very complex/ Limited remaining life <8.5† (69) 100–180 (5.6–10.0) 110–200 (6.1–11.1) <150/90 Consider likelihood
poor health (LTC or expectancy makes of benefit with statin
end-stage chronic benefit uncertain (secondary preven-
illnesses** or moder- tion more so than
ate-to-severe cognitive primary)
impairment or 2+ ADL
dependencies)
This represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes. The patient
characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consideration of patient and caregiver preferences is
an important aspect of treatment individualization. Additionally, a patient’s health status and preferences may change over time. ADL, activities of daily living.
‡A lower A1C goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden.
*Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, congestive heart
failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse CKD, myocardial infarction, and stroke. By “multiple,” we mean at least three,
but many patients may have five or more.

VO LU M E 3 5 , N U M B ER 1, W I N T ER 2 017
**The presence of a single end-stage chronic illness, such as stage 3–4 congestive heart failure or oxygen-dependent lung disease, CKD requiring dialysis, or
uncontrolled metastatic cancer, may cause significant symptoms or impairment of functional status and significantly reduce life expectancy.
†A1C of 8.5% (69 mmol/mol) equates to an estimated average glucose of ~200 mg/dL (11.1 mmol/L). Looser A1C targets >8.5% (69 mmol/mol) are not rec-
ommended because they may expose patients to more frequent higher glucose values and the acute risks from glycosuria, dehydration, hyperglycemic
hyperosmolar syndrome, and poor wound healing.
P O S I T I O N S TAT E M E N T

appropriate size cuff and with the • After the initial examination, and may suffice for treatment for
child seated and relaxed. Lifestyle annual routine follow-up is gener- many women. Medications should
modifications, including dietary ally recommended. Less frequent be added if needed to achieve gly-
modification and increased exer- examinations, every 2 years, may cemic targets. A
cise, should be implemented for 3–6 be acceptable on the advice of an • Insulin is the preferred medica-
months. If target blood pressure has eye care professional. E tion for treating hyperglycemia in
not been reached within 3–6 months, Neuropathy GDM because it does not cross the
pharmacotherapy should be initiated. placenta to a measurable extent.
Recommendations Metformin and glyburide may be
Dyslipidemia
• Consider an annual comprehen- used, but both cross the placenta
Recommendations sive foot exam for a child at the to the fetus, with metformin likely
• Obtain a fasting lipid profile on start of puberty or at age ≥10 crossing to a greater extent than
children ≥10 years of age soon after years, whichever is earlier, once glyburide. All oral agents lack
diabetes diagnosis (after glucose the youth has had type 1 diabetes long-term safety data. A
control has been established). E for 5 years. E • Metformin, when used to treat
• If lipids are abnormal, annual

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MANAGEMENT OF DIABETES polycystic ovary syndrome and
monitoring is reasonable. If IN PREGNANCY induce ovulation, need not be con-
LDL cholesterol values are tinued once pregnancy has been
within the accepted risk levels Preexisting Diabetes confirmed. A
(<100 mg/dL [2.6 mmol/L]), a Recommendations
lipid profile repeated every 3–5 General Principles for the
• Starting at puberty, preconception Management of Diabetes in
years is reasonable. E counseling should be incorporated
• After the age of 10 years, the Pregnancy
into routine diabetes care for all
addition of a statin is suggested in girls of childbearing potential. A Recommendations
patients who, despite MNT and • Family planning should be dis- • Potentially teratogenic medica-
lifestyle changes, continue to have cussed and effective contraception tions (e.g., ACE inhibitors and
LDL cholesterol >160 mg/dL (4.1 should be prescribed and used statins) should be avoided in sexu-
mmol/L) or LDL cholesterol >130 until a woman is prepared and ally active women of childbearing
mg/dL (3.4 mmol/L) and one or ready to become pregnant. A age who are not using reliable con-
more CVD risk factors, initiated • Preconception counseling should traception. B
after reproductive counseling and address the importance of glyce- • Fasting and postprandial SMBG
implementation of effective birth mic control as close to normal as is are recommended in both GDM
control due to the potential tera- safely possible, ideally A1C <6.5% and preexisting diabetes in preg-
togenic effects of statins. E (48 mmol/mol), to reduce the risk nancy to achieve glycemic control.
• The goal of therapy is an LDL of congenital anomalies. B Some women with preexisting
cholesterol value <100 mg/dL (2.6 • Women with preexisting type 1 or diabetes should also test blood
mmol/L). E type 2 diabetes who are planning glucose preprandially. B
Nephropathy pregnancy or who have become • The A1C target in pregnancy is
pregnant should be counseled on 6–6.5% (42–48 mmol/mol); <6%
Recommendations the risk of development and/or (42 mmol/mol) may be optimal if
• Annual screening for albuminuria progression of diabetic retinop- this can be achieved without sig-
with a random spot urine sample athy. Dilated eye examinations nificant hypoglycemia, but the
for UACR should be considered should occur before pregnancy target may be relaxed to <7% (53
once a child has had type 1 diabe- or in the first trimester, and then mmol/mol) if necessary to prevent
tes for 5 years. B patients should be monitored hypoglycemia. B
Retinopathy
every trimester and for 1 year post-
partum as indicated by degree of Preconception Counseling
Recommendations retinopathy and as recommended Observational studies show an in-
• An initial dilated and com- by the eye care provider. B creased risk of diabetic embryopathy,
prehensive eye examination is especially anencephaly, microcephaly,
GDM
recommended at age ≥10 years or congenital heart disease, and caudal
after puberty has started, which- Recommendations regression directly proportional to el-
ever is earlier, once a youth has had • Lifestyle change is an essential evations in A1C during the first 10
type 1 diabetes for 3–5 years. B component of GDM management weeks of pregnancy.

24 CLINICAL.DIABETESJOURNALS.ORG
 a b r i d g e d s ta n d a r d s o f c a r e 2 0 1 7

Preconception counseling visits admitted to the hospital if not per- • There should be a structured
should include rubella, syphilis, hepa- formed in the prior 3 months. B discharge plan tailored to the indi-
titis B virus, and HIV testing, as well • Insulin therapy should be initi- vidual patient with diabetes. B
as Pap smear, cervical cultures, blood ated for treatment of persistent Considerations on Admission
typing, prescription of prenatal vita- hyperglycemia starting at a thresh- Initial admission documentation
mins (with at least 400 µg folic acid), old ≥180 mg/dL (10.0 mmol/L). should state that the patient has type
and smoking cessation counseling if Once insulin therapy is started, a 1 or type 2 diabetes or no history of
indicated. target glucose range of 140–180 diabetes. Both hyperglycemia and
Diabetes-specific testing should mg/dL (7.8–10.0 mmol/L) is rec- hypoglycemia are associated with
include A1C, thyroid-stimulating ommended for the majority of
hormone, creatinine, and UACR. The adverse outcomes, including death.
critically ill patients A and non- High-quality care can often be en-
medication list should be reviewed for critically ill patients. C
potentially teratogenic drugs, and sured by the use of structured order
• More stringent goals such as <140 sets consistent with quality assurance
patients should be referred for a com- mg/dL (<7.8 mmol/L) may be
prehensive eye exam. Women with standards.
appropriate for selected patients,
preexisting diabetic retinopathy will as long as this can be achieved Glycemic Targets in

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need close monitoring during preg- without significant hypoglyce- Hospitalized Patients
nancy to ensure that retinopathy does
mia. C Standard Definition of Glucose
not progress.
• Intravenous (IV) insulin infusions Abnormalities
Preconception counseling resourc-
es tailored for adolescents are avail-
should be administered using val- • Hyperglycemia: >140 mg/dL
able at no cost through the ADA. idated written or computerized (7.8 mmol/L)
protocols that allow for pre- • Hypoglycemia: <54 mg/dL (3.0
Postpartum Care defined adjustments in the insulin mmol/L) or severe cognitive
Because GDM may represent pre- infusion rate based on glycemic impairment. (See the section on
existing undiagnosed type 2 or even fluctuations and insulin dose. E Hypoglycemia [p. 14] for addi-
type 1 diabetes, women with GDM • Basal insulin or a basal-plus-bo- tional details on the new criteria.)
should be tested for persistent diabe- lus-correction insulin regimen is
tes or prediabetes at 4–12 weeks post- the preferred treatment for non- A glucose value ≤70 mg/dL (3.9
partum with a 75-g OGTT using the critically ill patients with poor mmol/L) may be used as an alert
nonpregnancy criteria as outlined in oral intake or those who are tak- value and as a threshold for further
the section on classification and diag- titration of insulin regimens.
ing nothing by mouth. An insulin
nosis of diabetes above. regimen with basal, nutritional, Antihyperglycemic Agents in
Because GDM is associated with and correction components is the Hospitalized Patients
increased maternal risk for diabe- preferred treatment for noncriti- In most instances in the hospital set-
tes, women should also be tested ting, insulin is the preferred treatment
cally ill hospitalized patients with
every 1–3 years thereafter if the 4- for glycemic control, but in certain
good nutritional intake. A
to 12-week 75-g OGTT is normal, circumstances, a previous home regi-
• Sole use of sliding-scale insulin
with frequency of testing depend- men may be continued.
ing on other risk factors, including in the inpatient hospital setting is
family history, prepregnancy BMI, strongly discouraged. A Insulin Therapy
and need for insulin or oral glu- • A hypoglycemia management IV insulin protocols should be used
cose-lowering medication during protocol should be adopted and for critically ill patients. Basal-bolus
pregnancy. Ongoing evaluation may implemented by each hospital regimens that include correction dos-
be performed with any recommended or hospital system. A plan for es and account for oral intake may
glycemic test (e.g., A1C, FPG, or preventing and treating hypogly- be used for many noncritical-care
75-g OGTT using nonpregnant cemia should be established for patients. Scheduled subcutaneous
thresholds). each patient. Episodes of hypo- insulin injections should align with
glycemia in the hospital should be meals and bedtime or be given every
DIABETES CARE IN THE documented in the medical record 4–6 hours if no meals are taken or if
HOSPITAL, NURSING HOME, and tracked. E continuous enteral/parenteral therapy
AND SKILLED NURSING • The treatment regimen should be is being used.
FACILITY reviewed and changed as necessary Subcutaneous insulin should be
Recommendations to prevent further hypoglycemia administered 1–2 hours before IV
• Perform an A1C for all patients when a blood glucose value is ≤70 insulin is discontinued. Converting
with diabetes or hyperglycemia mg/dL (3.9 mmol/L). C to basal insulin at 60–80% of the

VO LU M E 3 5 , N U M B ER 1, W I N T ER 2 017 25
P O S I T I O N S TAT E M E N T

daily infusion dose has been shown Transition From the Acute Care and Driving” and “Diabetes and
to be effective. Premixed insulins are Setting Employment,” refer to Section 15
not routinely recommended for hos- Tailor a structured discharge plan (“Diabetes Advocacy”) of the com-
pital use. beginning at admission and update plete 2017 Standards.
as patient needs change. It is import-
Standards for Special Situations ant that patients be provided with
Refer to the full 2017 Standards of appropriate durable medical equip- Acknowledgments
Care for guidance on enteral/paren- ment, medications, supplies, and This abridged version of the ADA posi-
tion statement Standards of Medical Care
teral feedings, DKA and hyperosmo- prescriptions, along with appropriate in Diabetes—2017 was created by ADA’s
lar hyperglycemic state, and glucocor- education at the time of discharge. Primary Care Advisory Group, with special
ticoid therapy. Psychosocial factors should be con- thanks to Jay Shubrook, DO, Vallejo, CA,
Primary Care Advisory Group, Chair;
sidered, including social determinants Amy Butts, PA-C, MPAS, CDE, James J.
Perioperative Care of care. An outpatient follow-up visit Chamberlain, MD, Salt Lake City, UT; Eric
On the morning of surgery or a within 1 month of discharge is ad- L. Johnson, MD, Grand Forks, ND; Sandra
procedure, hold any oral hypoglyce- vised for all patients having hyper- Leal, PharmD, MPH, FAPhA, CDE,
Tucson, AZ; Andrew S. Rhinehart, MD,
mic agents; give half of the patient’s glycemia in the hospital. Continuing

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FACP, FACE, CDE, BC-ADM, CDTC,
NPH insulin dose or 60–80% doses contact may also be needed. Clear Abingdon, VA; and Neil Skolnik, MD,
of long-acting analog or pump basal communication with outpatient pro- Jenkintown, PA, with staff support from
viders either directly or via structured Sarah Bradley. Editorial assistance was
insulin. Monitor blood glucose every provided by Florence M. Jaffa, DO.
hospital discharge summaries facil-
4–6 hours while a patient is taking The full Standards of Medical Care in
itates safe transitions to outpatient
nothing by mouth and dose with care. If oral medications are held in
Diabetes—2017 was developed by the ADA’s
Professional Practice Committee: William
short-acting insulin as needed with the hospital, there should be proto- H. Herman, MD, MPH (Co-Chair), Rita
a target of 80–180 mg/dL (4.4–10.0 cols for resuming them 1–2 days be- R. Kalyani, MD, MHS, FACP (Co-Chair),*
mmol/L). Andrea L. Cherrington, MD, MPH, Donald
fore discharge. Factors to prevent re- R. Coustan, MD, Ian de Boer, MD, MS,
MNT in the Hospital admissions need to be considered. See Robert James Dudl, MD, Hope Feldman,
the section above on older adults with CRNP, FNP-BC, Hermes J. Florez, MD,
The goals of MNT are to optimize PhD, MPH,* Suneil Koliwad, MD, PhD,*
diabetes regarding long-term care and
glycemic control, provide adequate skilled nursing facilities.
Melinda Maryniuk, MEd, RD, CDE,
Joshua J. Neumiller, PharmD, CDE,
calories to meet metabolic demands, FASCP,* and Joseph Wolfsdorf, MB, BCh,
and address personal food preferenc- DIABETES ADVOCACY with staff support from Erika Gebel Berg,
es. The term “ADA diet” is no longer Advocacy Position Statements PhD, Sheri Colberg-Ochs, PhD, Alicia H.
McAuliffe-Fogarty, PhD, CPsychol, Sacha
used. A registered dietitian can serve For a list of ADA advocacy position Uelmen, RDN, CDE, and Robert Ratner,
as an inpatient team member. statements, including “Diabetes MD, FACP, FACE. *Subgroup leaders.

26 CLINICAL.DIABETESJOURNALS.ORG