ADA staff supporting the development of the Standards were Mindy Saraco, MHA, Malaika I. Hill, MA, Matthew P. Petersen, Shamera Robinson, MPH, RDN, and Kenneth P. Moritsugu, MD, MPH, FACPM. B. Nonalcoholic fatty liver disease, hepatitis C infection, pancreatitis, hearing impairment, HIV, cognitive impairment/dementia, hip fractures, low testosterone in men, obstructive sleep apnea, and periodontal disease are all more common in people with diabetes. Summary of glycemic recommendations for many nonpregnant adults with diabetes. 10.24 For patients with diabetes and ASCVD considered very high risk using specific criteria, if LDL cholesterol is ≥70 mg/dL on maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or PCSK9 inhibitor). Nonprofit websites can offer advice for providers and patients to determine the suitability of various options. C, 10.30 In adults with moderate hypertriglyceridemia (fasting or nonfasting triglycerides 175–499 mg/dL), clinicians should address and treat lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that raise triglycerides. Once initiated, metformin should be continued as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin. A, 10.12 An ACE inhibitor or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio (UACR) ≥300 mg/g creatinine (Cr) A or 30–299 mg/g Cr. The 2020 Standards of Medical Care in Diabetes includes all of ADA's current clinical practice recommendations and is intended to provide clinicians, patients, researchers, payers, and others with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. Source:https://care.diabetesjournals.org/content/43/Supplement_1/S98. We do not capture any email address. The medication regimen and medication-taking behavior should be reevaluated at regular intervals (every 3–6 months) and adjusted as needed to incorporate specific factors that impact choice of treatment. 4.12 Patients with type 1 diabetes should be screened for autoimmune thyroid disease soon after diagnosis and periodically thereafter. B, 6.13 Glucagon should be prescribed for all individuals at increased risk of level 2 hypoglycemia, defined as blood glucose <54 mg/dL (3.0 mmol/L), so it is available should it be needed. Adapted from Battelino T, Danne T, Bergenstal RM, et al. Reprinted from Davies MJ, D’Alessio DA, Fradkin J, et al. Modest and sustained weight loss has been shown to improve glycemic control and reduce the need for glucose-lowering medications. A, 9.2 Most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk. Children and Adolescents” in the complete 2020 Standards of Care describes the comprehensive treatment of children with type 2 diabetes. B. Access to care and quality improvement, 1.5 Providers should assess social context, including potential food insecurity, housing stability, and financial barriers, and apply that information to treatment decisions. Figure 9.1, Figure 9.2, and Table 9.1 provide details for informed decision-making on pharmacologic agents for type 2 diabetes. Considerations include cardiovascular comorbidities, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences. Use of custom therapeutic footwear can help reduce the risk of future foot ulcers in high-risk patients. B, 4.2 Diabetes care should be managed by a multidisciplinary team that may draw from primary care physicians, subspecialty physicians, nurse practitioners, physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals.
A, 10.35 For patients with ASCVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. A, 8.16 Metabolic surgery may be considered as an option for adults with type 2 diabetes and BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with tested efficacious nonsurgical methods. At the same time, older adults with diabetes also are at greater risk than other older adults for several common geriatric syndromes, such as polypharmacy, cognitive impairment, depression, urinary incontinence, injurious falls, and persistent pain. B. CLASSIFICATION AND DIAGNOSIS OF DIABETES, 3. A, 11.8 Periodically monitor serum Cr and potassium levels for the development of increased Cr or changes in potassium when ACE inhibitors, ARBs, or diuretics are used. Adapted from Davies MJ, D'Alessio DA, Fradkin J, et al. Sign In to Email Alerts with your Email Address. E, 13.62 Initiate pharmacologic therapy, in addition to lifestyle therapy, at diagnosis of type 2 diabetes. Children and Adolescents” in the complete 2020 Standards of Care for specific recommendations. Although no drugs have been approved by the U.S. Food and Drug Administration (FDA) for diabetes prevention, several have shown promise in research studies. Therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals. A, 8.8 Food availability should be queried, as well as other cultural circumstances that could affect dietary patterns. ADA’s grading system uses A , B , C , or E to show the evidence level that supports each recommendation.
B, 4.4 A follow-up visit should include most components of the initial comprehensive medical evaluation, including interval medical history, assessment of medication-taking behavior and intolerance/side effects, physical examination, laboratory evaluation as appropriate to assess attainment of A1C and metabolic targets, and assessment of risk for complications, diabetes self-management behaviors, nutrition, psychosocial health, and the need for referrals, immunizations, or other routine health maintenance screening. CVD and Risk Management” below for details.
B, 12.2 Screen for geriatric syndromes (i.e., polypharmacy, cognitive impairment, depression, urinary incontinence, falls, and persistent pain) in older adults as they may affect diabetes self-management and diminish quality of life. For patients with complications and reduced functionality, it is reasonable to set less intensive glycemic goals.
5. B, 10.36 Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary syndrome A and may have benefits beyond this period. B, 10.43 Among patients with type 2 diabetes who have established ASCVD or established kidney disease, an SGLT2 inhibitor or GLP-1 receptor agonist with demonstrated CVD benefit is recommended as part of the glucose-lowering regimen. 2020 ADA Guidelines: Medications for Type 2 Diabetes, GT Health, 15204 Omega Drive, Suite #240, Rockville, MD, 20850, United States, https://care.diabetesjournals.org/content/43/Supplement_1/S98. A meta-analysis of 13 randomized statin trials showed an odds ratio of 1.09 for a new diagnosis of diabetes, so that (on average) treatment of 255 patients with statins for 4 years resulted in one additional case of diabetes while simultaneously preventing 5.4 vascular events among those 255 patients. B, Evaluate for diabetes complications and potential comorbid conditions.
5.24 Children and adolescents with type 1 or type 2 diabetes or prediabetes should engage in 60 min/day or more of moderate- or vigorous-intensity aerobic activity, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days/week. Pharmacologic Approaches to Glycemic Treatment”, http://tools.acc.org/ASCVD-Risk-Estimator-Plus, “11. An earlier appointment (in 1–2 weeks) is preferred, and frequent contact may be needed. Recently, several groups have developed algorithms to predict episodes of hypoglycemia among inpatients. A, 10.16 Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels (≥150 mg/dL [1.7 mmol/L]) and/or low HDL cholesterol (<40 mg/dL [1.0 mmol/L] for men, <50 mg/dL [1.3 mmol/L] for women). 12.5 Older adults who are otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status should have lower glycemic goals (such as A1C <7.5% [58 mmol/mol]), while those with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have less stringent glycemic goals (such as A1C <8.0–8.5% [64–69 mmol/mol]).
C, 10.17 In adults not taking statins or other lipid-lowering therapy, it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter if under the age of 40 years, or more frequently if indicated. 15.8 A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. 12.10 Optimal nutrition and protein intake is recommended for older adults; regular exercise, including aerobic activity and resistance training, should be encouraged in all older adults who can safely engage in such activities. B, 2.8 Testing for prediabetes and/or type 2 diabetes should be considered in women planning pregnancy with overweight or obesity and/or who have one or more additional risk factor for diabetes (Table 2.3). Institutional Subscriptions and Site Licenses, Special Podcast Series: Therapeutic Inertia, Special Podcast Series: Influenza Podcasts, “4. 7.1 Use of technology should be individualized based on a patient’s needs, desires, skill level, and availability of devices. E. Screening for prediabetes and type 2 diabetes risk through an informal assessment of risk factors (Table 2.3) or with an assessment tool such as the ADA risk test (diabetes.org/socrisktest) is recommended to guide providers on whether performing a diagnostic test for prediabetes and previously undiagnosed type 2 diabetes (Table 2.2/2.5) is appropriate.
B If deterioration of medical status is associated with significant weight gain or loss, inpatient evaluation should be considered, specifically focused on the association between medication use, food intake, and glycemic status. A, 11.13 Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy. A. PREVENTION OR DELAY OF TYPE 2 DIABETES, 4. The recommendations are based on an extensive review of the clinical diabetes literature, supplemented … Health systems (to create a quality-oriented culture). Adapted with permission from Inzucchi SE, Bergenstal RM, Buse JB, et al. B, 4.13 Adult patients with type 1 diabetes should be screened for celiac disease in the presence of gastrointestinal symptoms, signs, or laboratory manifestations suggestive of celiac disease. C, 10.21 In patients with diabetes at higher risk, especially those with multiple ASCVD risk factors or aged 50–70 years, it is reasonable to use high-intensity statin therapy. For prevention and management of both ASCVD and HF, CV risk factors should be systematically assessed at least annually in all patients with diabetes. Microvascular Complications and Foot Care”, “Management of Diabetes in Long-term Care and Skilled Nursing Facilities”, “Type 1 Diabetes in Children and Adolescents”, “Evaluation and Management of Youth-Onset Type 2 Diabetes”, http://www.diabetesjournals.org/content/license, Standards of Medical Care in Diabetes—2020 Abridged for Primary Care Providers, 1. B, 8.12 Whenever possible, minimize medications for comorbid conditions that are associated with weight gain. E, 5.3 Clinical outcomes, health status, and well-being are key goals of DSMES that should be measured as part of routine care. 14.13 Lifestyle behavior change is an essential component of management of GDM and may suffice for the treatment of many women. Patients with diabetes should be encouraged to undergo recommended age- and sex-appropriate cancer screenings and to reduce their modifiable cancer risk factors (obesity, physical inactivity, and smoking). Adapted from Davies MJ, D'Alessio DA, Fradkin J, et al.
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