diabetes ada 2014 cuidado standar

8/9/2019 Diabetes Ada 2014 Cuidado Standar

1/136

S14 Diabetes Care Volume 37, Supplement 1, January 2014

Standards of Medical Care inAmerican Diabetes Association

Diabetesd2014

PS!"!#

S"A"$%$#"

Di

"

&

mo

"

&

'3

!(

A(Di

3

A!

DSora)teror*an

transplantation+

3

Some patients cannot be clearlyclassi)ied as type 1 or type 2diabetic(

Clinical presentation and disease

pro*ression -ary considerably in

bot& types o) diabetes(

ccasionally, patients dia*nosed

.it& type 2 diabetes may present

.it& /etoacidosis( C&ildren .it&

type 1 diabetes typically present

.it& t&e &allmar/ symptoms o)polyuriapolydipsia and

occasionally .it& diabetic

/etoacidosis 'DA+( o.e-er,

di))iculties in dia*nosis may occur

in c&ildren, adolescents, and

adults, .it& t&e true dia*nosis

becomin* more ob-ious

o-er time(

ri*inally appro-ed1( %ost recentre-ie. re-isionctober 2013(

D!5 10(2337dc146

S014 2014 by t&e

American Diabetes


2/136

Association( See &ttp5creati-ecommons(or*licensesby6 nc6nd3(0 )or details(
http://creativecommons.org/licenses/by-nc-nd/3.0/http://creativecommons.org/licenses/by-nc-nd/3.0/http://creativecommons.org/licenses/by-nc-nd/3.0/http://creativecommons.org/licenses/by-nc-nd/3.0/http://creativecommons.org/licenses/by-nc-nd/3.0/http://creativecommons.org/licenses/by-nc-nd/3.0/http://creativecommons.org/licenses/by-nc-nd/3.0/


3/136

care(diabetes8ournals(or* Position Statement S19

"able 1:ADA e-idence *radin* system )or Clinical Practice;ecommendations

uately po.ered,

includin*5c $-idence )rom a .ell6conducted trial at one or more institutions

c $-idence )rom a meta6analysis t&at incorporated >uality ratin*s in t&e analysis

B Supporti-e e-idence )rom .ell6conducted co&ort studiesc $-idence )rom a .ell6conducted prospecti-e co&ort study or re*istry

c $-idence )rom a .ell6conducted meta6analysis o) co&ort studies

Supporti-e e-idence )rom a .ell6conducted case6control study

C Supporti-e e-idence )rom poorly controlled or uncontrolled studies

c $-idence )rom randomi=ed clinical trials .it& one or more ma8or or t&reeor more minor met&odolo*ical )la.s t&at could in-alidate t&e results

c $-idence )rom obser-ational studies .it& &i*& potential )or bias 'suc& as case

series .it& comparison .it& &istorical controls+c $-idence )rom case series or case reports

Con)lictin* e-idence .it& t&e .ei*&t o) e-idence supportin* t&e recommendation

$ $?pert consensus or clinical e?perience

abnormal &emo*lobins s&ould be used( An

updated list is a-ailable at ...(n*sp(

or*inter)(asp( !n situations o) abnormal red

cell turno-er, suc& as pre*nancy, recent

blood loss or trans)usion, or some anemias,

only blood *lucose criteria s&ould be usedto dia*nose diabetes(

astin* and ".o6our Plasma

lucose

!n addition to t&e A1C test, t&e P and

26& P may also be used to dia*nose

diabetes( "&e current dia*nostic criteria

)or diabetes are summari=ed in "able 2(

"&e concordance bet.een t&e P and

26& P tests is ,100E( "&e concordance

bet.een A1C and eit&er *lucose6based

test is also imper)ect( #ational ealt&

and #utrition $?amination Sur-ey

'#A#$S+ data indicate t&at t&e A1C cutpoint o) FG(9E identi)ies one6t&ird )e.er

cases o) undia*nosed diabetes t&an a

)astin* *lucose cut point o) F12G m*dual clinical importance( "&e yper*lycemia and

Ad-erse Pre*nancy utcome 'AP+ study '43+, a lar*e6scale

'O29,000 pre*nant .omen+ multinational epidemiolo*ical study,

demonstrated t&at ris/ o) ad-erse maternal, )etal, and neonatal

outcomes continuously increased as a )unction o) maternal *lycemia

at 24K2 .ee/s, e-en .it&in ran*es pre-iously considered normal

)or pre*nancy( or most complications, t&ere .as no t&res&old )or

ris/( "&ese results &a-e led to care)ul reconsideration o) t&e

dia*nostic criteria )or D%( D% screenin* can be accomplis&ed

.it& eit&er o) t.o strate*ies5

1. @ne6step 26& 796* "" or

2. @".o6step approac& .it& a 16& 906* 'non)astin*+ screen

)ollo.ed by a 36& 1006* "" )or t&ose .&o screen positi-e

'"able G+

Di))erent dia*nostic criteria .ill identi)y di))erent ma*nitudes o)maternal &yper*lycemia and maternal)etal ris/(

!n t&e 2011 Standards o) Care '44+, ADA )or t&e )irst time

recommended t&at all pre*nant .omen not /no.n to &a-e prior

diabetes under*o a 796* "" at 24K2 .ee/s o) *estation based

on an !nternational Association o) Diabetes and Pre*nancy Study

roups '!ADPS+ consensus meetin* '49+( Dia*nostic cut points )or

t&e )astin*, 16&, and 26& P measurements .ere de)ined t&at

con-eyed an odds ratio )or ad-erse outcomes o) at least 1(79

compared .it& .omen .it& t&e mean *lucose le-els in t&e AP

study, a strate*y anticipated to si*ni)icantly increase t&e pre-alence

o) D% ')rom 9KGE to O19K20E+, primarily because only one

abnormal -alue, not t.o, is su))icient to ma/e t&e dia*nosis( ADA

reco*ni=ed t&at t&e anticipated increase in t&e incidence o) D%

dia*nosed by t&ese criteria .ould &a-e si*ni)icant impact on t&e

costs, medical in)rastructure capacity, and potential )or increased

@medicali=ation o) pre*nancies pre-iously cate*ori=ed as normal,

but

"able G:Screenin* )or anddia*nosis o)D%@ne6step'!ADPSconsensus+

Per)orm a 796*"", .it&plasma*lucosemeasurement)astin* and at1 and 2 &, at24K2 .ee/so) *estationin .omen notpre-iouslydia*nosed.it& o-ertdiabetes(

"&e ""s&ould beper)ormedin t&emornin*a)ter ano-erni*&t)ast o) atleast &(

"&e dia*nosiso) D% ismade .&enany o) t&e)ollo.in*plasma*lucose

-alues aree?ceeded5

c astin*5

F2 m*duent

insulin

in8ection

s or

noninsulint&erapies( $

3 &en

prescribi

n*S%B,

ensure

t&at

patients

recei-e

on*oin*

instructio

n and

re*ular

e-aluatio

n o)

S%B

tec&ni>ue and

S%B

results,

as .ell

as t&eir

ability to

use

S%B

data to

ad8ustt&erapy($

3&en

used

prop

erly,

conti

nuou

s

*luc

ose

moni

torin

*

'C

%+ in


17/136

S22 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

con8unction .it& intensi-e insulin re*imens is a use)ul toolto lo.er A1C in selected adults 'a*ed F29 years+ .it& type1 diabetes(A

3Alt&ou*& t&e e-idence )or A1C lo.erin* is less stron* in

c&ildren, teens, and youn*er adults, C% may be &elp)ul in

t&ese *roups( Success correlates .it& ad&erence to on*oin*

use o) t&e de-ice( C

3 C% may be a supplemental tool to S%B in t&ose .it&

&ypo*lycemia una.areness andor )re>uent &ypo*lycemicepisodes( $

%a8or clinical trials o) insulin6treated patients t&at demonstrated t&e

bene)its o) intensi-e *lycemic control on diabetes complications &a-e

included S%B as part o) multi)actorial inter-entions, su**estin* t&at

S%B is a component o) e))ecti-e t&erapy( S%B allo.s patients to

e-aluate t&eir indi-idual response to t&erapy and assess .&et&er

*lycemic tar*ets are bein* ac&ie-ed( ;esults o) S%B can be use)ul

in pre-entin* &ypo*lycemia and ad8ustin* medications 'particularly

prandial insulin doses+, medical nutrition t&erapy '%#"+, and p&ysical

acti-ity( $-idence also supports a correlation bet.een S%B

)re>uency and lo.er A1C 'G2+(

S%B )re>uency and timin* s&ould be dictated by t&e patientHs

speci)ic needs and *oals( S%B is especially important )or patients

treated .it& insulin to monitor )or and pre-ent asymptomatic

&ypo*lycemia and &yper*lycemia( %ost patients .it& type 1 diabetes

or on intensi-e insulin re*imens '%D! or insulin pump t&erapy+ s&ould

consider S%B prior to meals and snac/s, occasionally

postprandially, at bedtime, prior to e?ercise, .&en t&ey suspect lo.

blood *lucose, a)ter treatin* lo. blood *lucose until t&ey are

normo*lycemic, and prior to critical tas/s suc& as dri-in*( or many

patients, t&is .ill re>uire testin* GK times daily, alt&ou*& indi-idualneeds may -ary( A database study o) almost 27,000 c&ildren and

adolescents .it& type 1 diabetes s&o.ed t&at, a)ter ad8ustment )or

multiple con)ounders, increased daily )re>uency o) S%B .as

si*ni)icantly associated .it& lo.er A1C '20(2E per additional test per

day, le-elin* o)) at )i-e tests per day+ and .it& )e.er acute

complications'G3+( or patientson nonintensi-einsulin re*imens,suc& as t&ose.it& type 2

diabetes on basalinsulin, .&en toprescribe S%Band t&e testin*)re>uency areunclear becauset&ere isinsu))iciente-idence )ortestin* in t&isco&ort(

Se-eral

randomi=ed trials&a-e called into

>uestion t&eclinical utility and

cost6e))ecti-eness

o) routine S%B

in noninsulin6treated patients

'G4KGG+(

A recent meta6

analysis

su**ested t&at

S%B reduced

A1C by 0(29E at

G mont&s 'G7+, buta Coc&rane

re-ie. concluded

t&at t&e o-erall

e))ect o) S%B in

suc& patients is

minimal up to G

mont&s a)ter

initiation and

subsides a)ter 12

mont&s 'G+( A /ey

consideration is

t&at S%B alone

does not lo.erblood *lucose

le-elO to be use)ul,

t&e in)ormation

must be inte*rated

into clinical and

sel)6mana*ement

plans(

S%B accuracy is

instrument and user

dependent 'G+, so

it is important to

e-aluate eac&patientHs monitorin*

tec&ni>ue, bot&

initially and at

re*ular inter-als

t&erea)ter( ptimal

use o) S%B

re>uires proper

re-ie. and

interpretation o) t&e

data, bot& by t&e

patient and

pro-ider( Amon*patients .&o

c&ec/ed t&eir

blood *lucose at

least once daily,

many reported

ta/in* no action

.&en results .ere

&i*& or lo. '70+( !n

one study o)

insulin6naR-e

patients .it&

suboptimal initial

*lycemic control,use o) structured

S%B 'a paper

tool to collect and

interpret 76point

S%B pro)iles

o-er 3 days at

least >uarterly+

reduced A1C by

0(3E more t&an an

acti-e control

*roup '71+(

Patients s&ould be

tau*&t &o. to useS%B data to

ad8ust )ood inta/e,

e?ercise, or

p&armacolo*ical

t&erapy to ac&ie-e

speci)ic *oals( "&e

on*oin* need )or

and )re>uency o)

S%B s&ould be

ree-aluated at

eac& routine -isit(

Continuouslucose %onitorin*

;eal6time C%

t&rou*& t&e

measurement o)

interstitial *lucose

'.&ic& correlates

.ell .it& plasma

*lucose+ is

a-ailable( "&ese

sensors re>uire

calibration .it&

S%B, and t&e

latter are stillre>uired )or ma/in*

acute treatment

decisions( C%

de-ices &a-e

alarms )or &ypo6

and &yper*lycemic

e?cursions( A 2G6

.ee/ randomi=ed

trial


18/136

o) 322 type 1 diabetic patients s&o.ed t&at adults a*ed F29 years usin*

intensi-e insulin t&erapy and C% e?perienced a 0(9E reduction in A1C

')rom O7(G to 7(1E+ compared .it& usual intensi-e insulin t&erapy .it&

S%B '72+( Sensor use in t&ose ,29 years o) a*e 'c&ildren, teens, and

adults+ did not result in si*ni)icant A1C lo.erin*, and t&ere .as no

si*ni)icant di))erence in &ypo*lycemia in any *roup( "&e *reatest

predictor o) A1C lo.erin* )or all a*e6*roups .as )re>uency o) sensor use,

.&ic& .as lo.er in youn*er a*e6*roups( !n a smaller ;C" o) 12 adultsand c&ildren .it& baseline A1C ,7(0E, outcomes combinin* A1C and

&ypo*lycemia )a-ored t&e *roup usin* C%, su**estin* t&at C% is also

bene)icial )or indi-iduals .it& type 1 diabetes .&o &a-e already ac&ie-ed

e?cellent control '72+(

-erall, meta6analyses su**est t&at compared .it& S%B, C%

use is associated .it& A1C lo.erin* by O0(2GE '73+( "&e tec&nolo*y

may be particularly use)ul in t&ose .it& &ypo*lycemia una.areness

andor )re>uent &ypo*lycemic episodes, alt&ou*& studies &a-e not

s&o.n si*ni)icant reductions in se-ere &ypo*lycemia '73+( A C%

de-ice e>uipped .it& an automatic lo. *lucose suspend )eature .as

recently appro-ed

by t&e (S( ood

and Dru*

Administration

'DA+( "&e ASP!;$

trial o) 247 patients

s&o.ed t&at

sensor6au*mented

insulin pump

t&erapy .it& a lo.

*lucose suspendsi*ni)icantly

reduced nocturnal

&ypo*lycemia,

.it&out increasin*

A1C le-els )or

t&ose o-er 1G years

o) a*e '74+( "&ese

de-ices may o))er

t&e opportunity to

reduce se-ere

&ypo*lycemia )or

t&ose .it& a &istory

o) nocturnal

&ypo*lycemia(

C% )orms t&e

underpinnin* )or

t&e @arti)icial

pancreas or t&e

closed6loop

system( o.e-er,

be)ore C% is.idely adopted,

data must be

reported and

analy=ed usin* a

standard uni-ersal

template t&at is

predictable and

intuiti-e '79+(

b( A1C

Recommendations

3 Per)orm t&e

A1C test at

least t.o times

a year in

patients .&o

are meetin*

treatment

*oals 'and

.&o

&a-e stable*lycemiccontrol+( $

3 Per)orm t&e A1C

test >uarterly in

patients .&ose

t&erapy &as

c&an*ed


19/136


or .&o are not meetin* *lycemic *oals( $

3 se o) PC testin* )or A1C pro-ides t&e opportunity )or more

timely treatment c&an*es( $

A1C re)lects a-era*e *lycemia o-er se-eral mont&s 'G+ and &as

stron* predicti-e -alue )or diabetes complications '7G,77+( "&us,

A1C testin* s&ould be per)ormed routinely in all patients .it&

diabetes5 at initial assessment and as part o) continuin* care(

%easurement appro?imately e-ery 3 mont&s determines .&et&er

a patientHs *lycemic tar*ets &a-e been reac&ed and maintained(

"&e )re>uency o) A1C testin* s&ould be dependent on t&e clinical

situation, t&e treatment re*imen used, and t&e clinicianHs

8ud*ment( Some patients .it& stable *lycemia .ell .it&in tar*et

may do .ell .it& testin* only t.ice per year( nstable or &i*&ly

intensi-ely mana*ed patients 'e(*(, pre*nant type 1 diabetic

.omen+ may re>uire testin* more )re>uently t&an e-ery 3

mont&s(

A1C


20/136

*oals 'suc& as ,G(9E+ )or selected indi-idual patients, i) t&is can be

ac&ie-ed .it&out si*ni)icant &ypo*lycemia or ot&er ad-erse e))ects

o) treatment( Appropriate patients mi*&t include t&ose .it& s&ort

duration o) diabetes, lon* li)e e?pectancy, and no

si*ni)icant CVD( C

3


21/136


control is associated .it& si*ni)icantly decreased rates o)

micro-ascular 'retinopat&y and nep&ropat&y+ and neuropat&ic

complications( ollo.6up o) t&e DCC" co&orts in t&e $pidemiolo*y o)

Diabetes !nter-entions and Complications '$D!C+ study '2,3+

demonstrated persistence o) t&ese micro-ascular bene)its in

pre-iously intensi-ely treated sub8ects, e-en t&ou*& t&eir *lycemiccontrol appro?imated t&at o) pre-ious standard arm sub8ects durin*

)ollo.6up(

umamoto and Prospecti-e Diabetes Study"&e umamoto '4+ and Prospecti-e Diabetes Study 'PDS+

'9,G+ con)irmed t&at intensi-e *lycemic control .as associated .it&

si*ni)icantly decreased rates o) micro-ascular and neuropat&ic

complications in type 2 diabetic patients( uired to ac&ie-e near6eu*lycemia

s&ould also be considered

.&en settin*

*lycemic tar*ets(

o.e-er, based on

p&ysician 8ud*ment

and patient

pre)erences, select

patients, especiallyt&ose .it& little

comorbidity and

lon* li)e

e?pectancy, may

bene)it )rom

adoptin* more

intensi-e *lycemic

tar*ets 'e(*(, A1C

tar*et ,G(9E+ as

lon* as si*ni)icant

&ypo*lycemia does

not become a

barrier(

Cardio-ascularDisease utcomesCVD is a more

common cause o)

deat& t&an

micro-ascular

complications in

populations .it&

diabetes( o.e-er, it

is less clearly

impacted by

&yper*lycemia le-els

or intensity o)*lycemic control( !n

t&e DCC", t&ere .as

a trend to.ard lo.er

ris/ o) CVD e-ents

.it& intensi-e

control( !n t&e 6year

post6DCC" )ollo.6up

o) t&e $D!C co&ort,

participants

pre-iously

randomi=ed to t&e

intensi-e arm &ad a

si*ni)icant 97Ereduction in t&e ris/

o) non)atal

myocardial in)arction

'%!+, stro/e, or CVD

deat& compared .it&

t&ose pre-iously in

t&e standard arm

'2+( "&e bene)it o)

intensi-e *lycemic

control in t&is type 1

diabetic co&ort &as

recently been s&o.n

to persist )or se-eraldecades '3+(

!n type 2 diabetes,

t&ere is e-idence

t&at more intensi-e

treatment o)

*lycemia in ne.ly

dia*nosed patients

may reduce lon*6

term CVD rates(

Durin* t&e PDS

trial, t&ere .as a1GE reduction in

CVD e-ents

'combined )atal or

non)atal %! and

sudden deat&+ in t&e

intensi-e *lycemic

control arm t&at did

not reac& statistical

si*ni)icance 'P 9

0(092+, and t&ere

.as no su**estion

o) bene)it on ot&er

CVD outcomes'e(*(, stro/e+(

o.e-er, a)ter 10

years o) )ollo.6up,

t&ose ori*inally

randomi=ed to

intensi-e *lycemic

control &ad

si*ni)icant lon*6term

reductions in %!

'19E .it&

sul)onylurea or

insulin as initial

p&armacot&erapy,33E .it& met)ormin

as initial

p&armacot&erapy+

and in all6cause

mortality '13E and

27E, respecti-ely+

'7+(

"&e Action to

Control

Cardio-ascular ;is/

in Diabetes

'ACC;D+, Action

in Diabetes and

Vascular Disease5

Pretera? and

Diamicron %odi)ied

;elease Controlled

$-aluation

'ADVA#C$+, and

t&e Veterans A))airs

Diabetes "rial

'VAD"+ studies

su**ested no

si*ni)icant reduction

in CVD outcomes

.it& intensi-e

*lycemic control in

participants .&o &ad

more ad-anced type

2 diabetes t&an

PDS participants(

All t&ree trials .ere

conducted in

participants .it&

more lon*6standin*

diabetes 'mean

duration K11 years+and


22/136

eit&er /no.n CVD or multiple cardio-ascular ris/ )actors( Details o)

t&ese studies are re-ie.ed e?tensi-ely in an ADA position statement

'4+(

ACC;D

"&e ACC;D study participants &ad eit&er /no.n CVD or t.o or

more ma8or cardio-ascular ris/ )actors and .ere randomi=ed to

intensi-e *lycemic control '*oal A1C ,GE+ or standard *lycemic

control '*oal A1C 7KE+( "&e *lycemic control comparison .as

&alted early due to an increased mortality rate in t&e intensi-e

compared .it& t&e standard arm '1(41 -s( 1(14EyearO &a=ard ratio

L;M 1(22 L9E C! 1(01K 1(4GM+O .it& a similar increase in

cardio-ascular deat&s( !nitial analysis o) t&e ACC;D data

'e-aluatin* -ariables includin* .ei*&t *ain, use o) any speci)ic dru*

or dru* combination, and &ypo*lycemia+ did not identi)y a clear

e?planation )or t&e e?cess mortality in t&e intensi-e arm '1+( A

subse>uent analysis s&o.ed no increase in mortality in t&e intensi-e

arm participants .&o ac&ie-ed A1C le-els belo. 7E, nor in t&ose

.&o lo.ered t&eir A1C >uic/ly a)ter trial enrollment( "&ere .as no

A1C le-el at .&ic& intensi-e -ersus standard arm participants &ad

si*ni)icantly lo.er

mortality( "&e

&i*&est ris/ )or

mortality .as

obser-ed in

intensi-e arm

participants .it& t&e

&i*&est A1C le-els

'9+( Se-ere

&ypo*lycemia .as

si*ni)icantly moreli/ely in participants

randomi=ed to t&e

intensi-e *lycemic

control arm( nli/e

t&e DCC", .&ere

lo.er ac&ie-ed A1C

le-els .ere related

to si*ni)icantly

increased rates o)

se-ere

&ypo*lycemia, in

ACC;D e-ery

1E decline in A1C

)rom baseline to 4

mont&s into t&e

trial .as

associated .it& a

si*ni)icant

decrease in t&e

rate o) se-ere

&ypo*lycemia in

bot& arms '9+(

ADVA#C$

"&e primary

outcome o)

ADVA#C$ .as a

combination o)

micro-ascular

e-ents

'nep&ropat&y and

retinopat&y+ and

ma8or ad-erse

cardio-ascular

e-ents '%!, stro/e,

and cardio-ascular

deat&+( !ntensi-e

*lycemic control

'A1C ,G(9E, -s(

treatment to local

standards+

si*ni)icantly

reduced t&e primary

end point, primarilydue to a si*ni)icant

reduction in t&e

micro-ascular

outcome,

speci)ically

de-elopment o)

albuminuria '(300

m*24 &+, .it&


23/136


no si*ni)icant reduction in t&e macro-ascular outcome( "&ere .as

no di))erence in o-erall or cardio-ascular mortality bet.een t&e t.o

arms '+(

VAD"

"&e primary outcome o) t&e VAD" .as a composite o) CVD e-ents("&e trial randomi=ed type 2 diabetic participants .&o .ere

uncontrolled on insulin or on ma?imal dose oral a*ents 'median entry

A1C (4E+ to a strate*y o) intensi-e *lycemic control '*oal A1C ,

G(0E+ or standard *lycemic control, .it& a planned A1C separation

o) at least 1(9E( "&e cumulati-e primary outcome .as

nonsi*ni)icantly lo.er in t&e intensi-e arm '+( An ancillary study o)

t&e VAD" demonstrated t&at intensi-e *lycemic control si*ni)icantly

reduced t&e primary CVD outcome in indi-iduals .it& less

at&erosclerosis at baseline but not in persons .it& more e?tensi-e

baseline at&erosclerosis 'G+( A post &oc analysis s&o.ed t&at

mortality in t&e intensi-e -ersus standard *lycemic control arm .as

related to duration o) diabetes at study enrollment( "&ose .it&

diabetes duration less t&an 19 years &ad a mortality bene)it in t&eintensi-e arm, .&ile t&ose .it& duration o) 20 years or more &ad

&i*&er mortality in t&e intensi-e arm '7+(

ad-anced

at&erosclerosis,

and ad-anced

a*e)railty may

bene)it )rom less

a**ressi-e tar*ets(

Pro-iders s&ould be-i*ilant in

pre-entin* se-ere

&ypo*lycemia in

patients .it&

ad-anced disease

and s&ould not

a**ressi-ely

attempt to ac&ie-e

near6normal A1C

le-els in patients in

.&om suc& tar*ets

cannot be sa)ely

and reasonably

ac&ie-ed( Se-ere

or )re>uent

&ypo*lycemia is an

absolute indication

)or t&e modi)ication

o) treatment

re*imens, includin*

settin* &i*&er

*lycemic *oals(

%any )actors,

includin* patient

pre)erences, s&ould

be ta/en into

account .&en

de-elopin* a

patientHs

indi-iduali=ed *oals

'+ 'i*( 1+(

lycemic oals

;ecommended

*lycemic *oals )or

many nonpre*nant

adults are s&o.n

in "able ( "&e

recommendations

are based on

t&ose )or A1C

-alues, .it& blood

*lucose le-els t&at

appear to

correlate .it&

ac&ie-ement o) an

A1C o) ,7E( "&e

issue o) pre6

-ersus

postprandial

S%B tar*ets is

comple? '100+(

$le-ated

postc&allen*e '26

& ""+ *lucose

-alues &a-e been

associated .it&

increased

cardio-ascular ris/

independent o) P

in some

epidemiolo*icalstudies( !n diabetic

sub8ects, surro*ate

measures o)

-ascular pat&olo*y,

suc& as endot&elial

dys)unction, are

ne*ati-ely a))ected

by postprandial

&yper*lycemia '101+(

!t is clear t&at

postprandial

&yper*lycemia, li/e

preprandial

&yper*lycemia,

contributes to

ele-ated A1C le-els,

.it& its relati-e

contribution bein*

*reater at A1C le-els

t&at are closer to

7E( o.e-er,

outcome studies

&a-e clearly s&o.n

A1C to be t&e

primary predictor o)

complications, and

landmar/ *lycemic

control trials suc& as

t&e DCC" and

PDS relied

o-er.&elmin*ly on

preprandial S%B(

Additionally, an ;C"

in patients .it&

/no.n CVD )ound

no CVD bene)it o)

insulin re*imens

tar*etin*

postprandial *lucose

compared .it& t&ose

tar*etin* preprandial

*lucose '102+( A

reasonable

recommendation )or

postprandial testin*

and tar*ets is t&at )or

indi-iduals .&o &a-e

premeal *lucose

-alues .it&in tar*et

but &a-e A1C -alues

abo-e tar*et,

monitorin*

postprandial plasma


24/136

*lucose 'PP+ 1K2 & a)ter t&e start o) t&e meal and treatment aimed at reducin*

"&e e-idence )or a cardio-ascular bene)it o)

intensi-e *lycemic control primarily rests on lon*6

term )ollo.6up o) study co&orts treated early in

t&e course o) type 1 and type 2 diabetes, and a

subset analyses o) ACC;D, ADVA#C$, and

VAD"( A *roup6le-el meta6analysis o) t&e latter

t&ree trials su**ests t&at *lucose lo.erin* &as a

modest 'E+ but statistically si*ni)icant reduction

in ma8or CVD outcomes, primarily non)atal %!,

.it& no si*ni)icant e))ect on mortality( o.e-er,

&etero*eneity o) t&e mortality e))ects across

studies .as noted( A prespeci)ied sub*roup

analysis su**ested t&at ma8or CVD outcome

reduction occurred in patients .it&out /no.n

CVD at baseline '; 0(4 L9E C! 0(74K0(4M+

'+(

Con-ersely,

t&e mortality

)indin*s in

ACC;D

and

sub*roup

analyses o)

t&e VAD"

su**est t&att&e potential

ris/s o)

intensi-e

*lycemic

control may

out.ei*& its

bene)its in

some

patients(

"&ose .it&

lon*

duration o)

diabetes,

/no.n

&istory o)

se-ere&ypo*lycemi

a,

i*ure 1:Approac& tomana*emento)&yper*lycemia( Depiction

o) t&eelements o)decisionma/in* usedto determineappropriatee))orts toac&ie-e*lycemic

tar*ets( C&aracteristicspredicaments to.ard t&e le)t

8usti)y more strin*ent e))ortsto lo.er A1C, .&ereas t&oseto.ard t&e ri*&t arecompatible .it& lessstrin*ent e))orts( &erepossible, suc& decisionss&ould be made incon8unction .it& t&e patient,re)lectin* &is or &er

pre)erences, needs, and-alues( "&is @scale is notdesi*ned to be applied ri*idlybut to be used as a broadconstruct to &elp *uideclinical decisions( Adapted.it& permission )rom !smail6Bei*i et al( '+(


25/136

S2G Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

"able :Summary o) *lycemic recommendations )ormany nonpre*nantadults .it& diabetesA1C

Preprandial capillary plasma *lucose

Pea/ postprandial capillaryplasma *lucoseT c Ioalss&ould be indi-iduali=ed basedon5

c duration

o)

diabetesc

a*eli)e

e?pectanc

yc

comorbid

conditions

c /no.n CVD or ad-ancedmicro-ascularcomplications

c &ypo*lycemia una.arenessc indi-idual patient

considerationsc %ore orless strin*ent *lycemic

*oals

may be appropriate )or

indi-idual patients c Postprandial

*lucose may be tar*eted i) A1C

*oals are not met

despite reac&in*

preprandial *lucose

*oals

TPostprandial *lucose measurements s&ould be made 1K2 & a)ter t&ebe*innin* o) t&e meal, *enerally pea/ le-els in patients .it& diabetes(

1. se %D! in8ections '3K4in8ections perday o) basaland prandialinsulin+ or CS!!t&erapy(

2. %atc&prandialinsulin to

carbo&ydrate inta/e,premeal blood *lucose,and anticipated acti-ity(

3. or most patients 'especially.it& &ypo*lycemia+, useinsulin analo*s(

4. or patients .it& )re>uentnocturnal &ypo*lycemia andor&ypo*lycemia una.areness,use o) sensor6au*mented lo.*lucose suspend t&res&oldpump may be considered(

"&ere are

e?cellent

re-ie.s to *uide

t&e initiation and

mana*ement o)

insulin t&erapy to

ac&ie-e desired

PP -alues to ,10 m*d< may &elplo.er A1C(

lycemic *oals )or c&ildren are pro-idedin Section V!!!(A(1(a(

lycemic oals in Pre*nant omen

"&e *oals )or *lycemic control )or .omen .it&

D% are based on recommendations )rom t&e

i)t& !nternational or/s&op6Con)erence on

estational Diabetes %ellitus '103+ and &a-e

t&e )ollo.in* tar*ets )or maternal capillary

*lucose concentrations5

c Preprandial5 U9 m*d< '9(3mmol


26/136

a 'G2 episodes per 100 patient6years o)

t&erapy+( Since t&e DCC", a number o) rapid6

actin* and lon*6actin* insulin analo*s &a-e

been de-eloped( "&ese analo*s are

associated .it& less &ypo*lycemia .it& e>ual

A1C lo.erin* in type 1 diabetes '109,10G+(

;ecommended t&erapy )or type 1diabetes consists o) t&e )ollo.in*components5

*lycemic *oals

'109,107,10+( Alt&ou*&

most studies o) %D!

-ersus pump t&erapy

&a-e been small and o)

s&ort duration, a

systematic re-ie. and

meta6analysis concluded

t&at t&ere .ere no

systematic di))erences in

A1C or se-ere&ypo*lycemia rates in

c&ildren and adults

bet.een t&e t.o )orms o)

intensi-e insulin t&erapy

'73+( ;ecently, a lar*e

randomi=ed trial in type 1

diabetic patients .it&

nocturnal &ypo*lycemia

reported t&at sensor6

au*mented insulin pump

t&erapy

.it& t&e

t&res&old6

suspend

)eature

reduced

nocturnal

&ypo*lycem

ia, .it&out

increasin*

*lycated&emo*lobin

-alues '74+(

-erall,

intensi-e

mana*eme

nt t&rou*&

pump

t&erapyC

% and

acti-e

patient)amil

y

participation

s&ould be

stron*ly

encoura*ed

'10K111+(

or selected

indi-iduals

.&o &a-e

masteredcarbo&ydrat

e countin*,

education on

t&e impact o)

protein and

)at on

*lycemic

e?cursions

can be

incorporated

into

diabetes

mana*eme

nt '112+(

Screenin*

Because o)t&eincreased

)re>uencyo) ot&erautoimmune diseasesin type 1diabetes,screenin*)or t&yroiddys)unction, -itamin

B12

de)iciency,and celiacdiseases&ould beconsideredbased onsi*ns andsymptoms(Periodicscreenin* in

asymptomaticindi-iduals&as beenrecommended, but t&ee))ecti-eness andoptimal)re>uencyare unclear(


27/136


i*ure 2:Anti&yper*lycemic t&erapy in type 2 diabetes5 *eneral recommendations( DPP646i, DPP64 in&ibitorO ?Hs, bone )racturesO !, *astrointestinalO


28/136

on body .ei*&t, and &ypo*lycemia ris/( "&e position statement

rea))irms met)ormin as t&e pre)erred initial a*ent, barrin*

contraindication or intolerance, eit&er in addition to li)estyle

counselin* and support )or .ei*&t loss and e?ercise, or .&en

li)estyle e))orts alone &a-e not ac&ie-ed or maintained *lycemic

*oals( %et)ormin &as a lon*6standin* e-idence base )or e))icacy and

sa)ety, is ine?pensi-e, and may reduce ris/ o) cardio-ascular e-ents

'7+( &en met)ormin )ails to ac&ie-e or maintain *lycemic *oals,

anot&er a*ent

s&ould be added(

Alt&ou*& t&ere are

numerous trials

comparin* dual

t&erapy to

met)ormin alone,

)e. directly

compare dru*s as

add6on t&erapy(

Comparati-e

e))ecti-eness

meta6analyses

'114+ su**est t&at

o-erall, eac& ne.

class o) noninsulin

a*ents added to

initial t&erapy

lo.ers A1C around

0(K1(1E(


29/136


%any patients .it& type 2 diabetes e-entually re>uire and bene)it

)rom insulin t&erapy( "&e pro*ressi-e nature o) type 2 diabetes and

its t&erapies s&ould be re*ularly and ob8ecti-ely e?plained to patients(

Pro-iders s&ould a-oid usin* insulin as a t&reat or describin* it as a

)ailure or punis&ment( $>uippin* patients .it& an al*orit&m )or sel)6

titration o) insulin doses based on S%B results impro-es *lycemiccontrol in type 2 diabetic patients initiatin* insulin '119+( ;e)er to t&e

ADA6$ASD position statement )or more details on p&armacot&erapy

)or &yper*lycemia in type 2 diabetes '113+ 'i*( 2+(

$( %edical #utrition "&erapy

!eneral Recommendations

3 #utrition t&erapy is recommended )or all people .it& type 1

and type 2 diabetes as an e))ecti-e component

o) t&e o-erall treatment plan(A

3 !ndi-iduals .&o &a-e prediabetes or diabetes s&ould recei-e

indi-iduali=ed %#" as needed to ac&ie-e treatment *oals,

pre)erably pro-ided by a re*istered dietitian )amiliar .it& t&ecomponents o)

diabetes %#"(A

3 Because diabetes nutrition t&erapy can result in cost sa-in*s B

and impro-ed outcomes suc& as reduction in A1CA, nutrition

t&erapy s&ould be ade>uately reimbursed by insurance and ot&er

payers( $

$ner*y Balance, -er.ei*&t, and besity

3 or o-er.ei*&t or obese adults .it& type 2 diabetes or at ris/

)or diabetes, reducin* ener*y inta/e .&ile maintainin* a

&ealt&)ul eatin* pattern is recommended to promote

.ei*&t loss(A

3 %odest .ei*&t loss may pro-ide clinical bene)its 'impro-ed

*lycemia, blood pressure, andor lipids+ in some indi-iduals .it&

diabetes, especially t&ose early in t&e disease process( "o ac&ie-e

modest .ei*&t loss, intensi-e li)estyle inter-entions 'counselin*

about nutrition t&erapy, p&ysical acti-ity, and be&a-ior c&an*e+ .it&

on*oin* support are recommended(A

$atin* Patterns and %acronutrient

Distribution

3 $-idence su**ests t&at t&ere is not an ideal percenta*e o)

calories )rom

carbo&ydrate,

protein, and )at

)or all people

.it& diabetes BO

t&ere)ore,

macronutrient

distributions&ould be based

on indi-iduali=ed

assessment o)

current eatin*

patterns,

pre)erences, and

metabolic *oals(

$

3 A -ariety o)

eatin* patterns

'combinations

o) di))erent

)oods or )ood

*roups+ are

acceptable )or

t&e

mana*ement

o) diabetes(

Personal

pre)erence

'e(*(, tradition,

culture,

reli*ion, &ealt&

belie)s and

*oals,

economics+and metabolic

*oals s&ould

be considered

.&en

recommendin*

one eatin*

pattern o-er

anot&er( $

Carbo&ydrate Amountand Quality

3 %onitorin*

carbo&ydrateinta/e, .&et&er

by

carbo&ydrate

countin* or

e?perience6

based

estimation,

remains a /ey

strate*y in

ac&ie-in*

*lycemiccontrol( B

3 or *ood &ealt&,carbo&ydrate

inta/e )rom

-e*etables,

)ruits, .&ole

*rains, le*umes,

and dairy

products s&ould

be ad-ised o-er

inta/e )rom

ot&er

carbo&ydrate

sources,especially t&ose

t&at contain

added )ats,

su*ars,

or sodium( B

3 Substitutin*

lo.6*lycemic

load )oods )or

&i*&er6

*lycemic load

)oods may

modestlyimpro-e*lycemiccontrol( C

3 People .it&

diabetes s&ould

consume at

least t&e amount

o) )iber and

.&ole *rains

recommended

)or t&e *eneral

public( C

3 &ile

substitutin*

sucrose6

containin* )oods

)or isocaloric

amounts o)

ot&er

carbo&ydrates

may &a-e

similar blood

*lucose e))ects,

consumption

s&ould be

minimi=ed to

a-oid displacin*

nutrient6dense

)ood

c&oices(A

3 People .it&

diabetes and

t&ose at ris/ )or

diabetes s&ould

limit or a-oid

inta/e o) su*ar6

s.eetened

be-era*es

')rom anycaloric

s.eetener

includin* &i*&6

)ructose corn

syrup and

sucrose+ to

reduce ris/ )or

.ei*&t *ain and

.orsenin* o)

cardiometabolic

ris/ pro)ile( B

Dietary at Quantityand Quality

3 $-idence isinconclusi-e )oran idealamount o) total)at inta/e )orpeople .it&diabetesOt&ere)ore,*oals s&ouldbeindi-iduali=ed(Cat >ualityappears to be)ar moreimportant t&an>uantity( B


30/136


31/136


Alco&ol

3 !) adults .it& diabetes c&oose to drin/ alco&ol, t&ey s&ould be

ad-ised to do so in moderation 'one drin/ per day or less )or adult

.omen and t.o drin/s per day or less )or adult

men+( $

3 Alco&ol consumption may place people .it& diabetes at increased

ris/ )or delayed &ypo*lycemia, especially i) ta/in* insulin or insulin

secreta*o*ues( $ducation and a.areness re*ardin* t&e

reco*nition and mana*ement o) delayed &ypo*lycemia is

.arranted( C

Sodium

3 "&e recommendation )or t&e *eneral population to reduce sodium

to

,2,300 m*day is also appropriate )or people .it& diabetes( B

3 or indi-iduals .it& bot& diabetes and &ypertension, )urt&er

reduction in sodium inta/e s&ould be indi-iduali=ed( B

Primary Pre-ention o) "ype 2 Diabetes

3 Amon* indi-iduals at &i*& ris/ )or de-elopin* type 2 diabetes,

structured pro*rams t&at emp&asi=e li)estyle c&an*es t&at include

moderate .ei*&t loss '7E o) body .ei*&t+ and re*ular p&ysical

acti-ity '190 min.ee/+, .it& dietary strate*ies includin* reduced

calories and reduced inta/e o) dietary )at, can reduce t&e ris/ )or

de-elopin* diabetes and are t&ere)ore

recommended(A

3 !ndi-iduals at &i*& ris/ )or type 2 diabetes s&ould be encoura*ed

to ac&ie-e t&e (S( Department o) A*riculture 'SDA+

recommendation )or dietary )iber '14 * )iber1,000 /cal+ and )oods

containin* .&ole *rains 'one6&al) o) *rain inta/e+( B

"&e ADA recently released an updated position statement on

nutrition t&erapy )or adults li-in* .it& diabetes '11G+(

#utrition t&erapy is an inte*ral component o) diabetes pre-ention,

mana*ement, and sel)6mana*ement education( All indi-iduals .it&

diabetes s&ould recei-e indi-iduali=ed %#" pre)erably pro-ided by a

re*istered dietitian .&o is /no.led*eable and s/illed in pro-idin*

diabetes %#"( Compre&ensi-e *roup diabetes education pro*rams

includin* nutrition

t&erapy orindi-iduali=ededucationsessions &a-ereported A1Cdecreases o)

0(3K1E )or type 1diabetes '117K120+ and 0(9K2E)or type 2diabetes'9,121K137+(

!ndi-iduals .it&

type 1 diabetes

s&ould be o))ered

intensi-e insulin

t&erapy education

usin* t&e

carbo&ydrate6countin* meal

plannin* approac&

'117,11,120,124,1

3K140+O t&is

approac& &as been

s&o.n to impro-e

*lycemic control

'13,141+(

Consistent

carbo&ydrate inta/e

.it& respect to time

and amount can

result in impro-ed*lycemic control )or

indi-iduals usin*

)i?ed daily insulin

doses '142,143+( A

simple diabetes

meal plannin*

approac& suc& as

portion control or

&ealt&)ul )ood

c&oices may be

better suited )or

indi-iduals .it&

&ealt& literacy andnumeracy concerns

'129K127+(

ei*&t loss o) 2K

/* may pro-ide

clinical bene)its in

t&ose .it& type 2

diabetes, especially

early in t&e disease

process '144K14G+(

ei*&t loss studies

&a-e used a -ariety

o) ener*y6restrictedeatin* patterns,

.it& no clear

e-idence t&at one

eatin* pattern or

optimal

macronutrient

distribution .as

ideal( Alt&ou*&

se-eral studies

resulted in

impro-ements in

A1C at 1 year

'144,149,147K

14+, not all .ei*&t

loss inter-entions

led to 16year A1C

impro-ements

'12,190K194+(

"&e most

consistently

identi)ied c&an*es

in cardio-ascular

ris/ )actors .ere

an increase in Duality o)

li)e '213,21G,217+,

&ealt&y copin*

'21,21+, andlo.er costs

'220,221+( Better

outcomes .ere

reported )or DS%$

inter-entions t&at

.ere lon*er and

included )ollo.6up

support 'DS%S+

'207,222K224+, t&at


35/136


.ere culturally '229,22G+ and a*e appropriate '227,22+ and .ere

tailored to indi-idual needs and pre)erences, and t&at addressed

psyc&osocial issues and incorporated be&a-ioral strate*ies

'207,20,21,21,22K231+( Bot& indi-idual and *roup approac&es

&a-e been )ound e))ecti-e '232,233+( "&ere is *ro.in* e-idence )or

t&e role o) a community &ealt& .or/ers '234+ and peer '239K23+and lay leaders '240+ in deli-erin* DS%$ and DS%S as part o) t&e

DS%$S team '241+(

Diabetes education is associated .it& increased use o) primary and

pre-enti-e ser-ices '220,242,243+ and lo.er use o) acute, inpatient

&ospital ser-ices '220+( Patients .&o participate in diabetes

education are more li/ely to )ollo. best practice treatment

recommendations, particularly amon* t&e %edicare population, and

&a-e lo.er %edicare and commercial claim costs '221,242+(

"&e #ational Standards )or Diabetes Sel)6%ana*ement $ducation

and Support"&e #ational Standards )or Diabetes Sel)6%ana*ement $ducation and

Support are desi*ned to de)ine >uality DS%$ and DS%S and to assist

diabetes educators in a -ariety o) settin*s to pro-ide e-idence6based

education and sel)6mana*ement support '20G+( "&e standards are

re-ie.ed and updated e-ery 9 years by a tas/ )orce representin* /ey

or*ani=ations in-ol-ed in t&e )ield o) diabetes education and care(

Diabetes Sel)6%ana*ement $ducation and Support Pro-iders and

People it& Prediabetes"&e standards )or DS%$ and DS%S also apply to t&e education and

support o) people .it& prediabetes( Currently, t&ere are si*ni)icant

barriers to t&e pro-ision o) education and support to t&ose .it&

prediabetes( o.e-er, t&e strate*ies )or supportin* success)ul be&a-ior

c&an*e and t&e &ealt&y be&a-iors recommended )or people .it&prediabetes are lar*ely identical to t&ose )or people .it& diabetes( As

barriers to care are o-ercome, pro-iders o) DS%$ and DS%S, *i-en t&eir

trainin* and e?perience, are particularly .ell e>uipped to assist people

.it& prediabetes in de-elopin* and maintainin* be&a-iors t&at can

pre-ent or delay t&e onset o) diabetes '20G,244,249+(

;eimbursement

)or Diabetes Sel)6

%ana*ement

$ducation and

Support

DS%$, .&en

pro-ided by apro*ram t&at meets

national standards

)or DS%$ and is

reco*ni=ed by ADA

or ot&er appro-al

bodies, is

reimbursed as part

o) t&e %edicare

pro*ram as

o-erseen by t&e

Centers )or

%edicare and

%edicaid Ser-ices'C%S+( DS%$ is

also co-ered by

most &ealt&

insurance plans(

Alt&ou*& DS%S

&as been s&o.n to

be instrumental )or

impro-in*

outcomes, as

described in

@$-idence )or t&e

Bene)its o)

Diabetes Sel)6%ana*ement

$ducation and

Support, and can

be pro-ided in

)ormats suc& as

p&one calls and -ia

tele&ealt&, it

currently &as

limited

reimbursement as

)ace6to6)ace -isits

included as )ollo.6

up to DS%$(

( P&ysical Acti-ity

Recommendations

3 As is t&e case )or

all c&ildren,

c&ildren .it&

diabetes or

prediabetes

s&ould be

encoura*ed to

en*a*e in at

least

G0 min o)p&ysical acti-ityeac& day( B

3 Adults .it&

diabetes s&ould

be ad-ised to

per)orm at least

190 min.ee/ o)

moderate6

intensity aerobic

p&ysical acti-ity

'90K70E o)

ma?imum &eart

rate+, spread

o-er at least 3

days.ee/ .it&

no more t&an 2

consecuti-e days

.it&oute?ercise(A

3 !n t&e absence

o)

contraindication

s, adults .it&

type 2 diabetess&ould be

encoura*ed to

per)orm

resistance

trainin* at least

t.ice per .ee/(

A

$?ercise is an

important part o)

t&e diabetes

mana*ement plan(

;e*ular e?ercise&as been s&o.n to

impro-e blood

*lucose control,

reduce

cardio-ascular ris/

)actors, contribute

to .ei*&t loss, and

impro-e .ell6

bein*(

urt&ermore,

re*ular e?ercise

may pre-ent type 2

diabetes in &i*&6

ris/ indi-iduals

'23K29+(

Structured

e?ercise

inter-entions o) at

least .ee/sH

duration &a-e been

s&o.n to lo.er

A1C by an a-era*e

o) 0(GGE in people

.it& type 2

diabetes, e-en .it&

no si*ni)icant

c&an*e in B%!

'24G+( "&ere are

considerable data

)or t&e &ealt&

bene)its 'e(*(,

increased

cardio-ascular

)itness, muscle

stren*t&, impro-ed

insulin sensiti-ity,

etc(+ o) re*ular

p&ysical acti-ity )ort&ose .it& type 1

diabetes '247+(

i*&er le-els o)

e?ercise intensity

are associated .it&

*reater


36/136

impro-ements in A1C and in )itness '24+( t&er bene)its include

slo.in* t&e decline in mobility amon* o-er.ei*&t patients .it&

diabetes '24+( A 8oint position statement o) ADA and t&e

American Colle*e o) Sports %edicine summari=es t&e e-idence

)or t&e bene)its o) e?ercise in people .it& type 2 diabetes '290+(

re>uency and "ype o) $?ercise

"&e (S( Department o) ealt& and uman Ser-icesH P&ysicalActi-ity uidelines )or Americans '291+ su**est t&at adults o-er a*e

1 years do 190 min.ee/ o) moderate6intensity, or 79 min.ee/ o)

-i*orous aerobic p&ysical acti-ity, or an e>ui-alent combination o)

t&e t.o( !n addition, t&e *uidelines su**est t&at adults also do

muscle6stren*t&enin* acti-ities t&at in-ol-e all ma8or muscle *roups

2 or more days .ee/( "&e *uidelines su**est t&at adults o-er a*e

G9 years, or t&ose .it& disabilities, )ollo. t&e adult *uidelines i)

possible or 'i) t&is is not possible+ be as p&ysically acti-e as t&ey are

able( Studies included in t&e meta6analysis o) e))ects o) e?ercise

inter-entions on *lycemic control '24G+ &ad a mean o) 3(4

sessions.ee/, .it&

a mean o) 4 min

session( "&e DPP

li)estyle

inter-ention, .&ic&

included 190

min.ee/ o)

moderate6intensity

e?ercise, &ad a

bene)icial e))ect on

*lycemia in t&ose.it& prediabetes(

"&ere)ore, it seems

reasonable to

recommend t&at

people .it&

diabetes )ollo. t&e

p&ysical acti-ity

*uidelines )or t&e

*eneral population(

Pro*ressi-e

resistance e?ercise

impro-es insulin

sensiti-ity in older

men .it& type 2

diabetes to t&e

same or e-en a

*reater e?tent as

aerobic e?ercise

'292+( Clinical trials

&a-e pro-idedstron* e-idence )or

t&e A1C lo.erin*

-alue o) resistance

trainin* in older

adults .it& type 2

diabetes

'293,294+, and )or

an additi-e bene)it

o) combined

aerobic and

resistance e?ercise

in adults .it& type 2

diabetes '299,29G+(

!n t&e absence o)

contraindications,

patients .it& type 2

diabetes s&ould be

encoura*ed to do

at least t.o .ee/ly

sessions o)resistance e?ercise

'e?ercise .it& )ree

.ei*&ts or .ei*&t

mac&ines+, .it&

eac& session

consistin* o) at

least one set o) )i-e

or


37/136


more di))erent resistance e?ercises in-ol-in* t&e lar*e muscle *roups

'290+(

Pre6e?ercise $-aluation o) t&e Diabetic Patient

As discussed more )ully in Section V!(A(9, t&e area o) screenin*

asymptomatic diabetic patients )or coronary artery disease 'CAD+

remains unclear( An ADA consensus statement on t&is issue

concluded t&at routine screenin* is not recommended '297+(

Pro-iders s&ould use clinical 8ud*ment in t&is area( Certainly, &i*&6

ris/ patients s&ould be encoura*ed to start .it& s&ort periods o) lo.6

intensity e?ercise and increase t&e intensity and duration slo.ly(

Pro-iders s&ould assess patients )or conditions t&at mi*&t

contraindicate certain types o) e?ercise or predispose to in8ury, suc&

as uncontrolled &ypertension, se-ere autonomic neuropat&y, se-ere

perip&eral neuropat&y or &istory o) )oot lesions, and unstable

proli)erati-e retinopat&y( "&e patientHs a*e and pre-ious p&ysical

acti-ity le-el s&ould be considered( or type 1 diabetic patients, t&e

pro-ider s&ould customi=e t&e e?ercise re*imen to t&e indi-idualHs

needs( "&ose .it& complications may re>uire a more t&orou*&

e-aluation '247+(

$?ercise in t&e Presence o)

#onoptimal lycemic Control

Hyerglycemia" &en people .it& type 1diabetes are depri-ed o)

insulin )or 12K4 & and are /etotic, e?ercise can .orsen

&yper*lycemia and /etosis '29+O t&ere)ore, -i*orous acti-ity

s&ould be a-oided in t&e presence o) /etosis( o.e-er, it is not

necessary to postpone e?ercise based simply on &yper*lycemia,

pro-ided t&e patient )eels .ell and urine andor blood /etones are

ne*ati-e(

Hyoglycemia" !n indi-iduals ta/in*insulin andor insulin secreta*o*ues,

p&ysical acti-ity can cause &ypo*lycemia i) medication dose or

carbo&ydrate consumption is not altered( or indi-iduals on t&eset&erapies, added carbo&ydrate s&ould be in*ested i) pre6e?ercise

*lucose le-els are ,100 m*d< '9(G mmol


38/136

( Psyc&osocial Assessment and Care

Recommendations

3 !t is reasonable to include assessment o) t&e patientHs psyc&olo*ical

and social situation as an on*oin* part o) t&e

medical mana*ement o) diabetes( B

3 Psyc&osocial screenin* and )ollo.6up may include, but are not

limited to, attitudes about t&e illness, e?pectations )or medicalmana*ement and outcomes, a))ect mood, *eneral and

diabetes6related >uality o) li)e, resources ')inancial, social, and

emotional+, and

psyc&iatric &istory( $

3 ;outinely screen )or psyc&osocial problems suc& as

depression and diabetes6related distress, an?iety, eatin*

disorders, and co*niti-e impairment( B

$motional .ell6bein* is an important part o) diabetes care and sel)6

mana*ement( Psyc&olo*ical and social problems can impair t&e

indi-idualHs '2G3K2G9+ or )amilyHs ability '2GG+ to carry out diabetes

care tas/s and t&ere)ore compromise &ealt& status( "&ere are

opportunities )or t&e clinician to routinely assess psyc&osocial status

in a timely and

e))icient manner so

t&at re)erral )or

appropriate

ser-ices can be

accomplis&ed( A

systematic re-ie.

and meta6analysis

s&o.ed t&at

psyc&osocial

inter-entionsmodestly but

si*ni)icantly

impro-ed A1C

'standardi=ed

mean di))erence

20(2E+ and

mental &ealt&

outcomes(

o.e-er, t&ere .as

a limited

association

bet.een t&e e))ects

on A1C and mental

&ealt&, and no

inter-ention

c&aracteristics

predicted bene)it

on bot& outcomes

'2G7+(

Screenin*ey opportunities

)or routine

screenin* o)

psyc&osocial status

occur at dia*nosis,

durin* re*ularly

sc&eduled

mana*ement -isits,

durin*

&ospitali=ations,

.it& t&e disco-ery o)

complications, or

.&en problems .it&

*lucose control,

>uality o) li)e, or

sel)6mana*ement

are identi)ied(

Patients are li/ely to

e?&ibit psyc&olo*ical

-ulnerability at

dia*nosis and .&en

t&eir medical status

c&an*es, e(*(, end o)

t&e &oneymoon

period, .&en t&e

need )or intensi)iedtreatment is e-ident,

and .&en

complications are

disco-ered(

Depression a))ects

about 20K29E o)

people .it& diabetes

'2G+ and increases

t&e ris/ )or %! and

post6%! '2G+ and


39/136


all6cause mortality '270+( "&ere appears to be a bidirectional

relations&ip .it& bot& diabetes '271+ and metabolic syndrome '272+ and

depression(

Diabetes6related distress is distinct )rom clinical depression and is

-ery common '273K27G+ amon* people .it& diabetes and t&eir

)amily members '2GG+(

Pre-alence is reported as 1K49E, .it& an incidence o) 3K4E o-er 1

mont&s( i*& le-els o) distress are si*ni)icantly lin/ed to A1C, sel)6

e))icacy, dietary and e?ercise be&a-iors '21,274+, and medication ta/in*

'277+( t&er issues /no.n to impact sel)6mana*ement and &ealt&

outcomes include but are not limited to attitudes about t&e illness,

e?pectations )or medical mana*ement and outcomes, an?iety, *eneral

and diabetes6related >uality o) li)e, resources ')inancial, social, and

emotional+ '27+ and psyc&iatric &istory '27,20+( Screenin* tools are

a-ailable )or a number o) t&ese areas '22,21,22+(

;e)erral to %ental ealt& Specialist!ndications )or re)erral to a mental &ealt& specialist )amiliar .it&

diabetes mana*ement may include *ross disre*ard )or t&e

medical re*imen 'by sel) or ot&ers+ '23+, depression, possibility

o) sel)6&arm, debilitatin* an?iety 'alone or .it& depression+,

indications o) an eatin* disorder '24+, or co*niti-e )unctionin*

t&at si*ni)icantly impairs 8ud*ment( !t is pre)erable to incorporate

psyc&olo*ical assessment and treatment into routine care rat&er

t&an .aitin* )or a speci)ic problem or deterioration in metabolic

or psyc&olo*ical status '22,273+( !n t&e recent DA#2 study,

si*ni)icant diabetes6related distress .as reported by 44(GE o)

t&e participants, but only 23(7E reported t&at t&eir &ealt& care

team as/ed t&em &o. diabetes impacted t&eir li)e '273+(

Alt&ou*& t&e clinician may not )eel >uali)ied to treat psyc&olo*icalproblems '29+, usin* t&e patient6pro-ider relations&ip as a

)oundation can increase t&e li/eli&ood t&at t&e patient .ill accept

re)erral )or ot&er ser-ices( Collaborati-e care inter-entions and use

o) a team approac& &a-e demonstrated e))icacy in diabetes and

depression '2G,27+, and

inter-entions toen&ance sel)6mana*ement andaddress se-eredistress &a-e

demonstrated

e))icacy indiabetes6relateddistress '21+(

!( &en "reatmentoals Are #ot %et

Some people .it&

diabetes and t&eir

&ealt& care

pro-iders may not

ac&ie-e t&e desired

treatment *oals

'"able +(

;et&in/in* t&etreatment re*imen

may re>uire

assessment o)

barriers includin*

income, &ealt&

literacy, diabetes6

related distress,

depression, and

competin*

demands, includin*

t&ose related to

)amily

responsibilities anddynamics( t&er

strate*ies may

include culturally

appropriate and

en&anced DS%$

and DS%S,

comana*ement

.it& a diabetes

team, re)erral to a

medical social

.or/er )or

assistance .it&

insuranceco-era*e,

assessin*

medication6ta/in*

be&a-iors, or

c&an*e in

p&armacolo*ical

t&erapy( !nitiation o)

or increase in

S%B, use o)

C%, )re>uent

contact .it& t&e

patient, or re)erral

to a mental &ealt&pro)essional or

p&ysician .it&

special e?pertise in

diabetes may be

use)ul(

J( !ntercurrent!llness

"&e stress o)

illness, trauma,

andor sur*ery)re>uently

a**ra-ates

*lycemic control

and may

precipitate DA or

non/etotic

&yperosmolar

state, li)e6

t&reatenin*

conditions t&at

re>uire immediate

medical care to

pre-entcomplications and

deat&( Any

condition leadin*

to deterioration in

*lycemic control

necessitates more

)re>uent

monitorin* o) blood

*lucose and 'in

/etosis6prone

patients+ urine or

blood /etones( !)

accompanied by/etosis, -omitin*,

or alteration in

le-el o)

consciousness,

mar/ed

&yper*lycemia

re>uires temporary

ad8ustment o) t&e

treatment re*imen

and immediate

interaction .it& t&e

diabetes care

team( "&e patienttreated .it&

noninsulin

t&erapies or %#"

alone may

temporarily re>uire

insulin( Ade>uate

)luid and caloric

inta/e must be

assured( !n)ection

or de&ydration is

more li/ely to

necessitate

&ospitali=ation o)t&e person .it&

diabetes t&an t&e

person .it&out

diabetes(

"&e &ospitali=ed

patient s&ould be

treated by a

p&ysician .it&

e?pertise in

diabetes

mana*ement( or

)urt&er in)ormation

on mana*ement o)

patients


40/136

.it& &yper*lycemia in t&e &ospital, see Section !W(A( or )urt&er

in)ormation on mana*ement o) DA or &yper*lycemic non/etotic

&yperosmolar state, re)er to t&e ADA statement on &yper*lycemic

crises '2+(

( ypo*lycemia

Recommendations

3 !ndi-iduals at ris/ )or &ypo*lycemia s&ould be as/ed about

symptomatic and asymptomatic &ypo*lycemia at

eac& encounter( C

3 lucose '19K20 *+ is t&e pre)erred treatment )or t&e conscious

indi-idual .it& &ypo*lycemia, alt&ou*& any )orm o)

carbo&ydrate t&at contains *lucose may be used( A)ter 19 min

o) treatment, i) S%B s&o.s continued &ypo*lycemia, t&e

treatment s&ould be repeated( nce S%B returns to normal,

t&e indi-idual s&ould consume a meal or snac/ to pre-ent

recurrence o) &ypo*lycemia( $

3 luca*on s&ould be prescribed )or all indi-iduals at si*ni)icant ris/

o) se-ere &ypo*lycemia, and care*i-ers or )amily members o)

t&ese indi-iduals s&ould be instructed on its administration(

luca*on

administration is

not limited to

&ealt& carepro)essionals($

3 ypo*lycemia

una.areness or

one or more

episodes o)

se-ere&ypo*lycemia

s&ould tri**er re6

e-aluation o) t&e

treatmentre*imen( $

3 !nsulin6treated

patients .it&

&ypo*lycemia

una.areness

or an episode

o) se-ere

&ypo*lycemia

s&ould be

ad-ised to

raise t&eir

*lycemic

tar*ets to

strictly a-oid

)urt&er

&ypo*lycemi

a )or at least

se-eral

.ee/s, to

partiallyre-erse

&ypo*lycemi

a

una.areness

and

reduce ris/ o))utureepisodes(A

3 n*oin*

assessment o)

co*niti-e

)unction is

su**ested .it&increased

-i*ilance )or

&ypo*lycemia by

t&e clinician,

patient, and

care*i-ers i) lo.

co*nition andor

declinin*

co*nition is

)ound( B

ypo*lycemia ist&e leadin*limitin* )actor int&e *lycemicmana*ement o)type 1 andinsulin6treatedtype 2 diabetes'2+( %ild&ypo*lycemiamay beincon-enient or)ri*&tenin* to

patients .it&diabetes( Se-ere


41/136


&ypo*lycemia can cause acute &arm to t&e person .it& diabetes or

ot&ers, especially i) it causes )alls, motor -e&icle accidents, or ot&er

in8ury( A lar*e co&ort study su**ested t&at amon* older adults .it&

type 2 diabetes, a &istory o) se-ere &ypo*lycemia .as associated

.it& *reater ris/ o) dementia '20+( Con-ersely, in a substudy o) t&e

ACC;D trial, co*niti-e impairment at baseline or decline inco*niti-e )unction durin* t&e trial .as si*ni)icantly associated .it&

subse>uent episodes o) se-ere &ypo*lycemia '21+( $-idence )rom

t&e DCC"$D!C trial, .&ic& in-ol-ed youn*er adults and adolescents

.it& type 1 diabetes, su**ested no association o) )re>uency o)

se-ere &ypo*lycemia .it& co*niti-e decline '22+, as discussed in

Section V!!!(A(1(a(

As described in Section V(b(2, se-ere &ypo*lycemia .as associated

.it& mortality in participants in bot& t&e standard and intensi-e

*lycemia arms o) t&e ACC;D trial, but t&e relations&ips .it&

ac&ie-ed A1C and treatment intensity .ere not strai*&t)or.ard( An

association o) se-ere &ypo*lycemia .it& mortality .as also )ound in

t&e ADVA#C$ trial '23+( An association o) sel)6reported se-ere

&ypo*lycemia .it& 96year mortality &as also been reported in clinical

practice '24+(

!n 2013, ADA and "&e $ndocrine Society publis&ed a consensus

report on t&e impact and treatment o) &ypo*lycemia on diabetic

patients( Se-ere &ypo*lycemia .as de)ined as an e-ent re>uirin*

assistance o) anot&er person( Noun* c&ildren .it& type 1 diabetes

and t&e elderly .ere noted as particularly -ulnerable due to t&eir

limited ability to reco*ni=e &ypo*lycemic symptoms and e))ecti-ely

communicate t&eir needs( "&e report recommended t&at s&ort6actin*

insulin slidin* scales, o)ten used in lon*6term care )acilities, s&ould

be a-oided and comple? re*imens simpli)ied( !ndi-iduali=ed patient

education, dietary inter-ention 'e(*(, bedtime snac/ to pre-ent

o-erni*&t &ypo*lycemia+, e?ercise mana*ement, medicationad8ustment, *lucose monitorin*, and routine clinical sur-eillance may

impro-e patient outcomes '29+(

ypo*lycemia

treatment re>uires

in*estion o) *lucose6

or carbo&ydrate6

containin* )oods(

"&e acute *lycemic

response correlatesbetter .it& t&e

*lucose content t&an

.it& t&e

carbo&ydrate content

o) t&e )ood( Pure

*lucose is t&e

pre)erred treatment,

but any )orm o)

carbo&ydrate t&at

contains *lucose .ill

raise blood *lucose(

Added )at may retard

and t&en prolon* t&eacute *lycemic

response( n*oin*

insulin acti-ity or

insulin

secreta*o*ues may

lead to recurrent

&ypo*lycemia unless

)urt&er )ood is

in*ested a)ter

reco-ery(

luca*on

"&ose in closecontact .it&, or

&a-in* custodial

care o), people .it&

&ypo*lycemia6

prone diabetes

')amily members,

roommates, sc&ool

personnel, c&ild

care pro-iders,

correctional

institution sta)), or

co.or/ers+ s&ould

be instructed onuse o) *luca*on

/its( An indi-idual

does not need to be

a &ealt& care

pro)essional to

sa)ely administer

*luca*on( A

*luca*on /it

re>uires a

prescription( Care

s&ould be ta/en to

ensure t&at

*luca*on /its arenot e?pired(

ypo*lycemia

Pre-entionypo*lycemia

pre-ention is a

critical component

o) diabetes

mana*ement(

S%B and, )or

some patients, C%

are /ey tools to

assess t&erapy anddetect incipient

&ypo*lycemia(

Patients s&ould

understand

situations t&at

increase t&eir ris/ o)

&ypo*lycemia, suc&

as .&en )astin* )or

tests or procedures,

durin* or a)ter

intense e?ercise,

and durin* sleep,

and t&at&ypo*lycemia may

increase t&e ris/ o)

&arm to sel) or

ot&ers, suc& as .it&

dri-in*( "eac&in*

people .it& diabetes

to balance insulin

use, carbo&ydrate

inta/e, and e?ercise

is a necessary but

not al.ays su))icient

strate*y )or

pre-ention( !n type 1diabetes and

se-erely insulin6

de)icient type 2

diabetes,

&ypo*lycemia

una.areness, or

&ypo*lycemia6

associated

autonomic )ailure,

can se-erely

compromise

strin*ent diabetes

control and >ualityo) li)e( "&e de)icient

counter6re*ulatory

&ormone release

and autonomic

responses in t&is

syndrome are bot&

ris/ )actors )or, and

caused by,

&ypo*lycemia( A

corollary to t&is

@-icious cycle is

t&at se-eral .ee/s

o) a-oidance o)&ypo*lycemia &as

been demonstrated

to impro-e counter6

re*ulation and

a.areness to some

e?tent in many


42/136

patients '2G+( ence, patients .it& one or more episodes o) se-ere

&ypo*lycemia may bene)it )rom at least s&ort6term rela?ation o) *lycemic

tar*ets(


43/136


stomac& and &i*&er .it& t&ose t&at bypass portions o) t&e small intestine(

Additionally, intestinal bypass procedures may &a-e *lycemic e))ects t&at

are independent o) t&eir e))ects on .ei*&t, per&aps in-ol-in* t&e incretin

a?is(

"&ere is also e-idence )or diabetes remission )ollo.in* bariatric

sur*ery in persons .it& type 2 diabetes .&o are less se-erely obese(

ne randomi=ed trial compared ad8ustable *astric bandin* to @best

a-ailable medical and li)estyle t&erapy in sub8ects .it& type 2

diabetes and B%! 30K40 /*m2'302+( -erall, 73E o) sur*ically

treated patients ac&ie-ed @remission o) t&eir diabetes, compared

.it& 13E o) t&ose treated medically( "&e latter *roup lost only 1(7E

o) body .ei*&t, su**estin* t&at t&eir t&erapy .as not optimal( -erall

t&e trial &ad G0 sub8ects, and only 13 &ad a B%! under 39 /*m2,

ma/in* it di))icult to *enerali=e t&ese results .idely to diabetic

patients .&o are less se-erely obese or .it& lon*er duration o)

diabetes( !n a recent nonrandomi=ed study o) GG people .it& B%!

30K39 /*m2, E o) participants &ad remission o) t&eir type 2

diabetes up to G years a)ter sur*ery '303+(Disad-anta*esBariatric sur*ery is costly in t&e s&ort term and &as associated ris/s(

%orbidity and mortality rates directly related to t&e sur*ery &a-e been

reduced considerably in recent years, .it& 306day mortality rates no.

0(2E, similar to t&ose o) laparoscopic c&olecystectomy '304+( uire .ell

desi*ned clinical

trials, .it& optimal

medical and

li)estyle t&erapy,

and cardio-ascular

ris/ )actors as t&e

comparator(

%( !mmuni=ation

Recommendations

3 Annually pro-ide

an in)luen=a

-accine to all

diabetic patients

FG mont&s o)

a*e( C

3 Administer

pneumococcal

polysacc&aride

-accine to alldiabetic patients

F2 years o) a*e(

A one6time

re-accination is

recommended

)or indi-iduals (

G9 years o) a*e

.&o &a-e been

immuni=ed (9

years a*o(

t&er

indications )orrepeat

-accination

include

nep&rotic

syndrome,

c&ronic renal

disease, and

ot&er

immunocompro

mised states,

suc& as a)tertransplantation

( C3 Administer

&epatitis B

-accination to

un-accinated

adults .it&

diabetes .&o

are a*ed 1K9 years( C

3 Consider

administerin

* &epatitis B-accination

toun-accinated adults .it&diabetes.&o area*ed FG0years( C

!n)luen=a and

pneumonia are

common,

pre-entable

in)ectious diseases

associated .it&&i*& mortality and

morbidity in t&e

elderly and in

people .it& c&ronic

diseases( "&ou*&

t&ere are limited

studies reportin*

t&e morbidity and

mortality o)

in)luen=a and

pneumococcal

pneumonia

speci)ically inpeople .it&

diabetes,

obser-ational

studies o) patients

.it& a -ariety o)

c&ronic illnesses,

includin* diabetes,

s&o. t&at t&ese

conditions are

associated .it& an

increase in


44/136

&ospitali=ations )or in)luen=a and its complications( People .it&

diabetes may be at increased ris/ o) t&e bacteremic )orm o)

pneumococcal in)ection and &a-e been reported to &a-e a &i*&

ris/ o) nosocomial bacteremia, .&ic& &as a mortality rate as

&i*& as 90E '311+(

Sa)e and e))ecti-e -accines t&at *reatly reduce t&e ris/ o) serious

complications )rom t&ese diseases are a-ailable '312,313+( !n a

case6control series, in)luen=a -accine .as s&o.n to reduce

diabetes6related &ospital admission by as muc& as 7E durin* )lu

epidemics '312+( "&ere is su))icient e-idence to support t&at people

.it& diabetes &a-e appropriate serolo*ic and clinical responses to

t&ese -accinations(

"&e CDC Ad-isory Committee on !mmuni=ation Practices

recommends in)luen=a and pneumococcal -accines )or all

indi-iduals .it& diabetes '&ttp5 ...(cdc(*o--accinesrecs+(

epatitis B Vaccine


45/136

S3G Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

diabetes a*ed 23 years and o-er compared .it& adults .it&out

diabetes( Seropre-alence o) antibody to BV core anti*en,

su**estin* past or current in)ection, is G0E &i*&er amon* adults

.it& diabetes t&an t&ose .it&out, and t&ere is some e-idence t&at

diabetes imparts a &i*&er BV case )atality rate( "&e a*e

di))erentiation in t&e recommendations stems )rom CDCeconomic models su**estin* t&at -accination o) adults .it&

diabetes .&o .ere a*ed 20K9 years .ould cost an estimated

F79,000 per >uality6ad8usted li)e6year sa-ed, .&ile cost per

>uality6ad8usted li)e6year sa-ed increased si*ni)icantly at &i*&er

a*es( !n addition to competin* causes o) mortality in older adults,

t&e immune response to t&e -accine declines .it& a*e '314+(

"&ese ne. recommendations re*ardin* BV -accinations ser-e as a

reminder to clinicians t&at c&ildren and adults .it& diabetes need a

number o) -accinations, bot& t&ose speci)ically indicated because o)

diabetes as .ell as t&ose recommended )or t&e *eneral population

'&ttp5...(cdc(*o- -accinesrecs+(

V!( P;$V$#"!# A#D %A#A$%$#" D!AB$"$SC%P

'e(*(, &ypertension and dyslipidemia+ are clear ris/ )actors )or CVD,

and diabetes itsel) con)ers independent ris/( #umerous studies &a-e

s&o.n t&e e))icacy o) controllin* indi-idual cardio-ascular ris/ )actorsin pre-entin* or slo.in* CVD in people .it& diabetes(


46/136

3 !n pre*nant patients .it& diabetes and c&ronic &ypertension, blood

pressure tar*et *oals o) 110K12 G9K7 mm* are su**ested in

t&e interest o) lon*6term maternal &ealt& and minimi=in* impaired

)etal *ro.t&( AC$ in&ibitors and A;Bs are contraindicated durin*

pre*nancy( $

ypertension is a common comorbidity o) diabetes, a))ectin* t&e

ma8ority o) patients, .it& pre-alence dependin* on type o) diabetes,a*e, obesity, and et&nicity( ypertension is a ma8or ris/ )actor )or

bot& CVD and micro-ascular complications( !n type 1 diabetes,

&ypertension is o)ten t&e result o) underlyin* nep&ropat&y, .&ile in

type 2 diabetes it usually coe?ists .it& ot&er cardiometabolic ris/

)actors(

Screenin* and Dia*nosis

Blood pressure measurement s&ould be done by a trained indi-idual

and )ollo. t&e *uidelines establis&ed )or nondiabetic indi-iduals5

measurement in t&e seated position, .it& )eet on t&e )loor and arm

supported at &eart le-el, a)ter 9 min o) rest( Cu)) si=e s&ould be

appropriate )or t&e upper arm circum)erence( $le-ated -alues s&ould

be con)irmed on a

separate day(

ome blood

pressure sel)6

monitorin* and 246&

ambulatory blood

pressure monitorin*

may pro-ide

additional e-idence

o) @.&ite coat and

mas/ed

&ypertension and

ot&er discrepancies

bet.een o))ice and

@true blood

pressure( Studies in

nondiabetic

populations )ound

t&at &ome

measurements may

better correlate .it&

CVD ris/ t&an o))ice

measurements

'31,31+( o.e-er,

most o) t&e

e-idence o) bene)its

o) &ypertension

treatment in people

.it& diabetes is

based on o))ice

measurements(

"reatment oals

$pidemiolo*ical

analyses s&o. t&at

blood pressures (

11979 mm* are

associated .it&

increased

cardio-ascular

e-ent rates and

mortality in

indi-iduals .it&

diabetes '320K

322+ and t&at

SBP (120 mm*

predict lon*6term

end6sta*e renal

disease '$S;D+(

;andomi=ed clinical

trials &a-e

demonstrated t&e

bene)it 'reduction o)

CD e-ents,

stro/e, and

nep&ropat&y+ o)lo.erin* blood

pressure to ,140

mm* systolic

and ,0 mm*

diastolic in

indi-iduals .it&

diabetes


47/136


'320,323K329+( "&ere is limited e-idence )or t&e bene)its o) lo.er SBP

tar*ets(

"&e ACC;D trial e?amined .&et&er a lo.er SBP o) ,120

mm* pro-ides *reater cardio-ascular protection t&an an SBP

le-el o) 130K140 mm* in

patients .it& type 2 diabetes at &i*& ris/ )or CVD '32G+( "&e ; )or

t&e primary end point 'non)atal %!, non)atal stro/e, and CVD deat&+

in t&e intensi-e 'blood pressure 11G4 on 3(4 medications+ -ersus

standard *roup 'blood pressure 14370 on 2(1 medications+ .as 0(

'9E C! 0(73K1(0GO P 9 0(20+( ) t&e prespeci)ied secondary end

points, only stro/e and non)atal stro/e .ere statistically si*ni)icantly

reduced by intensi-e blood pressure treatment( "&e number needed

to treat to pre-ent one stro/e o-er t&e course o) 9 years .it&

intensi-e blood pressure mana*ement .as ( Serious ad-erse

e-ent rates 'includin* syncope and &yper/alemia+ .ere &i*&er .it&

intensi-e tar*ets '3(3E -s( 1(3EO P 9 0(001+( Albuminuria rates .ere

reduced .it& more intensi-e blood pressure *oals, but t&ere .ere no

di))erences in renal )unction nor in ot&er micro-ascularcomplications(

"&e ADVA#C$ trial 'treatment .it& an AC$ in&ibitor and a t&ia=ide6type

diuretic+ s&o.ed a reduced deat& rate but not in t&e composite

macro-ascular outcome( o.e-er, t&e ADVA#C$ trial &ad no speci)ied

tar*ets )or t&e randomi=ed comparison and t&e mean SBP in t&e

intensi-e *roup '139 mm*+ .as not as lo. as t&e mean SBP e-en in

t&e ACC;D standard6t&erapy *roup '327+( Post &oc analysis o)

ac&ie-ed blood pressure in se-eral &ypertension treatment trials &a-e

su**ested no bene)it o) lo.er ac&ie-ed SBP( As an e?ample, amon*

G,400 patients .it& diabetes and CAD enrolled in one trial, @ ti*&t control

'ac&ie-ed SBP ,130 mm*+ .as not associated .it& impro-ed

cardio-ascular outcomes compared .it& @usual care 'ac&ie-ed SBP

130K140 mm*+ '32+( Similar )indin*s emer*ed )rom an analysis o)

anot&er trial( "&ose .it& SBP ',119 mm*+ &ad increased rates o) CVD

e-ents, alt&ou*& t&ey &ad lo.er rates o) stro/e '32+(

bser-ational data, includin* t&at deri-ed )rom clinical trials,

may be

inappropriate )or

de)inin* blood

pressure tar*ets,

since sic/er

patients may &a-e

lo. blood

pressures or,con-ersely,

&ealt&ier or more

ad&erent patients

may ac&ie-e *oals

more readily( A

recent meta6

analysis o)

randomi=ed trials o)

adults .it& type 2

diabetes comparin*

prespeci)ied blood

pressure tar*ets

)ound no si*ni)icantreduction in

mortality or non)atal

%!( "&ere .as a

statistically

si*ni)icant 39E

relati-e reduction in

stro/e, but t&e

absolute ris/

reduction .as only

1E '330+(

%icro-ascular

complications .ere

not e?amined(Anot&er meta6

analysis t&at

included bot& trials

comparin* blood

pressure *oals and

trials comparin*

treatment strate*ies

concluded t&at a

systolic treatment

*oal o) 130K139

mm* .as

acceptable( it&

*oals ,130 mm*,t&ere .ere *reater

reductions in

stro/e, a 10E

reduction in

mortality, but no

reduction o) ot&er

CVD e-ents and

increased rates o)

serious ad-erse

e-ents( SBP ,130

mm* .as

associated .it&

reduced onset andpro*ression o)

albuminuria(

o.e-er, t&ere

.as &etero*eneity

in t&e measure,

rates o) more

ad-anced renal

disease outcomes

.ere not a))ected,

and t&ere .ere no

si*ni)icant c&an*es

in retinopat&y orneuropat&y '331+(

"&e clear body o)e-idence t&atSBP

(140 mm* is

&arm)ul su**ests

t&at clinicians

s&ould promptly

initiate and titrate

t&erapy in an

on*oin* )as&ion to

ac&ie-e and

maintain SBP ,140

mm* in -irtually

all patients(

Additionally,

patients .it& lon*

li)e e?pectancy 'in

.&om t&ere may

be renal bene)its

)rom lon*6term

stricter blood

pressure control+

or t&ose in .&om

stro/e ris/ is a

concern mi*&t, as

part o) s&ared

decision ma/in*,

appropriately &a-e

lo.er systolic

tar*ets suc& as ,

130 mm*( "&is is

especially true i) it

can be ac&ie-ed

.it& )e. dru*s and

.it&out side e))ects

o) t&erapy(

"reatmentStrate*ies

Alt&ou*& t&ere are

no .ell6controlled

studies o) diet and

e?ercise in t&e

treatment o)

ele-ated blood

pressure or

&ypertension in

indi-iduals .it&

diabetes, t&e

DAS study innondiabetic

indi-iduals &as

s&o.n

anti&ypertensi-e

e))ects similar to

p&armacolo*ical

monot&erapy(


48/136

o) reducin* sodium inta/e ',1,900 m* day+ and e?cess body .ei*&tO

increasin* consumption o) )ruits, -e*etables 'K10 ser-in*s per day+, and

lo.6)at dairy products '2K3 ser-in*s per day+O a-oidin* e?cessi-e alco&ol

consumption 'no more t&an 2 ser-in*s per day in men and no more t&an

1 ser-in* per day in .omen+ '332+O and increasin* acti-ity le-els '320+(

"&ese nonp&armacolo*ical strate*ies may also positi-ely a))ect *lycemia

and lipid control and as a result s&ould be encoura*ed in t&ose .it& e-en

mildly ele-ated blood pressure( "&eir e))ects on cardio-ascular e-ents&a-e n

diabetes ada 2014 cuidado standar

Documents