THE JOURNAL OF CLINICAL AND APPLIED RESERCH AND EDUCATION

Diabetes Care
January 2023 Volume 46, Supplement 1

Standards of Care in Diabetes-2023

American Diabetes Association

Presented by:- Dr. M. Kamrujjaman

Medical Officer
250 Bed District Sadar Hospital, Cox’s Bazar
ADA evidence-grading system for Standards of Care in Diabetes

Level of Evidence Description

A Clear evidence from well-conducted, generalizable

randomized controlled trials that are adequately powered
B Supportive evidence from well-conducted cohort studies

C Supportive evidence from poorly controlled or

uncontrolled studies
E Expert consensus or clinical experience
Diabetes can be classified into the following general categories:

1. Type 1 diabetes
2. Type 2 diabetes
3. Specific types of diabetes due to other causes, e.g., monogenic diabetes
syndromes, diseases of the exocrine pancreas, and drug- or chemical-
induced diabetes
4. Gestational diabetes mellitus
Criteria for the diagnosis of diabetes

FPG ≥ 126 mg/dL (7.0 mmol/L).

Or,
2-h PG ≥ 200 mg/dL (11.1 mmol/L) during OGTT.
Or,
A1C ≥ 6.5% (48 mmol/mol).
Or,
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis,
a random plasma glucose ≥ 200 mg/dL (11.1 mmol/L).
Only plasma blood glucose criteria should be used to diagnose diabetes in
following situations:-

1) Hemoglobinopathies including sickle cell disease,

2) Pregnancy (second and third trimesters and the postpartum period),
3) Glucose-6-phosphate dehydrogenase deficiency,
4) HIV treated with certain protease inhibitors (PIs) and nucleoside
reverse transcriptase inhibitors (NRTIs),
5) Hemodialysis,
6) Recent blood loss or transfusion, or
7) Erythropoietin therapy
Criteria defining prediabetes

FPG 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) (IFG)
Or,
2-h PG during 75-g OGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0
mmol/L) (IGT)
Or,
A1C 5.7–6.4% (39–47 mmol/mol)
Screening for and diagnosis of GDM

Perform a 75-g OGTT, with plasma glucose measurement when patient is

fasting and at 1 and 2 h, at 24–28 weeks of gestation in individuals not
previously diagnosed with diabetes. The diagnosis of GDM is made when
any of the following plasma glucose values are met or exceeded:-

Fasting: 92 mg/dL (5.1 mmol/L)

1 h: 180 mg/dL (10.0 mmol/L)
2 h: 153 mg/dL (8.5 mmol/L)
Criteria for screening for diabetes or prediabetes in asymptomatic
adults

1. Testing should be considered in adults with overweight or obesity (BMI ≥25

kg/m2 or ≥23 kg/m2 in Asian American individuals) who have one or more of
the following risk factors:
 First-degree relative with diabetes
 History of CVD
 Hypertension (140/90 mmHg or on therapy for hypertension)
 HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level
>250 mg/dL (2.82 mmol/L)
 Individuals with polycystic ovary syndrome

 Physical inactivity

 Other clinical conditions associated with insulin resistance

(e.g., severe obesity, acanthosis nigricans)
2. People with prediabetes (A1C ≥5.7% [39 mmol/mol], IGT, or IFG)
should be tested yearly.
3. People who were diagnosed with GDM should have lifelong testing at
least every 3 years.
4. For all other people, testing should begin at age 35 years.
5. If results are normal, testing should be repeated at a minimum of 3-year
intervals, with consideration of more frequent testing depending on initial
results and risk status.
6. People with HIV
REVIEW AND AGREE ON CONSIDER SPECIFIC FACTORS
MANAGEMENT PLAN ASSESS KEY PERSON THAT IMPACT CHOICE OF
 Review management plan CHARACTERISTICS TREATMENT
 Mutually agree on changes  The individual’s priorities  Individualized glycemic and weight
 Ensure agreed modification of therapy  Current Lifestyle and health goals
is implemented in a timely fashion to behaviors  Impact on weight, glycemia, and
avoid therapeutic inertia  Comorbidities cardiorenal protection
 Undertake decision cycle regularly (at  Clinical characteristics (i.e., age,  Underlying physiological factors
least once/twice a year) A1C, Wt)  Side effect profile of medications
 Operate in an integrated system of care  Issues such as motivation,  Complexity of regimen (i.e.,
depression, cognition frequency, mode of administration)
 Social determinants of health  Regimen choice to optimize
medication use and reduce treatment
discontinuation
DECISION CYCLE FOR  Access, cost, and availability of
PROVIDE ONGOING SUPPORT medication
AND MONITORING OF: PERSON—CENTERED
 Emotional well-being GLYCEMIC
 Lifestyle and health behaviors
 Tolerability of medications
MANAGEMENT IN
TYPE 2 DIABETES UTILIZE SHARED DICISION-
 Biofeedback including BGM/CGM,
MAKING TO CREATE A
weight, step count, A1C, BP, lipids
MANAGEMENT PLAN
 Ensure access to DSMES
AGREE ON MANAGEMENT PLAN  Involve an educated and informed
Specify SMART goals: person
IMPLEMENT MANAGEMENT  Specific  Explore personal preferences
PLAN  Measurable  Language matters
Ensure there is regular review; more  Achievable  Include motivational interviewing,
frequent contact initially is often  Realistic goal setting, and shared dicision
desirable for DSMES  Time limited making
 DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT

There are four critical times to evaluate the need for diabetes self-
management education and support:
1) At diagnosis,
2) Annually and/or when not meeting treatment targets,
3) When complicating factors develop (medical, physical, psychosocial),
and
4) When transitions in life and care occur. E
Continued
3. Diabetes self-management education and support should be person-
centered, may be offered in group or individual settings. A

4. Digital coaching and digital self-management interventions can

be effective methods to deliver diabetes self-management education and
support. B
 Medical nutrition therapy recommendations

1. For all people with overweight or obesity, behavioral modification to achieve and
maintain a minimum weight loss of 5% is recommended. A

2. Reducing overall carbohydrate intake improves glycemia and may be applied to

a variety of eating patterns. B

3. Emphasize on nutrient-dense carbohydrate sources that are high in fiber (at least
14 g fiber per 1,000 kcal) and minimally processed, with minimal added sugars. B
Continued
4. Replace sugar-sweetened beverages (including fruit juices) with water or
low calorie, no calorie beverages B and minimize consumption of foods with
added sugar. A

5. In individuals with type 2 diabetes, ingested protein appears to increase

insulin response without increasing plasma glucose concentrations.
Therefore, carbohydrate sources high in protein should be avoided when
trying to treat or prevent hypoglycemia. B
Continued
6. Eating foods rich in long-chain n-3 fatty acids, such as fatty fish (EPA and
DHA) and nuts and seeds, is recommended. B

7. Drinking of alcohol should do so in moderation (no more than one drink per
day for adult women and no more than two drinks per day for adult men). C

8. Sodium consumption should be limited to <2,300 mg/day. B

PHYSICAL ACTIVITY

1. Engage in 150 min or more of moderate- to vigorous-intensity aerobic

activity per week, spread over at least 3 days/week, with no more than 2
consecutive days without activity.

3. Decrease the amount of time spent in daily sedentary behavior. B Prolonged

sitting should be interrupted every 30 min for blood glucose benefits. C
Continued
4. Should engage in 2–3 sessions/week of resistance exercise on
nonconsecutive days.

5. Promote increase in non-sedentary activities. B Examples include walking,

yoga, housework, gardening, swimming, and dancing.

6. Flexibility training and balance training are recommended 2–3 times/week

for older adults with diabetes. C
SMOKING CESSATION: TOBACCO AND E-CIGARETTES

1. Advise all individuals not to use cigarettes and other tobacco products or e-
cigarettes. A

2. After identification of tobacco or e-cigarette use, include smoking cessation

counseling and other forms of treatment as a routine component of diabetes care. A

3. Address smoking cessation as part of diabetes education programs for those in

need. B
PSYCHOSOCIAL CARE

1. Psychosocial care, delivered by trained health care professionals, should be

provided to all people with diabetes B

2. When indicated, refer to mental health professionals or other

trained health care professionals for further assessment and treatment for
symptoms of diabetes distress, depression, suicidality, anxiety, treatment-
related fear of hypoglycemia, disordered eating, and/or cognitive capacities.
B Continued
3. Consider screening older adults (aged ≥ 65 years) with diabetes
for cognitive impairment, frailty, and depressive symptoms. B

4. Consider at least annual screening of depressive symptoms in all people

with diabetes. B

5. In people who are prescribed atypical antipsychotic medications, screen for

prediabetes and diabetes 4 months after medication initiation and sooner if
clinically indicated, at least annually. B
Sleep Health

1. Consider screening for sleep health in people with diabetes, including

symptoms of sleep disorders, disruptions to sleep due to diabetes symptoms or
management needs, and worries about sleep. B

2. Aim for consistent, uninterrupted sleep, even on weekends.

3. Long and short duration sleep negatively impact A1C.
4. Irregular sleep results in poorer glycemic control.
Glycemic Targets
1. An A1C goal for many nonpregnant adults of <7% (53 mmol/mol) without
significant hypoglycemia is appropriate. A

2. Lower A1C levels than the goal of 7% may be acceptable and even
beneficial if it can be achieved safely without significant hypoglycemia or
other adverse effects of treatment. B

3. Less stringent A1C goals (such as <8% [64 mmol/mol]) may be

appropriate for patients with limited life expectancy or where the harms of
treatment are greater than the benefits. B
Continued
Glycemic recommendations for many nonpregnant adults with diabetes

A1C <7.0% (53 mmol/mol)

Preprandial capillary plasma 80–130 mg/dL (4.4–7.2 mmol/L)

glucose

Peak postprandial capillary plasma <180 mg/dL (10.0 mmol/L)

glucose
Hypoglycemia

Classification of hypoglycemia
Level Glycemic criteria/description

Level 1 Glucose <70 mg/dL (3.9 mmol/L) and ≥54 mg/dL (3.0
mmol/L)
Level 2 Glucose <54 mg/dL (3.0 mmol/L)

Level 3 A severe event characterized by altered mental and/or

physical status requiring assistance for treatment of
hypoglycemia
 Treatment of Hypoglycemia

1. Glucose (approximately 15–20 g) is the preferred treatment for the

conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although
any form of carbohydrate may be used. B

2. Hypoglycemia unawareness or one or more episodes of level 3

hypoglycemia should trigger hypoglycemia avoidance education and
reevaluation and adjustment of the treatment plan to decrease hypoglycemia.
E Continued
3. Insulin-treated patients with hypoglycemia unawareness, one
level 3 hypoglycemic event, or a pattern of unexplained level 2
hypoglycemia should be advised to raise their glycemic targets. A

4. Glucagon should be prescribed for all individuals at increased risk of level

2 or 3 hypoglycemia. Caregivers, school personnel, or family members
should know where it is and when and how to administer it. Glucagon
administration is not limited to health care professionals. E
BLOOD GLUCOSE MONITORING

1. People with diabetes should be provided with blood glucose

monitoring devices. A

2. People who are on insulin using blood glucose monitoring should be

encouraged to check their blood glucose levels when appropriate based on
their insulin therapy. B

3. Be aware of medications and other factors, that can interfere with glucose
meter accuracy. E
CONTINUOUS GLUCOSE MONITORING DEVICES

1. Real-time continuous glucose monitoring A or intermittently

scanned continuous glucose monitoring B should be offered
for diabetes management in adults with diabetes on multiple daily injections
or continuous subcutaneous insulin infusion who are capable of using the
devices safely (either by themselves or with a caregiver).
Continued
2. Real-time continuous glucose monitoring A or intermittently scanned
continuous glucose monitoring C should be offered for diabetes management
in adults with diabetes on basal insulin who are capable of using the devices
safely (either by themselves or with a caregiver).
Insulin Delivery

1. Insulin pens are preferred in most cases. Still, insulin syringes may be used
for insulin delivery. C

2. Automated insulin delivery systems should be offered for diabetes

management to youth and adults with type 1 diabetes A and other types of
insulin-deficient diabetes E who are capable of using the device safely (either
by themselves or with a caregiver).
Continued
3. Insulin pump therapy can be offered for diabetes management to youth and
adults on multiple daily injections with type 2 diabetes who are capable of
using the device safely (either by themselves or with
a caregiver). A
Obesity and Weight Management for the Prevention and Treatment
of Type 2 Diabetes

1. Measure height and weight and calculate BMI at annual visits or more
frequently. E

2. Individuals with diabetes and overweight or obesity may benefit from

modest or larger magnitudes of weight loss. Relatively small weight loss
improves glycemia. A Larger, sustained weight losses (>10%) usually confer
greater benefits. B
Continued
NUTRITION, PHYSICAL ACTIVITY, AND BEHAVIORAL
THERAPY FOR WEIGHT REDUCTION

1. Nutrition, physical activity, and behavioral therapy to achieve and maintain

≥5% weight loss are recommended for most people with type 2 diabetes and
overweight or obesity. B

2. Behavioral changes that create an energy deficit, regardless of

macronutrient composition, will result in weight loss. A
Continued
3. For those who achieve weight loss goals, long-term (≥1 year) weight
maintenance programs that encourage regular physical activity (200–300
min/week) are recommended when available. A

5. Very-low-calorie meals (800–1,000 kcal/day) may be prescribed for

carefully selected individuals by trained practitioners. B

6. There is no clear evidence that nutrition supplements are effective for

weight loss. A
Pharmacotherapy for Weight Reduction

1. Consider the medication’s effect on weight. B

2. Whenever possible, minimize medications for comorbid conditions that are

associated with weight gain. E

3. Obesity pharmacotherapy is effective as an adjunct to nutrition, physical

activity, and behavioral counseling for selected people with type 2 diabetes
and BMI ≥27 kg/m2. Potential benefits and risks must be considered. A
Continued
4. If obesity pharmacotherapy is effective (typically defined as ≥5% weight
loss after 3 months’ use), further weight loss is likely with continued use.
When early response is insufficient (typically <5% weight loss after 3
months’ use), consider discontinuation of the medication and evaluate
alternative medications or treatment approaches. A
Approved Obesity Pharmacotherapy Options

 Short-term treatment (≤12 weeks):- Phentermine

 Long-term use (>12 weeks):-

1) Orlistat,
2) Phentermine/topiramate ER,
3) Naltrexone/bupropion ER,
4) Liraglutide 3 mg, and
5) Semaglutide 2.4 mg
METABOLIC SURGERY

1. Should be a recommended option to treat type 2 diabetes in screened

surgical candidates with BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asian
American individuals) and in adults with BMI 35.0– 39.9 kg/m2 (32.5–37.4
kg/m2 in Asian American individuals) who do not achieve durable weight loss
and improvement in comorbidities (including hyperglycemia) with
nonsurgical methods. A
Continued
2. Metabolic surgery may be considered as an option to treat type 2 diabetes in
adults with BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian
American individuals) who do not achieve durable weight loss and
improvement in comorbidities (including hyperglycemia) with nonsurgical
methods. A
Pharmacologic Approaches to Glycemic Treatment

Pharmacologic Therapy for Adults with Type 1 DM

1. Most individuals with type 1 diabetes should be treated with multiple daily
injections of prandial and basal insulin, or continuous subcutaneous insulin
infusion. A

2. Most individuals with type 1 diabetes should use rapid-acting insulin

analogs to reduce hypoglycemia risk. A
Pharmacologic Therapy for Adults with Type 2 DM

1. In adults with type 2 diabetes and established/high risk of atherosclerotic

cardiovascular disease, heart failure, and/or chronic kidney disease, the
treatment regimen should include agents that reduce cardiorenal risk (a
SGLT2 inhibitors and/or GLP1 receptor agonist). A

2. Metformin should be continued upon initiation of insulin therapy (unless

contraindicated or not tolerated) for ongoing glycemic and metabolic
benefits. A Continued
3. The early introduction of insulin should be considered if there is evidence
of ongoing catabolism (weight loss), if symptoms of hyperglycemia are
present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose levels
(≥300mg/dL [16.7mmol/L]) are very high. E

4. In adults with type 2 diabetes, a GLP1 receptor agonist is preferred to

insulin when possible. A
Continued
5. If insulin is used, combination therapy with a GLP1 receptor agonist is
recommended. A

8. Clinicians should be aware of the potential for overbasalization with insulin

therapy. Clinical signals that may prompt evaluation of overbasalization
include basal dose more than 0.5 units/kg/day, high bedtime–morning or
postpreprandial glucose differential, hypoglycemia (aware or unaware), and
high glycemic variability. E
 If injectable therapy is needed to reduce A1C

Consider GLP-1 RA or GIP/GLP-1 RA in most individuals prior to insulin.

INITIATION: Initiate appropriate starting dose for agent selected (varies within class)
TITRATION: Titrate to maintenance dose (varies within class)

If above A1C target

If already on GLP-1 RA or dual GIP

Add basal insulin and GLP-1 RA or if these are not
Choice of basal insulin should be based on person-specific appropriate OR insulin is preferred
considerations, including cost.

Add basal analog or bedtime NPH insulin

INITIATION: Start 10 units per day OR 0.1–0.2 units/kg per day
TITRATION: Set FPG target
Choose evidence-based titration algorithm, e.g., increase 2 units every 3 days to reach FPG target without
hypoglycemia
For hypoglycemia determine cause, if no clear reason lower dose by 10–20%
 Assess adequacy of basal insulin dose
Consider clinical signals to evaluate for overbasalization and need to consider adjunctive therapies (e.g., basal
dose more than ~0.5 units/kg/day, elevated bedtime–morning and/or post–preprandial differential,
hypoglycemia [aware or unaware], high variability

If above A1C target and not already on a GLP-1 RA or dual GIP and GLP-1 RA, If on bedtime NPH, consider converting to
consider these classes, either in free combination or fixed-ratio combination, twice-daily NPH regimen
with insulin. Conversion based on individual needs and
If A1C remains above target: current glycemic control. The following is
one possible approach:

INITIATION:
Add prandial insulin
Total dose = 80% of current bedtime NPH
Usually, one dose with the largest meal or meal with greatest PPG excursion;
dose
prandial insulin can be dosed individually or mixed with NPH as appropriate
2/3 given in the morning
INITIATION:
1/3 given at bedtime
4 units per day or 10% of basal insulin dose
TITRATION:
If A1C <8% (64 mmol/mol) consider lowering the basal dose by 4 units per day or
Titrate based on individualized needs
10% of basal dose
TITRATION:
Increase dose by 1–2 units or 10–15% twice weekly
For hypoglycemia determine cause, if no clear reason lower corresponding dose by
10–20% If above A1C target
 If above A1C target

Consider self-mixed/split insulin regimen

Stepwise additional Consider twice-daily premixed
Can adjust NPH and short/rapid-acting insulins
injections of prandial insulin regimen
separately
insulin (i.e., two, then three
additional injections) INITIATION:
INITIATION:
Total NPH dose = 80% of current NPH dose Usually unit per unit at the same
2/3 given before breakfast total insulin dose, but may
1/3 given before dinner require adjustment to individual
Add 4 units of short/rapid-acting insulin to needs
Proceed to full Basal-Bolus TITRATION:
regimen (i.e., basal insulin each injection or 10% of reduced NPH dose
TITRATION: Titrate based on individualized
and prandial insulin with needs
each meal) Titrate each component of the regimen
based on individualized needs

Intensifying to injectable therapies in type 2 diabetes

Cardiovascular Disease and Risk Management

Screening and Diagnosis of HTN in DM and Treatment Goal

1. Blood pressure should be measured at every routine clinical visit. When

possible, individuals found to have elevated blood pressure (systolic blood
pressure 120–129 mmHg and diastolic <80 mmHg) should have blood
pressure confirmed using multiple readings, including measurements on a
separate day, to diagnose hypertension. A
Continued
2. Hypertension is defined as a systolic blood pressure ≥130 mmHg or a
diastolic blood pressure ≥ 80 mmHg based on an average of ≥ 2
measurements obtained on ≥ 2 occasions. A Individuals with blood pressure ≥
180/110 mmHg and cardiovascular disease could be diagnosed with
hypertension at a single visit. E

3. All people with hypertension and diabetes should monitor

their blood pressure at home. A
Continued
4. Qualify for antihypertensive drug therapy when the blood pressure is
persistently elevated ≥130/80 mmHg. The on-treatment target blood pressure
goal is <130/80 mmHg, if it can be safely attained. B

5. In pregnant individuals with DM and chronic HTN, a BP threshold of

140/90 mmHg for initiation or titration of therapy is associated with better
pregnancy outcomes than reserving treatment for severe HTN. A. A BP target
of 110–135/ 85 mmHg is suggested in the interest of reducing the risk for
accelerated maternal hypertension. A
Treatment Strategies (Lifestyle & Pharmacologic Interventions)

1. For people with blood pressure >120/80 mmHg, lifestyle intervention

consists of weight loss when indicated, DASH-style eating pattern including
reducing sodium and increasing potassium intake, moderation of alcohol
intake, and increased physical activity. A

2. Individuals with confirmed office-based blood pressure ≥ 160/100 mmHg

should, in addition to lifestyle therapy, have prompt initiation and timely
titration of two drugs or a single-pill combination of drugs demonstrated to
reduce cardiovascular events in people with diabetes. A
Continued
3. ACE inhibitors or angiotensin receptor blockers are recommended
first-line therapy for hypertension in people with diabetes and CAD. A

4. An ACE inhibitor or ARB, at the maximum tolerated dose indicated for

blood pressure treatment, is the recommended first-line treatment for
hypertension in people with diabetes and urinary albumin-to-creatinine ratio
≥300 mg/g creatinine A or 30–299 mg/g creatinine. B

Continued
5. Individuals with hypertension who are not meeting blood pressure targets
on three classes of antihypertensive medications (including a diuretic) should
be considered for mineralocorticoid receptor antagonist therapy. A
Lipid Management in DM

1. 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. E

2. Obtain a lipid profile at initiation of statins or other lipid-lowering therapy,

4–12 weeks after initiation or a change in dose, and annually thereafter as it
may help to monitor the response to therapy and inform medication taking. E
Statin Treatment for Primary Prevention

1. For people with diabetes aged 40–75 years without atherosclerotic

cardiovascular disease, use moderate-intensity statin therapy in addition to
lifestyle therapy. A

2. For people with diabetes aged 40–75 at higher cardiovascular risk, including
those with one or more atherosclerotic cardiovascular disease risk factors, it is
recommended to use high-intensity statin therapy to reduce LDL cholesterol by
≥50% of baseline and to target an LDL cholesterol goal of <70 mg/dL. B
Statin Treatment for Secondary Prevention

1. For people of all ages with diabetes and ASCVDs, high-intensity statin
therapy should be added to lifestyle therapy. A

2. For people with diabetes and ASCVDs, treatment with high-intensity

statin therapy is recommended to target an LDL cholesterol reduction of
≥50% from baseline and an LDL cholesterol goal of <55 mg/dL.
Continued
3. Addition of ezetimibe or a PCSK9 inhibitor with proven benefit in this
population is recommended if this goal is not achieved on maximum tolerated
statin therapy. B

4. In individuals with ASCVDs or other cardiovascular risk factors on a statin

with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL),
the addition of icosapent ethyl can be considered to reduce cardiovascular
risk. A
Antiplatelet Agents
1. Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in
those with diabetes and a history of ASCVDs. A

2. For individuals with ASCVDs and documented aspirin allergy, clopidogrel

(75 mg/day) should be used. B

3. Dual antiplatelet therapy (with low-dose aspirin and a P2Y12

inhibitor) is reasonable for a year after an acute coronary syndrome and may
have benefits beyond this period. A Continued
4. Long-term treatment with dual antiplatelet therapy should be
considered for individuals with prior coronary intervention, high
ischemic risk, and low bleeding risk to prevent major adverse
cardiovascular events. A

5. Combination therapy with aspirin plus low-dose rivaroxaban should be

considered for individuals with stable coronary and/or peripheral artery
disease and low bleeding risk to prevent major adverse limb
and cardiovascular events. A
Chronic Kidney Disease and Risk Management

Screening of DM patients for CKD

1. At least annually, urinary albumin (e.g., spot urinary ACR) and eGFR
should be assessed in people with type 1 diabetes with duration of ≥5 years
and in all people with type 2 diabetes regardless of treatment. B

2. In people with established diabetic kidney disease, urinary albumin

(e.g., spot urinary ACR) and eGFR should be monitored 1–4 times per year
depending on the stage of the disease. B
Treatment of CKD in DM
1. Optimize glucose control to reduce the risk or slow the progression of
CKD. A

2. Optimize blood pressure control and reduce BP variability to reduce the risk
or slow the progression of chronic kidney disease. A

3. Do not discontinue renin angiotensin system blockade for increases in serum

creatinine (≤30%) in the absence of volume depletion. A
Continued
4. For people with type 2 diabetes and diabetic kidney disease, use of a
sodium–glucose cotransporter 2 inhibitor is recommended to reduce CKD
progression and cardiovascular events in patients with an eGFR ≥20
mL/min/1.73 m2 and urinary albumin ≥200 mg/g creatinine, A urinary
albumin ranging from normal to 200 mg/g creatinine. B

Continued
5. In people with type 2 diabetes and diabetic kidney disease,
consider use of SGLT 2 inhibitors (if eGFR is ≥ 20 mL/min/1.73 m2),
a GLP1 agonist, or a nonsteroidal MRA (if eGFR is ≥25 mL/min/1.73 m2)
additionally for cardiovascular risk reduction. A

6. For people with non–dialysis-dependent stage 3 or higher chronic kidney

disease, dietary protein intake should be aimed to a target level of 0.8 g/kg
body weight per day. A
Continued
7. For patients on dialysis, higher levels of dietary protein intake should be
considered since protein energy wasting is a major problem in some
individuals on dialysis. B

8. Patients should be referred for evaluation by a nephrologist if they have

continuously increasing urinary albumin levels and/or continuously decreasing
eGFR and if the eGFR is <30 mL/min/1.73 m2. A
 DIABETIC RETINOPATHY

1. Adults with type 1 diabetes should have an initial dilated and

comprehensive eye examination by an ophthalmologist or optometrist within
5 years after the onset of diabetes. B

2. People with type 2 diabetes should have an initial dilated and

comprehensive eye examination by an ophthalmologist or optometrist at the
time of the diabetes diagnosis. B
Continued
3. If there is no evidence of retinopathy for one or more annual eye exams and
glycemia is well controlled, then screening every 1–2 years may be
considered. If any level of diabetic retinopathy is present,
subsequent dilated retinal examinations should be repeated at least annually by
an ophthalmologist or optometrist. If retinopathy is progressing or sight-
threatening, then examinations will be required more frequently. B

Continued
4. Individuals of childbearing potential with preexisting type 1 or type 2
diabetes who are planning pregnancy or who are pregnant should be
counseled on the risk of development and/or progression of diabetic
retinopathy. B

5. Individuals with preexisting type 1 or type 2 diabetes should

receive an eye exam before pregnancy and in the first trimester and should be
monitored every trimester and for 1 year postpartum as indicated by the
degree of retinopathy. B
Neuropathy

1. All people with diabetes should be assessed for diabetic peripheral

neuropathy starting at diagnosis of type 2 diabetes and 5 years after the
diagnosis of type 1 diabetes and at least annually thereafter. B

2. Assessment for distal symmetric polyneuropathy should include a careful

history and assessment of either temperature or pinprick sensation (small-
fiber function) and vibration sensation using a 128-Hz tuning fork (for large-
fiber function). B
Continued
3. Gabapentinoids, SNRIs, TCAs, and sodium channel blockers are
recommended as initial pharmacologic treatments for neuropathic pain in
diabetes. A
Foot Care in DM
1. Perform a comprehensive foot evaluation at least annually to
identify risk factors for ulcers and amputations. A

2. Individuals with evidence of sensory loss or prior ulceration or amputation

should have their feet inspected at every visit. A

3. Provide general preventive foot self-care education to all people with

diabetes. B
Continued
4. The use of specialized therapeutic footwear is recommended for people with
diabetes at high risk for ulceration, including those with
loss of protective sensation, foot deformities, ulcers, callous formation, poor
peripheral circulation, or history of amputation. B

5. For chronic diabetic foot ulcers that have failed to heal with optimal
standard care alone, adjunctive treatment should be considered. A
 Diabetes Management Older Adults

1. In older adults with type 2 diabetes at increased risk of hypoglycemia,

medication classes with low risk of hypoglycemia are preferred. B

2. Overtreatment of diabetes is common in older adults and should be avoided.

B

3. Deintensification of treatment goals and simplification of complex treatment

plans (especially insulin) is recommended to reduce the risk of hypoglycemia.
B
Management of Diabetes in Pregnancy
1. Preconception counseling should address the importance of achieving
glucose levels as close to normal as is safely possible, ideally A1C <6.5% (48
mmol/mol). A

2. FBS and postprandial blood glucose monitoring are recommended in both

GDM and preexisting diabetes in pregnancy to achieve optimal glucose
levels. Glucose targets are FBS <95 mg/Dl (5.3 mmol/L) and either 1-h
postprandial glucose <140 mg/dL (7.8 mmol/L) or 2-h postprandial glucose
<120 mg/dL (6.7 mmol/L). B Continued
3. Insulin is the preferred medication for treating hyperglycemia
in gestational diabetes mellitus. Metformin and glyburide should not be used
as first-line agents, as both cross the placenta to the fetus. A

4. Metformin, when used to treat polycystic ovary syndrome and

induce ovulation, should be discontinued by the end of the
first trimester. A

Continued
5. Screen individuals with a recent history of GDM at 4–12 weeks
postpartum, using the 75-g OGTT and clinically appropriate nonpregnancy
diagnostic criteria. B

6. Individuals with a history of GDM should have lifelong screening for the
development of type 2 diabetes or prediabetes every 1–3 years. B
Diabetes Care in the Hospital

1. Perform an A1C test on all people with diabetes or hyperglycemia (blood

glucose >140 mg/dL [7.8 mmol/L]) admitted to the hospital if not performed in
the prior 3 months. B

2. Insulin therapy should be initiated for the treatment of persistent

hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L) (checked on
two occasions).

Continued
3. Once insulin therapy is started, a target glucose range of 140–180 mg/dL
(7.8–10.0 mmol/L) is recommended for most critically ill and noncritically ill
patients. A

3. Basal insulin or a basal plus bolus correction insulin regimen is the

preferred treatment for noncritically ill hospitalized patients with poor oral
intake or those who are taking nothing by mouth. A

4. An insulin regimen with basal, prandial, and correction components is the

preferred treatment for most noncritically ill hospitalized patients with
adequate nutritional intake. A
Thank you all.