3.
Type 1 diabetes
Type 2 diabetes
Gestational diabetes mellitus (GDM)
Specific types of diabetes due to other causes
Monogenic
Pancreatic diseases
Drug induced
Classification
4.
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, RBS ≥200 mg/dL (11.1
mmol/L)
Diagnosis
5.
FPG 5.6 - 6.9 mmol/L (IFG)
or
2-h PG during 75-g OGTT 7.8 - 11.0 mmol/L (IGT)
or
A1C 5.7–6.4%
Pre-diabetes
* WHO define the IFG cutoff at 110 mg/dL (6.1 mmol/L)
6.
75-g OGTT, with plasma glucose measurement when
patient is fasting and at 1 and 2 h, at 24–28 weeks of
gestation in women not previously diagnosed with
diabetes.
The diagnosis of GDM is made when any of the following
plasma glucose values are met or exceeded:
GDM
One-step strategy
Fasting 5.1 mmol/L
1 h 10.0 mmol/L
2 h 8.5 mmol/L
7.
Step 1:
Perform a 50-g GTT (nonfasting), with plasma glucose
measurement at 1 h, at 24–28 weeks of gestation in
women not previously diagnosed with diabetes.
If the plasma glucose level measured 1 h after the load is
≥7.2 mmol/L, 7.5 mmol/L, or 7.8 mmol/L, proceed to a
100-g OGTT.
GDM
Two-step strategy
8.
Step 2:
The 100-g OGTT should be performed when the patient is
fasting.
The diagnosis of GDM is made if at least two of the
following four plasma glucose levels (measured fasting
and 1 h, 2 h, 3 h during OGTT) are met or exceeded:
GDM
Two-step strategy
9. Carpenter-Coustan or NDDG
•• Fasting 5.3 mmol/L 5.8 mmol/L
•• 1 h 10.0 mmol/L 10.6 mmol/L
•• 2 h 8.6 mmol/L 9.2 mmol/L
•• 3 h 7.8 mmol/L 8.0 mmol/L
10.
The diagnosis of MODY should be considered in adults
diagnosed with diabetes with the following findings:
Onset at an early age (<25 years)
Diabetes without typical features of type 1 or type 2
diabetes (negative autoantibodies, nonobese, lacking
other metabolic features)
Multiple family members with same type of diabetes
Stable, mild fasting hyperglycemia (5.5–8.5 mmol/L),
stable A1C 5.6-7.6%
MODY
11.
In overweight or obese (BMI ≥25 kg/m2) adults who have
one or more of the following risk factors:
First-degree relative with diabetes
High-risk race/ethnicity (e.g., African American, Asian)
History of CVD
Hypertension
HDL <35 mg/dL and/or TG >250 mg/dL
Criteria for testing in asymptomatic
adults
12.
Women with PCOS
Physical inactivity
Other clinical conditions associated with insulin
resistance (e.g., severe obesity, acanthosis nigricans)
Patients with prediabetes should be tested yearly
For all other patients, testing should begin at age 45
years
Criteria for testing in asymptomatic
adults
13.
Metformin therapy should be considered in those with
prediabetes, especially for those with
BMI ≥35 kg/m2
aged <60 years, and
women with prior GDM
Prediabetes is associated with heightened cardiovascular
risk
Prevention or Delay of Type 2
Diabetes
18.
Annual vaccination against influenza
Vaccination against pneumococcal disease (PPSV23)
3-dose series of hepatitis B vaccine to unvaccinated
adults
Vaccinations
19.
A1C test at least two times a year in patients who have
stable glycemic control
A1C test quarterly in patients whose therapy has changed
or who are not meeting glycemic goals
Glycemic targets
A1c <7%
Preprandial 4.4-7.2 mmol/L
Postprandial (1-2h) <10 mmol/L
20.
Less stringent A1C goals (such as <8%) may be appropriate
for patients with-
history of severe hypoglycemia
limited life expectancy
advanced microvascular or macrovascular
complications
extensive comorbid conditions
long-standing diabetes in whom the goal is difficult to
achieve
Glycemic targets
21.
Hypoglycemia
Level Glycemic criteria/description
Level 1 Glucose <70 mg/dL (3.9 mmol/L) and
glucose ≥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
22.
Glucose (15–20 g) is the preferred treatment for the
conscious individual with blood glucose <70 mg/dL [3.9
mmol/L]
15 minutes after treatment, if SMBG shows continued
hypoglycemia, the treatment should be repeated.
Treatment
23.
Once SMBG returns to normal, the individual should
consume a meal or snack to prevent recurrence of
hypoglycemia
Glucagon should be prescribed for all individuals at
increased risk of level 2 hypoglycemia
Treatment
25.
Weight loss (>5%) overweight or obese adults with T2DM
and prediabetes
There is no single ideal dietary distribution of calories
among carbohydrates, fats, and proteins
Diets high in fiber, including vegetables, fruits, legumes,
whole grains, as well as dairy products
Medical nutrition therapy
26.
Diet rich in monounsaturated and polyunsaturated fats
Eating foods rich in long-chain n-3 fatty acids, such as
fatty fish, nuts and seeds
Higher intakes of nuts, berries, yogurt, coffee, and tea are
associated with reduced diabetes risk
Conversely, smoking, red meats and sugar-sweetened
beverages are associated with an increased risk
Medical nutrition therapy
27.
≥150 min moderate-to-vigorous intensity aerobic activity
per week, at least 3 days/week, with no more than 2
consecutive days without activity
All adults, and particularly those with T2DM, should avoid
prolonged sitting for >30 min for blood glucose benefits
Flexibility training and balance training are recommended
2–3 times/week for older adults with diabetes
Physical activity
28.
When choosing glucose-lowering medications for overweight
or obese patients, consider their effect on weight:
Agents associated with varying degrees of weight loss
include metformin, α-glucosidase inhibitors, SGLT2
inhibitors, GLP1 receptor agonists
DPP4 inhibitors are weight neutral
Insulin secretagogues, TZDs, and insulin often cause
weight gain
Obesity management
29.
Whenever possible, minimize medications for comorbid
conditions that are associated with weight gain:
antipsychotics
antidepressants
glucocorticoids
injectable progestins
anticonvulsants including gabapentin
possibly sedating antihistamines and anticholinergics
30.
Weight-loss medications are effective as adjuncts to diet,
physical activity, and behavioral counseling for selected patients
with type 2 diabetes and BMI ≥27 kg/m2:
1. Orlistat
2. Lorcaserin
3. Phentermine/ topiramate
4. Naltrexone/ bupropion
5. Liraglutide
31.
Metabolic surgery should be recommended as an option to
treat T2DM in appropriate surgical candidates with-
BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asians) and
BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asians)
who do not achieve durable weight loss and
improvement in comorbidities (including
hyperglycemia) with reasonable nonsurgical
methods.
Metabolic surgery
33.
Most people with type 1 diabetes should be treated with
multiple daily injections of prandial and basal insulin, or
continuous subcutaneous insulin infusion
Most individuals with type 1 diabetes should use rapid-
acting insulin analogs to reduce hypoglycemia risk
Type 1 diabetes
34.
Metformin is the preferred initial pharmacologic agent
Long-term use of metformin may be associated with
biochemical vitamin B12 deficiency, and periodic
measurement should be considered, especially in those
with anemia or peripheral neuropathy
Type 2 diabetes
35.
The early introduction of insulin should be considered if-
weight loss
symptoms of hyperglycemia
A1C levels (>10%) or blood glucose levels (≥16.7 mmol/L)
Dual therapy in patients who have A1C ≥1.5% above
their glycemic target
36.
Patients with established atherosclerotic CVD, SGLT2
inhibitors, or GLP1 receptor agonists are recommended
Patients with ASCVD at high risk of heart failure or in
whom heart failure coexists, SGLT2 inhibitors are
preferred
For patients CKD, consider use of a SGLT2 inhibitor, or
GLP1 receptor agonist
40.
Atherosclerotic cardiovascular disease
(ASCVD)
defined as coronary heart disease, cerebrovascular disease, or
peripheral arterial disease presumed to be of atherosclerotic origin
ASCVD risk factors include
LDL cholesterol ≥100 mg/dL (2.6 mmol/L)
HTN
smoking
CKD
albuminuria
family history of premature ASCVD
ACC/AHA ASCVD risk calculator is generally a useful tool to
estimate 10-year ASCVD risk
41.
Lifestyle Intervention
For patients with blood pressure >120/80 mmHg, lifestyle
intervention consists of
weight loss if overweight or obese
Dietary Approaches to Stop Hypertension (DASH) diet
moderation of alcohol intake and
increased physical activity
42.
43.
Blood pressure
Existing ASCVD or 10-year ASCVD risk >15% : <130/80
mmHg
For individuals at lower risk for cardiovascular disease
(10-year ASCVD risk <15%) and CKD, treat to a blood
pressure target of <140/90 mmHg.
44.
Pharmacologic
Interventions
An ACE inhibitor or ARB, is the recommended first-line
treatment if urinary ACR ≥30 mg/g
For patients treated with an ACE inhibitor, ARB or diuretic,
serum eGFR and serum potassium levels should be
monitored at least annually
45.
46.
Resistant hypertension
Resistant hypertension is defined as blood pressure
≥140/90 mmHg despite a therapeutic strategy that
includes appropriate lifestyle management plus a
diuretic and two other antihypertensive drugs
belonging to different classes at adequate doses
Exclude medication non-adherence, white coat
hypertension, and secondary hypertension
Consider mineralocorticoid receptor antagonist
therapy
49.
Lifestyle Intervention
Lifestyle modification focusing on weight loss (if indicated):
Mediterranean diet or DASH dietary pattern;
reduction of saturated fat and trans fat;
increase of dietary n-3 fatty acids,
viscous fiber, and plant stanols/sterols intake; and
increased physical activity
50.
Statin
ASCVD or 10-year ASCVD >20% high-intensity statin
therapy
aged <40 years with additional ASCVD risk factors, the
patient and provider should consider using moderate-
intensity statin
For patients with diabetes aged ≥40 without ASCVD, use
moderate-intensity statin
Statin therapy is contraindicated in pregnancy.
52.
Hypertriglyceridemia
≥500 mg/dL (5.7 mmol/L): evaluate for secondary causes
of hypertriglyceridemia and consider medical therapy
175–499 mg/dL:
address and treat lifestyle factors (obesity and
metabolic syndrome)
secondary factors (diabetes, CLD, CKD and/or
nephrotic syndrome, hypothyroidism)
medications that raise triglycerides
53.
Anti-platelet agents
Use aspirin therapy (75–162 mg/day) as a secondary
prevention strategy in those with diabetes and a history of
ASCVD
For patients with ASCVD and documented aspirin allergy,
clopidogrel (75 mg/day) should be used
Aspirin therapy (75–162 mg/day) may be considered as a
primary prevention strategy in those with diabetes who
are at increased cardiovascular risk
54.
Anti-platelet agents
These recommendations for using aspirin as primary
prevention include both men and women aged ≥50 years
with diabetes and at least one additional major risk factor
Family history of premature ASCVD
Hypertension
Dyslipidemia
Smoking or
Chronic kidney disease/albuminuria
…who are not at increased risk of bleeding
57.
At least once a year, assess urinary albumin (e.g., spot
urinary ACR) and eGFR
2 of 3 specimens collected within a 3-6 months period
should be abnormal before considering albuminuria
Optimize glucose control to reduce the risk or slow the
progression of CKD
58.
While ACE inhibitors or ARBs are often prescribed
for albuminuria without hypertension, clinical trials
have not been performed in this setting to determine
whether this improves renal outcomes
60.
To reduce the risk or slow the progression of diabetic
retinopathy
Optimize glycemic control
Optimize blood pressure and serum lipid control
61.
In high-risk PDR and, in some cases, severe NPDR:
Panretinal laser photocoagulation therapy
Intravitreous injections of anti–VEGF ranibizumab
The presence of retinopathy is not a contraindication to
aspirin therapy, as aspirin does not increase the risk of
retinal hemorrhage
Treatment
62.
ACE inhibitors and ARBs are both effective treatments in
diabetic retinopathy
In patients with dyslipidemia, retinopathy progression may
be slowed by the addition of fenofibrate
Adjunctive therapy
64.
Optimize glucose control to prevent or delay the
development of neuropathy in patients with type 1
diabetes and to slow the progression of neuropathy in
patients with type 2 diabetes
Pregabalin, duloxetine, or gabapentin are recommended
as initial pharmacologic treatments for neuropathic pain
Tapentadol, TCA, venlafaxine, crabamzepine, topical
capsaicin may be effective
Treatment
65.
Nonpharmacologic measures
adequate salt intake
avoiding medications that aggravate hypotension
compressive garments over the legs and abdomen
Pharmacologic measures:
Midodrine
Droxidopa
Orthostatic Hypotension
66.
Treatment of hypogonadism if present
PDE5 inhibitors
Intracorporeal or intraurethral prostaglandins
Vacuum devices or penile prostheses
Erectile Dysfunction
67.
A low-fiber, low-fat eating plan in small frequent meals
with a greater proportion of liquid calories may be useful
Withdrawing drugs with adverse effects on
gastrointestinal motility including opioids, anticholinergics,
tricyclic antidepressants, GLP-1 RA, and possibly DPP4
inhibitors may also improve intestinal motility
Gastroparesis
68.
In cases of severe gastroparesis, pharmacologic
interventions are needed:
Metoclopramide
Domperidone, erythromycin
Gastric electrical stimulation using a surgically
implantable device
Gastroparesis
70.
The examination should include
inspection of the skin
assessment of foot deformities
neurological assessment
vascular assessment
Patients with symptoms of claudication or decreased or
absent pedal pulses should be referred for ABI and for
further vascular assessment as appropriate
71.
General preventive foot self-care education
Use of custom therapeutic footwear
Wounds without evidence of soft tissue or bone infection
do not require antibiotic therapy
Management
72.
Most diabetic foot infections are polymicrobial, with
aerobic gram-positive cocci
Those at risk for infection with antibiotic-resistant
organisms or with chronic, previously treated, or severe
infections require broader-spectrum regimens
Hyperbaric oxygen therapy (HBOT) has mixed evidence
supporting its use as an adjunctive treatment
74.
Multiple coexisting chronic illnesses, cognitive
impairment, or functional dependence: less stringent
glycemic goals (such as A1C <8.0–8.5%)
Otherwise healthy: lower glycemic goals (such as
A1C <7.5%)
Treatment goals
75.
Metformin is the first-line agent
Insulin secretagogues: associated with hypoglycemia and
should be used with caution. If used, shorter-duration
sulfonylureas, such as glipizide
DPP-4 inhibitors: few side effects and minimal
hypoglycemia
SGLT2 inhibitors: long-term experience in this population
is limited
Pharmacological therapy
76.
Insulin:
Once-daily basal insulin associated with minimal side
effects
Multiple daily injections of insulin may be too complex
GLP-1 receptor agonists: associated with nausea,
vomiting, diarrhea, and weight loss
Pharmacological therapy
78.
Preconception glycemic management: ideally A1C <6.5%
Women with preexisting diabetes who are planning
pregnancy or who have become pregnant should be
counseled on the risk of development and/or progression
of diabetic retinopathy
Preexisting diabetes
79.
Dilated eye examinations:
before pregnancy or in the first trimester
every trimester
1-year postpartum
Preexisting diabetes
80.
Insulin is the preferred agent for management of both
type 1 and type 2 diabetes in pregnancy
Oral agents are generally insufficient to overcome the
insulin resistance in type 2 diabetes and are ineffective in
type 1 diabetes
Management of preexisting
DM
81.
Lifestyle change is an essential component
Insulin is the preferred medication
Metformin and glyburide should not be used as first-line
agents
Metformin, when used to treat PCOS and induce
ovulation, should be discontinued once pregnancy has
been confirmed
Management of GDM
83.
Women with type 1 or type 2 diabetes should be prescribed-
low-dose aspirin 60–150 mg/day (usual dose 81 mg/day)
from the end of the first trimester until the baby is born
……in order to lower the risk of preeclampsia
Preeclampsia and Aspirin
84.
Blood pressure targets: 120–160/80–105 mmHg
Potentially teratogenic medications (i.e., ACE inhibitors,
angiotensin receptor blockers, statins) should be avoided
Safe in pregnancy: methyldopa, nifedipine, labetalol,
diltiazem, clonidine, and prazosin
Management of HTN
85.
75-g OGTT at 4–12 weeks postpartum
Lifelong screening at least every 3 years
Prediabetes: intensive lifestyle interventions or metformin
Postpartum care
87.
Hyperglycemia in hospitalized patients is defined as blood
glucose levels >7.8 mmol/L
An admission A1C value ≥6.5% suggests that diabetes
preceded hospitalization
88.
Insulin therapy should be initiated for treatment of
persistent hyperglycemia ≥10.0 mmol/L
Target glucose range: 7.8–10.0 mmol/L
In the patient who is eating meals, glucose monitoring
should be performed before meals
In the patient who is not eating, glucose monitoring is
advised every 4–6 h
89.
Noncritically ill poor oral intake or
NPO
Basal insulin or
basal plus
correction
good nutritional
intake
basal, prandial,
and correction
Critical care setting continuous IV
insulin
Insulin regimen
90.
Sole use of sliding scale insulin in the inpatient
hospital setting is strongly discouraged
Insulin regimen
91.
Once-a-day, short-acting GC (e.g. prednisone):
intermediate-acting (NPH) insulin
For long-acting GC e.g. dexamethasone or multidose
glucocorticoid: long-acting insulin
For higher doses of GC: prandial and correctional insulin
in addition to basal insulin
Glucocorticoid Therapy
92.
Target glucose range for the perioperative period should
be 4.4–10.0 mmol/L
Withhold metformin the day of surgery
Perioperative Care
93.
Withhold any other oral hypoglycemic agents the morning
of surgery or procedure and give half of NPH dose or 60–
80% doses of long-acting analog or pump basal insulin.
Monitor blood glucose at least every 4–6 h while NPO
and dose with short- or rapid-acting insulin as needed
Perioperative Care
