This is the fourth and last article in a series of posts describing the latest standards of medical care in diabetes released by the American Diabetes Association recently.
Assessment of Glycemic Control
Most patients using intensive insulin regimens (multiple-dose insulin or insulin pump therapy) should perform Self-monitoring of blood glucose (SMBG)
- prior to meals and snacks,
- at bedtime,
- occasionally postprandially,
- prior to exercise,
- when they suspect low blood glucose,
- after treating low blood glucose until they are normoglycemic, and
- prior to critical tasks such as driving
Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control).
Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals.
Point-of-care testing for A1C provides the opportunity for more timely treatment changes.
A reasonable A1C goal for many nonpregnant adults is <7% (53 mmol/mol).
Providers might reasonably suggest more stringent A1C goals (such as <6.5% [48 mmol/mol]) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment (i.e., polypharmacy). Appropriate patients might include those with
- a short duration of diabetes,
- type 2 diabetes treated with lifestyle or metformin only,
- long life expectancy, or
- no significant CVD.
Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients
- with a history of severe hypoglycemia,
- limited life expectancy,
- advanced microvascular or macrovascular complications,
- extensive comorbid conditions, or
- long-standing diabetes in whom the goal is difficult to achieve despite DSME, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents, including insulin.
PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT
Pharmacologic Therapy for Type 1 Diabetes
Most people with type 1 diabetes should be treated with multiple daily injection (MDI) therapy including prandial and basal insulin or continuous subcutaneous insulin infusion (CSII; insulin pump therapy).
Most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk.
Consider educating individuals with type 1 diabetes on matching prandial insulin doses to carbohydrate intake, premeal blood glucose levels, and anticipated physical activity.
Individuals with type 1 diabetes who have been successfully using CSII should have continued access to this therapy after they turn 65 years of age.
Pharmacologic Therapy for Type 2 Diabetes
Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacologic agent for the treatment of type 2 diabetes.
Long-term use of metformin may be associated with biochemical vitamin B12 deficiency, and periodic measurement of vitamin B12 levels should be considered in metformin-treated patients, especially in those with anemia or peripheral neuropathy.
Consider initiating insulin therapy (with or without additional agents) in patients with newly diagnosed type 2 diabetes who are symptomatic and/or have an A1C ≥10% (86 mmol/mol) and/ or blood glucose levels ≥300 mg/ dL (16.7 mmol/L).
If noninsulin monotherapy at maximum tolerated dose does not achieve or maintain the A1C target after 3 months, add a second oral agent, a second oral agent, a GLP-1 receptor agonist, or basal insulin.
A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include efficacy, hypoglycemia risk, impact on weight, potential side effects, cost, and patient preferences.
For patients with type 2 diabetes who are not achieving glycemic goals, insulin therapy should not be delayed.
In patients with long-standing suboptimally controlled type 2 diabetes and established atherosclerotic cardiovascular disease (ASCVD), empagliflozin or liraglutide should be considered because they have been shown to reduce cardiovascular and all-cause mortality when added to standard care.
In addition to the above, the Standards also provide guidance on the management of chronic kidney disease, neuropathy, lipid management, coronary heart disease, diabetic retinopathy, foot care, management of diabetes in older adults; children and adolescents, and the management of diabetes in pregnancy.
Link to the new Standards of Medical Care in Diabetes 2017:
Link to the news release: