2018-ADA-Standards-of-Care

S110 Microvascular Complications and Foot Care Diabetes Care Volume 41, Supplement 1, January 2018

beneath the foveal center and may in diagnosing diabetic retinopathy should diagnosis should have an initial dilated
threaten reading vision. A perform the examinations. Youth with and comprehensive eye examination at
c The presence of retinopathy is not a type 1 or type 2 diabetes are also at the time of diagnosis.
contraindication to aspirin therapy risk for complications and need to be
for cardioprotection, as aspirin does screened for diabetic retinopathy (80). If Pregnancy
not increase the risk of retinal hem- diabetic retinopathy is present, prompt
orrhage. A referral to an ophthalmologist is recom- Pregnancy is associated with a rapid pro-
mended. Subsequent examinations for gression of diabetic retinopathy (87,88).
Diabetic retinopathy is a highly specific patients with type 1 or type 2 diabetes Women with preexisting type 1 or type 2
vascular complication of both type 1 and are generally repeated annually for pa- diabetes who are planning pregnancy or
type 2 diabetes, with prevalence strongly tients with minimal to no retinopathy. Ex- who have become pregnant should be
related to both the duration of diabetes ams every 1–2 years may be cost-effective counseled on the risk of development
and the level of glycemic control (69). Di- after one or more normal eye exams, and/or progression of diabetic retinopa-
abetic retinopathy is the most frequent and in a population with well-controlled thy. In addition, rapid implementation of
cause of new cases of blindness among type 2 diabetes, there was essentially no intensive glycemic management in the
adults aged 20–74 years in developed risk of development of significant retinop- setting of retinopathy is associated with
countries. Glaucoma, cataracts, and other athy with a 3-year interval after a normal early worsening of retinopathy (79). Women
disorders of the eye occur earlier and examination (81). Less frequent intervals who develop gestational diabetes melli-
more frequently in people with diabetes. have been found in simulated modeling tus do not require eye examinations dur-
to be potentially effective in screening for ing pregnancy and do not appear to be at
In addition to diabetes duration, factors diabetic retinopathy in patients without increased risk of developing diabetic ret-
that increase the risk of, or are associated diabetic retinopathy (82). More frequent inopathy during pregnancy (89).
with, retinopathy include chronic hypergly- examinations by the ophthalmologist will
cemia (70), diabetic kidney disease (71), be required if retinopathy is progressing. Treatment
hypertension (72), and dyslipidemia (73). Two of the main motivations for screen-
Intensive diabetes management with the Retinal photography with remote read- ing for diabetic retinopathy are to prevent
goal of achieving near-normoglycemia ing by experts has great potential to pro- loss of vision and to intervene with treat-
has been shown in large prospective ran- vide screening services in areas where ment when vision loss can be prevented
domized studies to prevent and/or delay qualified eye care professionals are not or reversed.
the onset and progression of diabetic ret- readily available (83,84). High-quality fun-
inopathy and potentially improve patient- dus photographs can detect most clinically Photocoagulation Surgery
reported visual function (28,74–76). significant diabetic retinopathy. Interpreta-
tion of the images should be performed Two large trials, the Diabetic Retinopathy
Lowering blood pressure has been by a trained eye care provider. Retinal pho- Study (DRS) in patients with PDR and the
shown to decrease retinopathy progres- tography may also enhance efficiency and Early Treatment Diabetic Retinopathy
sion, although tight targets (systolic blood reduce costs when the expertise of ophthal- Study (ETDRS) in patients with macular
pressure ,120 mmHg) do not impart ad- mologists can be used for more complex edema, provide the strongest support
ditional benefit (75). ACE inhibitors and examinations and for therapy (85). In-person for the therapeutic benefits of photoco-
ARBs are both effective treatments in di- exams are still necessary when the retinal agulation surgery. The DRS (90) showed in
abetic retinopathy (77). In patients with photos are of unacceptable quality and for 1978 that panretinal photocoagulation
dyslipidemia, retinopathy progression follow-up if abnormalities are detected. Ret- surgery reduced the risk of severe vision
may be slowed by the addition of fenofi- inal photos are not a substitute for compre- loss from PDR from 15.9% in untreated eyes
brate, particularly with very mild nonpro- hensive eye exams, which should be to 6.4% in treated eyes with the greatest
liferative diabetic retinopathy (NPDR) at performed at least initially and at intervals benefit ratio in those with more advanced
baseline (73). Several case series and a thereafter as recommended by an eye care baseline disease (disc neovascularization
controlled prospective study suggest professional. Results of eye examinations or vitreous hemorrhage). In 1985, the
that pregnancy in patients with type 1 di- should be documented and transmitted ETDRS also verified the benefits of panreti-
abetes may aggravate retinopathy and to the referring health care professional. nal photocoagulation for high-risk PDR
threaten vision, especially when glycemic and in older-onset patients with severe
control is poor at the time of conception Type 1 Diabetes NPDR or less-than-high-risk PDR. Panreti-
(78,79). Laser photocoagulation surgery nal laser photocoagulation is still com-
can minimize the risk of vision loss (79). Because retinopathy is estimated to take monly used to manage complications of
at least 5 years to develop after the onset diabetic retinopathy that involve retinal
Screening of hyperglycemia, patients with type 1 di- neovascularization and its complications.
The preventive effects of therapy and abetes should have an initial dilated and
the fact that patients with proliferative comprehensive eye examination within Anti–Vascular Endothelial Growth Factor
diabetic retinopathy (PDR) or macular 5 years after the diagnosis of diabetes (86). Treatment
edema may be asymptomatic provide
strong support for screening to detect di- Type 2 Diabetes Recent data from the Diabetic Retinopa-
abetic retinopathy. thy Clinical Research Network and others
Patients with type 2 diabetes who may demonstrate that intravitreal injections
An ophthalmologist or optometrist have had years of undiagnosed diabe- of anti–vascular endothelial growth fac-
who is knowledgeable and experienced tes and have a significant risk of preva- tor (anti-VEGF) agent, specifically ranibi-
lent diabetic retinopathy at the time of zumab, resulted in visual acuity outcomes
that were not inferior to those observed

care.diabetesjournals.org Microvascular Complications and Foot Care S111

in patients treated with panretinal laser at starting at diagnosis of type 2 di- control can effectively prevent DPN and
2 years of follow-up (91). In addition, it was abetes and 5 years after the di- cardiac autonomic neuropathy (CAN) in
observed that patients treated with ranibi- agnosis of type 1 diabetes and at type 1 diabetes (97,98) and may modestly
zumab tended to have less peripheral visual least annually thereafter. B slow their progression in type 2 diabetes
field loss, fewer vitrectomy surgeries for sec- c Assessment for distal symmetric poly- (30), but does not reverse neuronal loss.
ondary complications from their prolifera- neuropathy should include a careful Therapeutic strategies (pharmacologic
tive disease, and a lower risk of developing history and assessment of either tem- and nonpharmacologic) for the relief of
diabetic macular edema. However, a po- perature or pinprick sensation (small- painful DPN and symptoms of autonomic
tential drawback in using anti-VEGF ther- fiber function) and vibration sensation neuropathy can potentially reduce pain
apy to manage proliferative disease is that using a 128-Hz tuning fork (for large- (99) and improve quality of life.
patients were required to have a greater fiber function). All patients should
number of visits and received a greater have annual 10-g monofilament test- Diagnosis
number of treatments than is typically re- ing to identify feet at risk for ulcera- Diabetic Peripheral Neuropathy
quired for management with panretinal la- tion and amputation. B Patients with type 1 diabetes for 5 or
ser, which may not be optimal for some c Symptoms and signs of autonomic more years and all patients with type 2
patients. Other emerging therapies for ret- neuropathy should be assessed in diabetes should be assessed annually for
inopathy that may use sustained intravitreal patients with microvascular compli- DPN using the medical history and simple
delivery of pharmacologic agents are cur- cations. E clinical tests. Symptoms vary according to
rently under investigation. In April, the the class of sensory fibers involved. The
FDA approved ranibizumab for the treat- Treatment most common early symptoms are in-
ment of diabetic retinopathy. c Optimize glucose control to prevent duced by the involvement of small fibers
and include pain and dysesthesias (un-
While the ETDRS (92) established the or delay the development of neu- pleasant sensations of burning and tin-
benefit of focal laser photocoagulation ropathy in patients with type 1 gling). The involvement of large fibers
surgery in eyes with clinically significant diabetes A and to slow the pro- may cause numbness and loss of protec-
macular edema (defined as retinal edema gression of neuropathy in patients tive sensation (LOPS). LOPS indicates the
located at or within 500 mm of the center with type 2 diabetes. B presence of distal sensorimotor poly-
of the macula), current data from well- c Assess and treat patients to reduce neuropathy and is a risk factor for di-
designed clinical trials demonstrate that pain related to diabetic peripheral abetic foot ulceration. The following
intravitreal anti-VEGF agents provide a neuropathy B and symptoms of au- clinical tests may be used to assess small-
more effective treatment regimen for tonomic neuropathy and to im- and large-fiber function and protective
central-involved diabetic macular edema prove quality of life. E sensation:
than monotherapy or even combination c Either pregabalin or duloxetine are
therapy with laser (93–95). There are cur- recommended as initial pharmaco- 1. Small-fiber function: pinprick and tem-
rently three anti-VEGF agents commonly logic treatments for neuropathic pain perature sensation
used to treat eyes with central-involved in diabetes. A
diabetic macular edemadbevacizumab, 2. Large-fiber function: vibration percep-
ranibizumab, and aflibercept (69). The diabetic neuropathies are a heteroge- tion and 10-g monofilament
neous group of disorders with diverse clini-
In both DRS and ETDRS, laser photoco- cal manifestations. The early recognition 3. Protective sensation: 10-g monofilament
agulation surgery was beneficial in re- and appropriate management of neuropa-
ducing the risk of further visual loss in thy in the patient with diabetes is important. These tests not only screen for the pres-
affected patients, but generally not benefi- ence of dysfunction but also predict
cial in reversing already diminished acuity. 1. Diabetic neuropathy is a diagnosis of future risk of complications. Electrophys-
Anti-VEGF therapy improves vision and has exclusion. Nondiabetic neuropathies iological testing or referral to a neurolo-
replaced the need for laser photocoagula- may be present in patients with diabe- gist is rarely needed, except in situations
tion in the vast majority of patients with tes and may be treatable. where the clinical features are atypical or
diabetic macular edema (96). Most pa- the diagnosis is unclear.
tients require near-monthly administration 2. Numerous treatment options exist for
of intravitreal therapy with anti-VEGF symptomatic diabetic neuropathy. In all patients with diabetes and DPN,
agents during the first 12 months of treat- causes of neuropathy other than diabetes
ment, with fewer injections needed in sub- 3. Up to 50% of diabetic peripheral neu- should be considered, including toxins
sequent years to maintain remission from ropathy (DPN) may be asymptomatic. (alcohol), neurotoxic medications (che-
central-involved diabetic macular edema. If not recognized and if preventive foot motherapy), vitamin B12 deficiency, hypo-
care is not implemented, patients are thyroidism, renal disease, malignancies
NEUROPATHY at risk for injuries to their insensate feet. (multiple myeloma, bronchogenic carci-
noma), infections (HIV), chronic inflamma-
Recommendations 4. Recognition and treatment of autonomic tory demyelinating neuropathy, inherited
neuropathy may improve symptoms, re- neuropathies, and vasculitis (100). See
Screening duce sequelae, and improve quality of American Diabetes Association position
c All patients should be assessed for life. statement “Diabetic Neuropathy” for
more details (99).
diabetic peripheral neuropathy Specific treatment for the underlying nerve
damage, other than improved glycemic
control, is currently not available. Glycemic

S112 Microvascular Complications and Foot Care Diabetes Care Volume 41, Supplement 1, January 2018

Diabetic Autonomic Neuropathy and inadequate lubrication (103). Lower medication side effects is recommended
urinary tract symptoms manifest as uri- to achieve pain reduction and improve
The symptoms and signs of autonomic nary incontinence and bladder dysfunction quality of life (113–115).
neuropathy should be elicited carefully (nocturia, frequent urination, urination ur-
during the history and physical examination. gency, and weak urinary stream). Evaluation Pregabalin, a calcium channel a2-d
Major clinical manifestations of diabetic au- of bladder function should be performed for subunit ligand, is the most extensively
tonomic neuropathy include hypoglycemia individuals with diabetes who have recur- studied drug for DPN. The majority of
unawareness, resting tachycardia, ortho- rent urinary tract infections, pyelonephritis, studies testing pregabalin have reported
static hypotension, gastroparesis, constipa- incontinence, or a palpable bladder. favorable effects on the proportion of
tion, diarrhea, fecal incontinence, erectile participants with at least 30–50% im-
dysfunction, neurogenic bladder, and sudo- Treatment provement in pain (112,114,116–119).
motor dysfunction with either increased or However, not all trials with pregabalin
decreased sweating. Glycemic Control have been positive (112,114,120,121), es-
Cardiac Autonomic Neuropathy. CAN is as- pecially when treating patients with ad-
sociated with mortality independently of Near-normal glycemic control, imple- vanced refractory DPN (118). Adverse
other cardiovascular risk factors (101,102). mented early in the course of diabetes, effects may be more severe in older pa-
In its early stages, CAN may be completely has been shown to effectively delay or tients (122) and may be attenuated by
asymptomatic and detected only by de- prevent the development of DPN and lower starting doses and more gradual
creased heart rate variability with deep CAN in patients with type 1 diabetes titration.
breathing. Advanced disease may be (104–107). Although the evidence for
associated with resting tachycardia the benefit of near-normal glycemic con- Duloxetine is a selective norepineph-
(.100 bpm) and orthostatic hypotension trol is not as strong for type 2 diabetes, rine and serotonin reuptake inhibitor.
(a fall in systolic or diastolic blood pres- some studies have demonstrated a mod- Doses of 60 and 120 mg/day showed
sure by .20 mmHg or .10 mmHg, re- est slowing of progression without re- efficacy in the treatment of pain associ-
spectively, upon standing without an versal of neuronal loss (30,108). Specific ated with DPN in multicenter random-
appropriate increase in heart rate). CAN glucose-lowering strategies may have dif- ized trials, although some of these had
treatment is generally focused on allevi- ferent effects. In a post hoc analysis, par- high drop-out rates (112,114,119,121).
ating symptoms. ticipants, particularly men, in the Bypass Duloxetine also appeared to improve
Gastrointestinal Neuropathies. Gastrointes- Angioplasty Revascularization Investi- neuropathy-related quality of life (123).
tinal neuropathies may involve any por- gation in Type 2 Diabetes (BARI 2D) trial In longer-term studies, a small increase
tion of the gastrointestinal tract with treated with insulin sensitizers had a in A1C was reported in people with dia-
manifestations including esophageal lower incidence of distal symmetric pol- betes treated with duloxetine compared
dysmotility, gastroparesis, constipation, yneuropathy over 4 years than those with placebo (124). Adverse events may
diarrhea, and fecal incontinence. Gastro- treated with insulin/sulfonylurea (109). be more severe in older people, but may
paresis should be suspected in individuals be attenuated with lower doses and
with erratic glycemic control or with up- Neuropathic Pain slower titrations of duloxetine.
per gastrointestinal symptoms without
another identified cause. Exclusion of or- Neuropathic pain can be severe and can Tapentadol is a centrally acting opioid
ganic causes of gastric outlet obstruction impact quality of life, limit mobility, and analgesic that exerts its analgesic effects
or peptic ulcer disease (with esophago- contribute to depression and social dys- through both m-opioid receptor agonism
gastroduodenoscopy or a barium study function (110). No compelling evidence and noradrenaline reuptake inhibition.
of the stomach) is needed before consider- exists in support of glycemic control or Extended-release tapentadol was ap-
ing a diagnosis of or specialized testing for lifestyle management as therapies for proved by the FDA for the treatment of
gastroparesis. The diagnostic gold standard neuropathic pain in diabetes or prediabe- neuropathic pain associated with diabe-
for gastroparesis is the measurement of tes, which leaves only pharmaceutical in- tes based on data from two multicenter
gastric emptying with scintigraphy of di- terventions (111). clinical trials in which participants ti-
gestible solids at 15-min intervals for 4 h trated to an optimal dose of tapentadol
after food intake. The use of 13C octanoic Pregabalin and duloxetine have re- were randomly assigned to continue
acid breath test is emerging as a viable ceived regulatory approval by the FDA, that dose or switch to placebo (125,126).
alternative. Health Canada, and the European Medi- However, both used a design enriched for
Genitourinary Disturbances. Diabetic auto- cines Agency for the treatment of neu- patients who responded to tapentadol
nomic neuropathy may also cause genito- ropathic pain in diabetes. The opioid and therefore their results are not gener-
urinary disturbances, including sexual tapentadol has regulatory approval in alizable. A recent systematic review and
dysfunction and bladder dysfunction. In the U.S. and Canada, but the evidence meta-analysis by the Special Interest
men, diabetic autonomic neuropathy of its use is weaker (112). Comparative Group on Neuropathic Pain of the Inter-
may cause erectile dysfunction and/or effectiveness studies and trials that in- national Association for the Study of Pain
retrograde ejaculation (99). Female sexual clude quality-of-life outcomes are rare, found the evidence supporting the effec-
dysfunction occurs more frequently in so treatment decisions must consider tiveness of tapentadol in reducing neu-
those with diabetes and presents as de- each patient’s presentation and comor- ropathic pain to be inconclusive (112).
creased sexual desire, increased pain dur- bidities and often follow a trial-and-error Therefore, given the high risk for addic-
ing intercourse, decreased sexual arousal, approach. Given the range of partially ef- tion and safety concerns compared with
fective treatment options, a tailored and the relatively modest pain reduction, the
stepwise pharmacologic strategy with use of extended-release tapentadol is
careful attention to relative symptom im-
provement, medication adherence, and

care.diabetesjournals.org Microvascular Complications and Foot Care S113

not generally recommended as a first- intraurethral prostaglandins, vacuum de- Foot ulcers and amputation, which are
or second-line therapy. vices, or penile prostheses. As with DPN consequences of diabetic neuropathy
treatments, these interventions do not and/or peripheral arterial disease (PAD),
Tricyclic antidepressants, gabapentin, change the underlying pathology and nat- are common and represent major causes
venlafaxine, carbamazepine, tramadol, ural history of the disease process but of morbidity and mortality in people with
and topical capsaicin, although not ap- may improve the patient’s quality of life. diabetes. Early recognition and treatment
proved for the treatment of painful DPN, of patients with diabetes and feet at risk
may be effective and considered for the FOOT CARE for ulcers and amputations can delay or
treatment of painful DPN (99,112,114). prevent adverse outcomes.
Recommendations
Orthostatic Hypotension The risk of ulcers or amputations is in-
c Perform a comprehensive foot eval- creased in people who have the following
Treating orthostatic hypotension is chal- uation at least annually to identify risk factors:
lenging. The therapeutic goal is to mini- risk factors for ulcers and amputa-
mize postural symptoms rather than to tions. B + Poor glycemic control
restore normotension. Most patients re- + Peripheral neuropathy with LOPS
quire both nonpharmacologic measures c All patients with diabetes should + Cigarette smoking
(e.g., ensuring adequate salt intake, avoid- have their feet inspected at every + Foot deformities
ing medications that aggravate hypoten- visit. C + Preulcerative callus or corn
sion, or using compressive garments over + PAD
the legs and abdomen) and pharmacologic c Obtain a prior history of ulceration, + History of foot ulcer
measures. Physical activity and exercise amputation, Charcot foot, angio- + Amputation
should be encouraged to avoid decondi- plasty or vascular surgery, cigarette + Visual impairment
tioning, which is known to exacerbate or- smoking, retinopathy, and renal dis- + Diabetic kidney disease (especially pa-
thostatic intolerance, and volume repletion ease and assess current symptoms
with fluids and salt is critical. Midodrine and of neuropathy (pain, burning, numb- tients on dialysis)
droxidopa are approved by the FDA for the ness) and vascular disease (leg fa-
treatment of orthostatic hypotension. tigue, claudication). B Clinicians are encouraged to review
American Diabetes Association screening
Gastroparesis c The examination should include in- recommendations for further details and
spection of the skin, assessment practical descriptions of how to perform
Treatment for diabetic gastroparesis may of foot deformities, neurological components of the comprehensive foot
be very challenging. Dietary changes may assessment (10-g monofilament examination (129).
be useful, such as eating multiple small testing with at least one other as-
meals and decreasing dietary fat and fiber sessment: pinprick, temperature, Evaluation for Loss of Protective
intake. Withdrawing drugs with adverse vibration), and vascular assessment Sensation
effects on gastrointestinal motility includ- including pulses in the legs and All adults with diabetes should undergo a
ing opioids, anticholinergics, tricyclic an- feet. B comprehensive foot evaluation at least
tidepressants, glucagon-like peptide 1 annually. Detailed foot assessments may
receptor agonists, pramlintide, and pos- c Patients with symptoms of claudi- occur more frequently in patients with
sibly dipeptidyl peptidase 4 inhibitors, cation or decreased or absent pedal histories of ulcers or amputations, foot
may also improve intestinal motility (127, pulses should be referred for ankle- deformities, insensate feet, and PAD
128). In cases of severe gastroparesis, brachial index and for further vas- (130). Foot inspections should occur at
pharmacologic interventions are needed. cular assessment as appropriate. C every visit in all patients with diabetes.
Only metoclopramide, a prokinetic agent, To assess risk, clinicians should ask about
is approved by the FDA for the treatment c A multidisciplinary approach is rec- history of foot ulcers or amputation, neu-
of gastroparesis. However, the level of ommended for individuals with foot ropathic and peripheral vascular symp-
evidence regarding the benefits of meto- ulcers and high-risk feet (e.g., dialysis toms, impaired vision, renal disease,
clopramide for the management of gas- patients and those with Charcot foot, tobacco use, and foot care practices. A
troparesis is weak, and given the risk for prior ulcers, or amputation). B general inspection of skin integrity and
serious adverse effects (extrapyramidal musculoskeletal deformities should be
signs such as acute dystonic reactions, c Refer patients who smoke or who performed. Vascular assessment should
drug-induced parkinsonism, akathisia, have histories of prior lower-extremity include inspection and palpation of pedal
and tardive dyskinesia), its use in the treat- complications, loss of protective sen- pulses.
ment of gastroparesis beyond 5 days is no sation, structural abnormalities, or pe-
longer recommended by the FDA or the ripheral arterial disease to foot care The neurological exam performed as
European Medicines Agency. It should be specialists for ongoing preventive part of the foot examination is designed
reserved for severe cases that are unre- care and life-long surveillance. C to identify LOPS rather than early neurop-
sponsive to other therapies (128). athy. The 10-g monofilament is the most
c Provide general preventive foot useful test to diagnose LOPS. Ideally, the
Erectile Dysfunction self-care education to all patients 10-g monofilament test should be per-
with diabetes. B formed with at least one other assess-
In addition to treatment of hypogonad- ment (pinprick, temperature or vibration
ism if present, treatments for erectile c The use of specialized therapeutic
dysfunction may include phosphodiester- footwear is recommended for high-
ase type 5 inhibitors, intracorporeal or risk patients with diabetes includ-
ing those with severe neuropathy,
foot deformities, or history of am-
putation. B

S114 Microvascular Complications and Foot Care Diabetes Care Volume 41, Supplement 1, January 2018

sensation using a 128-Hz tuning fork, or when patients with neuropathy present healing compared to comprehensive
ankle reflexes). Absent monofilament with the acute onset of a red, hot, swollen wound care in patients with chronic di-
sensation suggests LOPS, while at least foot or ankle, and Charcot neuroarthrop- abetic foot ulcers (138). A systematic re-
two normal tests (and no abnormal test) athy should be excluded. Early diagnosis view by the International Working Group
rules out LOPS. and treatment of Charcot neuroarthrop- on the Diabetic Foot of interventions
athy is the best way to prevent defor- to improve the healing of chronic dia-
Evaluation for Peripheral Arterial mities that increase the risk of ulceration betic foot ulcers concluded that analysis of
Disease and amputation. The routine prescription the evidence continues to present meth-
Initial screening for PAD should include a of therapeutic footwear is not generally odological challenges as randomized con-
history of decreased walking speed, leg recommended. However, patients should trolled studies remain few with a majority
fatigue, claudication, and an assessment be provided adequate information to aid being of poor quality (135). HBOT also
of the pedal pulses. Ankle-brachial index in selection of appropriate footwear. Gen- does not seem to have a significant effect
testing should be performed in patients eral footwear recommendations include a on health-related quality of life in patients
with symptoms or signs of PAD. broad and square toe box, laces with three with diabetic foot ulcers (139,140). A re-
or four eyes per side, padded tongue, qual- cent review concluded that the evidence
Patient Education ity lightweight materials, and sufficient to date remains inconclusive regarding
All patients with diabetes and particularly size to accommodate a cushioned insole. the clinical and cost-effectiveness of
those with high-risk foot conditions (his- Use of custom therapeutic footwear can HBOT as an adjunctive treatment to stan-
tory of ulcer or amputation, deformity, help reduce the risk of future foot ulcers in dard wound care for diabetic foot ulcers
LOPS, or PAD) and their families should high-risk patients (130,132). (141). Results from the recently published
be provided general education about risk Dutch DAMOCLES (Does Applying More
factors and appropriate management Most diabetic foot infections are poly- Oxygen Cure Lower Extremity Sores?)
(131). Patients at risk should understand microbial, with aerobic gram-positive trial demonstrated that HBOT in patients
the implications of foot deformities, LOPS, cocci. staphylococci and streptococci are with diabetes and ischemic wounds did
and PAD; the proper care of the foot, in- the most common causative organisms. not significantly improve complete
cluding nail and skin care; and the impor- Wounds without evidence of soft tissue wound healing and limb salvage (142).
tance of foot monitoring on a daily basis. or bone infection do not require antibiotic The Centers for Medicare & Medicaid Ser-
Patients with LOPS should be educated on therapy. Empiric antibiotic therapy can be vices currently covers HBOT for diabetic
ways to substitute other sensory modalities narrowly targeted at gram-positive cocci foot ulcers that have failed a standard
(palpation or visual inspection using an un- in many patients with acute infections, but course of wound therapy when there
breakable mirror) for surveillance of early those at risk for infection with antibiotic- are no measurable signs of healing for
foot problems. resistant organisms or with chronic, previ- at least 30 consecutive days (143). HBOT
ously treated, or severe infections require should be a topic of shared decision-
The selection of appropriate footwear broader-spectrum regimens and should be making before treatment is considered
and footwear behaviors at home should referred to specialized care centers (133). for selected patients with diabetic foot
also be discussed. Patients’ understand- Foot ulcers and wound care may re- ulcers (143).
ing of these issues and their physical abil- quire care by a podiatrist, orthopedic or
ity to conduct proper foot surveillance vascular surgeon, or rehabilitation spe- References
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136. Kranke P, Bennett MH, Martyn-St James M, controlled clinical trial. Diabetes Care 2016;39: a health technology assessment. Ont Health Tech-
Schnabel A, Debus SE, Weibel S. Hyperbaric oxy- 392–399 nol Assess Ser 2017;17:1–142
gen therapy for chronic wounds. Cochrane Data- 139. Li G, Hopkins RB, Levine MAH, et al. Re- 142. Santema KTB, Stoekenbroek RM, Koelemay
base Syst Rev 2015;6:CD004123 lationship between hyperbaric oxygen therapy MJW, et al. Hyperbaric oxygen therapy in the
137. L o¨ndahl M, Katzman P, N il ss on A, and quality of life in participants with chronic treatment of ischemic lower extremity ulcers in
Hammarlund C. Hyperbaric oxygen therapy diabetic foot ulcers: data from a randomized patients with diabetes: results of the DAMO2CLES
facilitates healing of chronic foot ulcers in pa- controlled trial. Acta Diabetol 2017;54:823– multicenter randomized clinical trial. Diabetes
tients with diabetes. Diabetes Care 2010;33: 831 Care. 26 October 2017 [Epub ahead of print].
998–1003 140. Boulton AJM. The Diabetic Foot [Internet], DOI: https://doi.org/10.2337/dc17-0654
138. Fedorko L, Bowen JM, Jones W, et al. Hyper- 2000. South Dartmouth, MA, MDText.com, Inc. 143. Huang ET, Mansouri J, Murad MH, et al.;
baric oxygen therapy does not reduce indica- Available from http://www.ncbi.nlm.nih.gov/ UHMS CPG Oversight Committee. A clinical prac-
tions for amputation in patients with diabetes books/NBK409609/. Accessed 5 October 2017 tice guideline for the use of hyperbaric oxygen
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Diabetes Care Volume 41, Supplement 1, January 2018 S119

11. Older Adults: Standards of American Diabetes Association
Medical Care in Diabetesd2018

Diabetes Care 2018;41(Suppl. 1):S119–S125 | https://doi.org/10.2337/dc18-S011

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” 11. OLDER ADULTS
includes ADA’s current clinical practice recommendations and is intended to provide
the components of diabetes care, general treatment goals and guidelines, and tools
to evaluate quality of care. Members of the ADA Professional Practice Committee, a
multidisciplinary expert committee, are responsible for updating the Standards of
Care annually, or more frequently as warranted. For a detailed description of ADA
standards, statements, and reports, as well as the evidence-grading system for ADA’s
clinical practice recommendations, please refer to the Standards of Care Introduction.
Readers who wish to comment on the Standards of Care are invited to do so at
professional.diabetes.org/SOC.

Recommendations

c Consider the assessment of medical, psychological, functional, and social geriatric
domains in older adults to provide a framework to determine targets and ther-
apeutic approaches for diabetes management. C

c Screening for geriatric syndromes may be appropriate in older adults expe-
riencing limitations in their basic and instrumental activities of daily living as
they may affect diabetes self-management and be related to health-related
quality of life. C

Diabetes is an important health condition for the aging population; approximately one- Suggested citation: American Diabetes Associa-
quarter of people over the age of 65 years have diabetes and one-half of older adults tion. 11. Older adults: Standards of Medical Care in
have prediabetes (1), and this proportion is expected to increase rapidly in the coming Diabetesd2018. Diabetes Care 2018;41(Suppl. 1):
decades. Older individuals with diabetes have higher rates of premature death, func- S119–S125
tional disability, accelerated muscle loss, and coexisting illnesses, such as hypertension,
coronary heart disease, and stroke, than those without diabetes. Older adults with © 2017 by the American Diabetes Association.
diabetes also are at greater risk than other older adults for several common geriatric Readers may use this article as long as the work
syndromes, such as polypharmacy, cognitive impairment, urinary incontinence, injuri- is properly cited, the use is educational and not
ous falls, and persistent pain. These conditions may impact older adults’ diabetes self- for profit, and the work is not altered. More infor-
management abilities (2). mation is available at http://www.diabetesjournals
.org/content/license.
Screening for diabetes complications in older adults should be individualized and
periodically revisited, as the results of screening tests may impact therapeutic ap-
proaches and targets (2–4). Older adults are at increased risk for depression and should
therefore be screened and treated accordingly (5). Diabetes management may require
assessment of medical, psychological, functional, and social domains. This may
provide a framework to determine targets and therapeutic approaches. Particular
attention should be paid to complications that can develop over short periods of
time and/or that would significantly impair functional status, such as visual and
lower-extremity complications. Please refer to the American Diabetes Association
(ADA) consensus report “Diabetes in Older Adults” for details (2).

S120 Older Adults Diabetes Care Volume 41, Supplement 1, January 2018

NEUROCOGNITIVE FUNCTION Older adults with diabetes should be and, conversely, severe hypoglycemia
carefully screened and monitored for cog- has been linked to increased risk of de-
Recommendation nitive impairment (2). Several organiza- mentia. Therefore, it is important to rou-
tions have released simple assessment tinely screen older adults for cognitive
c Screening for early detection of tools, such as the Mini-Mental State Ex- dysfunction and discuss findings with the
mild cognitive impairment or de- amination (15) and the Montreal Cogni- patients and their caregivers. Hypoglyce-
mentia and depression is indicated tive Assessment (16), which may help to mic events should be diligently monitored
for adults 65 years of age or older at identify patients requiring neuropsycho- and avoided, whereas glycemic targets and
the initial visit and annually as ap- logical evaluation, particularly those in pharmacologic interventions may need
propriate. B whom dementia is suspected (i.e., experi- to be adjusted to accommodate for the
encing memory loss and decline in their changing needs of the older adult (2).
Older adults with diabetes are at higher basic and instrumental activities of daily
risk of cognitive decline and institution- living). Annual screening for cognitive im- TREATMENT GOALS
alization (6,7). The presentation of cog- pairment is indicated for adults 65 years
nitive impairment ranges from subtle of age or older for early detection of Recommendations
executive dysfunction to memory loss mild cognitive impairment or dementia
and overt dementia. People with diabetes (4). People who screen positive for cogni- c Older adults who are otherwise
have higher incidences of all-cause de- tive impairment should receive diagnostic healthy with few coexisting chronic
mentia, Alzheimer disease, and vascular assessment as appropriate, including re- illnesses and intact cognitive func-
dementia than people with normal glu- ferral to a behavioral health provider tion and functional status should
cose tolerance (8). The effects of hyper- for formal cognitive/neuropsychological have lower glycemic goals (A1C
glycemia and hyperinsulinemia on the evaluation (17). ,7.5% [58 mmol/mol]), while those
brain are areas of intense research. Clinical with multiple coexisting chronic ill-
trials of specific interventionsdincluding HYPOGLYCEMIA nesses, cognitive impairment, or
cholinesterase inhibitors and glutamater- functional dependence should have
gic antagonistsdhave not shown positive Recommendation less stringent glycemic goals (A1C
therapeutic benefit in maintaining or sig- ,8.0–8.5% [64–69 mmol/mol]). C
nificantly improving cognitive function or c Hypoglycemia should be avoided in
in preventing cognitive decline (9). Pilot older adults with diabetes. It should c Glycemic goals for some older
studies in patients with mild cognitive im- be assessed and managed by ad- adults might reasonably be relaxed
pairment evaluating the potential bene- justing glycemic targets and phar- as part of individualized care, but
fits of intranasal insulin therapy and macologic interventions. B hyperglycemia leading to symp-
metformin therapy provide insights for toms or risk of acute hyperglycemic
future clinical trials and mechanistic stud- It is important to prevent hypoglycemia to complications should be avoided in
ies (10–12). reduce the risk of cognitive decline (18) all patients. C
and other major adverse outcomes. In-
The presence of cognitive impairment tensive glucose control in the Action to c Screening for diabetes complica-
can make it challenging for clinicians to Control Cardiovascular Risk in Diabetes- tions should be individualized in
help their patients to reach individualized Memory in Diabetes study (ACCORD older adults. Particular attention
glycemic, blood pressure, and lipid targets. MIND) was not found to have benefits on should be paid to complications
Cognitive dysfunction makes it difficult for brain structure or cognitive function during that would lead to functional im-
patients to perform complex self-care follow-up (14). Of note, in the Diabetes pairment. C
tasks, such as glucose monitoring and ad- Control and Complications Trial (DCCT),
justing insulin doses. It also hinders their no significant long-term declines in cogni- c Treatment of hypertension to indi-
ability to appropriately maintain the tim- tive function were observed though par- vidualized target levels is indicated
ing and content of diet. When clinicians ticipants had relatively high rates of in most older adults. C
are managing patients with cognitive dys- recurrent severe hypoglycemia (19). It is
function, it is critical to simplify drug reg- also important to carefully assess and re- c Treatment of other cardiovascular
imens and to involve caregivers in all assess patients’ risk for worsening of gly- risk factors should be individualized
aspects of care. cemic control and functional decline. in older adults considering the time
Older adults are at higher risk of hypogly- frame of benefit. Lipid-lowering
Poor glycemic control is associated with cemia for many reasons, including insulin therapy and aspirin therapy may
a decline in cognitive function (13), and deficiency necessitating insulin therapy benefit those with life expectancies
longer duration of diabetes is associated and progressive renal insufficiency. In ad- at least equal to the time frame of
with worsening cognitive function. There dition, older adults tend to have higher primary prevention or secondary in-
are ongoing studies evaluating whether rates of unidentified cognitive deficits, tervention trials. E
preventing or delaying diabetes onset causing difficulty in complex self-care
may help to maintain cognitive function in activities (e.g., glucose monitoring, Rationale
older adults. However, studies examining the adjusting insulin doses, etc.). These The care of older adults with diabetes is
effects of intensive glycemic and blood pres- cognitive deficits have been associated complicated by their clinical, cognitive,
sure control to achieve specific targets have with increased risk of hypoglycemia, and functional heterogeneity. Some older
not demonstrated a reduction in brain func- individuals may have developed diabetes
tion decline (14). years earlier and have significant compli-
cations, others are newly diagnosed and
may have had years of undiagnosed

Older Adults S121

diabetes with resultant complications,
and still other older adults may have
truly recent-onset disease with few or
no complications (20). Some older adults
with diabetes have other underlying
chronic conditions, substantial diabetes-
related comorbidity, limited cognitive or
physical functioning, or frailty (21,22).
Other older individuals with diabetes
have little comorbidity and are active.
Life expectancies are highly variable but
are often longer than clinicians realize.
Providers caring for older adults with di-
abetes must take this heterogeneity into
consideration when setting and prioritiz-
ing treatment goals (23) (Table 11.1). In
addition, older adults with diabetes
should be assessed for disease treatment
and self-management knowledge, health
literacy, and mathematical literacy (nu-
meracy) at the onset of treatment.

A1C is used as the standard biomarker
for glycemic control in all patients with
diabetes but may have limitations in pa-
tients who have medical conditions that
impact red blood cell turnover (see Sec-
tion 2 “Classification and Diagnosis of
Diabetes” for additional details on the
limitations of A1C) (24). Many conditions
associated with increased red blood cell
turnover, such as hemodialysis, recent
blood loss or transfusion, or erythropoie-
tin therapy, are commonly seen in frail
older adults, which can falsely increase
or decrease A1C. In these instances,
plasma blood glucose and finger-stick
readings should be used for goal setting
(Table 11.1).
Healthy Patients With Good Functional
Status
There are few long-term studies in older
adults demonstrating the benefits of in-
tensive glycemic, blood pressure, and lipid
control. Patients who can be expected to
live long enough to reap the benefits of
long-term intensive diabetes manage-
ment, who have good cognitive and phys-
ical function, and who choose to do so via
shared decision-making may be treated
using therapeutic interventions and goals
similar to those for younger adults with
diabetes (Table 11.1). As with all patients
with diabetes, diabetes self-management
education and ongoing diabetes self-
management support are vital compo-
nents of diabetes care for older adults
and their caregivers. Self-management
knowledge and skills should be reas-
sessed when regimen changes are

Table 11.1—Framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes (2)

Patient characteristics/health Rationale Reasonable A1C goal‡ Fasting or preprandial Bedtime glucose Blood pressure Lipids
status glucose

Healthy (few coexisting chronic Longer remaining life ,7.5% (58 mmol/mol) 90–130 mg/dL 90–150 mg/dL ,140/90 mmHg Statin unless contraindicated
illnesses, intact cognitive and expectancy ,8.0% (64 mmol/mol) (5.0–7.2 mmol/L) (5.0–8.3 mmol/L) ,140/90 mmHg or not tolerated
functional status)
Intermediate remaining ,8.5%† (69 mmol/mol) 90–150 mg/dL 100–180 mg/dL Statin unless contraindicated
Complex/intermediate (multiple life expectancy, high (5.0–8.3 mmol/L) (5.6–10.0 mmol/L) or not tolerated
coexisting chronic illnesses* treatment burden,
or 21 instrumental ADL hypoglycemia 100–180 mg/dL 110–200 mg/dL ,150/90 mmHg Consider likelihood of benefit
impairments or mild-to-moderate vulnerability, fall risk (5.6–10.0 mmol/L) (6.1–11.1 mmol/L) with statin (secondary
cognitive impairment) prevention more so than
Limited remaining life primary)
Very complex/poor health (LTC or expectancy makes
end-stage chronic illnesses** benefit uncertain
or moderate-to-severe cognitive
impairment or 21 ADL
dependencies)

care.diabetesjournals.org This represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes. The patient characteristic categories are general concepts. Not
every patient will clearly fall into a particular category. Consideration of patient and caregiver preferences is an important aspect of treatment individualization. Additionally, a patient’s health status and
preferences may change over time. ADL, activities of daily living. ‡A lower A1C goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden. *Coexisting
chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, congestive heart failure, depression, emphysema, falls, hypertension, incontinence,
stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. By “multiple,” we mean at least three, but many patients may have five or more (47). **The presence of a single end-stage chronic
illness, such as stage 3–4 congestive heart failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer, may cause significant symptoms or impairment of
functional status and significantly reduce life expectancy. †A1C of 8.5% (69 mmol/mol) equates to an estimated average glucose of ;200 mg/dL (11.1 mmol/L). Looser A1C targets above 8.5% (69 mmol/mol) are
not recommended as they may expose patients to more frequent higher glucose values and the acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing.

S122 Older Adults Diabetes Care Volume 41, Supplement 1, January 2018

made or an individual’s functional abil- PHARMACOLOGIC THERAPY (35). However, it is contraindicated in pa-
ities diminish. In addition, declining or tients with advanced renal insufficiency
impaired ability to perform diabetes self- Recommendations and should be used with caution in pa-
care behaviors may be an indication for tients with impaired hepatic function or
referral of older adults with diabetes for c In older adults at increased risk of congestive heart failure due to the in-
cognitive and physical functional assess- hypoglycemia, medication classes creased risk of lactic acidosis. Metformin
ment using age-normalized evaluation with low risk of hypoglycemia are may be temporarily discontinued before
tools (3,17). preferred. B procedures, during hospitalizations, and
when acute illness may compromise renal
Patients With Complications and c Overtreatment of diabetes is com- or liver function.
Reduced Functionality mon in older adults and should be
For patients with advanced diabetes com- avoided. B Thiazolidinediones
plications, life-limiting comorbid illnesses, Thiazolidinediones, if used at all, should
or substantial cognitive or functional im- c Deintensification (or simplification) be used very cautiously in those with, or
pairments, it is reasonable to set less inten- of complex regimens is recommen- at risk for, congestive heart failure and
sive glycemic goals (Table 11.1). Factors to ded to reduce the risk of hypoglyce- those at risk for falls or fractures.
consider in individualizing glycemic goals mia, if it can be achieved within the
are outlined in Fig. 6.1. These patients are individualized A1C target. B Insulin Secretagogues
less likely to benefit from reducing the Sulfonylureas and other insulin secreta-
risk of microvascular complications and Special care is required in prescribing gogues are associated with hypoglycemia
more likely to suffer serious adverse ef- and monitoring pharmacologic therapies and should be used with caution. If used,
fects from hypoglycemia. However, pa- in older adults (29). See Fig. 8.1 for gen- shorter-duration sulfonylureas such as
tients with poorly controlled diabetes eral recommendations regarding antihy- glipizide are preferred. Glyburide is a
may be subject to acute complications perglycemic treatment for adults with longer-duration sulfonylurea and contra-
of diabetes, including dehydration, poor type 2 diabetes and Table 8.1 for patient indicated in older adults (36).
wound healing, and hyperglycemic hyper- and drug-specific factors to consider
osmolar coma. Glycemic goals at a mini- when selecting antihyperglycemic agents. Incretin-Based Therapies
mum should avoid these consequences. Cost may be an important consideration, Oral dipeptidyl peptidase 4 inhibitors
especially as older adults tend to be on have few side effects and minimal hypo-
Vulnerable Patients at the End of Life many medications. It is important to glycemia, but their costs may be a bar-
For patients receiving palliative care and match complexity of the treatment rier to some older patients. A systematic
end-of-life care, the focus should be to regimen to the self-management ability review concluded that incretin-based
avoid symptoms and complications from of an older patient. Many older adults agents do not increase major adverse car-
glycemic management. Thus, when organ with diabetes struggle to maintain the diovascular events (37).
failure develops, several agents will have frequent blood glucose testing and in-
to be titrated or discontinued. For the sulin injection regimens they previ- Glucagon-like peptide 1 receptor ago-
dying patient, most agents for type 2 di- ously followed, perhaps for many nists are injectable agents, which require
abetes may be removed (25). There is, decades, as they develop medical condi- visual, motor, and cognitive skills. They
however, no consensus for the manage- tions that may impair their ability to fol- may be associated with nausea, vomit-
ment of type 1 diabetes in this scenario low their regimen safely. Individualized ing, and diarrhea. Also, weight loss with
(26). See p. S123, END-OF-LIFE CARE, for addi- glycemic goals should be established glucagon-like peptide 1 receptor agonists
tional information. (Fig. 6.1) and periodically adjusted based may not be desirable in some older pa-
on coexisting chronic illnesses, cognitive tients, particularly those with cachexia.
Beyond Glycemic Control function, and functional status (2). Tighter
Although hyperglycemia control may be glycemic control in older adults with mul- Sodium–Glucose Cotransporter 2
important in older individuals with diabe- tiple medical conditions is associated with Inhibitors
tes, greater reductions in morbidity and an increased risk of hypoglycemia and Sodium–glucose cotransporter 2 inhibi-
mortality are likely to result from control considered overtreatment but, unfor- tors offer an oral route, which may be
of other cardiovascular risk factors rather tunately, is common in clinical practice convenient for older adults with diabetes;
than from tight glycemic control alone. (30–32). When patients are found to however, long-term experience is limited
There is strong evidence from clinical tri- have an insulin regimen with complexity despite the initial efficacy and safety data
als of the value of treating hypertension beyond their self-management abilities, reported with these agents.
in older adults (27,28). There is less evi- deintensification (or simplification) can
dence for lipid-lowering therapy and as- reduce hypoglycemia and disease-related Insulin Therapy
pirin therapy, although the benefits of distress without worsening glycemic con- The use of insulin therapy requires that
these interventions for primary preven- trol (33,34). patients or their caregivers have good
tion and secondary intervention are likely visual and motor skills and cognitive abil-
to apply to older adults whose life expec- Metformin ity. Insulin therapy relies on the ability
tancies equal or exceed the time frames Metformin is the first-line agent for older of the older patient to administer insulin
of the clinical trials. adults with type 2 diabetes. Recent stud- on their own or with the assistance
ies have indicated that it may be used of a caregiver. Insulin doses should be
safely in patients with estimated glomer- titrated to meet individualized glycemic
ular filtration rate $30 mL/min/1.73 m2 targets and to avoid hypoglycemia.

care.diabetesjournals.org Older Adults S123

Once-daily basal insulin injection ther- institutional quality assessment. LTC facil- excursions without the practitioner being
apy is associated with minimal side ef- ities should develop their own policies notified. Providers may make adjustments
fects and may be a reasonable option in and procedures for prevention and man- to treatment regimens by telephone, fax,
many older patients. Multiple daily injec- agement of hypoglycemia. or order directly at the LTC facilities pro-
tions of insulin may be too complex for vided they are given timely notification
the older patient with advanced diabetes Resources from a standardized alert system.
complications, life-limiting coexisting Staff of LTC facilities should receive ap-
chronic illnesses, or limited functional propriate diabetes education to improve The following alert strategy could be
status. the management of older adults with considered:
diabetes. Treatments for each patient
Other Factors to Consider should be individualized. Special man- 1. Call provider immediately: in case of
The needs of older adults with diabetes agement considerations include the low blood glucose levels (#70 mg/dL
and their caregivers should be evaluated need to avoid both hypoglycemia and [3.9 mmol/L]). Low finger-stick blood
to construct a tailored care plan. Social the metabolic complications of diabe- glucose values should be confirmed by
difficulties may impair their quality of tes and the need to provide adequate laboratory glucose measurement.
life and increase the risk of functional de- diabetes training to LTC staff (2,40).
pendency (38). The patient’s living situa- For more information, see the ADA posi- 2. Call as soon as possible: a) glucose
tion must be considered, as it may affect tion statement “Management of Diabetes values between 70 and 100 mg/dL (be-
diabetes management and support. So- in Long-term Care and Skilled Nursing Fa- tween 3.9 and 5.6 mmol/L) (regimen
cial and instrumental support networks cilities” (38). may need to be adjusted), b) glu-
(e.g., adult children, caretakers) that pro- cose values greater than 250 mg/dL
vide instrumental or emotional support Nutritional Considerations (13.9 mmol/L) within a 24-h period,
for older adults with diabetes should be An older adult residing in an LTC facility c) glucose values greater than 300
included in diabetes management discus- may have irregular and unpredictable mg/dL (16.7 mmol/L) over 2 consecu-
sions and shared decision-making. meal consumption, undernutrition, an- tive days, d) when any reading is too
orexia, and impaired swallowing. Further- high for the glucometer, or e) the pa-
Older adults in assisted living facilities more, therapeutic diets may inadvertently tient is sick, with vomiting or other
may not have support to administer their lead to decreased food intake and contrib- malady that can reflect hyperglycemic
own medications, whereas those living ute to unintentional weight loss and un- crisis and may lead to poor oral intake,
in a nursing home (community living cen- dernutrition. Diets tailored to a patient’s thus requiring regimen adjustment.
ters) may rely completely on the care plan culture, preferences, and personal goals
and nursing support. Those receiving pal- might increase quality of life, satisfaction END-OF-LIFE CARE
liative care (with or without hospice) may with meals, and nutrition status (41).
require an approach that emphasizes Recommendations
comfort and symptom management, Hypoglycemia
while deemphasizing strict metabolic Older adults with diabetes in LTC are es- c When palliative care is needed in
and blood pressure control. pecially vulnerable to hypoglycemia. They older adults with diabetes, strict
have a disproportionately high number of blood pressure control may not be
TREATMENT IN SKILLED NURSING clinical complications and comorbidities that necessary, and withdrawal of ther-
FACILITIES AND NURSING HOMES can increase hypoglycemia risk: impaired apy may be appropriate. Similarly,
cognitive and renal function, slowed hor- the intensity of lipid management
Recommendations monal regulation and counterregulation, can be relaxed, and withdrawal of
suboptimal hydration, variable appetite lipid-lowering therapy may be ap-
c Consider diabetes education for the and nutritional intake, polypharmacy, and propriate. E
staff of long-term care facilities to slowed intestinal absorption (42). Emerging
improve the management of older studies suggest that insulin and noninsu- c Overall comfort, prevention of dis-
adults with diabetes. E lin agents confer similar glycemic outcomes tressing symptoms, and preserva-
and rates of hypoglycemia in LTC popula- tion of quality of life and dignity
c Patients with diabetes residing in tions (30,43). are primary goals for diabetes man-
long-term care facilities need care- agement at the end of life. E
ful assessment to establish glycemic Another consideration for the LTC set-
goals and to make appropriate ting is that unlike the hospital setting, med- The management of the older adult at the
choices of glucose-lowering agents ical providers are not required to evaluate end of life receiving palliative medicine or
based on their clinical and functional the patients daily. According to federal hospice care is a unique situation. Overall,
status. E guidelines, assessments should be done palliative medicine promotes comfort,
at least every 30 days for the first 90 days symptom control and prevention (pain, hy-
Management of diabetes in the long-term after admission and then at least once poglycemia, hyperglycemia, and dehydra-
care (LTC) setting (i.e., nursing homes and every 60 days. Although in practice the tion), and preservation of dignity and
skilled nursing facilities) is unique. Individ- patients may actually be seen more fre- quality of life in patients with limited life
ualization of health care is important in all quently, the concern is that patients may expectancy (40,44). A patient has the right
patients; however, practical guidance is have uncontrolled glucose levels or wide to refuse testing and treatment, whereas
needed for medical providers as well as providers may consider withdrawing
the LTC staff and caregivers (39). Training treatment and limiting diagnostic testing,
should include diabetes detection and including a reduction in the frequency of
finger-stick testing (45). Glucose targets

S124 Older Adults Diabetes Care Volume 41, Supplement 1, January 2018

should aim to prevent hypoglycemia and 3. Young-Hyman D, de Groot M, Hill-Briggs F, Type 2 Diabetes Study. Diabetes Care 2014;37:
hyperglycemia. Treatment interventions Gonzalez JS, Hood K, Peyrot M. Psychosocial 507–515
need to be mindful of quality of life. Care- care for people with diabetes: a position state- 19. The Diabetes Control and Complications Trial/
ful monitoring of oral intake is warranted. ment of the American Diabetes Association. Di- Epidemiology of Diabetes Interventions (DCCT/
The decision process may need to involve abetes Care 2016;39:2126–2140 EDIC) Study Research Group. Long-term effect of
the patient, family, and caregivers, lead- 4. The National Academy of Sciences. Cognitive diabetes and its treatment on cognitive function.
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Des Devel Ther 2013;7:1471–1478 26. Angelo M, Ruchalski C, Sproge BJ. An ap-
2. A patient with organ failure: prevent- 10. Craft S, Baker LD, Montine TJ, et al. Intranasal proach to diabetes mellitus in hospice and pallia-
ing hypoglycemia is of greater signifi- insulin therapy for Alzheimer disease and amnes- tive medicine. J Palliat Med 2011;14:83–87
cance. Dehydration must be prevented tic mild cognitive impairment: a pilot clinical trial. 27. Beckett NS, Peters R, Fletcher AE, et al.;
and treated. In people with type 1 di- Arch Neurol 2012;69:29–38 HYVET Study Group. Treatment of hypertension
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titrated. The main goal is to avoid hypo- Mereu L, Senior P. Antidiabetic drugs and their panel members appointed to the Eighth Joint Na-
glycemia, allowing for glucose values in potential role in treating mild cognitive impairment tional Committee (JNC 8). JAMA 2014;311:507–
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intake. In patients with type 1 diabetes, 14. Launer LJ, Miller ME, Williamson JD, et al.; diabetes: prevalence, drug treatment and glyce-
there is no consensus, but a small ACCORD MIND investigators. Effects of intensive mic control. Diabetes Res Clin Pract 2014;105:
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glycemic complications. randomised open-label substudy. Lancet Neurol Steinman MA. Potential overtreatment of diabe-
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pdfs/data/statistics/national-diabetes-statistics- 16. Nasreddine ZS, Phillips NA, Be´dirian V, et al. comorbid dementia. Diabetes Care 2015;38:588–
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2. Kirkman MS, Briscoe VJ, Clark N, et al. Diabe- brief screening tool for mild cognitive impair- 33. Munshi MN, Slyne C, Segal AR, Saul N, Lyons
tes in older adults. Diabetes Care 2012;35:2650– ment. J Am Geriatr Soc 2005;53:695–699 C, Weinger K. Simplification of insulin regimen in
2664 17. American Psychological Association. Guide- older adults and risk of hypoglycemia. JAMA In-
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18. Feinkohl I, Aung PP, Keller M, et al.; Edinburgh and life expectancy in older patients with diabetes
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diabetes and kidney disease: a systematic review. 40. Sinclair A, Morley JE, Rodriguez-Man~as L, with type 2 diabetes in long-term care facilities.
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36. Campanelli CM; American Geriatrics Society statement on behalf of the International Associa- 44. Quinn K, Hudson P, Dunning T. Diabetes man-
2012 Beers Criteria Update Expert Panel. tion of Gerontology and Geriatrics (IAGG), the agement in patients receiving palliative care.
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37. Rotz ME, Ganetsky VS, Sen S, Thomas TF. 41. Dorner B, Friedrich EK, Posthauer ME. Prac- tive care physicians in the UK. Palliat Med 2006;
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S126 Diabetes Care Volume 41, Supplement 1, January 2018

12. Children and Adolescents: American Diabetes Association
Standards of Medical Care
in Diabetesd2018

Diabetes Care 2018;41(Suppl. 1):S126–S136 | https://doi.org/10.2337/dc18-S012

12. CHILDREN AND ADOLESCENTS The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”
includes ADA’s current clinical practice recommendations and is intended to provide
the components of diabetes care, general treatment goals and guidelines, and tools
to evaluate quality of care. Members of the ADA Professional Practice Committee, a
multidisciplinary expert committee, are responsible for updating the Standards of
Care annually, or more frequently as warranted. For a detailed description of ADA
standards, statements, and reports, as well as the evidence-grading system for ADA’s
clinical practice recommendations, please refer to the Standards of Care
Introduction. Readers who wish to comment on the Standards of Care are invited
to do so at professional.diabetes.org/SOC.

TYPE 1 DIABETES Suggested citation: American Diabetes Associa-
tion. 12. Children and adolescents: Standards of
Three-quarters of all cases of type 1 diabetes are diagnosed in individuals ,18 years of Medical Care in Diabetesd2018. Diabetes Care
age (although recent data using genetic risk scoring would suggest that over 40% of 2018;41(Suppl. 1):S126–S136
patients with autoimmune diabetes are diagnosed over the age of 30 years) (1). The
provider must consider the unique aspects of care and management of children and © 2017 by the American Diabetes Association.
adolescents with type 1 diabetes, such as changes in insulin sensitivity related to Readers may use this article as long as the work
physical growth and sexual maturation, ability to provide self-care, supervision in is properly cited, the use is educational and not
the child care and school environment, and neurological vulnerability to hypoglycemia for profit, and the work is not altered. More infor-
and hyperglycemia in young children, as well as possible adverse neurocognitive effects mation is available at http://www.diabetesjournals
of diabetic ketoacidosis (DKA) (2,3). Attention to family dynamics, developmental stages, .org/content/license.
and physiological differences related to sexual maturity are all essential in developing and
implementing an optimal diabetes treatment plan (4). Due to the nature of clinical
research in children, the recommendations for children and adolescents are less likely
to be based on clinical trial evidence. However, expert opinion and a review of available
and relevant experimental data are summarized in the American Diabetes Association
(ADA) position statement “Type 1 Diabetes Through the Life Span” (5) and have been
updated in the ADA position statement “Type 1 Diabetes in Children and Adolescents: A
Position Statement by the American Diabetes Association” (6).

A multidisciplinary team of specialists trained in pediatric diabetes management
and sensitive to the challenges of children and adolescents with type 1 diabetes and
their families should provide care for this population. It is essential that diabetes self-
management education and support (DSMES), medical nutrition therapy, and psycho-
social support be provided at diagnosis and regularly thereafter in a developmentally
appropriate format that builds on prior knowledge by individuals experienced with the
educational, nutritional, behavioral, and emotional needs of the growing child and
family. The appropriate balance between adult supervision and independent self-
care should be defined at the first interaction and reevaluated at subsequent visits.

care.diabetesjournals.org Children and Adolescents S127

The balance between adult supervision and family stresses that could im- on diabetes management and disease
and independent self-care will evolve as pact adherence to diabetes man- outcomes (15). Furthermore, the com-
the adolescent gradually becomes an agement and provide appropriate plexities of diabetes management require
emerging young adult. referrals to trained mental health ongoing parental involvement in care
professionals, preferably experi- throughout childhood with developmen-
Diabetes Self-management Education enced in childhood diabetes. E tally appropriate family teamwork be-
and Support c Mental health professionals should tween the growing child/teen and parent
be considered integral members of in order to maintain adherence and to pre-
Recommendation the pediatric diabetes multidisci- vent deterioration in glycemic control
plinary team. E (16,17). As diabetes-specific family con-
c Youth with type 1 diabetes and c Encourage developmentally appro- flict is related to poorer adherence and
parents/caregivers (for patients priate family involvement in diabe- glycemic control, it is appropriate to inquire
aged ,18 years) should receive tes management tasks for children about such conflict during visits and to ei-
culturally sensitive and develop- and adolescents, recognizing that ther help to negotiate a plan for resolution
mentally appropriate individualized premature transfer of diabetes care or refer to an appropriate mental health
diabetes self-management educa- to the child can result in nonadher- specialist (18). Monitoring of social adjust-
tion and support according to na- ence and deterioration in glycemic ment (peer relationships) and school per-
tional standards at diagnosis and control. A formance can facilitate both well-being
routinely thereafter. B c Providers should consider asking and academic achievement (19). Subop-
youth and their parents about social timal glycemic control is a risk factor for
No matter how sound the medical regi- adjustment (peer relationships) and below average school performance and
men, it can only be effective if the family school performance to determine increased absenteeism (20).
and/or affected individuals are able to whether further intervention is
implement it. Family involvement is a vital needed. B Shared decision-making with youth
component of optimal diabetes man- c Assess youth with diabetes for psy- regarding the adoption of regimen com-
agement throughout childhood and ado- chosocial and diabetes-related dis- ponents and self-management behaviors
lescence. Health care providers (the tress, generally starting at 7–8 years can improve diabetes self-efficacy, ad-
diabetes care team) who care for chil- of age. B herence, and metabolic outcomes (21).
dren and adolescents must be capable of c At diagnosis and during routine follow- Although cognitive abilities vary, the
evaluating the educational, behavioral, up care, consider assessing psychoso- ethical position often adopted is the
emotional, and psychosocial factors that cial issues and family stresses that “mature minor rule,” whereby children
impact implementation of a treatment could impact diabetes management after age 12 or 13 years who appear to
plan and must work with the individual and provide appropriate referrals to be “mature” have the right to consent or
and family to overcome barriers or rede- trained mental health professionals, withhold consent to general medical
fine goals as appropriate. DSME and preferably experienced in childhood treatment, except in cases in which re-
DSMS require periodic reassessment, es- diabetes. E fusal would significantly endanger health
pecially as the youth grows, develops, c Offer adolescents time by themselves (22).
and acquires the need for greater inde- with their care provider(s) starting at
pendent self-care skills. In addition, it is age 12 years, or when developmen- Beginning at the onset of puberty or at
necessary to assess the educational needs tally appropriate. E diagnosis of diabetes, all adolescent girls
and skills of day care providers, school c Starting at puberty, preconception and women with childbearing potential
nurses, or other school personnel who par- counseling should be incorporated should receive education about the risks
ticipate in the care of the young child with into routine diabetes care for all of malformations associated with un-
diabetes (7). girls of childbearing potential. A planned pregnancies and poor metabolic
control and the use of effective contra-
School and Child Care Rapid and dynamic cognitive, develop- ception to prevent unplanned pregnancy.
As a large portion of a child’s day is spent mental, and emotional changes occur Preconception counseling using devel-
in school, close communication with and during childhood, adolescence, and emerg- opmentally appropriate educational tools
the cooperation of school or day care per- ing adulthood. Diabetes management dur- enables adolescent girls to make well-
sonnel are essential for optimal diabetes ing childhood and adolescence places informed decisions (23). Preconception
management, safety, and maximal aca- substantial burdens on the youth and fam- counseling resources tailored for adoles-
demic opportunities. Refer to the ADA ily, necessitating ongoing assessment of cents are available at no cost through the
position statements “Diabetes Care in psychosocial status and diabetes distress ADA (24). Refer to the recent ADA position
the School Setting” (8) and “Care of Young during routine diabetes visits (10–14). statement “Psychosocial Care for People
Children With Diabetes in the Child Care Early detection of depression, anxiety, With Diabetes” for further details (15).
Setting” (9) for additional details. eating disorders, and learning disabilities
can facilitate effective treatment op- Screening
Psychosocial Issues tions and help minimize adverse effects
Screening for psychosocial distress and
Recommendations mental health problems is an important
component of ongoing care. It is impor-
c At diagnosis and during routine follow- tant to consider the impact of diabetes on
up care, assess psychosocial issues quality of life as well as the development

S128 Children and Adolescents Diabetes Care Volume 41, Supplement 1, January 2018

of mental health problems related to di- improve glycemic control. Benefits that near normalization of blood glucose
abetes distress, fear of hypoglycemia (and of continuous glucose monitoring levels was more difficult to achieve in ad-
hyperglycemia), symptoms of anxiety, dis- correlate with adherence to ongo- olescents than in adults. Nevertheless,
ordered eating behaviors as well as eating ing use of the device. B the increased use of basal-bolus regimens,
disorders, and symptoms of depression c Automated insulin delivery systems insulin pumps, frequent blood glucose
(25). Consider assessing youth for diabe- improve glycemic control and re- monitoring, goal setting, and improved pa-
tes distress, generally starting at 7 or duce hypoglycemia in adolescents tient education in youth from infancy
8 years of age (15). Consider screening and should be considered in adoles- through adolescence have been associa-
for depression and disordered eating be- cents with type 1 diabetes. B ted with more children reaching the blood
haviors using available screening tools c AnA1Cgoalof,7.5% (58 mmol/mol) glucose targets recommended by ADA
(10,26). With respect to disordered eat- is recommended across all pediatric (42–45), particularly in those families in
ing, it is important to recognize the age-groups. E which both the parents and the child with
unique and dangerous disordered eating diabetes participate jointly to perform the
behavior of insulin omission for weight Current standards for diabetes man- required diabetes-related tasks. Further-
control in type 1 diabetes (27). The pres- agement reflect the need to lower glu- more, studies documenting neurocognitive
ence of a mental health professional on cose as safely as possible. This should be imaging differences related to hyperglyce-
pediatric multidisciplinary teams high- done with stepwise goals. When estab- mia in children provide another motivation
lights the importance of attending to lishing individualized glycemic targets, for lowering glycemic targets (2).
the psychosocial issues of diabetes. special consideration should be given to
These psychosocial factors are signifi- the risk of hypoglycemia in young children In selecting glycemic goals, the long-
cantly related to nonadherence, suboptimal (aged ,6 years) who are often unable term health benefits of achieving a lower
glycemic control, reduced quality of life, to recognize, articulate, and/or manage A1C should be balanced against the risks
and higher rates of acute and chronic di- hypoglycemia. of hypoglycemia and the developmental
abetes complications. burdens of intensive regimens in children
Type 1 diabetes can be associated with and youth. In addition, achieving lower
Glycemic Control adverse effects on cognition during child- A1C levels is more likely to be related to
hood and adolescence. Factors that setting lower A1C targets (46,47). A1C
Recommendations contribute to adverse effects on brain and blood glucose goals are presented
development and function include young in Table 12.1.
c The majority of children and adoles- age or DKA at onset of type 1 diabetes,
cents with type 1 diabetes should severe hypoglycemia at ,6 years of age, Autoimmune Conditions
be treated with intensive insulin and chronic hyperglycemia (28,29). How-
regimens, either via multiple daily ever, meticulous use of new therapeutic Recommendation
injections or continuous subcutane- modalities, such as rapid- and long-acting
ous insulin infusion. A insulin analogs, technological advances c Assess for the presence of autoim-
(e.g., continuous glucose monitors, low- mune conditions associated with
c All children and adolescents with glucose suspend insulin pumps, and au- type 1 diabetes soon after the di-
type 1 diabetes should self-monitor tomated insulin delivery systems), and agnosis and if symptoms develop. B
blood glucose levels multiple times intensive self-management education
daily, including premeal, prebed- now make it more feasible to achieve ex- Because of the increased frequency of
time, and as needed for safety in cellent glycemic control while reducing other autoimmune diseases in type 1 di-
specific clinical situations such as the incidence of severe hypoglycemia abetes, screening for thyroid dysfunction
exercise, driving, or for symptoms (30–39). A strong relationship exists be- and celiac disease should be considered
of hypoglycemia. B tween frequency of blood glucose moni- (48,49). Periodic screening in asymptom-
toring and glycemic control (32–41). atic individuals has been recommended,
c Continuous glucose monitoring but the optimal frequency and benefit of
should be considered in children The Diabetes Control and Complica- screening are unclear.
and adolescents with type 1 diabe- tions Trial (DCCT), which did not enroll
tes, whether using injections or children ,13 years of age, demonstrated Although much less common than thy-
continuous subcutaneous insulin in- roid dysfunction and celiac disease, other
fusion, as an additional tool to help autoimmune conditions, such as Addison

Table 12.1—Blood glucose and A1C goals for children and adolescents with type 1 diabetes
Blood glucose goal range

Before meals Bedtime/overnight A1C Rationale

90–130 mg/dL 90–150 mg/dL ,7.5% A lower goal (,7.0% [53 mmol/mol]) is reasonable if it can be
(5.0–7.2 mmol/L) (5.0–8.3 mmol/L) (58 mmol/mol) achieved without excessive hypoglycemia

Key concepts in setting glycemic goals:

c Goals should be individualized, and lower goals may be reasonable based on a benefit-risk assessment.

c Blood glucose goals should be modified in children with frequent hypoglycemia or hypoglycemia unawareness.

c Postprandial blood glucose values should be measured when there is a discrepancy between preprandial blood glucose values and A1C levels and to
assess preprandial insulin doses in those on basal-bolus or pump regimens.

care.diabetesjournals.org Children and Adolescents S129

disease (primary adrenal insufficiency), au- Celiac Disease provided that further testing is performed
toimmune hepatitis, autoimmune gastritis, (verification of endomysial antibody pos-
dermatomyositis, and myasthenia gravis, Recommendations itivity on a separate blood sample). It is
occur more commonly in the population also advisable to check for HLA types in
with type 1 diabetes than in the general c Screen individuals with type 1 dia- patients who are diagnosed without a
pediatric population and should be assessed betes for celiac disease soon after small intestinal biopsy. Asymptomatic
and monitored as clinically indicated. the diagnosis of diabetes by mea- at-risk children should have an intestinal
suring IgA tissue transglutaminase biopsy (61).
Thyroid Disease antibodies, with documentation of
normal total serum IgA levels or, if In symptomatic children with type 1 di-
Recommendations IgA deficient, IgG tissue transglut- abetes and confirmed celiac disease, gluten-
amine and deamidated gliadin anti- free diets reduce symptoms and rates of
c Consider testing individuals with bodies. B hypoglycemia (62). The challenging die-
type 1 diabetes for antithyroid per- tary restrictions associated with having
oxidase and antithyroglobulin an- c Repeat screening within 2 years of both type 1 diabetes and celiac disease
tibodies soon after the diagnosis. diabetes diagnosis and then again place a significant burden on individuals.
E after 5 years and consider more fre- Therefore, a biopsy to confirm the diag-
quent screening in children who nosis of celiac disease is recommended,
c Measure thyroid-stimulating hor- have symptoms or a first-degree especially in asymptomatic children, be-
mone concentrations at diagnosis relative with celiac disease. B fore endorsing significant dietary changes.
when clinically stable or soon after A gluten-free diet was beneficial in asymp-
glycemic control has been estab- c Individuals with biopsy-confirmed tomatic adults with positive antibodies
lished. If normal, consider recheck- celiac disease should be placed confirmed by biopsy (63).
ing every 1–2 years or sooner if the on a gluten-free diet and have a
patient develops symptoms sugges- consultation with a dietitian experi- Management of Cardiovascular
tive of thyroid dysfunction, thyro- enced in managing both diabetes Risk Factors
megaly, an abnormal growth rate, and celiac disease. B
or an unexplained glycemic varia- Hypertension
tion. A Celiac disease is an immune-mediated dis-
order that occurs with increased fre- Recommendations
Autoimmune thyroid disease is the quency in patients with type 1 diabetes
most common autoimmune disorder (1.6–16.4% of individuals compared with Screening
associated with diabetes, occurring in 0.3–1% in the general population) (48,49, c Blood pressure should be measured
17–30% of patients with type 1 diabetes 56–58,59).
(50). At the time of diagnosis, about 25% Screening. Screening for celiac disease in- at each routine visit. Children found
of children with type 1 diabetes have thy- cludes measuring serum levels of IgA and to have high-normal blood pressure
roid autoantibodies (51); their presence tissue transglutaminase antibodies, or, (systolic blood pressure or diastolic
is predictive of thyroid dysfunctiond with IgA deficiency, screening can include blood pressure $90th percentile
most commonly hypothyroidism, al- measuring IgG tissue transglutaminase an- for age, sex, and height) or hy-
though hyperthyroidism occurs in ;0.5% tibodies or IgG deamidated gliadin peptide pertension (systolic blood pressure
of patients with type 1 diabetes (52, antibodies. Because most cases of celiac or diastolic blood pressure $95th
53). For thyroid autoantibodies, a recent disease are diagnosed within the first percentile for age, sex, and height)
study from Sweden indicated antithyroid 5 years after the diagnosis of type 1 diabe- should have elevated blood
peroxidase antibodies were more predic- tes, screening should be considered at the pressure confirmed on 3 separate
tive than antithyroglobulin antibodies in time of diagnosis and repeated at 2 and days. B
multivariate analysis (54). Thyroid func- then 5 years (58).
tion tests may be misleading (euthyroid Treatment
sick syndrome) if performed at the time Although celiac disease can be diag- c Initial treatment of high-normal
of diagnosis owing to the effect of previous nosed more than 10 years after diabetes
hyperglycemia, ketosis or ketoacidosis, diagnosis, there are insufficient data after blood pressure (systolic blood pres-
weight loss, etc. Therefore, if performed 5 years to determine the optimal screen- sure or diastolic blood pressure
at diagnosis and slightly abnormal, thy- ing frequency. Measurement of tissue consistently $90th percentile for
roid function tests should be performed transglutaminase antibody should be con- age, sex, and height) includes die-
soon after a period of metabolic stability sidered at other times in patients with tary modification and increased
and good glycemic control. Subclinical symptoms suggestive of celiac disease exercise, if appropriate, aimed at
hypothyroidism may be associated with (58). A small-bowel biopsy in antibody- weight control. If target blood pres-
increased risk of symptomatic hypoglyce- positive children is recommended to confirm sure is not reached within 3–6
mia (55) and reduced linear growth rate. the diagnosis (60). European guidelines months of initiating lifestyle inter-
Hyperthyroidism alters glucose metabo- on screening for celiac disease in chil- vention, pharmacologic treatment
lism and usually causes deterioration of dren (not specific to children with type 1 should be considered. E
glycemic control. diabetes) suggest that biopsy may not c In addition to lifestyle modification,
be necessary in symptomatic children pharmacologic treatment of hyper-
with high antibody titers (i.e., greater tension (systolic blood pressure or
than 10 times the upper limit of normal) diastolic blood pressure consistently
$95th percentile for age, sex, and
height) should be considered as

S130 Children and Adolescents Diabetes Care Volume 41, Supplement 1, January 2018

soon as hypertension is confirmed. E mg/dL (4.1 mmol/L) or LDL choles- and Blood Institute recommends obtaining
c ACE inhibitors or angiotensin recep- terol .130 mg/dL (3.4 mmol/L) and a fasting lipid panel beginning at 2 years of
one or more cardiovascular disease age (71). Abnormal results from a random
tor blockers may be considered for risk factors, following reproductive lipid panel should be confirmed with a
the treatment of elevated (.30 mg/ counseling and implementation of fasting lipid panel. Data from the SEARCH
g) urinary albumin-to-creatinine ra- effective birth control due to the for Diabetes in Youth (SEARCH) study
tio (B) and hypertension (E) in chil- potential teratogenic effects of sta- show that improved glucose control
dren and adolescents, following tins. B over a 2-year period is associated with a
reproductive counseling and imple- c The goal of therapy is an LDL cho- more favorable lipid profile; however, im-
mentation of effective birth control lesterol value ,100 mg/dL (2.6 proved glycemic control alone will not
due to the potential teratogenic ef- mmol/L). E normalize lipids in youth with type 1 di-
fects of both drug classes. E abetes and dyslipidemia (78).
c The goal of treatment is blood pres- Population-based studies estimate that
sure consistently ,90th percentile 14–45% of children with type 1 diabetes Neither long-term safety nor cardio-
for age, sex, and height. E have two or more atherosclerotic cardio- vascular outcome efficacy of statin ther-
vascular disease (ASCVD) risk factors apy has been established for children;
Blood pressure measurements should (65–67), and the prevalence of CVD however, studies have shown short-
be performed using the appropriate size risk factors increases with age (67), with term safety equivalent to that seen in
cuff with the child seated and relaxed. girls having a higher risk burden than adults and efficacy in lowering LDL
Hypertension should be confirmed on at boys (66). cholesterol levels in familial hypercho-
least 3 separate days. Evaluation should Pathophysiology. The atherosclerotic pro- lesterolemia or severe hyperlipidemia,
proceed as clinically indicated. Treatment cess begins in childhood, and although improving endothelial function and caus-
is generally initiated with an ACE inhibi- ASCVD events are not expected to occur ing regression of carotid intimal thicken-
tor, but an angiotensin receptor blocker during childhood, observations using a ing (79,80). Statins are not approved for
can be used if the ACE inhibitor is not variety of methodologies show that youth patients aged ,10 years, and statin treat-
tolerated (e.g., due to cough) (64). with type 1 diabetes may have subclinical ment should generally not be used in
CVD within the first decade of diagnosis children with type 1 diabetes before
Normal blood pressure levels for age, (68–70). Studies of carotid intima-media this age. Statins are contraindicated in
sex, and height and appropriate methods thickness have yielded inconsistent re- pregnancy; therefore, prevention of un-
for measurement are available online at sults (64). planned pregnancies is of paramount im-
nhlbi.nih.gov/files/docs/resources/heart/ Treatment. Pediatric lipid guidelines pro- portance for postpubertal girls (see
hbp_ped.pdf. vide some guidance relevant to children Section 13 “Management of Diabetes in
with type 1 diabetes (71–73); however, Pregnancy” for more information). The
Dyslipidemia there are few studies on modifying lipid multicenter, randomized, placebo-con-
levels in children with type 1 diabetes. A trolled Adolescent Type 1 Diabetes Car-
Recommendations 6-month trial of dietary counseling pro- dio-Renal Intervention Trial (AdDIT)
duced a significant improvement in lipid provides safety data on pharmacologic
Testing levels (74); likewise, a lifestyle interven- treatment with an ACE inhibitor and
c Obtain a lipid profile in children tion trial with 6 months of exercise in ad- statin in adolescents with type 1 diabetes.
olescents demonstrated improvement in
$10 years of age soon after the di- lipid levels (75). Smoking
agnosis of diabetes (after glucose
control has been established). If ab- Although intervention data are sparse, Recommendation
normal, repeat lipid profile after the American Heart Association catego-
fasting. E rizes children with type 1 diabetes in the c Elicit a smoking history at initial and
c If lipids are abnormal, annual moni- highest tier for cardiovascular risk and follow-up diabetes visits; discour-
toring is reasonable. If LDL choles- recommends both lifestyle and pharma- age smoking in youth who do not
terol values are within the accepted cologic treatment for those with elevated smoke, and encourage smoking ces-
risk level (,100 mg/dL [2.6 mmol/L]), LDL cholesterol levels (73,76). Initial ther- sation in those who do smoke. A
a lipid profile repeated every 5 years apy should be with a Step 2 American
is reasonable. E Heart Association diet, which restricts sat- The adverse health effects of smoking are
urated fat to 7% of total calories and re- well recognized with respect to future
Treatment stricts dietary cholesterol to 200 mg/day. cancer and CVD risk. Despite this, smok-
c Initial therapy should consist of op- Data from randomized clinical trials in ing rates are significantly higher among
children as young as 7 months of age in- youth with diabetes than among youth
timizing glucose control and medi- dicate that this diet is safe and does not without diabetes (81,82). In youth with
cal nutrition therapy using a Step interfere with normal growth and devel- diabetes, it is important to avoid addi-
2 American Heart Association diet opment (77). tional CVD risk factors. Smoking increases
to decrease the amount of satu- the risk of onset of albuminuria; there-
rated fat in the diet. B For children with a significant family fore, smoking avoidance is important to
c After the age of 10 years, addition history of CVD, the National Heart, Lung, prevent both microvascular and macrovas-
of a statin is suggested in patients cular complications (71,83). Discouraging
who, despite medical nutrition ther- cigarette smoking, including e-cigarettes,
apy and lifestyle changes, continue
to have LDL cholesterol .160

care.diabetesjournals.org Children and Adolescents S131

is an important part of routine diabetes Retinopathy “Classification and Diagnosis of Diabetes.”
care. In younger children, it is important For additional support for these recom-
to assess exposure to cigarette smoke in Recommendations mendations, see the ADA position state-
the home due to the adverse effects of ment “Evaluation and Management of
secondhand smoke and to discourage c An initial dilated and comprehen- Youth-Onset Type 2 Diabetes (91).
youth from ever smoking if exposed to sive eye examination is recom- Type 2 diabetes in youth has increased
smokers in childhood. mended once youth have had type 1 over the past 20 years, and recent estimates
diabetes for 3–5 years, provided suggest an incidence of ;5,000 new cases
Microvascular Complications they are age $10 years or puberty per year in the U.S. (92). The Centers for
Diabetic Kidney Disease has started, whichever is earlier. Disease Control and Prevention published
B projections for type 2 diabetes prevalence
Recommendations using the SEARCH databasedassuming a
c After the initial examination, annual 2.3% annual increase, the prevalence in
Screening routine follow-up is generally rec- those under 20 years of age will quadru-
c Annual screening for albuminuria ommended. Less-frequent exami- ple in 40 years (93,94).
nations, every 2 years, may be
with a random spot urine sample for acceptable on the advice of an eye Evidence suggests that type 2 diabetes
albumin-to-creatinine ratio should be care professional and based on risk in youth is different not only from type 1
performed at puberty or at age $10 factor assessment. E diabetes but also from type 2 diabetes in
years, whichever is earlier, once the adults and has unique features, such as a
child has had diabetes for 5 years. B Retinopathy (like albuminuria) most com- more rapidly progressive decline in b-cell
monly occurs after the onset of puberty function and accelerated development of
Treatment and after 5–10 years of diabetes duration diabetes complications (95,96). Type 2
c When persistently elevated urinary (88). Referrals should be made to eye care diabetes disproportionately impacts
professionals with expertise in diabetic youth of ethnic and racial minorities and
albumin-to-creatinine ratio (.30 retinopathy and experience in counseling can occur in complex psychosocial and
mg/g) is documented with at least the pediatric patient and family on the cultural environments, which may make
two of three urine samples, treat- importance of early prevention and it difficult to sustain healthy lifestyle
ment with an ACE inhibitor or an- intervention. changes and self-management behaviors.
giotensin receptor blocker may be Additional risk factors associated with
considered and the dose titrated to Neuropathy type 2 diabetes in youth include adiposity,
maintain blood pressure within the family history of diabetes, female sex, and
age-appropriate normal range. The Recommendation low socioeconomic status (96).
urine samples should be obtained
over a 6-month interval following c Consider an annual comprehensive As with type 1 diabetes, youth with
efforts to improve glycemic control foot exam at the start of puberty or type 2 diabetes spend much of the day in
and normalize blood pressure. B at age $10 years, whichever is ear- school. Therefore, close communication
lier, once the youth has had type 1 with and the cooperation of school person-
Data from 7,549 participants ,20 years diabetes for 5 years. B nel are essential for optimal diabetes man-
of age in the T1D Exchange clinic registry agement, safety, and maximal academic
emphasize the importance of good glyce- Diabetic neuropathy rarely occurs in pre- opportunities.
mic and blood pressure control, particu- pubertal children or after only 1–2 years
larly as diabetes duration increases, in of diabetes (88), although data suggest a Recommendations
order to reduce the risk of diabetic kidney prevalence of distal peripheral neuropa-
disease. The data also underscore the im- thy of 7% in 1,734 youth with type 1 di- Screening and Diagnosis
portance of routine screening to ensure abetes and associated with the presence c Risk-based screening for prediabe-
early diagnosis and timely treatment of of CVD risk factors (89). A comprehensive
albuminuria (84). An estimation of glomer- foot exam, including inspection, palpation tes and/or type 2 diabetes should
ular filtration rate (GFR), calculated using of dorsalis pedis and posterior tibial be considered in children and ado-
GFR estimating equations from the serum pulses, and determination of propriocep- lescents after the onset of puberty
creatinine, height, age, and sex (85), should tion, vibration, and monofilament sensa- or $10 years of age, whichever
be considered at baseline and repeated as tion, should be performed annually along occurs earlier, who are over-
indicated based on clinical status, age, di- with an assessment of symptoms of neu- weight (BMI .85th %) or obese
abetes duration, and therapies. Improved ropathic pain (90). Foot inspection can (BMI .95th %) and who have one
methods are needed to screen for early be performed at each visit to educate or more additional risk factors for
GFR loss, since estimated GFR is inaccu- youth regarding the importance of foot diabetes (see Table 2.5). A
rate at GFR .60 ml/min/1.73 m2 (85,86). care (see Section 10 “Microvascular c If tests are normal, repeat testing
The AdDIT study in adolescents with type Complications and Foot Care”). at a minimum of 3-year intervals E,
1 diabetes demonstrated safety of ACE or more frequently if BMI is increas-
inhibitor treatment, but did not change TYPE 2 DIABETES ing. C
the urinary albumin-to-creatinine ratio For information on testing for type 2 di- c Fasting plasma glucose, 2-h plasma
over the course of the study (87). abetes and prediabetes in children and glucose during a 75-g oral glucose
adolescents, please refer to Section 2 tolerance test, and A1C can be used

S132 Children and Adolescents Diabetes Care Volume 41, Supplement 1, January 2018

to test for prediabetes or diabetes c Given the necessity of long-term c All youth with type 2 diabetes and
in children and adolescents. B weight management for children their families should receive compre-
and adolescents with type 2 diabetes, hensive diabetes self-management
In the last decade, the incidence and prev- lifestyle intervention should be based education and support that is specific
alence of type 2 diabetes in adolescents on a chronic care model and offered to youth with type 2 diabetes and
has increased dramatically, especially in ra- in the context of diabetes care. E culturally competent. B
cial and ethnic minority populations (97). A
few recent studies suggest oral glucose c Youth with diabetes, like all chil- The general treatment goals for youth
tolerance tests or fasting plasma glucose dren, should be encouraged to with type 2 diabetes are the same as
values as more suitable diagnostic tests participate in at least 60 min of those for youth with type 1 diabetes. A
than A1C in the pediatric population, es- moderate to vigorous physical ac- multidisciplinary diabetes team, including
pecially among certain ethnicities (98). tivity per day (and strength training a physician, diabetes nurse educator, reg-
However, many of these studies do not on at least 3 days/week) B and to istered dietitian, and psychologist or social
recognize that diabetes diagnostic criteria decrease sedentary behavior. C worker, is essential. In addition to blood
are based on long-term health outcomes, glucose control, initial treatment must in-
and validations are not currently available c Nutrition for youth with type 2 di- clude management of comorbidities such
in the pediatric population (99). ADA ac- abetes, like all children, should fo- as obesity, dyslipidemia, hypertension, and
knowledges the limited data supporting cus on healthy eating patterns that microvascular complications.
A1C for diagnosing type 2 diabetes in chil- emphasize consumption of nutrient-
dren and adolescents. Although A1C is dense, high-quality foods and Current treatment options for youth-
not recommended for diagnosis of diabe- decreased consumption of calorie- onset type 2 diabetes are limited to two
tes in children with cystic fibrosis or symp- dense, nutrient-poor foods, partic- approved drugsdinsulin and metformin
toms suggestive of acute onset of type 1 ularly sugar-added beverages. B (95). Presentation with ketosis or ke-
diabetes and only A1C assays without in- toacidosis requires a period of insulin
terference are appropriate for children Pharmacologic Management therapy until fasting and postprandial gly-
with hemoglobinopathies, ADA continues c Initiate pharmacologic therapy, in cemia have been restored to normal or
to recommend A1C for diagnosis of type 2 near-normal levels. Metformin therapy
diabetes in this population (100,101). addition to lifestyle therapy, at di- may be used as an adjunct after resolu-
agnosis of type 2 diabetes. A tion of ketosis/ketoacidosis. Initial treat-
Diagnostic Challenges c In metabolically stable patients ment should also be with insulin when the
Given the current obesity epidemic, distin- (A1C ,8.5% and asymptomatic), distinction between type 1 diabetes and
guishing between type 1 and type 2 diabe- metformin is the initial pharmaco- type 2 diabetes is unclear and in patients
tes in children can be difficult. Overweight logic treatment of choice if renal who have random blood glucose concen-
and obesity are common in children function is .30 ml/min/1.73 m2. A trations 250 mg/dL (13.9 mmol/L) and/or
with type 1 diabetes (102), and diabetes- c Youth with marked hyperglycemia A1C $8.5% (69 mmol/mol) (105).
associated autoantibodies and ketosis (blood glucose $250 mg/dL [13.9
may be present in pediatric patients mmol/L],A1C$8.5% [69 mmol/mol]) Patients and their families must priori-
with features of type 2 diabetes (including without ketoacidosis at diagnosis tize lifestyle modifications such as eating
obesity and acanthosis nigricans) (103). At who are symptomatic with poly- a balanced diet, achieving and maintaining
onset, DKA occurs in ;6% of youth aged uria, polydipsia, nocturia, and/or a healthy weight, and exercising regularly. A
10–19 years with type 2 diabetes (104). weight loss should be treated ini- family-centered approach to nutrition and
Accurate diagnosis is critical, as treatment tially with basal insulin while met- lifestyle modification is essential in children
regimens, educational approaches, die- formin is initiated and titrated to with type 2 diabetes, and nutrition recom-
tary advice, and outcomes differ markedly maximally tolerated dose to achieve mendations should be culturally appropri-
between patients with the two diagnoses. A1C goal. E ate and sensitive to family resources (see
c When the A1C target is no longer met Section 4 “Lifestyle Management”). Given
Management with metformin monotherapy, or if the complex social and environmental
contraindications or intolerable side context surrounding youth with type 2 di-
Recommendations effects of metformin develop, basal abetes, individual-level lifestyle interven-
insulin therapy should be initiated. E tions may not be sufficient to target the
Lifestyle Management c In patients initially treated with complex interplay of family dynamics,
c Overweight or obese youth with basal insulin and metformin who mental health, community readiness, and
are meeting glucose targets based the broader environmental system (95).
type 2 diabetes and their families on home blood glucose monitoring,
should be provided with develop- basal insulin can be tapered over When insulin treatment is not required,
mentally and culturally appropriate 2–6 weeks by decreasing the insulin initiation of metformin is recommended.
comprehensive lifestyle programs dose by 10–30% every few days. A The Treatment Options for Type 2 Diabe-
that are integrated with diabetes c Use of medications not approved by tes in Adolescents and Youth (TODAY)
management to achieve 7–10% de- the U.S. Food and Drug Administra- study found that metformin alone pro-
crease in excess weight. C tion for youth with type 2 diabetes vided durable glycemic control (A1C #8%
is not recommended outside of re- [64 mmol/mol] for 6 months) in approxi-
search trials. B mately half of the subjects (106). To date,

care.diabetesjournals.org Children and Adolescents S133

the TODAY study is the only trial combin- port and links to resources for tran- 2. Barnea-Goraly N, Raman M, Mazaika P, et al.;
ing lifestyle and metformin therapy in sitioning young adults. B Diabetes Research in Children Network (DirecNet).
youth with type 2 diabetes; the combina- Alterations in white matter structure in young
tion did not perform better than metfor- Care and close supervision of diabetes children with type 1 diabetes. Diabetes Care
min alone in achieving durable glycemic management are increasingly shifted 2014;37:332–340
control (106). from parents and other adults to the youth 3. Cameron FJ, Scratch SE, Nadebaum C, et al.;
with type 1 or type 2 diabetes throughout DKA Brain Injury Study Group. Neurological conse-
Small retrospective analyses and a recent childhood and adolescence. The shift from quences of diabetic ketoacidosis at initial presenta-
prospective multicenter nonrandomized pediatric to adult health care providers, tion of type 1 diabetes in a prospective cohort study
study suggest that bariatric or metabolic however, often occurs abruptly as the older of children. Diabetes Care 2014;37:1554–1562
surgery may have similar benefits in obese teen enters the next developmental stage 4. Markowitz JT, Garvey KC, Laffel LMB. Develop-
adolescents with type 2 diabetes compared referred to as emerging adulthood (111), mental changes in the roles of patients and families
with those observed in adults. Teenagers which is a critical period for young people in type 1 diabetes management. Curr Diabetes Rev
experience similar degrees of weight loss, who have diabetes. During this period 2015;11:231–238
diabetes remission, and improvement of of major life transitions, youth begin to 5. Chiang JL, Kirkman MS, Laffel LMB, Peters AL;
cardiometabolic risk factors for at least move out of their parents’ homes and Type 1 Diabetes Sourcebook authors. Type 1 dia-
3 years after surgery (107). No randomized must become fully responsible for their betes through the life span: a position statement
trials, however, have yet compared the diabetes care. Their new responsibilities of the American Diabetes Association. Diabetes
effectiveness and safety of surgery to include self-management of their diabe- Care 2014;37:2034–2054
those of conventional treatment options tes, making medical appointments, and 6. Chiang J, Garvey KC, Hood K, et al. Type 1 di-
in adolescents (108). financing health care, once they are no abetes in children and adolescents: a position
longer covered by their parents’ health statement by the American Diabetes Association.
Comorbidities insurance plans (ongoing coverage until Diabetes Care. In press
Comorbidities may already be present at age 26 years is currently available under 7. Driscoll KA, Volkening LK, Haro H, et al. Are
the time of diagnosis of type 2 diabetes in provisions of the U.S. Affordable Care children with type 1 diabetes safe at school? Ex-
youth (96,109). Therefore, blood pres- Act). In addition to lapses in health care, amining parent perceptions. Pediatr Diabetes
sure measurement, a fasting lipid panel, this is also a period associated with de- 2015;16:613–620
assessment of random urine albumin-to- terioration in glycemic control; increased 8. Jackson CC, Albanese-O’Neill A, Butler KL, et al.
creatinine ratio, and a dilated eye exam- occurrence of acute complications; psy- Diabetes care in the school setting: a position
ination should be performed at diagnosis. chosocial, emotional, and behavioral statement of the American Diabetes Association.
Thereafter, screening guidelines and treat- challenges; and the emergence of chronic Diabetes Care 2015;38:1958–1963
ment recommendations for hypertension, complications (112–115). The transition 9. Siminerio LM, Albanese-O’Neill A, Chiang JL,
dyslipidemia, urine albumin excretion, and period from pediatric to adult care is et al.; American Diabetes Association. Care of
retinopathy are similar to those for youth prone to fragmentation in health care de- young children with diabetes in the child care set-
with type 1 diabetes. Additional problems livery, which may adversely impact health ting: a position statement of the American Diabetes
that may need to be addressed include care quality, cost, and outcomes (116). Association. Diabetes Care 2014;37:2834–2842
polycystic ovary disease and other comor- 10. Corathers SD, Kichler J, Jones N-HY, Houchen
bidities associated with pediatric obesity, Although scientific evidence is limited, A, Jolly M, Morwessel N, et al. Improving depres-
such as sleep apnea, hepatic steatosis, or- it is clear that comprehensive and coordi- sion screening for adolescents with type 1 diabe-
thopedic complications, and psychosocial nated planning that begins in early ado- tes. Pediatrics 2013;132:e1395-e1402
concerns. The ADA consensus report lescence, or at least 1 year before the date 11. Hood KK, Beavers DP, Yi-Frazier J, et al. Psy-
“Youth-Onset Type 2 Diabetes Consensus of transition, is necessary to facilitate a chosocial burden and glycemic control during the
Report: Current Status, Challenges, and seamless transition from pediatric to adult first 6 years of diabetes: results from the SEARCH
Priorities” (95) and an American Academy health care (112,113,117–119). A compre- for Diabetes in Youth study. J Adolesc Health
of Pediatrics clinical practice guideline hensive discussion regarding the chal- 2014;55:498–504
(110) provide guidance on the preven- lenges faced during this period, including 12. Ducat L, Philipson LH, Anderson BJ. The men-
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Recommendations with the ADA and other organizations has Factors associated with diabetes-specific health-
developed transition tools for clinicians related quality of life in youth with type 1 diabe-
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artery tonometry demonstrates altered endothe- saturated fat, low-cholesterol diet: the STRIP baby 93. Imperatore G, Boyle JP, Thompson TJ, et al.;
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diatr Diabetes 2007;8:193–198 vention Project for children. Acta Paediatr 1999; jections of type 1 and type 2 diabetes burden in
70. Urbina EM, Wadwa RP, Davis C, Snively BM, 88:505–512 the U.S. population aged ,20 years through
Dolan LM, Daniels SR, et al. Prevalence of in- 78. Maahs DM, Dabelea D, D’Agostino RB Jr, 2050: dynamic modeling of incidence, mortality,
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diabetes mellitus differs by measurement site and cose control predicts 2-year change in lipid profile 2515–2520
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71. Expert Panel on Integrated Guidelines for Car- 79. McCrindle BW, Ose L, Marais AD. Efficacy and diabetes in U.S. youth in 2009: the SEARCH for
diovascular Health and Risk Reduction in Children safety of atorvastatin in children and adolescents diabetes in youth study. Diabetes Care 2014;37:
and Adolescents; National Heart, Lung, and Blood with familial hypercholesterolemia or severe hy- 402–408
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tion. Lipid screening and cardiovascular health in controlled trial. JAMA 2004;292:331–337 TODAY Study Group. Characteristics of adoles-
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73. Kavey R-EW, Allada V, Daniels SR, et al.; cational disparities in rates of smoking among di- tes: the TODAY cohort at baseline. J Clin
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Epidemiology and Prevention; American Heart As- Prevalence of tobacco use and association be- adolescents from 2001 to 2009. JAMA 2014;311:
sociation Council on Nutrition, Physical Activity tween cardiometabolic risk factors and cigarette 1778–1786
and Metabolism; American Heart Association smoking in youth with type 1 or type 2 diabetes 98. Buse JB, Kaufman FR, Linder B, Hirst K, El
Council on High Blood Pressure Research; Amer- mellitus. J Pediatr 2011;158:594–601 Ghormli L, Willi S; HEALTHY Study Group. Diabetes
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100. Kester LM, Hey H, Hannon TS. Using hemo- 107. Inge TH, Courcoulas AP, Jenkins TM, et al.; Association of Clinical Endocrinologists, the Amer-
globin A1c for prediabetes and diabetes diagnosis Teen-LABS Consortium. Weight loss and health ican Osteopathic Association, the Centers for Dis-
in adolescents: can adult recommendations be status 3 years after bariatric surgery in adoles- ease Control and Prevention, Children with
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366:2247–2256 American Academy of Pediatrics, the American .org. Accessed 20 June 2017

Diabetes Care Volume 41, Supplement 1, January 2018 S137

13. Management of Diabetes American Diabetes Association
in Pregnancy: Standards of Medical
Care in Diabetesd2018

Diabetes Care 2018;41(Suppl. 1):S137–S143 | https://doi.org/10.2337/dc18-S013

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” 13. MANAGEMENT OF DIABETES IN PREGNANCY
includes ADA’s current clinical practice recommendations and is intended to provide
the components of diabetes care, general treatment goals and guidelines, and tools
to evaluate quality of care. Members of the ADA Professional Practice Committee, a
multidisciplinary expert committee, are responsible for updating the Standards of
Care annually, or more frequently as warranted. For a detailed description of ADA
standards, statements, and reports, as well as the evidence-grading system for ADA’s
clinical practice recommendations, please refer to the Standards of Care
Introduction. Readers who wish to comment on the Standards of Care are invited
to do so at professional.diabetes.org/SOC.

DIABETES IN PREGNANCY

The prevalence of diabetes in pregnancy has been increasing in the U.S. The majority is
gestational diabetes mellitus (GDM) with the remainder primarily preexisting type 1
diabetes and type 2 diabetes. The rise in GDM and type 2 diabetes in parallel with
obesity both in the U.S. and worldwide is of particular concern. Both type 1 diabetes
and type 2 diabetes in pregnancy confer significantly greater maternal and fetal risk
than GDM, with some differences according to type of diabetes as outlined below. In
general, specific risks of uncontrolled diabetes in pregnancy include spontaneous
abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hy-
poglycemia, and neonatal hyperbilirubinemia, among others. In addition, diabetes
in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later
in life (1,2).

PRECONCEPTION COUNSELING

Recommendations Suggested citation: American Diabetes Associa-
tion. 13. Management of diabetes in pregnancy:
c Starting at puberty, preconception counseling should be incorporated into rou- Standards of Medical Care in Diabetesd2018.
tine diabetes care for all girls of childbearing potential. A Diabetes Care 2018;41(Suppl. 1):S137–S143

c Family planning should be discussed and effective contraception should © 2017 by the American Diabetes Association.
be prescribed and used until a woman is prepared and ready to become Readers may use this article as long as the work
pregnant. A is properly cited, the use is educational and not
for profit, and the work is not altered. More infor-
c Preconception counseling should address the importance of glycemic control as mation is available at http://www.diabetesjournals
close to normal as is safely possible, ideally A1C ,6.5% (48 mmol/mol), to reduce .org/content/license.
the risk of congenital anomalies. B

All women of childbearing age with diabetes should be counseled about the impor-
tance of tight glycemic control prior to conception. Observational studies show an
increased risk of diabetic embryopathy, especially anencephaly, microcephaly,

S138 Management of Diabetes in Pregnancy Diabetes Care Volume 41, Supplement 1, January 2018

congenital heart disease, and caudal re- Preconception counseling visits should in- with insulin dosage and to avoid hyper-
gression, directly proportional to eleva- clude rubella, syphilis, hepatitis B virus, glycemia or hypoglycemia. Referral to a
tions in A1C during the first 10 weeks of and HIV testing, as well as Pap smear, registered dietitian is important in order
pregnancy. Although observational stud- cervical cultures, blood typing, prescrip- to establish a food plan and insulin-to-
ies are confounded by the association be- tion of prenatal vitamins (with at least carbohydrate ratio and to determine
tween elevated periconceptional A1C and 400 mg of folic acid), and smoking cessa- weight gain goals.
other poor self-care behaviors, the quan- tion counseling if indicated. Diabetes-
tity and consistency of data are convinc- specific testing should include A1C, Insulin Physiology
ing and support the recommendation to thyroid-stimulating hormone, creatinine, Early pregnancy is a time of insulin sensi-
optimize glycemic control prior to con- and urinary albumin–to–creatinine ratio; tivity, lower glucose levels, and lower in-
ception, with A1C ,6.5% (48 mmol/mol) review of the medication list for potentially sulin requirements in women with type 1
associated with the lowest risk of congen- teratogenic drugs, i.e., ACE inhibitors (8), diabetes. The situation rapidly reverses as
ital anomalies (3,4). angiotensin receptor blockers (8), and insulin resistance increases exponentially
statins (9,10); and referral for a compre- during the second and early third trimes-
There are opportunities to educate all hensive eye exam. Women with preexist- ters and levels off toward the end of the
women and adolescents of reproductive ing diabetic retinopathy will need close third trimester. In women with normal
age with diabetes about the risks of monitoring during pregnancy to ensure pancreatic function, insulin production is
unplanned pregnancies and improved that retinopathy does not progress. sufficient to meet the challenge of this
maternal and fetal outcomes with preg- physiological insulin resistance and to
nancy planning (5). Effective preconcep- GLYCEMIC TARGETS IN maintain normal glucose levels. However,
tion counseling could avert substantial PREGNANCY in women with GDM or preexisting dia-
health and associated cost burdens in betes, hyperglycemia occurs if treatment
offspring (6). Family planning should be Recommendations is not adjusted appropriately.
discussed, and effective contraception
should be prescribed and used until a c Fasting and postprandial self- Glucose Monitoring
woman is prepared and ready to become monitoring of blood glucose are recom- Reflecting this physiology, fasting and
pregnant. mended in both gestational diabetes postprandial monitoring of blood glucose
mellitus and preexisting diabetes in is recommended to achieve metabolic con-
To minimize the occurrence of compli- pregnancy to achieve glycemic con- trol in pregnant women with diabetes. Pre-
cations, beginning at the onset of puberty trol. Some women with preexisting prandial testing is also recommended for
or at diagnosis, all women with diabetes diabetes should also test blood glu- women with preexisting diabetes using in-
of childbearing potential should receive cose preprandially. B sulin pumps or basal-bolus therapy, so that
education about 1) the risks of malforma- premeal rapid-acting insulin dosage can be
tions associated with unplanned pregnan- c Due to increased red blood cell turn- adjusted. Postprandial monitoring is associ-
cies and poor metabolic control and over, A1C is slightly lower in normal ated with better glycemic control and lower
2) the use of effective contraception at pregnancy than in normal nonpreg- risk of preeclampsia (11–13). There are no
all times when preventing a pregnancy. nant women. The A1C target in preg- adequately powered randomized trials
Preconception counseling using develop- nancy is 6–6.5% (42–48 mmol/mol); comparing different fasting and postmeal
mentally appropriate educational tools ,6% (42 mmol/mol) may be opti- glycemic targets in diabetes in pregnancy.
enables adolescent girls to make well- mal if this can be achieved without
informed decisions (5). Preconception significant hypoglycemia, but the Similar to the targets recommended
counseling resources tailored for adoles- target may be relaxed to ,7% by the American College of Obstetri-
cents are available at no cost through the (53 mmol/mol) if necessary to pre- cians and Gynecologists (14), the ADA-
American Diabetes Association (ADA) (7). vent hypoglycemia. B recommended targets for women with
type 1 or type 2 diabetes (the same as
Preconception Testing Pregnancy in women with normal glucose for GDM; described below) are as follows:
metabolism is characterized by fasting
Recommendation levels of blood glucose that are lower ○ Fasting ,95 mg/dL (5.3 mmol/L) and
than in the nonpregnant state due to either
c Women with preexisting type 1 or insulin-independent glucose uptake by
type 2 diabetes who are planning the fetus and placenta and by postpran- ○ One-hour postprandial ,140 mg/dL
pregnancy or who have become dial hyperglycemia and carbohydrate in- (7.8 mmol/L) or
pregnant should be counseled on tolerance as a result of diabetogenic
the risk of development and/or placental hormones. In patients with pre- ○ Two-hour postprandial ,120 mg/dL
progression of diabetic retinopathy. existing diabetes, glycemic targets are (6.7 mmol/L)
Dilated eye examinations should oc- usually achieved through a combination
cur before pregnancy or in the first of insulin administration and medical nu- These values represent optimal control if
trimester, and then patients should trition therapy. Because glycemic targets they can be achieved safely. In practice, it
be monitored every trimester and in pregnancy are stricter than in nonpreg- may be challenging for women with type 1
for 1-year postpartum as indicated nant individuals, it is important that diabetes to achieve these targets without
by the degree of retinopathy and women with diabetes eat consistent hypoglycemia, particularly women with a
as recommended by the eye care amounts of carbohydrates to match history of recurrent hypoglycemia or hypo-
provider. B glycemia unawareness.

care.diabetesjournals.org Management of Diabetes in Pregnancy S139

If women cannot achieve these targets used, but both cross the placenta to plasma glucose ,95 mg/dL [5.3 mmol/L])
without significant hypoglycemia, the ADA the fetus, with metformin likely cross- who meet glucose goals after a week of
suggests less stringent targets based on clin- ing to a greater extent than glyburide. medical nutrition therapy can safely per-
ical experience and individualization of care. All oral agents lack long-term safety form self-monitoring of blood glucose
data. A every other day, rather than daily (26).
A1C in Pregnancy c Metformin, when used to treat
Observational studies show the lowest polycystic ovary syndrome and in- Medical Nutrition Therapy
rates of adverse fetal outcomes in association duce ovulation, need not be con- Medical nutrition therapy for GDM is an
with A1C ,6–6.5% (42–48 mmol/mol) tinued once pregnancy has been individualized nutrition plan developed
early in gestation (4,15–17). Clinical trials confirmed. A between the woman and a registered di-
have not evaluated the risks and benefits etitian familiar with the management of
of achieving these targets, and treatment GDM is characterized by increased risk of GDM (27,28). The food plan should pro-
goals should account for the risk of ma- macrosomia and birth complications and vide adequate calorie intake to promote
ternal hypoglycemia in setting an individ- an increased risk of maternal type 2 diabe- fetal/neonatal and maternal health,
ualized target of ,6% (42 mmol/mol) tes after pregnancy. The association of achieve glycemic goals, and promote ap-
to ,7% (53 mmol/mol). Due to physio- macrosomia and birth complications with propriate gestational weight gain. There
logical increases in red blood cell turn- oral glucose tolerance test (OGTT) results is is no definitive research that identifies a
over, A1C levels fall during normal continuous with no clear inflection points specific optimal calorie intake for women
pregnancy (18,19). Additionally, as A1C (20). In other words, risks increase with with GDM or suggests that their calorie
represents an integrated measure of glu- progressive hyperglycemia. Therefore, all needs are different from those of pregnant
cose, it may not fully capture postprandial women should be tested as outlined in women without GDM. The food plan should
hyperglycemia, which drives macrosomia. Section 2 “Classification and Diagnosis of be based on a nutrition assessment with
Thus, although A1C may be useful, it Diabetes.” Although there is some het- guidance from the Dietary Reference Intakes
should be used as a secondary measure erogeneity, many randomized controlled (DRI). The DRI for all pregnant women
of glycemic control in pregnancy, after trials suggest that the risk of GDM may be recommends a minimum of 175 g of carbo-
self-monitoring of blood glucose. reduced by diet, exercise, and lifestyle hydrate, a minimum of 71 g of protein, and
counseling, particularly when interven- 28 g of fiber. As is true for all nutrition
In the second and third trimesters, tions are started during the first or early therapy in patients with diabetes, the
A1C ,6% (42 mmol/mol) has the lowest in the second trimester (21–23). amount and type of carbohydrate will im-
risk of large-for-gestational-age infants, pact glucose levels, especially postmeal
whereas other adverse outcomes in- Lifestyle Management excursions.
crease with A1C $6.5% (48 mmol/mol). After diagnosis, treatment starts with
Taking all of this into account, a target of medical nutrition therapy, physical activ- Pharmacologic Therapy
6–6.5% (42–48 mmol/mol) is recom- ity, and weight management depending Women with greater initial degrees of hy-
mended but ,6% (42 mmol/mol) may on pregestational weight, as outlined in perglycemia may require earlier initiation
be optimal as pregnancy progresses. the section below on preexisting type 2 of pharmacologic therapy. Treatment has
These levels should be achieved without diabetes, and glucose monitoring aiming been demonstrated to improve perinatal
hypoglycemia, which, in addition to the for the targets recommended by the Fifth outcomes in two large randomized stud-
usual adverse sequelae, may increase International Workshop-Conference on ies as summarized in a U.S. Preventive
the risk of low birth weight. Given the Gestational Diabetes Mellitus (24): Services Task Force review (29). Insulin
alteration in red blood cell kinetics during is the first-line agent recommended for
pregnancy and physiological changes in ○ Fasting ,95 mg/dL (5.3 mmol/L) and treatment of GDM in the U.S. While indi-
glycemic parameters, A1C levels may either vidual randomized controlled trials sup-
need to be monitored more frequently port the efficacy and short-term safety
than usual (e.g., monthly). ○ One-hour postprandial ,140 mg/dL of metformin (30,31) and glyburide (32)
(7.8 mmol/L) or for the treatment of GDM, both agents
MANAGEMENT OF GESTATIONAL cross the placenta. There is not agree-
DIABETES MELLITUS ○ Two-hour postprandial ,120 mg/dL ment regarding the comparative advan-
(6.7 mmol/L) tages and disadvantages of the two oral
Recommendations agents; the most recent systematic re-
Depending on the population, studies sug- view of randomized controlled trials com-
c Lifestyle change is an essential com- gest that 70–85% of women diagnosed paring metformin and glyburide for GDM
ponent of management of gesta- with GDM under Carpenter-Coustan or found no clear differences in maternal or
tional diabetes mellitus and may National Diabetes Data Group (NDDG) cri- neonatal outcomes (33). A more recent
suffice for the treatment of many teria can control GDM with lifestyle mod- randomized controlled trial demon-
women. Medications should be ification alone; it is anticipated that this strated that glyburide and metformin
added if needed to achieve glyce- proportion will be even higher if the lower are comparable oral treatments for
mic targets. A International Association of the Diabetes GDM regarding glucose control and ad-
and Pregnancy Study Groups (IADPSG) verse effects. In this study, they were
c Insulin is the preferred medication for (25) diagnostic thresholds are used. A re- combined, with data demonstrating a
treating hyperglycemia in gestational cent randomized controlled trial suggests high efficacy rate with a significantly
diabetes mellitus as it does not cross that women with mild GDM (fasting
the placenta to a measurable extent.
Metformin and glyburide may be

S140 Management of Diabetes in Pregnancy Diabetes Care Volume 41, Supplement 1, January 2018

reduced need for insulin, with a possible and type 2 diabetes in pregnancy this approach would reduce morbidity,
advantage for metformin over glyburide because it does not cross the pla- save lives, and lower health care costs (49).
as first-line therapy (34). However, more centa, and because oral agents are
definitive studies are required in this area. generally insufficient to overcome Type 1 Diabetes
Long-term safety data are not available the insulin resistance in type 2 dia- Women with type 1 diabetes have an in-
for any oral agent (35). betes and are ineffective in type 1 di- creased risk of hypoglycemia in the first
abetes. E trimester and, like all women, have al-
Sulfonylureas tered counterregulatory response in
The physiology of pregnancy necessitates pregnancy that may decrease hypoglyce-
Concentrations of glyburide in umbilical cord frequent titration of insulin to match mia awareness. Education for patients
plasma are approximately 70% of maternal changing requirements and underscores and family members about the preven-
levels (36). Glyburide was associated with the importance of daily and frequent self- tion, recognition, and treatment of hypo-
a higher rate of neonatal hypoglycemia monitoring of blood glucose. In the first glycemia is important before, during, and
and macrosomia than insulin or metfor- trimester, there is often a decrease in after pregnancy to help to prevent and
min in a 2015 systematic review (37). total daily insulin requirements, and manage the risks of hypoglycemia. Insulin
women, particularly those with type 1 di- resistance drops rapidly with delivery of
Metformin abetes, may experience increased hypo- the placenta. Women become very insu-
glycemia. In the second trimester, rapidly lin sensitive immediately following deliv-
Metformin was associated with a lower risk increasing insulin resistance requires ery and may initially require much less
of neonatal hypoglycemia and less maternal weekly or biweekly increases in insulin insulin than in the prepartum period.
weight gain than insulin in 2015 systematic dose to achieve glycemic targets. In
reviews (37–39); however, metformin general, a smaller proportion of the total Pregnancy is a ketogenic state, and
may slightly increase the risk of prematu- daily dose should be given as basal insulin women with type 1 diabetes, and to a lesser
rity. Furthermore, nearly half of patients (,50%) and a greater proportion (.50%) extent those with type 2 diabetes, are at risk
with GDM who were initially treated with as prandial insulin. Late in the third tri- for diabetic ketoacidosis at lower blood glu-
metformin in a randomized trial needed mester, there is often a leveling off or cose levels than in the nonpregnant state.
insulin in order to achieve acceptable glu- small decrease in insulin requirements. Women with preexisting diabetes, espe-
cose control (30). Umbilical cord blood Due to the complexity of insulin manage- cially type 1 diabetes, need ketone strips
levels of metformin are higher than simul- ment in pregnancy, referral to a specialized at home and education on diabetic ketoaci-
taneous maternal levels (40,41). None of center offering team-based care (with dosis prevention and detection. In addition,
these studies or meta-analyses evaluated team members including high-risk obste- rapid implementation of tight glycemic con-
long-term outcomes in the offspring. Pa- trician, endocrinologist, or other provider trol in the setting of retinopathy is associ-
tients treated with oral agents should be experienced in managing pregnancy in ated with worsening of retinopathy (50).
informed that they cross the placenta, women with preexisting diabetes, dietitian,
and although no adverse effects on the nurse, and social worker, as needed) is rec- Type 2 Diabetes
fetus have been demonstrated, long-term ommended if this resource is available. Type 2 diabetes is often associated with
studies are lacking. obesity. Recommended weight gain during
None of the currently available insulin pregnancy for overweight women is 15–25
Randomized, double-blind, controlled preparations have been demonstrated to lb and for obese women is 10–20 lb (51).
trials comparing metformin with other cross the placenta. Glycemic control is often easier to achieve
therapies for ovulation induction in in women with type 2 diabetes than in
women with polycystic ovary syndrome Preeclampsia and Aspirin those with type 1 diabetes but can require
have not demonstrated benefit in prevent- much higher doses of insulin, sometimes
ing spontaneous abortion or GDM (42), Recommendation necessitating concentrated insulin formula-
and there is no evidence-based need to tions. As in type 1 diabetes, insulin require-
continue metformin in such patients once c Women with type 1 or type 2 dia- ments drop dramatically after delivery. The
pregnancy has been confirmed (43–45). betes should be prescribed low- risk for associated hypertension and other
dose aspirin 60–150 mg/day (usual comorbidities may be as high or higher with
Insulin dose 81 mg/day) from the end of type 2 diabetes as with type 1 diabetes,
the first trimester until the baby is even if diabetes is better controlled and of
Insulin may be required to treat hypergly- born in order to lower the risk of shorter apparent duration, with pregnancy
cemia, and its use should follow the preeclampsia. A loss appearing to be more prevalent in the
guidelines below. Both multiple daily in- third trimester in women with type 2 dia-
sulin injections and continuous subcuta- Diabetes in pregnancy is associated with betes compared with the first trimester in
neous insulin infusion are reasonable an increased risk of preeclampsia (47). women with type 1 diabetes (52,53).
alternatives, and neither has been shown Based upon the results of clinical trials,
to be superior during pregnancy (46). the U.S. Preventive Services Task Force PREGNANCY AND DRUG
recommends the use of low-dose aspirin CONSIDERATIONS
MANAGEMENT OF PREEXISTING (81 mg/day) as a preventive medication
TYPE 1 DIABETES AND TYPE 2 after 12 weeks of gestation in women Recommendations
DIABETES IN PREGNANCY who are at high risk for preeclampsia (48).
A cost-benefit analysis has concluded that c In pregnant patients with diabetes
Insulin Use and chronic hypertension, blood

Recommendation

c Insulin is the preferred agent for man-
agement of both type 1 diabetes

care.diabetesjournals.org Management of Diabetes in Pregnancy S141

pressure targets of 120–160/80– Gestational Diabetes Mellitus history of GDM and prediabetes, only 5–6
105 mmHg are suggested in the women need to be treated with either
interest of optimizing long-term ma- Initial Testing intervention to prevent one case of dia-
ternal health and minimizing impaired betes over 3 years (64). In these women,
fetal growth. E Because GDM may represent preexisting lifestyle intervention and metformin re-
c Potentially teratogenic medications undiagnosed type 2 or even type 1 diabe- duced progression to diabetes by 35%
(i.e., ACE inhibitors, angiotensin re- tes, women with GDM should be tested and 40%, respectively, over 10 years com-
ceptor blockers, statins) should be for persistent diabetes or prediabetes at pared with placebo (65). If the pregnancy
avoided in sexually active women of 4–12 weeks postpartum with a 75-g OGTT has motivated the adoption of a healthier
childbearing age who are not using using nonpregnancy criteria as outlined in diet, building on these gains to support
reliable contraception. B Section 2 “Classification and Diagnosis of weight loss is recommended in the post-
Diabetes.” partum period.
In normal pregnancy, blood pressure is
lower than in the nonpregnant state. Postpartum Follow-up Preexisting Type 1 and Type 2 Diabetes
In a pregnancy complicated by diabetes Insulin sensitivity increases with delivery
and chronic hypertension, target goals The OGTT is recommended over A1C at of the placenta and then returns to pre-
for systolic blood pressure 120–160 the time of the 4- to 12-week postpartum pregnancy levels over the following
mmHg and diastolic blood pressure 80– visit because A1C may be persistently im- 1–2 weeks. In women taking insulin, par-
105 mmHg are reasonable (54). Lower pacted (lowered) by the increased red ticular attention should be directed to hy-
blood pressure levels may be associ- blood cell turnover related to pregnancy poglycemia prevention in the setting of
ated with impaired fetal growth. In a or blood loss at delivery and because the breastfeeding and erratic sleep and eat-
2015 study targeting diastolic blood pres- OGTT is more sensitive at detecting glu- ing schedules.
sure of 100 mmHg versus 85 mmHg in cose intolerance, including both predia-
pregnant women, only 6% of whom had betes and diabetes. Reproductive-aged Contraception
GDM at enrollment, there was no dif- women with prediabetes may develop A major barrier to effective preconception
ference in pregnancy loss, neonatal care, type 2 diabetes by the time of their next care is the fact that the majority of pregnan-
or other neonatal outcomes, although pregnancy and will need preconception cies are unplanned. Planning pregnancy is
women in the less intensive treatment evaluation. Because GDM is associated critical in women with preexisting diabetes
group had a higher rate of uncontrolled with an increased lifetime maternal risk due to the need for preconception glycemic
hypertension (55). for diabetes estimated at 50–70% after control and preventive health services.
15–25 years (60,61), women should also Therefore, all women with diabetes of child-
During pregnancy, treatment with ACE be tested every 1–3 years thereafter if the bearing potential should have family plan-
inhibitors and angiotensin receptor block- 4- to 12-week 75-g OGTT is normal, with ning options reviewed at regular intervals.
ers is contraindicated because they may frequency of testing depending on other This applies to women in the immediate
cause fetal renal dysplasia, oligohydram- risk factors including family history, pre- postpartum period. Women with diabetes
nios, and intrauterine growth restriction pregnancy BMI, and need for insulin or have the same contraception options and
(8). Antihypertensive drugs known to be oral glucose-lowering medication during recommendations as those without diabe-
effective and safe in pregnancy include pregnancy. Ongoing evaluation may be tes. The risk of an unplanned pregnancy
methyldopa, labetalol, diltiazem, cloni- performed with any recommended glyce- outweighs the risk of any given contracep-
dine, and prazosin. Chronic diuretic use mic test (e.g., A1C, fasting plasma glu- tion option.
during pregnancy is not recommended cose, or 75-g OGTT using nonpregnant
as it has been associated with restricted thresholds). References
maternal plasma volume, which may re- 1. Holmes VA, Young IS, Patterson CC, et al.; Di-
duce uteroplacental perfusion (56). On Gestational Diabetes Mellitus and Type 2 abetes and Pre-eclampsia Intervention Trial Study
the basis of available evidence, statins Diabetes Group. Optimal glycemic control, pre-eclampsia,
should also be avoided in pregnancy (57). and gestational hypertension in women with type 1
Women with a history of GDM have a diabetes in the Diabetes and Pre-eclampsia Inter-
POSTPARTUM CARE greatly increased risk of conversion to vention Trial. Diabetes Care 2011;34:1683–1688
type 2 diabetes over time and not solely 2. Dabelea D, Hanson RL, Lindsay RS, et al. Intra-
Postpartum care should include psy- within the 4- to 12-week postpartum time uterine exposure to diabetes conveys risks for
chosocial assessment and support for frame (60). In the prospective Nurses’ type 2 diabetes and obesity: a study of discordant
self-care. Health Study II, subsequent diabetes risk sibships. Diabetes 2000;49:2208–2211
after a history of GDM was significantly 3. Guerin A, Nisenbaum R, Ray JG. Use of mater-
Lactation lower in women who followed healthy nal GHb concentration to estimate the risk of con-
In light of the immediate nutritional and eating patterns (62). Adjusting for BMI genital anomalies in the offspring of women with
immunological benefits of breastfeeding moderately, but not completely, attenua- prepregnancy diabetes. Diabetes Care 2007;30:
for the baby, all women including those ted this association. Interpregnancy or post- 1920–1925
with diabetes should be supported in at- partum weight gain is associated with 4. Jensen DM, Korsholm L, Ovesen P, et al. Peri-
tempts to breastfeed. Breastfeeding may increased risk of adverse pregnancy out- conceptional A1C and risk of serious adverse preg-
also confer longer-term metabolic benefits comes in subsequent pregnancies (63) and nancy outcome in 933 women with type 1 diabetes.
to both mother (58) and offspring (59). earlier progression to type 2 diabetes. Diabetes Care 2009;32:1046–1048
5. Charron-Prochownik D, Sereika SM, Becker D,
Both metformin and intensive lifestyle et al. Long-term effects of the booster-enhanced
intervention prevent or delay progression READY-Girls preconception counseling program
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and a history of GDM. Of women with a

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in teens with diabetes. Diabetes Care 2013;36: by lifestyle intervention: the Finnish Gestational 37. Balsells M, Garc´ıa-Patterson A, Sola` I, Roque´
3870–3874 Diabetes Prevention Study (RADIEL): a random- M, Gich I, Corcoy R. Glibenclamide, metformin,
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United States. Am J Obstet Gynecol 2015;212: vent gestational diabetes mellitus and improve 38. Jiang Y-F, Chen X-Y, Ding T, Wang X-F, Zhu
74.e1–74.e9 pregnancy outcome in overweight and obese Z-N, Su S-W. Comparative efficacy and safety of
7. Charron-Prochownik D, Downs J. Diabetes and pregnant women. Am J Obstet Gynecol 2017; OADs in management of GDM: network meta-
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American Diabetes Association, 2016 24. Metzger BE, Buchanan TA, Coustan DR, et al. docrinol Metab 2015;100:2071–2080
8. Bullo M, Tschumi S, Bucher BS, Bianchetti MG, Summary and recommendations of the Fifth Interna- 39. Camelo Castillo W, Boggess K, Stu¨rmer T,
Simonetti GD. Pregnancy outcome following expo- tional Workshop-Conference on Gestational Diabetes Brookhart MA, Benjamin DK Jr, Jonsson Funk M.
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review. Hypertension 2012;60:444–450 25. Mayo K, Melamed N, Vandenberghe H, tational diabetes. JAMA Pediatr 2015;169:452–
9. Taguchi N, Rubin ET, Hosokawa A, et al. Pre- Berger H. The impact of adoption of the Interna- 458
natal exposure to HMG-CoA reductase inhibitors: tional Association of Diabetes in Pregnancy Study 40. Vanky E, Zahlsen K, Spigset O, Carlsen SM.
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Toxicol 2008;26:175–177 gestational diabetes. Am J Obstet Gynecol 2015; polycystic ovary syndrome. Fertil Steril 2005;83:
10. Bateman BT, Hernandez-Diaz S, Fischer MA, 212:224.e1–224.e9 1575–1578
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Traub AI, Ennis C, McCance DR. Preprandial versus monitoring: a randomized controlled trial. Obstet 42. Vanky E, Stridsklev S, Heimstad R, et al. Met-
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12. de Veciana M, Major CA, Morgan MA, et al. gestational diabetes mellitus. Cochrane Database nol Metab 2010;95:E448–E455
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S144 Diabetes Care Volume 41, Supplement 1, January 2018

14. Diabetes Care in the Hospital: American Diabetes Association
Standards of Medical Care in
Diabetesd2018

Diabetes Care 2018;41(Suppl. 1):S144–S151 | https://doi.org/10.2337/dc18-S014

14. DIABETES CARE IN THE HOSPITAL The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”
includes ADA’s current clinical practice recommendations and is intended to provide
the components of diabetes care, general treatment goals and guidelines, and tools
to evaluate quality of care. Members of the ADA Professional Practice Committee, a
multidisciplinary expert committee, are responsible for updating the Standards of
Care annually, or more frequently as warranted. For a detailed description of ADA
standards, statements, and reports, as well as the evidence-grading system for ADA’s
clinical practice recommendations, please refer to the Standards of Care Introduc-
tion. Readers who wish to comment on the Standards of Care are invited to do so at
professional.diabetes.org/SOC.

In the hospital, both hyperglycemia and hypoglycemia are associated with adverse
outcomes, including death (1,2). Therefore, inpatient goals should include the pre-
vention of both hyperglycemia and hypoglycemia. Hospitals should promote the short-
est safe hospital stay and provide an effective transition out of the hospital that
prevents acute complications and readmission.

For in-depth review of inpatient hospital practice, consult recent reviews that focus
on hospital care for diabetes (3,4).

HOSPITAL CARE DELIVERY STANDARDS

Recommendation

c Peform an A1C on all patients with diabetes or hyperglycemia (blood
glucose .140 mg/dL) admitted to the hospital if not performed in the prior
3 months. B

High-quality hospital care for diabetes requires both hospital care delivery standards, Suggested citation: American Diabetes As-
often assured by structured order sets, and quality assurance standards for process sociation. 14. Diabetes care in the hospital:
improvement. “Best practice” protocols, reviews, and guidelines (2) are inconsistently Standards of Medical Care in Diabetesd2018.
implemented within hospitals. To correct this, hospitals have established protocols for Diabetes Care 2018;41(Suppl. 1):S144–S151
structured patient care and structured order sets, which include computerized physi-
cian order entry (CPOE). © 2017 by the American Diabetes Association.
Readers may use this article as long as the work
Considerations on Admission is properly cited, the use is educational and not
Initial orders should state the type of diabetes (i.e., type 1 or type 2 diabetes) or no previous for profit, and the work is not altered. More infor-
history of diabetes. Because inpatient insulin use (5) and discharge orders (6) can be more mation is available at http://www.diabetesjournals
effective if based on an A1C level on admission (7), perform an A1C test on all patients .org/content/license.
with diabetes or hyperglycemia admitted to the hospital if the test has not been
performed in the prior 3 months. In addition, diabetes self-management knowledge
and behaviors should be assessed on admission and diabetes self-management edu-
cation (DSME) should be provided, if appropriate. DSME should include appropriate

care.diabetesjournals.org Diabetes Care in the Hospital S145

skills needed after discharge, such as tak- hyperglycemia starting at a threshold therapy is started, a target glucose range
ing antihyperglycemic medications, mon- $180 mg/dL (10.0 mmol/L). Once of 140–180 mg/dL (7.8–10.0 mmol/L) is
itoring glucose, and recognizing and insulin therapy is started, a target recommended for the majority of critically
treating hypoglycemia (2). glucose range of 140–180 mg/dL ill and noncritically ill patients (2). More
(7.8–10.0 mmol/L) is recommended stringent goals, such as ,140 mg/dL
Physician Order Entry for the majority of critically ill pa- (7.8 mmol/L), may be appropriate for se-
tients and noncritically ill patients. A lected patients, as long as this can be
Recommendation c More stringent goals, such as 110– achieved without significant hypoglyce-
140 mg/dL (6.1–7.8 mmol/L), may mia. Conversely, higher glucose ranges
c Insulin should be administered using be appropriate for selected pa- may be acceptable in terminally ill pa-
validated written or computerized tients, if this can be achieved with- tients, in patients with severe comorbid-
protocols that allow for predefined out significant hypoglycemia. C ities, and in inpatient care settings where
adjustments in the insulin dosage frequent glucose monitoringor close nurs-
based on glycemic fluctuations. E Standard Definition of Glucose ing supervision is not feasible.
Abnormalities
The National Academy of Medicine rec- Hyperglycemia in hospitalized patients is de- Clinical judgment combined with on-
ommends CPOE to prevent medication- fined as blood glucose levels .140 mg/dL going assessment of the patient’s clinical
related errors and to increase efficiency (7.8 mmol/L) (2,16). Blood glucose levels status, including changes in the trajectory
in medication administration (8). A Co- that are persistently above this level of glucose measures, illness severity, nu-
chrane review of randomized controlled may require alterations in diet or a change tritional status, or concomitant medica-
trials using computerized advice to im- in medications that cause hypergly- tions that might affect glucose levels
prove glucose control in the hospital cemia. An admission A1C value $6.5% (e.g., glucocorticoids), should be incorpo-
found significant improvement in the per- (48 mmol/mol) suggests that diabetes rated into the day-to-day decisions re-
centage of time patients spent in the preceded hospitalization (see Section garding insulin doses (2).
target glucose range, lower mean blood 2 “Classification and Diagnosis of Diabe-
glucose levels, and no increase in hypo- tes”) (2,16). The hypoglycemia alert value BEDSIDE BLOOD GLUCOSE
glycemia (9). Thus, where feasible, there in hospitalized patients is defined as MONITORING
should be structured order sets that blood glucose #70 mg/dL (3.9 mmol/L)
provide computerized advice for glucose (17) and clinically significant hypoglyce- Indications
control. Electronic insulin order templates mia as glucose values ,54 mg/dL (3.0 In the patient who is eating meals, glu-
also improve mean glucose levels without mmol/L). Severe hypoglycemia is defined cose monitoring should be performed
increasing hypoglycemia in patients with as that associated with severe cognitive before meals. In the patient who is not
type 2 diabetes, so structured insulin or- impairment regardless of blood glucose eating, glucose monitoring is advised ev-
der sets should be incorporated into the level (17). ery 4–6 h (2). More frequent blood glu-
CPOE (10). cose testing ranging from every 30 min to
Moderate Versus Tight Glycemic every 2 h is required for patients receiv-
Diabetes Care Providers in the Hospital Control ing intravenous insulin. Safety standards
Appropriately trained specialists or spe- A meta-analysis of over 26 studies, includ- should be established for blood glucose
cialty teams may reduce length of stay, ing the Normoglycemia in Intensive Care monitoring that prohibit the sharing of
improve glycemic control, and improve Evaluation–Survival Using Glucose Algo- fingerstick lancing devices, lancets, and
outcomes, but studies are few (11,12). A rithm Regulation (NICE-SUGAR) study, needles (21).
call to action outlined the studies needed showed increased rates of severe hypo-
to evaluate these outcomes (13). Details glycemia (defined in the analysis as blood Point-of-Care Meters
of team formation are available from the glucose ,40 mg/dL [2.2 mmol/L]) and Point-of-care (POC) meters have limitations
Society of Hospital Medicine and the Joint mortality in tightly versus moderately for measuring blood glucose. Although the
Commission standards for programs. controlled cohorts (18). Recent random- U.S. Food and Drug Administration (FDA)
ized controlled studies and meta-analyses has standards for blood glucose meters
Quality Assurance Standards in surgical patients have also reported used by lay persons, there have been ques-
Even the best orders may not be carried that targeting moderate perioperative tions about the appropriateness of these
out in a way that improves quality, nor are blood glucose levels to ,180 mg/dL (10 criteria, especially in the hospital and for
they automatically updated when new ev- mmol/L) is associated with lower rates lower blood glucose readings (22). Signifi-
idence arises. To this end, the Joint Com- of mortality and stroke compared with cant discrepancies between capillary, ve-
mission has an accreditation program for a liberal target glucose .200 mg/dL nous, and arterial plasma samples have
the hospital care of diabetes (14), and the (11.1 mmol/L), whereas no significant ad- been observed in patients with low or
Society of Hospital Medicine has a work- ditional benefit was found with more high hemoglobin concentrations and
book for program development (15). strict glycemic control (,140 mg/dl [7.8 with hypoperfusion. Any glucose result
mmol/L]) (19,20). Insulin therapy should that does not correlate with the pa-
GLYCEMIC TARGETS be initiated for treatment of persistent tient’s clinical status should be confirmed
IN HOSPITALIZED PATIENTS hyperglycemia starting at a threshold through conventional laboratory glucose
$180 mg/dL (10.0 mmol/L). Once insulin tests. The FDA established a separate cat-
Recommendations egory for POC glucose meters for use in
health care settings and has released
c Insulin therapy should be initi-
ated for treatment of persistent

S146 Diabetes Care in the Hospital Diabetes Care Volume 41, Supplement 1, January 2018

guidance on in-hospital use with stricter shown to be the best method for achiev- Type 1 Diabetes
standards (23). Before choosing a device ing glycemic targets. Intravenous insulin
for in-hospital use, consider the device’s infusions should be administered based For patients with type 1 diabetes, dosing
approval status and accuracy. on validated written or computerized insulin based solely on premeal glucose
protocols that allow for predefined ad- levels does not account for basal insulin
Continuous Glucose Monitoring justments in the infusion rate, account- requirements or caloric intake, increasing
Continuous glucose monitoring (CGM) ing for glycemic fluctuations and insulin both hypoglycemia and hyperglycemia
provides frequent measurements of in- dose (2). risks and potentially leading to diabetic
terstitial glucose levels, as well as direc- ketoacidosis (DKA). Typically, basal insulin
tion and magnitude of glucose trends, Noncritical Care Setting dosing schemes are based on body
which may have an advantage over weight, with some evidence that patients
POC glucose testing in detecting and re- Outside of critical care units, scheduled with renal insufficiency should be treat-
ducing the incidence of hypoglycemia insulin regimens are recommended to ed with lower doses (34). An insulin
(24). Several inpatient studies have manage hyperglycemia in patients regimen with basal and correction com-
shown that CGM use did not improve glu- with diabetes. Regimens using insulin ponents is necessary for all hospitalized
cose control but detected a greater num- analogs and human insulin result in sim- patients with type 1 diabetes, with the
ber of hypoglycemic events than POC ilar glycemic control in the hospital set- addition of nutritional insulin if the pa-
testing (25). However, a recent review ting (30). tient is eating.
has recommended against using CGM
in adults in a hospital setting until The use of subcutaneous rapid- or Transitioning Intravenous to Subcutaneous
more safety and efficacy data become short-acting insulin before meals or ev- Insulin
available (25). ery 4–6 h if no meals are given or if the
patient is receiving continuous enteral/ When discontinuing intravenous insulin,
ANTIHYPERGLYCEMIC AGENTS parenteral nutrition is indicated to correct a transition protocol is associated with
IN HOSPITALIZED PATIENTS hyperglycemia (2). Basal insulin or a basal less morbidity and lower costs of care
plus bolus correction insulin regimen is (35) and is therefore recommended. A pa-
Recommendations the preferred treatment for noncritically tient with type 1 or type 2 diabetes being
ill patients with poor oral intake or those transitioned to outpatient subcutane-
c A basal plus bolus correction insulin who are taking nothing by mouth (NPO). ous insulin should receive subcutaneous
regimen, with the addition of nutri- An insulin regimen with basal, nutritional, basal insulin 2–4 h before the intravenous
tional insulin in patients who have and correction components is the pre- insulin is discontinued. Converting to
good nutritional intake, is the pre- ferred treatment for noncritically ill hos- basal insulin at 60–80% of the daily infusion
ferred treatment for noncritically ill pitalized patients with good nutritional dose has been shown to be effective
patients. A intake. (2,35,36). For patients continuing regi-
mens with concentrated insulin in the in-
c Sole use of sliding scale insulin in If the patient is eating, insulin injec- patient setting, it is important to ensure
the inpatient hospital setting is tions should align with meals. In such in- the correct dosing by utilizing an individ-
strongly discouraged. A stances, POC glucose testing should be ual pen and cartridge for each patient,
performed immediately before meals. If meticulous pharmacist supervision of
In most instances in the hospital setting, oral intake is poor, a safer procedure is to the dose administered, or other means
insulin is the preferred treatment for glyce- administer the rapid-acting insulin imme- (37,38).
mic control (2). However, in certain circum- diately after the patient eats or to count
stances, it may be appropriate to continue the carbohydrates and cover the amount Noninsulin Therapies
home regimens including oral antihyper- ingested (30). The safety and efficacy of noninsulin anti-
glycemic medications (26). If oral medica- hyperglycemic therapies in the hospital
tions are held in the hospital, there should A randomized controlled trial has setting is an area of active research. A
be a protocol for resuming them 1– shown that basal-bolus treatment im- few recent randomized pilot trials in gen-
2 days before discharge. Insulin pens proved glycemic control and reduced hos- eral medicine and surgery patients re-
are the subject of an FDA warning be- pital complications compared with sliding ported that a dipeptidyl peptidase 4
cause of potential blood-borne diseases, scale insulin in general surgery patients inhibitor alone or in combination with
and care should be taken to follow the with type 2 diabetes (31). Prolonged basal insulin was well tolerated and re-
label insert “For single patient use only.” sole use of sliding scale insulin in the in- sulted in similar glucose control and fre-
Recent reports, however, have indicated patient hospital setting is strongly dis- quency of hypoglycemia compared with a
that the inpatient use of insulin pens ap- couraged (2,13). basal-bolus regimen (39–41). However, a
pears to be safe and may be associated recent FDA bulletin states that providers
with improved nurse satisfaction com- While there is evidence for using pre- should consider discontinuing saxagliptin
pared with the use of insulin vials and mixed insulin formulations in the outpa- and alogliptin in people who develop
syringes (27–29). tient setting (32), a recent inpatient study heart failure (42). A review of antihyper-
of 70/30 NPH/regular insulin versus glycemic medications concluded that
Insulin Therapy basal-bolus therapy showed comparable glucagon-like peptide 1 receptor agonists
Critical Care Setting glycemic control but significantly in- show promise in the inpatient setting
In the critical care setting, continuous creased hypoglycemia in the group re- (43); however, proof of safety and effi-
intravenous insulin infusion has been ceiving premixed insulin (33). Therefore, cacy awaits the results of randomized
premixed insulin regimens are not rou-
tinely recommended for in-hospital use.

care.diabetesjournals.org Diabetes Care in the Hospital S147

controlled trials (44). Moreover, the gas- treating hypoglycemia for each patient. MEDICAL NUTRITION THERAPY
trointestinal symptoms associated with An American Diabetes Association (ADA) IN THE HOSPITAL
the glucagon-like peptide 1 receptor ago- consensus report suggested that a pa-
nists may be problematic in the inpatient tient’s overall treatment regimen be re- The goals of medical nutrition therapy in
setting. viewed when a blood glucose value the hospital are to provide adequate cal-
of #70 mg/dL (3.9 mmol/L) is identified ories to meet metabolic demands, opti-
Regarding the sodium–glucose trans- because such readings often predict im- mize glycemic control, address personal
porter 2 (SGLT2) inhibitors, the FDA minent severe hypoglycemia (2). food preferences, and facilitate creation
includes warnings about DKA and uro- of a discharge plan. The ADA does not
sepsis (45), urinary tract infections, and Episodes of hypoglycemia in the hospi- endorse any single meal plan or specified
kidney injury (46) on the drug labels. A tal should be documented in the medical percentages of macronutrients. Current
recent review suggested SGLT2 inhibi- record and tracked (2). nutrition recommendations advise indi-
tors be avoided in severe illness, when vidualization based on treatment goals,
ketone bodies are present, and during Triggering Events physiological parameters, and medication
prolonged fasting and surgical proce- Iatrogenic hypoglycemia triggers may in- use. Consistent carbohydrate meal plans
dures (3). Until safety and effectiveness clude sudden reduction of corticosteroid are preferred by many hospitals as they
are established, SGLT2 inhibitors cannot dose, reduced oral intake, emesis, new facilitate matching the prandial insulin
be recommended for routine in-hospital NPO status, inappropriate timing of short- dose to the amount of carbohydrate con-
use. acting insulin in relation to meals, reduced sumed (51). Regarding enteral nutritional
infusion rate of intravenous dextrose, un- therapy, diabetes-specific formulas ap-
HYPOGLYCEMIA expected interruption of oral, enteral, or pear to be superior to standard formulas
parenteral feedings, and altered ability of in controlling postprandial glucose, A1C,
Recommendations the patient to report symptoms (3). and the insulin response (52).

c A hypoglycemia management pro- Predictors of Hypoglycemia When the nutritional issues in the hos-
tocol should be adopted and imple- In one study, 84% of patients with an ep- pital are complex, a registered dietitian,
mented by each hospital or hospital isode of severe hypoglycemia (,40 mg/dL knowledgeable and skilled in medical nu-
system. A plan for preventing and [2.2 mmol/L]) had a prior episode of hy- trition therapy, can serve as an individual
treating hypoglycemia should be poglycemia (,70 mg/dL [3.9 mmol/L]) inpatient team member. That person
established for each patient. Epi- during the same admission (47). In an- should be responsible for integrating in-
sodes of hypoglycemia in the hospi- other study of hypoglycemic episodes formation about the patient’s clinical con-
tal should be documented in the (,50 mg/dL [2.8 mmol/L]), 78% of pa- dition, meal planning, and lifestyle habits
medical record and tracked. E tients were using basal insulin, with the and for establishing realistic treatment
incidence of hypoglycemia peaking be- goals after discharge. Orders should also
c The treatment regimen should be tween midnight and 6 A.M. Despite recog- indicate that the meal delivery and nutri-
reviewed and changed as neces- nition of hypoglycemia, 75% of patients tional insulin coverage should be coordi-
sary to prevent further hypoglyce- did not have their dose of basal insulin nated, as their variability often creates
mia when a blood glucose value is changed before the next insulin adminis- the possibility of hyperglycemic and hy-
#70 mg/dL (3.9 mmol/L). C tration (48). poglycemic events.

Patients with or without diabetes may ex- Prevention SELF-MANAGEMENT IN THE
perience hypoglycemia in the hospital Common preventable sources of iatro- HOSPITAL
setting. While hypoglycemia is associated genic hypoglycemia are improper pre-
with increased mortality, hypoglycemia scribing of hypoglycemic medications, Diabetes self-management in the hospital
may be a marker of underlying disease inappropriate management of the first may be appropriate for select youth and
rather than the cause of increased mor- episode of hypoglycemia, and nutrition– adult patients (53,54). Candidates include
tality. However, until it is proven not to be insulin mismatch, often related to an patients who successfully conduct self-
causal, it is prudent to avoid hypoglyce- unexpected interruption of nutrition. Stud- management of diabetes at home, have
mia. Despite the preventable nature of ies of “bundled” preventative therapies the cognitive and physical skills needed to
many inpatient episodes of hypoglyce- including proactive surveillance of gly- successfully self-administer insulin, and
mia, institutions are more likely to have cemic outliers and an interdisciplinary perform self-monitoring of blood glucose.
nursing protocols for hypoglycemia treat- data-driven approach to glycemic man- In addition, they should have adequate
ment than for its prevention when both agement showed that hypoglycemic epi- oral intake, be proficient in carbohydrate
are needed. sodes in the hospital could be prevented. estimation, use multiple daily insulin in-
Compared with baseline, two such stud- jections or continuous subcutaneous in-
A hypoglycemia prevention and man- ies found that hypoglycemic events fell sulin infusion (CSII) pump therapy, have
agement protocol should be adopted and by 56% to 80% (49,50). The Joint Commis- stable insulin requirements, and un-
implemented by each hospital or hospital sion recommends that all hypoglycemic derstand sick-day management. If self-
system. There should be a standardized episodes be evaluated for a root cause management is to be used, a protocol should
hospital-wide, nurse-initiated hypogly- and the episodes be aggregated and re- include a requirement that the patient,
cemia treatment protocol to immedi- viewed to address systemic issues. nursing staff, and physician agree that pa-
ately address blood glucose levels of tient self-management is appropriate. If
#70 mg/dL (3.9 mmol/L), as well as in-
dividualized plans for preventing and

S148 Diabetes Care in the Hospital Diabetes Care Volume 41, Supplement 1, January 2018

CSII is to be used, hospital policy and pro- Correctional insulin coverage should be mg/dL (4.4–10.0 mmol/L).
cedures delineating guidelines for CSII added as needed before each feeding. 2. Perform a preoperative risk assessment
therapy, including the changing of infu- For patients receiving continuous periph-
sion sites, are advised (55). eral or central parenteral nutrition, regu- for patients at high risk for ischemic
lar insulin may be added to the solution, heart disease and those with autono-
STANDARDS FOR SPECIAL particularly if .20 units of correctional mic neuropathy or renal failure.
SITUATIONS insulin have been required in the past 3. Withhold metformin the day of surgery.
24 h. A starting dose of 1 unit of human 4. Withhold any other oral hypoglycemic
Enteral/Parenteral Feedings regular insulin for every 10 g dextrose has agents the morning of surgery or pro-
For patients receiving enteral or paren- been recommended (57), to be adjusted cedure and give half of NPH dose or
teral feedings who require insulin, insulin daily in the solution. Correctional insulin 60–80% doses of a long-acting analog
should be divided into basal, nutritional, should be administered subcutaneously. or pump basal insulin.
and correctional components. This is par- For full enteral/parenteral feeding guid- 5. Monitor blood glucose at least every
ticularly important for people with type 1 ance, the reader is encouraged to consult 4–6 h while NPO and dose with short-
diabetes to ensure that they continue to review articles (2,58) and see Table 14.1. acting insulin as needed.
receive basal insulin even if the feedings
are discontinued. One may use the pa- Glucocorticoid Therapy A review found that perioperative gly-
tient’s preadmission basal insulin dose Glucocorticoid type and duration of action cemic control tighter than 80–180 mg/dL
or a percentage of the total daily dose must be considered in determining insulin (4.4–10.0 mmol/L) did not improve out-
of insulin when the patient is being fed treatment regimens. Once-a-day, short- comes and was associated with more hy-
(usually 30 to 50% of the total daily dose acting glucocorticoids such as prednisone poglycemia (62); therefore, in general,
of insulin) to estimate basal insulin re- peak in about 4 to 8 h (59), so cover- tighter glycemic targets are not advised.
quirements. However, if no basal insulin age with intermediate-acting (NPH) insulin A recent study reported that, compared
was used, consider using 5 units of NPH/ may be sufficient. For long-acting gluco- with the usual insulin dose, on average a
detemir insulin subcutaneously every corticoids such as dexamethasone or mul- ;25% reduction in the insulin dose given
12 h or 10 units of insulin glargine every tidose or continuous glucocorticoid use, the evening before surgery was more
24 h (56). For patients receiving continu- long-acting insulin may be used (26,58). likely to achieve perioperative blood glu-
ous tube feedings, the total daily nutri- For higher doses of glucocorticoids, in- cose levels in the target range with de-
tional component may be calculated as creasing doses of prandial and supplemen- creased risk for hypoglycemia (63).
1 unit of insulin for every 10–15 g carbo- tal insulin may be needed in addition to
hydrate per day or as a percentage of the basal insulin (60). Whatever orders are In noncardiac general surgery pa-
total daily dose of insulin when the pa- started, adjustments based on antici- tients, basal insulin plus premeal regular
tient is being fed (usually 50 to 70% of pated changes in glucocorticoid dosing or short-acting insulin (basal-bolus) cov-
the total daily dose of insulin). Correc- and POC glucose test results are critical. erage has been associated with improved
tional insulin should also be administered glycemic control and lower rates of peri-
subcutaneously every 6 h using human Perioperative Care operative complications compared with
regular insulin or every 4 h using a rapid- Many standards for perioperative care the traditional sliding scale regimen (reg-
acting insulin such as lispro, aspart, or gluli- lack a robust evidence base. However, ular or short-acting insulin coverage only
sine. For patients receiving enteral bolus the following approach (61) may be con- with no basal dosing) (31,64).
feedings, approximately 1 unit of regu- sidered:
lar human insulin or rapid-acting insulin Diabetic Ketoacidosis and
should be given per 10–15 g carbohydrate 1. Target glucose range for the peri- Hyperosmolar Hyperglycemic State
subcutaneously before each feeding. operative period should be 80–180 There is considerable variability in the
presentation of DKA and hyperosmolar

Table 14.1—Insulin dosing for enteral/parenteral feedings

Situation Basal/nutritional Correctional

Continuous enteral feedings Continue prior basal or, if none, calculate from TDD or SQ regular insulin every 6 h or rapid-acting insulin
Bolus enteral feedings consider 5 units NPH/detemir every 12 h or 10 units every 4 h for hyperglycemia
Parenteral feedings glargine/degludec daily

Nutritional: regular insulin every 6 h or rapid-acting insulin
every 4 h, starting with 1 unit per 10–15 g of
carbohydrate; adjust daily

Continue prior basal or, if none, calculate from TDD or SQ regular insulin every 6 h or rapid-acting insulin
consider 5 units NPH/detemir every 12 h or 10 units every 4 h for hyperglycemia
glargine/degludec daily

Nutritional: give regular insulin or rapid-acting insulin SQ
before each feeding, starting with 1 unit per 10–15 g of
carbohydrate; adjust daily

Add regular insulin to TPN IV solution, starting with 1 unit SQ regular insulin every 6 h or rapid-acting insulin

per 10 g of carbohydrate; adjust daily every 4 h for hyperglycemia

IV, intravenous; SQ, subcutaneous; TDD, total daily dose; TPN, total parenteral nutrition.

care.diabetesjournals.org Diabetes Care in the Hospital S149

hyperglycemic state, ranging from eugly- be discharged to varied settings, including + Discharge summaries should be trans
cemia or mild hyperglycemia and acidosis home (with or without visiting nurse ser-
to severe hyperglycemia, dehydration, vices), assisted living, rehabilitation, or mitted to the primary physician as soon
and coma; therefore, treatment individu- skilled nursing facilities. For the patient as possible after discharge.
alization based on a careful clinical and who is discharged to home or to assisted liv-
laboratory assessment is needed (65). ing, the optimal program will need to con- + Appointment-keeping behavior is en-
sider diabetes type and severity, effects of
Management goals include restoration the patient’s illness on blood glucose levels, hanced when the inpatient team sched-
of circulatory volume and tissue perfu- and the patient’s capacities and desires. ules outpatient medical follow-up prior
sion, resolution of hyperglycemia, and to discharge.
correction of electrolyte imbalance and An outpatient follow-up visit with the
ketosis. It is also important to treat any primary care provider, endocrinologist, or It is recommended that the following
correctable underlying cause of DKA such diabetes educator within 1 month of dis- areas of knowledge be reviewed and ad-
as sepsis. charge is advised for all patients having dressed prior to hospital discharge:
hyperglycemia in the hospital. If glycemic
In critically ill and mentally obtunded medications are changed or glucose con- + Identification of the health care pro-
patients with DKA or hyperosmolar hy- trol is not optimal at discharge, an earlier
perglycemic state, continuous intra- appointment (in 1–2 weeks) is preferred, vider who will provide diabetes care
venous insulin is the standard of care. and frequent contact may be needed to after discharge.
However, there is no significant differ- avoid hyperglycemia and hypoglycemia.
ence in outcomes for intravenous regular A recent discharge algorithm for glycemic + Level of understanding related to the
insulin versus subcutaneous rapid-acting medication adjustment based on admis-
analogs when combined with aggressive sion A1C found that the average A1C in diabetes diagnosis, self-monitoring of
fluid management for treating mild or patients with diabetes after discharge blood glucose, explanation of home
moderate DKA (66). Patients with uncom- was significantly improved (6). Therefore, blood glucose goals, and when to call
plicated DKA may sometimes be treated if an A1C from the prior 3 months is un- the provider.
with subcutaneous insulin in the emer- available, measuring the A1C in all patients
gency department or step-down units with diabetes or hyperglycemia admitted + Definition, recognition, treatment,
(67), an approach that may be safer and to the hospital is recommended.
more cost-effective than treatment with and prevention of hyperglycemia and
intravenous insulin (68). If subcutaneous Clear communication with outpatient hypoglycemia.
administration is used, it is important to providers either directly or via hospital
provide adequate fluid replacement, discharge summaries facilitates safe transi- + Information on consistent nutrition
nurse training, frequent bedside testing, tions to outpatient care. Providing informa-
infection treatment if warranted, and ap- tion regarding the cause of hyperglycemia habits.
propriate follow-up to avoid recurrent (or the plan for determining the cause), re-
DKA. Several studies have shown that lated complications and comorbidities, and + If relevant, when and how to take
the use of bicarbonate in patients with recommended treatments can assist out-
DKA made no difference in resolution of patient providers as they assume ongoing blood glucose–lowering medications,
acidosis or time to discharge, and its use is care. including insulin administration.
generally not recommended (69). For fur-
ther information regarding treatment, re- The Agency for Healthcare Research + Sick-day management.
fer to recent in-depth reviews (3,70). and Quality (AHRQ) recommends that, + Proper use and disposal of needles
at a minimum, discharge plans include the
TRANSITION FROM THE ACUTE following (72): and syringes.
CARE SETTING
Medication Reconciliation It is important that patients be pro-
Recommendation vided with appropriate durable medical
+ The patient’s medications must be equipment, medications, supplies (e.g.,
c There should be a structured dis- insulin pens), and prescriptions along with
charge plan tailored to the individ- cross-checked to ensure that no chronic appropriate education at the time of dis-
ual patient with diabetes. B medications were stopped and to en- charge in order to avoid a potentially dan-
sure the safety of new prescriptions. gerous hiatus in care.
A structured discharge plan tailored to the
individual patient may reduce length of + Prescriptions for new or changed med PREVENTING ADMISSIONS AND
hospital stay and readmission rates and in- READMISSIONS
crease patient satisfaction (71). Therefore, ication should be filled and reviewed
there should be a structured discharge with the patient and family at or before Preventing Hypoglycemic Admissions
plan tailored to each patient. Discharge discharge. in Older Adults
planning should begin at admission and Insulin-treated patients 80 years of age or
be updated as patient needs change. Structured Discharge Communication older are more than twice as likely to visit
the emergency department and nearly
Transition from the acute care setting is + Information on medication changes, five times as likely to be admitted for
a risky time for all patients. Inpatients may insulin-related hypoglycemia than those
pending tests and studies, and follow- 45–64 years of age (73). However, older
up needs must be accurately and adults with type 2 diabetes in long-term
promptly communicated to outpa- care facilities taking either oral antihyper-
tient physicians. glycemic agents or basal insulin have sim-
ilar glycemic control (74), suggesting that
oral therapy may be used in place of in-
sulin to lower the risk of hypoglycemia for
some patients. In addition, many older
adults with diabetes are overtreated (75),
with half of those maintaining an A1C ,7%
being treated with insulin or a sulfonylurea,

S150 Diabetes Care in the Hospital Diabetes Care Volume 41, Supplement 1, January 2018

which are associated with hypoglycemia. To unknown diabetes in the ICU. Crit Care Med recommendations from an ASHP Foundation ex-
further lower the risk of hypoglycemia- 2015;43:e541–e550 pert consensus panel. Am J Health Syst Pharm
related admissions in older adults, providers 8. Institute of Medicine. Preventing Medica- 2013;70:1404–1413
may, on an individual basis, relax A1C tar- tion Errors. Aspden P, Wolcott J, Bootman JL, 22. Boyd JC, Bruns DE. Quality specifications for
gets to ,8% or ,8.5% in patients with Cronenwett LR, Eds. Washington, DC, The Na- glucose meters: assessment by simulation model-
shortened life expectancies and signifi- tional Academies Press, 2007 ing of errors in insulin dose. Clin Chem 2001;47:
cant comorbidities (refer to Section 9. Gillaizeau F, Chan E, Trinquart L, et al. Comput- 209–214
11 “Older Adults” for detailed criteria). erized advice on drug dosage to improve prescrib- 23. U.S. Food and Drug Administration. Blood Glu-
ing practice. Cochrane Database Syst Rev 2013; cose Monitoring Test Systems for Prescription
Preventing Readmissions 11:CD002894 Point-of-Care Use: Guidance for Industry and Food
In patients with diabetes, the readmission 10. Wexler DJ, Shrader P, Burns SM, Cagliero E. and Drug Administration Staff [Internet], 2016.
rate is between 14 and 20% (76). Risk Effectiveness of a computerized insulin order Available from https://www.fda.gov/downloads/
factors for readmission include lower so- template in general medical inpatients with medicaldevices/deviceregulationandguidance/
cioeconomic status, certain racial/ethnic type 2 diabetes: a cluster randomized trial. Diabe- guidancedocuments/ucm380325.pdf. Accessed
minority groups, comorbidities, urgent tes Care 2010;33:2181–2183 21 November 2016
admission, and recent prior hospitaliza- 11. Wang YJ, Seggelke S, Hawkins RM, et al. Im- 24. Wallia A, Umpierrez GE, Rushakoff RJ, et al.;
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4. Bogun M, Inzucchi SE. Inpatient management Glucose concentrations of less than 3.0 mmol/L inpatient management of patients with type 2
of diabetes and hyperglycemia. Clin Ther 2013;35: (54 mg/dL) should be reported in clinical trials: a diabetes undergoing general surgery (RABBIT 2
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Predictive value of admission hemoglobin A1c on Study of Diabetes. Diabetes Care 2017;40:155– Bellastella G, Esposito K. Intensification of insulin
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therapy in medicine and surgery patients with 18. NICE-SUGAR Study Investigators, Finfer S, imens in type 2 diabetes: a systematic review and
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6. Umpierrez GE, Reyes D, Smiley D, et al. Hospi- Med 2009;360:1283–1297 33. Bellido V, Suarez L, Rodriguez MG, et al. Com-
tal discharge algorithm based on admission HbA1c 19. Sathya B, Davis R, Taveira T, Whitlatch H, Wu parison of basal-bolus and premixed insulin regi-
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20. Umpierrez G, Cardona S, Pasquel F, et al. Ran- glargine and glulisine in hospitalized subjects with
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36. Shomali ME, Herr DL, Hill PC, Pehlivanova M, 50. Milligan PE, Bocox MC, Pratt E, Hoehner CM, taneous rapid-acting insulin analogues for dia-
Sharretts JM, Magee MF. Conversion from intra- Krettek JE, Dunagan WC. Multifaceted approach betic ketoacidosis. Cochrane Database Syst Rev
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501–507 65. Kitabchi AE, Umpierrez GE, Miles JM, Fisher abetic kidney disease: a report from an ADA
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of a hypoglycemia reduction bundle and a diabetes. Diabetes Care 2009;32:1335–1343 2864–2883

S152 Diabetes Care Volume 41, Supplement 1, January 2018

15. Diabetes Advocacy: Standards American Diabetes Association
of Medical Care in Diabetesd2018

Diabetes Care 2018;41(Suppl. 1):S152–S153 | https://doi.org/10.2337/dc18-S015

15. DIABETES ADVOCACY The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”
includes ADA’s current clinical practice recommendations and is intended to provide
the components of diabetes care, general treatment goals and guidelines, and tools
to evaluate quality of care. Members of the ADA Professional Practice Committee, a
multidisciplinary expert committee, are responsible for updating the Standards of
Care annually, or more frequently as warranted. For a detailed description of ADA
standards, statements, and reports, as well as the evidence-grading system for ADA’s
clinical practice recommendations, please refer to the Standards of Care Introduction.
Readers who wish to comment on the Standards of Care are invited to do so at
professional.diabetes.org/SOC.

Managing the daily health demands of diabetes can be challenging. People living with
diabetes should not have to face additional discrimination due to diabetes. By advocating
for the rights of those with diabetes at all levels, the American Diabetes Association
(ADA) can help to ensure that they live a healthy and productive life. A strategic goal of
the ADA is that more children and adults with diabetes live free from the burden of
discrimination.

One tactic for achieving this goal is to implement the ADA’s Standards of Care
through advocacy-oriented position statements. The ADA publishes evidence-based,
peer-reviewed statements on topics such as diabetes and employment, diabetes and
driving, and diabetes management in certain settings such as schools, child care
programs, and correctional institutions. In addition to the ADA’s clinical position
statements, these advocacy position statements are important tools in educating
schools, employers, licensing agencies, policy makers, and others about the inter-
section of diabetes medicine and the law.

ADVOCACY POSITION STATEMENTS
Partial list, with the most recent publications appearing first

Diabetes Care in the School Setting (1) Suggested citation: American Diabetes Associa-
First publication: 1998 (revised 2015) tion. 15. Diabetes advocacy: Standards of Med-
A sizeable portion of a child’s day is spent in school, so close communication with ical Care in Diabetesd2018. Diabetes Care
and cooperation of school personnel are essential to optimize diabetes manage- 2018;41(Suppl. 1):S152–S153
ment, safety, and academic opportunities. See the ADA position statement “Diabe-
tes Care in the School Setting” (http://care.diabetesjournals.org/content/38/10/ © 2017 by the American Diabetes Association.
1958.full). Readers may use this article as long as the work
is properly cited, the use is educational and not
Care of Young Children With Diabetes in the Child Care Setting (2) for profit, and the work is not altered. More infor-
First publication: 2014 mation is available at http://www.diabetesjournals
Very young children (aged ,6 years) with diabetes have legal protections and can .org/content/license.
be safely cared for by child care providers with appropriate training, access to

care.diabetesjournals.org Diabetes Advocacy S153

resources, and a system of communication Driving” (http://care.diabetesjournals that nearly 80,000 inmates have diabe-
with parents and the child’s diabetes pro- .org/content/37/Supplement_1/S97). tes, correctional institutions should have
vider. See the ADA position statement written policies and procedures for the
“Care of Young Children With Diabetes in Diabetes and Employment (4) management of diabetes and for the train-
the Child Care Setting” (http://care First publication: 1984 (revised 2009) ing of medical and correctional staff in
.diabetesjournals.org/content/37/10/ Any person with diabetes, whether insulin diabetes care practices. See the ADA
2834). treated or noninsulin treated, should be el- position statement “Diabetes Manage-
igible for any employment for which he or ment in Correctional Institutions” (http://
Diabetes and Driving (3) she is otherwise qualified. Employment de- care.diabetesjournals.org/content/37/
First publication: 2012 cisions should never be based on gener- Supplement_1/S104).
People with diabetes who wish to operate alizations or stereotypes regarding the
motor vehicles are subject to a great vari- effects of diabetes. When questions References
ety of licensing requirements applied by arise about the medical fitness of a person 1. Jackson CC, Albanese-O’Neill A, Butler KL,
both state and federal jurisdictions, which with diabetes for a particular job, a health et al. Diabetes care in the school setting: a
may lead to loss of employment or signif- care professional with expertise in treating position statement of the American Diabetes
icant restrictions on a person’s license. diabetes should perform an individualized Association. Diabetes Care 2015;38:1958–
Presence of a medical condition that can assessment. See the ADA position state- 1963
lead to significantly impaired conscious- ment “Diabetes and Employment” (http:// 2. Siminerio LM, Albanese-O’Neill A, Chiang JL,
ness or cognition may lead to drivers being care.diabetesjournals.org/content/37/ et al. Care of young children with diabetes in the
evaluated for their fitness to drive. People Supplement_1/S112). child care setting: a position statement of the
with diabetes should be individually as- American Diabetes Association. Diabetes Care
sessed by a health care professional knowl- Diabetes Management in Correctional 2014;37:2834–2842
edgeable in diabetes if license restrictions Institutions (5) 3. American Diabetes Association. Diabetes and
are being considered, and patients should First publication: 1989 (revised 2008) driving. Diabetes Care 2014;37:(Suppl. 1):S97–S103
be counseled about detecting and avoid- People with diabetes in correctional fa- 4. American Diabetes Association. Diabetes and
ing hypoglycemia while driving. See the cilities should receive care that meets employment. Diabetes Care 2014;37(Suppl. 1):
ADA position statement “Diabetes and national standards. Because it is estimated S112–S117
5. American Diabetes Association. Diabetes
management in correctional institutions. Diabe-
tes Care 2014;37(Suppl. 1):S104–S111

PROFESSIONAL PRACTICE COMMITTEE DISCLOSURES S154 Diabetes Care Volume 41, Supplement 1, January 2018

Professional Practice Committee,
American College of
CardiologydDesignated
Representatives, and American
Diabetes Association Staff
Disclosures

Diabetes Care 2018;41(Suppl. 1):S154–S155 | https://doi.org/10.2337/dc18-SDIS01

The following financial or other conflicts of interest cover the period 12 months before December 2017

Member Employment Research grant Other research
support
Rita R. Kalyani, MD, MHS, FACP (Chair) Johns Hopkins University, Baltimore, MD None None
Christopher P. Cannon, MD Brigham and Women’s Hospital, Amgen, Arisaph, Boehringer Ingelheim, None
Boston, MA Bristol-Myers Squibb, Daiichi Sankyo,
Andrea L. Cherrington, MD, MPH None
Donald R. Coustan, MD University of Alabama, Birmingham, AL Janssen, Merck, Takeda None
Ian H. de Boer, MD, MS The Warren Alpert Medical School of Brown None
None Medtronic,
University, Providence, RI Abbott
University of Washington, Seattle, WA Research grant from ADA None

Hope Feldman, CRNP, FNP-BC Abbottsford-Falls Family Practice & None None
Counseling, Philadelphia, PA
Judith Fradkin, MD None None
National Institute of Diabetes and Digestive
David Maahs, MD, PhD and Kidney Diseases, Bethesda, MD Medtronic, Dexcom, Roche, Insulet, None
Bigfoot Common
Melinda Maryniuk, MEd, RD, CDE Stanford University, School of Medicine, None Sensing
Medha N. Munshi, MD Stanford, CA None
None
Joshua J. Neumiller, PharmD, Joslin Diabetes Center, Boston, MA None None
CDE, FASCP Beth Israel Deaconess Medical Center, Sanofi, Novo Nordisk, Merck, Boehringer
Harvard Medical School, Boston, MA
Guillermo E. Umpierrez, MD, CDE, Washington State University, Spokane, WA Ingelheim, AstraZeneca
FACE, FACP
Emory University, Atlanta, GA

Sandeep Das, MD, MPH^ University of Texas Southwestern Medical None None
Mikhail Kosiborod, MD^ Center None None

University of Missouri-Kansas City School of
Medicine

William T. Cefalu, MD (Staff)† American Diabetes Association, Arlington, VA Sanofi*# None
Erika Gebel Berg, PhD (Staff) American Diabetes Association, Arlington, VA None None
Tamara Darsow, PhD (Staff) American Diabetes Association, Arlington, VA None None
Matthew P. Petersen (Staff) American Diabetes Association, Arlington, VA None None
Sacha Uelmen, RDN, CDE (Staff) American Diabetes Association, Arlington, VA None None

care.diabetesjournals.org Disclosures S155

Speakers’ bureau/

Member honoraria Ownership interest Consultant/advisory board Other

R.R.K. None None None None
C.P.C. None None Alnylam, Amarin, Amgen, Arisaph, None
AstraZeneca, Boehringer Ingelheim,
A.L.C. AstraZeneca (Women Connection Health Coinvestigator, drug study by Merck
Scientists Board) (Volunteer Chief Medical Bristol-Myers Squibb, Eisai, Sharp & Dohme;
D.R.C. GlaxoSmithKline, Kowa, Lipimedix,
I.H.d.B. None Officer) Merck, Pfizer, Regeneron, Sanofi, Takeda Site investigator, drug study by
H.F. None None Boehringer Ingelheim
None None None None
J.F. None None
D.M. None None
None None Boehringer Ingelheim, Member, American Diabetes
M.M. None Association Primary Care Advisory
M.N.M. None Janssen, Ironwood
J.J.N. Novo Nordisk, None None Group;
G.E.U. Sanofi, Eli Lilly None Member, Diabetes Spectrum
None
S.D.^ None Insulet, Helmsely Charitable Trust Editorial Board
M.K.^ None None
None
W.T.C.† None Sanofi Editorial Boards, The Journal of
E.G.B. None Pediatrics and Diabetes Technology &
T.D.
M.P.P. None Therapeutics; Associate Editor,
S.U. None Diabetic Medicine; and Secretary-
None General, International Society for
None Pediatric and Adolescent Diabetes
None
None
None

None None Editor in Chief, Diabetes Spectrum
None Sanofi Member, Endocrine Society Council

None Roche Diagnostic Member, American Association
None AstraZeneca, Sanofi, GlaxoSmithKline, of Clinical Endocrinologists Board
Amgen, Boehringer Ingelheim, Novo
None of Directors
None Nordisk, Merck (Diabetes), Eisai, ZS Editor in Chief, BMJ Open Diabetes
None Pharma, Glytec, Janssen, Intarcia,
None Research & Care
None Novartis None
Sanofi, Intarcia, Adocia None

None Former Editor in Chief, Diabetes Care
None None
None None
None None
None

^American College of Cardiologyddesignated representative (Section 9); *$$10,000 per year from company to individual; #grant or contract is to

university or other employer; †prior to joining ADA, no active disclosures.

S156 Diabetes Care Volume 41, Supplement 1, January 2018

Index

INDEX A1C testing bile acid sequestrants, S79, S81 Cholesterol Treatment Trialists’ Collaboration,
in African Americans, S15, S58 blood pressure control. see hypertension S93
in children, adolescents, S58, S128 bromocriptine, S79, S81
clinical trials, S59–S60 cholesteryl ester transfer protein (CETP) inhibi-
CVD and, S59–S60 canagliflozin, S79, S81, S99–S100, S108 tors, S93, S94
diagnostic, S14–S15 cancer, S32
glycemic targets and, S60–S61 CANVAS Program, S99–S100, S108 Chronic Care Model, S8–S10, S28
goals, S58–S59 CANVAS-R trial, S100 CKD. see kidney disease
hemoglobinopathies in, S15 capsaicin, S113 classification, S4, S13–S14
limitations, S57 carbamazepine, S113 cognitive impairment/dementia, S32, S95, S120
mean glucose and, S57–S58 carbohydrates, S40–S42 colesevelam, S79, S81
microvascular complications and, S59 cardiac autonomic neuropathy, S112 community health workers (CHWs), S10
in older adults, S121 cardiovascular disease comorbidities evaluation, assessment
prediabetes screening, S16
in pregnancy, S139 A1C testing and, S59–S60 anxiety disorders, S34
recommendations, S57 antiplatelet agents, S95–S96 autoimmune diseases, S32
red blood cell turnover, S15 assessment of, S86 cancer, S32
asymptomatic patients, screening, cognitive impairment/dementia, S32
acarbose, S79, S81 depression, S34–S35
ACCORD BP trial, S87, S88 S96–S99 disordered eating behaviors, S35
ACCORD MIND trial, S120 atherosclerotic, S5, S75, S86 fatty liver disease, S33
ACCORD trial, S32–S33, S59–S61, S94, S108 cardiac testing, S96–S99 fractures, S33
ACE inhibitors, S89, S91, S109, S141 children, adolescents, S129–S131 hearing impairment, S33
acute kidney injury (AKI), S89, S106–S107 coronary heart disease, S96–S101 HIV, S33–S34
ADAG study, S57–S58, S61–S62 heart failure, S99 hyperglycemia/hypoglycemia, S32–S33
ADA Statements, S1 hypertension/blood pressure control, medical evaluation, S29–S32
adolescents. see children and adolescents nutrition therapy, S33
ADVANCE BP trial, S87, S88 S86–S91 obstructive sleep apnea, S34
ADVANCE trial, S59–S61 lifestyle management, S99 pancreatitis, S33
advocacy position statements, S152–S153 lipid management, S5, S91–S95 patient-centered collaborative care,
Affordable Care Act, S9, S133 medications, clinical trials, S97–S100
age in A1C testing, S15, S20 prevention of, S53 S28–S29
a-glucosidase inhibitors, S79, S81 primary prevention, S93 periodontal disease, S34
AIM-HIGH trial, S94 revisions summary, S5 psychosocial/emotional disorders, S34,
albiglutide, S80, S81 risk stratification, S92–S93
alcohol, S40, S42–S43, S70, S88, S94, S111 secondary prevention, S93 S45–S46
Alli (orlistat), S68 statins, S33, S91–S95 recommendations, S28
alogliptin, S79, S81, S97–S99 type 1 diabetes, S93 revisions summary, S4
amylin mimetics, S74, S80, S81 celiac disease, S129 serious mental illness, S35
anacetrapib, S94 CGM. see continuous glucose monitoring (CGM) statins, S33
angiotensin receptor blockers, S89, S91, Charcot neuroarthropathy, S114 testosterone levels, S34
children and adolescents Consensus Reports, S1
S109, S141 A1C testing in, S58, S128 continuous glucose monitoring (CGM)
antihyperglycemic therapy, S5, S67, S75–S76, autoimmune diseases, S128–S129 children, adolescents, S128
celiac disease, S129 described, S56–S57
S96–S100, S146–S147 comorbidities, S133 flash, S56
antihypertensive medications, S89–S91, continuous glucose monitoring, S128 hospital care, S146
CVD risk factor management, S129–S131 hybrid closed-loop systems, S57
S109, S141 DSMES, S127 recommendations, S55
antiplatelet agents, S95–S96 dyslipidemia in, S130 revisions summary, S4–S5
Antithrombotic Trialists’ Collaboration, S95 glycemic control, S128 type 1 diabetes, S73–S74
anti-VEGF, S109–S111 hypertension in, S129–S130 continuous subcutaneous insulin infusion (CSII),
anxiety disorders, S34 hypoglycemia, S61–S62 S74, S147–S148
ASCVD. see cardiovascular disease kidney disease, S131 contraception, S141
aspart, S80, S82 lifestyle management, S132 Contrave (naltrexone/bupropion), S69
ASPIRE trial, S57 mature minor rule, S127 coronary heart disease, S96–S101
aspirin resistance, S96 neuropathy, S131 correctional facilities, S153
aspirin therapy, S95–S96, S140 pediatric to adult care transition, S133 cost-effectiveness model, S52–S53
atherosclerotic cardiovascular disease. see pharmacologic therapy, S132–S133 costs
physical activity/exercise, S43–S44, S52 of medications, S81–S82
cardiovascular disease prediabetes screening, S4, S5, S16, reduction strategies, system-level, S9
atorvastatin, S92 cystic fibrosis–related diabetes screening, S24
autoimmune diseases, S32, S128–S129 S19, S20
autonomic neuropathy, S44, S111–S113 psychosocial issues, S127–S128 dapagliflozin, S79, S81
retinopathy, S131 DASH diet, S41
balance training, S43 school, child care, S127, S152–S153 DAWN2 study, S45–S46
bariatric surgery, S67–S70 smoking cessation, S130–S131 degludec, S80, S82
BARI 2D trial, S112 thyroid disease, S129 depression, S34–S35, S127–S128
b-blockers, S96 type 1 diabetes, S126–S131 detemir, S80, S82, S148
Belviq (lorcaserin), S68 type 2 diabetes, S19, S20, S131–S133 Diabetes Control and Complications Trial
biguanides, S79, S81
(DCCT), S59, S74, S108, S120, S128

care.diabetesjournals.org Index S157

diabetes distress, S35, S45–S46, S128 classification, S13 HPS2-THRIVE trial, S94
Diabetes Prevention Program, S52–S53 contraception, S141 hyperbaric oxygen therapy, S114
Diabetes Prevention Recognition Program, S52 definition, S20–S21 hyperglycemia, S9–S10, S32, S60
diabetes self-management education and diagnosis, S21–S22 hyperkalemia, S89
management of, S139–S140 hyperosmolar hyperglycemic state, S148–S149
support (DSMES), S8, S38–S39, S53, S127 nutrition in, S139 hypertension
diabetic retinopathy, S44, S109–S111 pharmacologic therapy, S139–S140
Diabetic Retinopathy Study, S110, S111 physical activity and, S44 antihypertensive medications, S89–S91,
diagnosis postpartum care, S141 S109, S141
prevalence of, S137
ADA risk test, S18 testing recommendations, S20 in children, adolescents, S129–S130
community screening, S20 type 2 diabetes and, S141 clinical trials, S87
confirmation of, S15 glargine, S80, S82, S148 kidney disease and, S108–S109
monogenic syndromes, S22–S25 glimepiride, S79, S81 lifestyle management, S88–S89
one-step strategy, S21, S22 glipizide, S10, S79, S81 meta-analyses of trials, S87
revisions summary, S4 GLP-1 agonists in older adults, S120, S121
testing interval, S20 characterization, S69, S74, S76 in pregnancy, S87
tests, criteria, S14, S15 in CKD, S108 resistant, S89–S90
two-step strategy, S21, S22 clinical trials, S97–S98, S100 screening, diagnosis, S87
disordered eating behaviors, S35 costs of, S81–S82 treatment, individualization of, S87–S88
dopamine-2 agonists, S79, S81 older adults, S122 treatment goals, S87
DPP-4 inhibitors pharmacology, S79–S80 treatment recommendations, S90
characterization, S83 stopping therapy, S83 treatment strategies, S88–S91
clinical trials, S97–S99 glucagon, S62 hypertriglyceridemia, S94
costs, S81 glulisine, S80, S82 hypoglycemia
hospital care, S146–S147 glyburide, S79, S81, S140 anxiety disorders and, S34
older adults, S122 glycemic management. see also A1C testing assessment of, S32–S33
pharmacology, S76, S79 control, assessment of, S55 children/older adults, S61–S62
driving, S153 intercurrent illness, S62 classification of, S61
dulaglutide, S80, S81 physical activity and, S44 cognitive decline/impairment, S61
duloxetine, S112 recommendations, S55, S60 food insecurity and, S9–S10
revisions summary, S4–S5 glucagon, S62
e-cigarettes, S44–S45 self-monitoring of blood glucose (SMBG), hospital care, S147
EDIC study, S59 iatrogenic, S147
ELIXA trial, S97–S98, S100 S55–S56, S60 mortality, S61
empagliflozin, S79, S81, S97–S98, S100, S108 nocturnal, S57
EMPA-REG OUTCOME, S97–S99, S108 HAPO study, S21 in older adults, S120, S123
employment, S153 hearing impairment, S33 physical activity and, S44
end-of-life care, S122–S124 hemoglobinopathies, S15 predictors of, S147
eplerenone, S109 hepatitis B, S29, S32 prevention, S62, S147
erectile dysfunction, S113 herbal supplements, S40, S42 recommendations, S61
ETDRS trial, S110, S111 HIV, S33–S34 symptoms of, S61
evidence-grading system (ADA), S2 homelessness, S10 treatment, S62
EXAMINE, S97–S99 hospital care triggering events, S147
exenatide, exenatide ER, S79, S81, hypoglycemia unawareness, S34, S57, S61, S62
admission, S144–S145
S97–S98, S100 admission/readmission prevention, immune-mediated diabetes, S17
exercise/physical activity, S43–S44, S52, immunizations, S29–S30
S149–S150 IMPROVE-IT trial, S93
S66–S67 antihyperglycemic agents, S146–S147 incretin-based therapies, S69, S74, S76, S81,
EXSCEL trial, S97–S98, S100 critical care units, S146
eye disease, S44, S109–S111 delivery standards, S144–S145 S97–S98
ezetimide, S92, S93 diabetes care providers, S145 influenza, S29, S32
diabetes self-management, S147–S148 insulin therapy
fats (dietary), S40, S42 discharge planning, S149
fatty liver disease, S33 DKA, S148–S149 basal, S82
fenofibrate, S94 DPP-4 inhibitors, S146–S147 bolus, S82–S83
fibrate, S94 enteral/parenteral feedings, S148 carbohydrate intake and, S42
finerenone, S109 glucocorticoid therapy, S148 combination injectable, S83
flash CGM device, S56 glucose abnormalities definitions, S145 concentrated preparations, S83
flexibility training, S43 glucose monitoring, bedside, S145–S146 correctional, in hospital care, S148
fluvastatin, S92 glycemic control, moderate vs. tight, S145 costs, S82
food insecurity, S9–S10 glycemic targets, S145 CSII/CGM, S74
foot care, S5, S113–S114 hyperosmolar hyperglycemic state, food insecurity patients, S10
FOURIER trial, S93 in GDM, S140
FPG testing, S14 S148–S149 hospital care, S146, S148
fractures, S33 hypoglycemia, S147 inhaled, S83
insulin therapy, S146, S148 older adults, S122–S123
gabapentin, S113 medical nutrition therapy, S147 pharmacology, S80
gastrointestinal neuropathies, S112 medication reconciliation, S149 premixed, S83
gastroparesis, S113 perioperative care, S148 SMBG, S55–S56, S60
GDM. see gestational diabetes mellitus physician order entry, S145 type 1 diabetes, S73–S74
generalized anxiety disorder, S34 posttransplantation diabetes therapy, S25 type 2 diabetes, S76, S78, S82–S83
genitourinary disturbances, S112 quality assurance standards, S145
gestational diabetes mellitus. see also revisions summary, S6 jail, S153
HOT trial, S87, S88
pregnancy

S158 Index Diabetes Care Volume 41, Supplement 1, January 2018

kidney disease medical nutrition therapy (MNT), S29, S38–S43, diet, physical activity, behavioral therapy,
acute kidney injury, S89, S106–S107 S52, S91, S107–S108, S139, S147. see also S43–S44, S52, S66–S67
albuminuria assessment, S106 nutrition therapy
children, adolescents, S131 medications, S67–S69
complications of, S107 Medicare, S39 metabolic surgery, S67–S70
diagnosis of, S106 medications. see also specific drugs and drug prediabetes screening, S16
eGFR assessment, S106 prediabetes testing recommendations,
epidemiology, S106 classes
glucose-lowering medications, S108 cardiovascular outcomes trials, S77–S81 S4, S5
glycemic control, S108 combination therapy, S75–S81, S83, S93 recommendations, S65, S66
hypertension and, S108–S109 compliance, S8–S9 treatment options, S66
interventions, S107–S109 concomitant, S67 obstructive sleep apnea, S34
nutrition therapy, S107–S108 costs, S81–S82 older adults
physical activity and, S44 CVOTs, S97–S100 A1C in, S121
proteins, dietary, S42 diabetes screening, S20 admission/readmission prevention,
recommendations, S105–S106 efficacy, safety assessment, S67
revisions summary, S5 obesity management, S67–S69 S149–S150
screening, S105 pharmacology, S79–S80 alert strategy, S123
stages, S106, S107 recommendations, S53 aspirin use in, S96
surveillance, S107 type 1 diabetes, S73–S75 assisted living facilities, S123
treatment, S105–S106 type 2 diabetes, S75–S83 cognitive impairment/dementia, S32, S95,

Kumamoto Study, S59 Mediterranean diet, S33, S41, S42 S120
meglitinides (glinides), S79, S81 CVD primary prevention, S93
language barriers, S10 metformin hypertension in, S120, S121
laropiprant, S94 hypoglycemia, S61–S62
LEADER trial, S97–S98, S100, S108 A1C guidelines, S4 hypoglycemia in, S120, S123
lifestyle management in CKD, S108 insulin therapy, S122–S123
coronary heart disease, S96 LTC facilities, S123
cardiovascular disease, S99 costs, S81 nutrition, S123
children, adolescents, S132 CVD risk reduction agents with, S100– palliative, end-of-life care, S122–S124
cost-effectiveness model, S52–S53 pharmacologic therapies, S122–S123
DSMES, S8, S38–S39, S53 S101 recommendations, S119
gestational diabetes mellitus, S139 in GDM, S140 revisions summary, S5
hypertension, S88–S89 pharmacology, S79 statins, S33, S91–S95
lipids, S91 type 1 diabetes, S74 treatment goals, S60, S120–S122
nutrition therapy, S39–S43, S52 type 2 diabetes, S53, S75–S78 orlistat (Alli), S68
physical activity/exercise, S43–S44, metoclopramide, S113 orlistat (Xenical), S68
micronutrients, in MNT, S40, S42 orthostatic hypotension, S113
S52, S66–S67 microvascular complications, S5. see also
psychosocial issues, S34, S45–S46 specific conditions palliative, end-of-life care, S122–S124
recommendations, S38 miglitol, S79, S81 pancreas, pancreatic islet transplantation, S33,
revisions summary, S4 mineralocorticoid receptor antagonists,
smoking cessation, S44–S45 S91, S109 S74–S75
technology platforms, S52 mobile apps, S52 pancreatitis, S33
weight, S41, S52, S66–S67, S88 modified plate method, S42 patient-centered care, S7–S8, S28–S29
linagliptin, S79, S81 Patient-Centered Medical Home, S8
lipase inhibitors, S68 nateglinide, S79, S81 PCSK9 inhibitors, S92–S95
lipid management National Diabetes Education Program, S8 pediatric to adult care transition, S133
in children and adolescents, S130 National Quality Strategy, S9 periodontal disease, S34
hypertriglyceridemia, S94 neonatal diabetes screening, S22–S23 peripheral arterial disease, S114
lifestyle modifications, S91 nephropathy. see kidney disease peripheral neuropathy, S44, S111–S113
revisions summary, S5 neuropathic pain, S112–S113 pharmacotherapy. see medications; specific
statins, S33, S91–S95 neuropathy, S44, S111–S113, S131
therapy, monitoring, S91 new-onset diabetes after transplantation medications by name
liraglutide (Saxenda), S69, S80, S81, S82, phentermine (Lomaira), S68
S97–S98, S108 (NODAT), S24–S25 photocoagulation surgery, S109–S111
lispro, S80, S82 niacin, S94 physical activity/exercise, S43–S44, S52,
lixisenatide, S80, S81, S82, S97–S98, S100 NPH, S80, S82, S83, S148
Lomaira (phentermine), S68 nutrition therapy S66–S67
Look AHEAD trial, S66, S99 pioglitazone, S79, S81
lorcaserin (Belviq), S68 alcohol, S40, S42–S43, S88 pitavastatin, S92
loss of protective sensation (LOPS), S111, carbohydrates, S40–S42 plant-based diets, S41
S113–S114 comorbidities, S33 plasma glucose testing, S15
lovastatin, S92 DASH diet, S41 pneumococcal pneumonia, S29, S32
fats (dietary), S40, S42 point-of-care (POC) meters, S145–S146
maturity-onset diabetes/young (MODY), in GDM, S139 population health
S23–S24 herbal supplements, S40, S42
hospital care, S147 care delivery systems, S8
meal planning, S39–S43, S52, S88, S107–S108 kidney disease, S107–S108 Chronic Care Model, S8–S10, S28
medical evaluation lifestyle management, S39–S43, S52 community support, S10
Mediterranean diet, S33, S41, S42 defined, S7
immunizations, S29–S30 older adults, S123 food insecurity, S9–S10
pre-exercise, S44 proteins, S40, S42 homelessness, S10
recommendations, S29 language barriers, S10
referrals, S32, S46, S109 obesity management patient-centered care, S7–S8
assessment, S65–S66 recommendations, S7
diabetes screening, S20 revisions summary, S4
social context, determinants, S9
system-level improvement strategies, S8

care.diabetesjournals.org Index S159

posttransplantation diabetes screening, S24–S25 SAVOR-TIMI 53, S97–S99 children and adolescents, S126–S131
pramlintide, S77, S80, S81 saxagliptin, S79, S81, S97–S98 classification, S13–S14
pravastatin, S92 Saxenda (liraglutide), S69, S80–S82, S97–S98, CVD/A1C and, S59
prediabetes diagnosis (see diagnosis)
S108 disordered eating behaviors in, S35
described, S16 schizophrenia, S35 idiopathic, testing for, S17
increased risk categories, S17 school, child care, S127, S152–S153 insulin therapy, S73–S74
screening, S4, S15–S16 scientific reviews, S2 medications, S73–S75
screening in asymptomatic adults, S16, SEARCH study, S130 pathophysiology, S14
self-monitoring of blood glucose (SMBG), physical activity/exercise, S43–S44
S19–S20 predictors, S14
serious mental illness, S35 S55–S56, S60 retinopathy and, S110
pregabalin, S112 semaglutide, S97–S98, S100, S108 risk testing, S17
pregnancy. see also gestational diabetes mellitus SGLT2 inhibitors stages of, S14
A1C in, S139 surgical treatment, S74–S75
antihypertensive medications, S90–S91, S141 characterization, S74 testing recommendations, S16–S17
glucose monitoring, S138–S139 clinical trials, S97–S100 type 2 diabetes
glycemic targets in, S138 costs, S81 age as risk factor, S20
hypertension in, S87 hospital care, S147 BMI as risk factor, S20
insulin physiology, S138 kidney disease, S106–S108 children and adolescents, S19, S20, S131–S133
lactation, S141 older adults, S122 classification, S13–S14
medications contraindicated, S91, pharmacology, S76, S79 CVD/A1C and, S59
stopping therapy, S83 described, S19
S140–S141 shoes, S114 diagnosis (see diagnosis)
postpartum care, S141 simvastatin, S92–S94 DKA in, S19
preconception counseling, testing, sitagliptin, S79, S81, S97–S99 ethnicity as risk factor, S20
smoking cessation, S44–S45, S130–S131 hypertriglyceridemia, S94
S137–S138 sodium, S40, S42, S88, S107–S108 medications, S75–S83
preeclampsia, aspirin and, S140 spironolactone, S91, S109 pathophysiology, S14
preexisting diabetes, S140 SPRINT trial, S87, S88 physical activity/exercise, S43–S44
prevalence of diabetes in, S137 SSRIs, S68 prevention/delay, S4, S51–S53
retinopathy and, S110 Standards of Care statements, S1, S3 proteins, dietary, S42
revisions summary, S5–S6 statins, S33, S91–S95 retinopathy and, S110
prison, S153 sulfonylureas risk-based screening, S19
Professional Practice Committee (PPC), S3 costs, S81 screening in asymptomatic adults, S16,
proteins, S40, S42 food insecurity patients, S10
psychosis, S35 in GDM, S140 S19–S20
psychosocial/emotional disorders, S34, S45–S46 older adults, S122 screening in dental practices, S20
P2Y12 receptor antagonists, S96 pharmacology, S79 serious mental illness, S35
stopping therapy, S83 testing recommendations, S17–S19
Qsymia (phentermine/topiramate), S68 type 2 diabetes, S76 weight management, S41, S52
SUSTAIN-6, S97–S98, S100, S108
race/ethnicity in A1C testing, S15, S20 sweeteners (nonnutritive), S41, S43 UK Prospective Diabetes Study (UKPDS), S59, S96
ranibizumab, S109–S111
REMOVAL trial, S74 tai chi, S43 VADT trial, S59, S60
repaglinide, S79, S81 tapentadol, S112–S113 venlafaxine, S113
retinal photography, S109, S110 TECOS, S97–S99
retinopathy, S44, S109–S111, S131 testosterone levels, S34 weight management, S41, S52, S66–S67, S88
REVEAL trial, S94 thiazolidinediones, S76, S79, S81, S83, S122
risk management thyroid disease, S129 Xenical (orlistat), S68
tobacco, S44–S45
calculator, S92–S93 tramadol, S113 yoga, S43
revisions summary, S5 tricyclic antidepressants, S113
statins based on, S92 2-h PG testing, S14
stratification, S92 type 1 diabetes
rosiglitazone, S79, S81
rosuvastatin, S92, S95