Diabetes Care

A. Initial evaluation

A complete medical evaluation should be performed to classify the patient, detect the presence or absence of diabetes complications, assist in formulating a management plan, and provide a basis for continuing care. If the diagnosis of diabetes has already been made, the evaluation should review the previous treatment and the past and present degrees of glycemic control. Laboratory tests appropriate to the evaluation of each patient??s general medical condition should be performed. A focus on the components of comprehensive care (Table 5) will assist the health care team to ensure optimal management of the patient with diabetes.

Table 5?? Components of the comprehensive diabetes evaluation

Medical history

* Symptoms, results of laboratory tests, and special examination results related to the diagnosis of diabetes
* Prior A1C records
* Eating patterns, nutritional status, and weight history; growth and development in children and adolescents
* Details of previous treatment programs, including nutrition and diabetes self-management education, attitudes, and health beliefs
* Current treatment of diabetes, including medications, meal plan, and results of glucose monitoring and patients?? use of data

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* Exercise history
* Frequency, severity, and cause of acute complications such as ketoacidosis and hypoglycemia
* Prior or current infections, particularly skin, foot, dental, and genitourinary infections
* Symptoms and treatment of chronic eye; kidney; nerve; genitourinary (including sexual), bladder, and gastrointestinal function (including symptoms of celiac disease in type 1 diabetic patients); heart; peripheral vascular; foot; and cerebrovascular complications associated with diabetes
* Other medications that may affect blood glucose levels
* Risk factors for Atherosclerosis: smoking, hypertension, obesity, dyslipidemia, and family history
* History and treatment of other conditions, including endocrine and eating disorders
* Assessment for mood disorder
* Family history of diabetes and other endocrine disorders
* Lifestyle, cultural, psychosocial, educational, and economic factors that might influence the management of diabetes
* Tobacco, alcohol, and/or controlled substance use
* Contraception and reproductive and sexual history

Physical examination

* Height and weight measurement (and comparison to norms in children and adolescents)
* Sexual maturation staging (during pubertal period)
* Blood pressure determination, including orthostatic measurements when indicated, and comparison to age-related norms
* Fundoscopic examination
* Oral examination
* Thyroid palpation
* Cardiac examination
* Abdominal examination (e.g., for hepatomegaly)
* Evaluation of pulses by palpation and with auscultation
* Hand/finger examination
* Foot examination
* Skin examination (for acanthosis nigricans and insulin-injection sites)
* Neurological examination
* Signs of diseases that can cause secondary diabetes (e.g., hemochromatosis, pancreatic disease)

Laboratory evaluation

* A1C
* Fasting lipid profile, including total cholesterol, HDL cholesterol, triglycerides, and LDL cholesterol, liver function tests with further evaluation for fatty liver or hepatitis if abnormal
* Test for microalbuminuria in type 1 diabetic patients who have had diabetes for at least 5 years and in all patients with type 2 diabetes; some advocate beginning screening of pubertal children before 5 years of diabetes
* Serum creatinine and calculated GFR in adults (check creatinine in children if proteinuria is present)
* Thyroid-stimulating hormone (TSH) in all type 1 diabetic patients; in type 2 if clinically indicated
* Electrocardiogram in adults, if clinically indicated
* Urinalysis for ketones, protein, sediment

Referrals

* Eye exam, if indicated
* Family planning for women of reproductive age
* MNT, as indicated
* Diabetes educator, if not provided by physician or practice staff
* Behavioral specialist, as indicated
* Foot specialist, as indicated
* Other specialties and services as appropriate

B. Management

People with diabetes should receive medical care from a physician-coordinated team. Such teams may include, but are not limited to, physicians, nurse practitioners, physician??s assistants, nurses, dietitians, pharmacists, and mental health professionals with expertise and a special interest in diabetes. It is essential in this collaborative and integrated team approach that individuals with diabetes assume an active role in their care.

The management plan should be formulated as an individualized therapeutic alliance among the patient and family, the physician, and other members of the health care team. Any plan should recognize diabetes self-management education (DSME) as an integral component of care. In developing the plan, consideration should be given to the patient??s age, school or work schedule and conditions, physical activity, eating patterns, social situation and personality, cultural factors, and presence of complications of diabetes or other medical conditions. A variety of strategies and techniques should be used to provide adequate education and development of problem-solving skills in the various aspects of diabetes management. Implementation of the management plan requires that each aspect is understood and agreed on by the patient and the care providers and that the goals and treatment plan are reasonable.

C. Glycemic control

1. Assessment of glycemic control

Techniques are available for health providers and patients to assess the effectiveness of the management plan on glycemic control.

a. Self-monitoring of blood glucose

Recommendations

* Clinical trials using insulin that have demonstrated the value of tight glycemic control have used self-monitoring of blood glucose (SMBG) as an integral part of the management strategy. (A)
* SMBG should be carried out three or more times daily for patients using multiple insulin injections. (A)
* For patients using less frequent insulin injections or oral agents or medical nutrition therapy (MNT) alone, SMBG is useful in achieving glycemic goals. (E)
* To achieve postprandial glucose targets, postprandial SMBG may be appropriate. (E)
* Instruct the patient in SMBG and routinely evaluate the patient??s technique and ability to use data to adjust therapy. (E)

The ADA??s consensus statements on SMBG provide a comprehensive review of the subject. Major clinical trials assessing the impact of glycemic control on diabetes complications have included SMBG as part of multifactorial interventions, suggesting that SMBG is a component of effective therapy. SMBG allows patients to evaluate their individual response to therapy and assess whether glycemic targets are being achieved. Results of SMBG can be useful in preventing hypoglycemia and adjusting medications, MNT, and physical activity.

The frequency and timing of SMBG should be dictated by the particular needs and goals of the patients. Daily SMBG is especially important for patients treated with insulin to monitor for and prevent asymptomatic hypoglycemia and hyperglycemia. For most patients with type 1 diabetes and pregnant women taking insulin, SMBG is recommended three or more times daily. The optimal frequency and timing of SMBG for patients with type 2 diabetes on oral agent therapy is not known but should be sufficient to facilitate reaching glucose goals. Patients with type 2 diabetes on insulin typically need to perform SMBG more frequently than those not using insulin. When adding to or modifying therapy, type 1 and type 2 diabetic patients should test more often than usual. The role of SMBG in stable diet-treated patients with type 2 diabetes is not known.

Because the accuracy of SMBG is instrument and user dependent, it is important for health care providers to evaluate each patient??s monitoring technique, both initially and at regular intervals thereafter. In addition, optimal use of SMBG requires proper interpretation of the data. Patients should be taught how to use the data to adjust food intake, exercise, or pharmacological therapy to achieve specific glycemic goals. Health professionals should evaluate at regular intervals the patient??s ability to use SMBG data to guide treatment.

b. A1C

Recommendations

* Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). (E)
* Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. (E)
* Use of point-of-care testing for A1C allows for timely decisions on therapy changes, when needed. (E)

By performing an A1C test, health providers can measure a patient??s average glycemia over the preceding 2??3 months and, thus, assess treatment efficacy. A1C testing should be performed routinely in all patients with diabetes, first to document the degree of glycemic control at initial assessment and then as part of continuing care. Since the A1C test reflects mean glycemia over the preceding 2??3 months, measurement approximately every 3 months is required to determine whether a patient??s metabolic control has been reached and maintained within the target range. Thus, regular performance of the A1C test permits detection of departures from the target (Table 6) in a timely fashion. For any individual patient, the frequency of A1C testing should be dependent on the clinical situation, the treatment regimen used, and the judgment of the clinician.

Key concepts in setting glycemic goals:

* A1C is the primary target for glycemic control
* Goals should be individualized
* Certain populations (children, pregnant women, and elderly) require special considerations
* More stringent glycemic goals (i.e., a normal A1C, <6%) may further reduce complications at the cost of increased risk of hypoglycemia
* Less intensive glycemic goals may be indicated in patients with severe or frequent hypoglycemia
* Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals

* Referenced to a nondiabetic range of 4.0??6.0% using a DCCT-based assay.
** Postprandial glucose measurements should be made 1??2 h after the beginning of the meal, generally peak levels in patients with diabetes.
^ Current NCEP/ATP III guidelines suggest that in patients with triglycerides 200 mg/dl, the “non-HDL cholesterol” (total cholesterol minus HDL) be utilized. The goal is 130 mg/dl (34).
$ For women, it has been suggested that the HDL goal be increased by 10 mg/dl.

The A1C test is subject to certain limitations. Conditions that affect erythrocyte turnover (hemolysis, blood loss) and hemoglobin variants must be considered, particularly when the A1C result does not correlate with the patient??s clinical situation. The availability of the A1C result at the time that the patient is seen (point of care testing) has been reported to result in the frequency of intensification of therapy and improvement in glycemic control.

Glycemic control is best judged by the combination of the results of the patient??s SMBG testing (as performed) and the current A1C result. The A1C should be used not only to assess the patient??s control over the preceding 2??3 months but also as a check on the accuracy of the meter (or the patient??s self-reported results) and the adequacy of the SMBG testing schedule. Table 7 contains the correlation between A1C levels and mean plasma glucose levels based on data from the Diabetes Control and Complications Trial (DCCT).

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AMERICAN DIABETES ASSOCIATION
DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004

References
1.  Bode BW (Ed.): Medical Management of Type 1 Diabetes. 4th ed. Alexandria, VA, American Diabetes Association, 2004
2.  Zimmerman BR (Ed.): Medical Management of Type 2 Diabetes. 4th ed. Alexandria, VA, American Diabetes Association, 1998
3.  Kilingensmith G (Ed.): Intensive Diabetes Management.  3rd ed.  Alexandria, VA, American Diabetes Association, 2003
4.  The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 20:1183-1197, 1997
4a.World Health Organization:  Diabetes Mellitus: Report of a WHO Study Group. Geneva, World Health Org., 1985 (Tech. Rep. Ser., no. 727)
5.  The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 26:3160 - 3167, 2003
6.  Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaaniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344:1343-1350, 2001
7.  Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, Hu ZX, Lin J, Xiao JZ, Cao HB, Liu PA, Jiang XG, Jiang YY, Wang JP, Zheng H, Zhang H, Bennett PH, Howard BV: Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the DaQing IGT and Diabetes Study. Diabetes Care 20:537- 544, 1997
8.  The Diabetes Prevention Program Research Group:  Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346:393- 403, 2002
9.  Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M: Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomized trial. Lancet 359:2072-2077, 2002
10.  Sjostrom L, et al: XENDOS ( Xenical in the prevention of diabetes in obese subjects):  a landmark study.  Poster presented at the International Congress on Obesity (ICO), San Paulo, Brazil, 2002
11.  Buchanan TA, Xiang AH, Peters RK, Kjos SL, Marroquin A, Goico J, Ochoa C, Tan S, Berkowitz, Hodis HN, Azen SP: Preservation of pancreatic β-cell function and prevention of type 2 diabetes by pharmacological trewatment of insulin resistance in high-risk hispanic women. Diabetes 51:2796 -2803, 2002
12.  Engelgau ME, Narayan KMV, Herman WH:  Screening for type 2 diabetes (Technical Review).  Diabetes Care 23:1563-1580, 2000 [erratum appears in Diabetes Care 23:1868 -1869, 2000]
13.  American Diabetes Association: Type 2 diabetes in children and adolescents (Consensus Statement).  Diabetes Care 23:381-389, 2000
14.  American Diabetes Association: Gestational diabetes mellitus (Position Statement). Diabetes Care 27 (Suppl. 1):S88 - S90, 2004
15.  The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of longterm complications in insulin-dependent diabetes mellitus. N Engl J Med 329: 977-986, 1993
16.  The UK Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352: 837- 853, 1998
17.  The UK Prospective Diabetes Study Group: Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 352:854 -865, 1998

May 27, 10 • Diabetes mellitus