PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT, 11.

Tight glycemic control in older adults with multiple medical conditions is considered overtreatment and is associated with an increased risk of hypoglycemia; unfortunately, overtreatment is common in clinical practice.

Older adults are at higher risk of hypoglycemia for many reasons, including insulin deficiency necessitating insulin therapy and progressive renal insufficiency.

Glycemic Targets” above.). A, 10.43c In patients with type 2 diabetes and established HF, an SGLT2 inhibitor may be considered to reduce risk of HF hospitalization. The prevalence of diabetes in pregnancy is increasing in the U.S. along with the epidemic in obesity seen worldwide.

A, 11.10 Patients should be referred for evaluation by a nephrologist if they have an eGFR <30 mL/min/1.73 m2.

Among patients with type 2 diabetes who have established: ASCVD: Atherosclerotic cardiovascular disease or indicators of high risk. Screening for diabetes complications in older adults should be individualized and periodically revisited, as the results of screening tests may impact targets and therapeutic approaches. The American Diabetes Association (ADA) 2020 Guideline revisions are available. Sufficient cognitive and physical skills, adequate oral intake, proficiency in carbohydrate estimation, and knowledge of sick-day management are some of the requirements.
Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young), diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (such as with glucocorticoid use, in the treatment of HIV/AIDS, or after organ transplantation).


See “15.

Diabetes Care 2018;41:2669–2701. Studies have shown that at least 70–85% of women with GDM can control it with lifestyle modification alone. B, 13.67 If glycemic targets are no longer met with metformin (with or without basal insulin), liraglutide (a GLP-1 receptor agonist) therapy should be considered in children 10 years of age or older if they have no past medical history or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2. Cost, side effects, and durable efficacy require consideration when using other pharmacologic agents for diabetes prevention in those with prediabetes. Follow-up of three large studies of lifestyle intervention for diabetes prevention has shown sustained reduction in the rate of conversion to type 2 diabetes: 39% reduction at 30 years in the Da Qing Diabetes Prevention Study, 43% reduction at 7 years in the Finnish Diabetes Prevention Study, and 34% reduction at 10 years and 27% reduction at 15 years in the U.S. Diabetes Prevention Program Outcomes Study. 6.1 Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control).

This calculator includes diabetes as a risk factor because diabetes itself confers increased risk for ASCVD. Patients with diabetes should be encouraged to undergo recommended age- and sex-appropriate cancer screenings and to reduce their modifiable cancer risk factors (obesity, physical inactivity, and smoking). The Standards of Medical Care in Diabetes is updated annually, or more frequently online if new evidence or regulatory changes merit immediate incorporation, and is published in Diabetes Care.

C, 6.12 Glucose (15–20 g) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL [3.9 mmol/L]), although any form of carbohydrate that contains glucose may be used.

A An insulin regimen with basal, prandial, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake.

The advantages of Metformin are its efficacy in lowering A1c, being inexpensive, improving insulin resistance, potential weight loss, not causing hypoglycemia, and having the most extended clinical safety data - since its approval in 1957 in France and 1995 in the U.S. B. C, 8.9 For patients who achieve short-term weight-loss goals, long-term (≥1 year) weight maintenance programs are recommended when available. A, 11.3 For patients with type 2 diabetes and DKD, consider use of an SGLT2 inhibitor in patients with an eGFR ≥30 mL/min/1.73 m2 and urinary albumin >30 mg/g Cr, particularly in those with urinary albumin >300 mg/g Cr, to reduce risk of CKD progression, CV events, or both. Decision support (basing care on evidence-based, effective care guidelines), 4. The recommendations are based on an extensive review of the clinical diabetes literature, supplemented with input from ADA staff and the medical community at large. B, 10.2 All hypertensive patients with diabetes should monitor their blood pressure at home. Health systems (to create a quality-oriented culture).

A, 10.43a In patients with type 2 diabetes and established ASCVD, multiple ASCVD risk factors, or DKD, an SGLT2 inhibitor with demonstrated CV benefit is recommended to reduce the risk of major adverse CV events and HF hospitalization. *Referring clinicians may wish to discuss with their nephrology service, depending on local arrangements regarding treating or referring. Diabetes Care in the Hospital” in the complete 2020 Standards of Care for guidance on enteral/parenteral feedings, glucocorticoid therapy, perioperative care, and diabetic ketoacidosis and hyperosmolar hyperglycemic state. Unless there is a clear clinical diagnosis based on overt signs of hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist. All patients should have annual 10-g monofilament testing to identify feet at risk for ulceration and amputation. E, 6.2 Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals.

CLASSIFICATION AND DIAGNOSIS OF DIABETES, 3. A, 13.63 In incidentally diagnosed or metabolically stable patients (A1C <8.5% [69 mmol/mol] and asymptomatic), metformin is the initial pharmacologic treatment of choice if renal function is normal.

C, 8.7 As all energy-deficit food intake will result in weight loss, eating plans should be individualized to meet the patient’s protein, fat, and carbohydrate needs while still promoting weight loss. PREVENTION OR DELAY OF TYPE 2 DIABETES, 4. The American College of Cardiology’s designated representatives (for Section 10) were Sandeep Das, MD, MPH, FACC, and Mikhail Kosiborod, MD, FACC.

10.38 In asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as ASCVD risk factors are treated. B, 11.7 In nonpregnant patients with diabetes and hypertension, either an ACE inhibitor or an ARB is recommended for those with modestly elevated UACR (30–299 mg/g Cr) B and is strongly recommended for those with UACR ≥300 mg/g Cr and/or eGFR <60 mL/min/1.73 m2. A, 10.9 Patients with confirmed office-based blood pressure ≥160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce CV events in patients with diabetes. 4.3 A complete medical evaluation should be performed at the initial visit to: Confirm the diagnosis and classify diabetes.

B, 11.35 Patients with symptoms of claudication or decreased or absent pedal pulses should be referred for ankle-brachial index and for further vascular assessment as appropriate. C, 5.28 Flexibility training and balance training are recommended 2–3 times/week for older adults with diabetes. B, 10.43 Among patients with type 2 diabetes who have established ASCVD or established kidney disease, an SGLT2 inhibitor or GLP-1 receptor agonist with demonstrated CVD benefit is recommended as part of the glucose-lowering regimen. Self-monitoring of blood glucose (SMBG) may help with self-management and medication adjustment, particularly in individuals taking insulin. Metformin is contraindicated for use in patients with an eGFR <30 mL/min/1.73 m2. B, 12.13 Deintensification (or simplification) of complex regimens is recommended to reduce the risk of hypoglycemia and polypharmacy, if it can be achieved within the individualized A1C target. Institutional Subscriptions and Site Licenses, Special Podcast Series: Therapeutic Inertia, Special Podcast Series: Influenza Podcasts, “4.

C, 14.20 Potentially harmful medications in pregnancy (i.e., ACE inhibitors, ARBs, statins) should be stopped at conception and avoided in sexually active women of childbearing age who are not using reliable contraception. Population health is defined as “the health outcomes of a group of individuals, including the distribution of health outcomes within the group”; these outcomes can be measured in terms of health outcomes (mortality, morbidity, health, and functional status), disease burden (incidence and prevalence), and behavioral and metabolic factors (exercise, diet, A1C, etc.). A.


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