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The 2014 Standards of Medical Care in Diabetes

Jan 2, 2014

The "need to knows" for diabetes care…. 

Current criteria for diagnosing diabetes includes an A1c ≥6.5%, a fasting blood glucose of ≥126mg/dL, a two-hour plasma glucose ≥200mg/dL during an oral glucose tolerance test, or with classic hyperglycemia symptoms a random plasma glucose ≥200mg/dL.

Screening for T2DM and pre-diabetes should be considered in patients who are overweight or obese with one or more additional risk factors for diabetes. The same recommendations are made for screening in children except with two or more additional risk factors. Annual tests to quantitate urine albumin excretion should be done for patients with diabetes longer than 5 years for T1DM and at diagnosis for T2DM to screen for nephropathy. ACE inhibitors/ARBs for primary prevention of diabetic kidney are not recommended in patients with normal blood pressure. T21DM adults should have eye exams within 5 years of onset and then annually, and T2DM should have them shortly after diagnosis. All patients should be screened for distal symmetric polyneuropathy starting at diagnoses for T2DM and 5 years after diagnoses of T1DM and then annually. Foot exams should be completed annually and self inspection for ulcers should be done regularly to help reduce the risk of future amputations.

Self-monitoring should be done regularly for patients on multiple-dose insulin therapy. Prior to meals, an occasional post-prandial, and at bedtime are recommended. Results help guide treatment changes and success. A1c tests should be performed at least twice a year in patients meeting goals and quarterly in patients not meeting glycemic goals. Lowering A1c to below or around 7% has been shown to reduce microvascular complications of diabetes. Diabetic patients should receive self-management education and support.

Most T1DM should be treated with a multiple-dose insulin approach including a basal injection and three prandial insulin injections. Counting carbohydrates and nutritional management is essential for managing insulin doses. Metformin is the preferred initial treatment for T2DM and if A1c goals are not met over 3 months adding a second oral agent may be added.

Diabetics should maintain a systolic blood pressure goal of <140mmHg and when blood pressure is higher than 120/80mmHg lifestyle changes should be initiated. When blood pressure is higher than 140/80mmHg, pharmacological treatment should be added to lifestyle changes. Most diabetes patients should have lipid levels measured annually unless well controlled. Low risk patients with LDL remaining over 100mh/dL should consider statin treatment in addition to lifestyle changes. Patients with over cardiovascular disease should maintain LDL levels lower than 70mg/dL and start higher doses of statins with lifestyle changes. Aspirin therapy as a primary prevention is recommended for type one and two diabetics with an increased risk of cardiovascular disease.

Practice Pearls
  • Lowering A1c to below or around 7% reduces complications
  • Patients with impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or an A1c between 5.7-6.4% should target a weight loss of 7% and increase exercise to at least 150min a week.
  • Metformin therapy for prevention of T2DM may be considered in patients with IGT, IFG, A1c 5.7-6.4%, BMI > 35kg/m2, over the age of 60, and women with prior gestational diabetes mellitus.

Executive Summary: Standards of Medical Care in Diabetes 2014. Diabetes Care;37(S1):s4-s13. January 2014.