![
Glucose (15–20 g) is the preferred treatment for the
conscious individual with blood glucose <70 mg/dL [3.9
mmol/L]
15 minutes after treatment, if SMBG shows continued
hypoglycemia, the treatment should be repeated.
Treatment](https://image.slidesharecdn.com/adaguidelines2019dr-190312112310/85/ADA-guidelines-2019_Dr-Tarik-22-320.jpg)
ADA guidelines 2019_Dr.Tarik
- 1. Dr. Md. Tarikul Islam FCPS (Medicine) P-II Course Student Dept. of Medicine (Brown unit), BSMMU
- 2. 1921
- 3. Type 1 diabetes Type 2 diabetes Gestational diabetes mellitus (GDM) Specific types of diabetes due to other causes Monogenic Pancreatic diseases Drug induced Classification
- 4. FPG ≥126 mg/dL (7.0 mmol/L) or 2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT or A1C ≥6.5% (48 mmol/mol) or In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, RBS ≥200 mg/dL (11.1 mmol/L) Diagnosis
- 5. FPG 5.6 - 6.9 mmol/L (IFG) or 2-h PG during 75-g OGTT 7.8 - 11.0 mmol/L (IGT) or A1C 5.7–6.4% Pre-diabetes * WHO define the IFG cutoff at 110 mg/dL (6.1 mmol/L)
- 6. 75-g OGTT, with plasma glucose measurement when patient is fasting and at 1 and 2 h, at 24–28 weeks of gestation in women not previously diagnosed with diabetes. The diagnosis of GDM is made when any of the following plasma glucose values are met or exceeded: GDM One-step strategy Fasting 5.1 mmol/L 1 h 10.0 mmol/L 2 h 8.5 mmol/L
- 7. Step 1: Perform a 50-g GTT (nonfasting), with plasma glucose measurement at 1 h, at 24–28 weeks of gestation in women not previously diagnosed with diabetes. If the plasma glucose level measured 1 h after the load is ≥7.2 mmol/L, 7.5 mmol/L, or 7.8 mmol/L, proceed to a 100-g OGTT. GDM Two-step strategy
- 8. Step 2: The 100-g OGTT should be performed when the patient is fasting. The diagnosis of GDM is made if at least two of the following four plasma glucose levels (measured fasting and 1 h, 2 h, 3 h during OGTT) are met or exceeded: GDM Two-step strategy
- 9. Carpenter-Coustan or NDDG •• Fasting 5.3 mmol/L 5.8 mmol/L •• 1 h 10.0 mmol/L 10.6 mmol/L •• 2 h 8.6 mmol/L 9.2 mmol/L •• 3 h 7.8 mmol/L 8.0 mmol/L
- 10. The diagnosis of MODY should be considered in adults diagnosed with diabetes with the following findings: Onset at an early age (<25 years) Diabetes without typical features of type 1 or type 2 diabetes (negative autoantibodies, nonobese, lacking other metabolic features) Multiple family members with same type of diabetes Stable, mild fasting hyperglycemia (5.5–8.5 mmol/L), stable A1C 5.6-7.6% MODY
- 11. In overweight or obese (BMI ≥25 kg/m2) adults who have one or more of the following risk factors: First-degree relative with diabetes High-risk race/ethnicity (e.g., African American, Asian) History of CVD Hypertension HDL <35 mg/dL and/or TG >250 mg/dL Criteria for testing in asymptomatic adults
- 12. Women with PCOS Physical inactivity Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) Patients with prediabetes should be tested yearly For all other patients, testing should begin at age 45 years Criteria for testing in asymptomatic adults
- 13. Metformin therapy should be considered in those with prediabetes, especially for those with BMI ≥35 kg/m2 aged <60 years, and women with prior GDM Prediabetes is associated with heightened cardiovascular risk Prevention or Delay of Type 2 Diabetes
- 18. Annual vaccination against influenza Vaccination against pneumococcal disease (PPSV23) 3-dose series of hepatitis B vaccine to unvaccinated adults Vaccinations
- 19. A1C test at least two times a year in patients who have stable glycemic control A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals Glycemic targets A1c <7% Preprandial 4.4-7.2 mmol/L Postprandial (1-2h) <10 mmol/L
- 20. Less stringent A1C goals (such as <8%) may be appropriate for patients with- history of severe hypoglycemia limited life expectancy advanced microvascular or macrovascular complications extensive comorbid conditions long-standing diabetes in whom the goal is difficult to achieve Glycemic targets
- 21. Hypoglycemia Level Glycemic criteria/description Level 1 Glucose <70 mg/dL (3.9 mmol/L) and glucose ≥54 mg/dL (3.0 mmol/L) Level 2 Glucose <54 mg/dL (3.0 mmol/L) Level 3 A severe event characterized by altered mental and/or physical status requiring assistance
- 22. Glucose (15–20 g) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL [3.9 mmol/L] 15 minutes after treatment, if SMBG shows continued hypoglycemia, the treatment should be repeated. Treatment
- 23. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia Glucagon should be prescribed for all individuals at increased risk of level 2 hypoglycemia Treatment
- 25. Weight loss (>5%) overweight or obese adults with T2DM and prediabetes There is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins Diets high in fiber, including vegetables, fruits, legumes, whole grains, as well as dairy products Medical nutrition therapy
- 26. Diet rich in monounsaturated and polyunsaturated fats Eating foods rich in long-chain n-3 fatty acids, such as fatty fish, nuts and seeds Higher intakes of nuts, berries, yogurt, coffee, and tea are associated with reduced diabetes risk Conversely, smoking, red meats and sugar-sweetened beverages are associated with an increased risk Medical nutrition therapy
- 27. ≥150 min moderate-to-vigorous intensity aerobic activity per week, at least 3 days/week, with no more than 2 consecutive days without activity All adults, and particularly those with T2DM, should avoid prolonged sitting for >30 min for blood glucose benefits Flexibility training and balance training are recommended 2–3 times/week for older adults with diabetes Physical activity
- 28. When choosing glucose-lowering medications for overweight or obese patients, consider their effect on weight: Agents associated with varying degrees of weight loss include metformin, α-glucosidase inhibitors, SGLT2 inhibitors, GLP1 receptor agonists DPP4 inhibitors are weight neutral Insulin secretagogues, TZDs, and insulin often cause weight gain Obesity management
- 29. Whenever possible, minimize medications for comorbid conditions that are associated with weight gain: antipsychotics antidepressants glucocorticoids injectable progestins anticonvulsants including gabapentin possibly sedating antihistamines and anticholinergics
- 30. Weight-loss medications are effective as adjuncts to diet, physical activity, and behavioral counseling for selected patients with type 2 diabetes and BMI ≥27 kg/m2: 1. Orlistat 2. Lorcaserin 3. Phentermine/ topiramate 4. Naltrexone/ bupropion 5. Liraglutide
- 31. Metabolic surgery should be recommended as an option to treat T2DM in appropriate surgical candidates with- BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asians) and BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asians) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with reasonable nonsurgical methods. Metabolic surgery
- 32. Pharmacologic Approaches to Glycemic Treatment
- 33. Most people with type 1 diabetes should be treated with multiple daily injections of prandial and basal insulin, or continuous subcutaneous insulin infusion Most individuals with type 1 diabetes should use rapid- acting insulin analogs to reduce hypoglycemia risk Type 1 diabetes
- 34. Metformin is the preferred initial pharmacologic agent Long-term use of metformin may be associated with biochemical vitamin B12 deficiency, and periodic measurement should be considered, especially in those with anemia or peripheral neuropathy Type 2 diabetes
- 35. The early introduction of insulin should be considered if- weight loss symptoms of hyperglycemia A1C levels (>10%) or blood glucose levels (≥16.7 mmol/L) Dual therapy in patients who have A1C ≥1.5% above their glycemic target
- 36. Patients with established atherosclerotic CVD, SGLT2 inhibitors, or GLP1 receptor agonists are recommended Patients with ASCVD at high risk of heart failure or in whom heart failure coexists, SGLT2 inhibitors are preferred For patients CKD, consider use of a SGLT2 inhibitor, or GLP1 receptor agonist
- 39. Cardiovascular Disease and Risk Management
- 40. Atherosclerotic cardiovascular disease (ASCVD) defined as coronary heart disease, cerebrovascular disease, or peripheral arterial disease presumed to be of atherosclerotic origin ASCVD risk factors include LDL cholesterol ≥100 mg/dL (2.6 mmol/L) HTN smoking CKD albuminuria family history of premature ASCVD ACC/AHA ASCVD risk calculator is generally a useful tool to estimate 10-year ASCVD risk
- 41. Lifestyle Intervention For patients with blood pressure >120/80 mmHg, lifestyle intervention consists of weight loss if overweight or obese Dietary Approaches to Stop Hypertension (DASH) diet moderation of alcohol intake and increased physical activity
- 43. Blood pressure Existing ASCVD or 10-year ASCVD risk >15% : <130/80 mmHg For individuals at lower risk for cardiovascular disease (10-year ASCVD risk <15%) and CKD, treat to a blood pressure target of <140/90 mmHg.
- 44. Pharmacologic Interventions An ACE inhibitor or ARB, is the recommended first-line treatment if urinary ACR ≥30 mg/g For patients treated with an ACE inhibitor, ARB or diuretic, serum eGFR and serum potassium levels should be monitored at least annually
- 46. Resistant hypertension Resistant hypertension is defined as blood pressure ≥140/90 mmHg despite a therapeutic strategy that includes appropriate lifestyle management plus a diuretic and two other antihypertensive drugs belonging to different classes at adequate doses Exclude medication non-adherence, white coat hypertension, and secondary hypertension Consider mineralocorticoid receptor antagonist therapy
- 49. Lifestyle Intervention Lifestyle modification focusing on weight loss (if indicated): Mediterranean diet or DASH dietary pattern; reduction of saturated fat and trans fat; increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity
- 50. Statin ASCVD or 10-year ASCVD >20% high-intensity statin therapy aged <40 years with additional ASCVD risk factors, the patient and provider should consider using moderate- intensity statin For patients with diabetes aged ≥40 without ASCVD, use moderate-intensity statin Statin therapy is contraindicated in pregnancy.
- 51. Statin High-intensity statin therapy (lowers LDL cholesterol by ≥50%) Moderate-intensity statin therapy (lowers LDL cholesterol by 30–50%) Atorvastatin 40–80 mg Rosuvastatin 20–40 mg Atorvastatin 10–20 mg Rosuvastatin 5–10 mg Simvastatin 20–40 mg Pravastatin 40–80 mg
- 52. Hypertriglyceridemia ≥500 mg/dL (5.7 mmol/L): evaluate for secondary causes of hypertriglyceridemia and consider medical therapy 175–499 mg/dL: address and treat lifestyle factors (obesity and metabolic syndrome) secondary factors (diabetes, CLD, CKD and/or nephrotic syndrome, hypothyroidism) medications that raise triglycerides
- 53. Anti-platelet agents Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes and a history of ASCVD For patients with ASCVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used Aspirin therapy (75–162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased cardiovascular risk
- 54. Anti-platelet agents These recommendations for using aspirin as primary prevention include both men and women aged ≥50 years with diabetes and at least one additional major risk factor Family history of premature ASCVD Hypertension Dyslipidemia Smoking or Chronic kidney disease/albuminuria …who are not at increased risk of bleeding
- 57. At least once a year, assess urinary albumin (e.g., spot urinary ACR) and eGFR 2 of 3 specimens collected within a 3-6 months period should be abnormal before considering albuminuria Optimize glucose control to reduce the risk or slow the progression of CKD
- 58. While ACE inhibitors or ARBs are often prescribed for albuminuria without hypertension, clinical trials have not been performed in this setting to determine whether this improves renal outcomes
- 60. To reduce the risk or slow the progression of diabetic retinopathy Optimize glycemic control Optimize blood pressure and serum lipid control
- 61. In high-risk PDR and, in some cases, severe NPDR: Panretinal laser photocoagulation therapy Intravitreous injections of anti–VEGF ranibizumab The presence of retinopathy is not a contraindication to aspirin therapy, as aspirin does not increase the risk of retinal hemorrhage Treatment
- 62. ACE inhibitors and ARBs are both effective treatments in diabetic retinopathy In patients with dyslipidemia, retinopathy progression may be slowed by the addition of fenofibrate Adjunctive therapy
- 63. Neuropathy
- 64. Optimize glucose control to prevent or delay the development of neuropathy in patients with type 1 diabetes and to slow the progression of neuropathy in patients with type 2 diabetes Pregabalin, duloxetine, or gabapentin are recommended as initial pharmacologic treatments for neuropathic pain Tapentadol, TCA, venlafaxine, crabamzepine, topical capsaicin may be effective Treatment
- 65. Nonpharmacologic measures adequate salt intake avoiding medications that aggravate hypotension compressive garments over the legs and abdomen Pharmacologic measures: Midodrine Droxidopa Orthostatic Hypotension
- 66. Treatment of hypogonadism if present PDE5 inhibitors Intracorporeal or intraurethral prostaglandins Vacuum devices or penile prostheses Erectile Dysfunction
- 67. A low-fiber, low-fat eating plan in small frequent meals with a greater proportion of liquid calories may be useful Withdrawing drugs with adverse effects on gastrointestinal motility including opioids, anticholinergics, tricyclic antidepressants, GLP-1 RA, and possibly DPP4 inhibitors may also improve intestinal motility Gastroparesis
- 68. In cases of severe gastroparesis, pharmacologic interventions are needed: Metoclopramide Domperidone, erythromycin Gastric electrical stimulation using a surgically implantable device Gastroparesis
- 69. Diabetic foot
- 70. The examination should include inspection of the skin assessment of foot deformities neurological assessment vascular assessment Patients with symptoms of claudication or decreased or absent pedal pulses should be referred for ABI and for further vascular assessment as appropriate
- 71. General preventive foot self-care education Use of custom therapeutic footwear Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy Management
- 72. Most diabetic foot infections are polymicrobial, with aerobic gram-positive cocci Those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections require broader-spectrum regimens Hyperbaric oxygen therapy (HBOT) has mixed evidence supporting its use as an adjunctive treatment
- 73. Older adults
- 74. Multiple coexisting chronic illnesses, cognitive impairment, or functional dependence: less stringent glycemic goals (such as A1C <8.0–8.5%) Otherwise healthy: lower glycemic goals (such as A1C <7.5%) Treatment goals
- 75. Metformin is the first-line agent Insulin secretagogues: associated with hypoglycemia and should be used with caution. If used, shorter-duration sulfonylureas, such as glipizide DPP-4 inhibitors: few side effects and minimal hypoglycemia SGLT2 inhibitors: long-term experience in this population is limited Pharmacological therapy
- 76. Insulin: Once-daily basal insulin associated with minimal side effects Multiple daily injections of insulin may be too complex GLP-1 receptor agonists: associated with nausea, vomiting, diarrhea, and weight loss Pharmacological therapy
- 77. Pregnancy
- 78. Preconception glycemic management: ideally A1C <6.5% Women with preexisting diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy Preexisting diabetes
- 79. Dilated eye examinations: before pregnancy or in the first trimester every trimester 1-year postpartum Preexisting diabetes
- 80. Insulin is the preferred agent for management of both type 1 and type 2 diabetes in pregnancy Oral agents are generally insufficient to overcome the insulin resistance in type 2 diabetes and are ineffective in type 1 diabetes Management of preexisting DM
- 81. Lifestyle change is an essential component Insulin is the preferred medication Metformin and glyburide should not be used as first-line agents Metformin, when used to treat PCOS and induce ovulation, should be discontinued once pregnancy has been confirmed Management of GDM
- 82. Glycemic targets Fasting <5.3 mmol/L Postprandial (1h) <7.8 mmol/L Postprandial (2h) <6.7 mmol/L A1c <6%
- 83. Women with type 1 or type 2 diabetes should be prescribed- low-dose aspirin 60–150 mg/day (usual dose 81 mg/day) from the end of the first trimester until the baby is born ……in order to lower the risk of preeclampsia Preeclampsia and Aspirin
- 84. Blood pressure targets: 120–160/80–105 mmHg Potentially teratogenic medications (i.e., ACE inhibitors, angiotensin receptor blockers, statins) should be avoided Safe in pregnancy: methyldopa, nifedipine, labetalol, diltiazem, clonidine, and prazosin Management of HTN
- 85. 75-g OGTT at 4–12 weeks postpartum Lifelong screening at least every 3 years Prediabetes: intensive lifestyle interventions or metformin Postpartum care
- 86. Diabetes Care in the Hospital
- 87. Hyperglycemia in hospitalized patients is defined as blood glucose levels >7.8 mmol/L An admission A1C value ≥6.5% suggests that diabetes preceded hospitalization
- 88. Insulin therapy should be initiated for treatment of persistent hyperglycemia ≥10.0 mmol/L Target glucose range: 7.8–10.0 mmol/L In the patient who is eating meals, glucose monitoring should be performed before meals In the patient who is not eating, glucose monitoring is advised every 4–6 h
- 89. Noncritically ill poor oral intake or NPO Basal insulin or basal plus correction good nutritional intake basal, prandial, and correction Critical care setting continuous IV insulin Insulin regimen
- 90. Sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged Insulin regimen
- 91. Once-a-day, short-acting GC (e.g. prednisone): intermediate-acting (NPH) insulin For long-acting GC e.g. dexamethasone or multidose glucocorticoid: long-acting insulin For higher doses of GC: prandial and correctional insulin in addition to basal insulin Glucocorticoid Therapy
- 92. Target glucose range for the perioperative period should be 4.4–10.0 mmol/L Withhold metformin the day of surgery Perioperative Care
- 93. Withhold any other oral hypoglycemic agents the morning of surgery or procedure and give half of NPH dose or 60– 80% doses of long-acting analog or pump basal insulin. Monitor blood glucose at least every 4–6 h while NPO and dose with short- or rapid-acting insulin as needed Perioperative Care
- 94. Diabetes Pre-diabetes Targets Fasting 7 mmol/L 5.6-6.9 mmol/L 4.4-7.2 mmol/L 2h 75g glucose 11.1 mmol/L 7.8-11 mmol/L <10 mmol/L A1c 6.5% 5.7-6.4% <7%
- 96. Blood pressure ASCVD/ 10y risk>15% 10y risk<15% CKD Albuminuria <130/80mmHg <140/90mmHg ACEi/ARB CCB Diuretics ACEi/ARB >160/100mmHg 2 drugs
- 97. Lipid management ASCVD/ 10y risk>20% <40 yrs ASCVD risk factors TG>500 mg/dl High-intensity statin Moderate- intensity statin Rx TG<500 mg/dl Sec. factors >40 yrs No ASCVD
- 98. Low dose aspirin Sec. prevention Pri. prevention H/O ASCVD Age ≥50 years + DL/HTN/CKD/ Smoking/ F/H Pregnancy
- 100. GDM Insulin 120-160/80-105 mmHgBP 50g GTT, Then 100g GTT 75g GTT 2 steps 1 step FPG< 5.3 1h PPG< 7.8 2h PPG< 6.7 Glycemic targets
- 101. Thank You