Table 2.
Summary of Recommendations
| Section 1. Screening, Diagnosis, Glycemic Targets, Glycemic Monitoring | |
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| Q 1: How is the diagnosis of diabetes mellitus made and what is the current screening protocol for prediabetes and diabetes? | |
| R 1.1 | The diagnosis of diabetes mellitus (DM) is based on the following criteria (Table 4): • Fasting plasma glucose (FPG) concentration ≥126 mg/dL (after ≥8 h of an overnight fast), or • Plasma glucose (PG) concentration ≥200 mg/dL 2 h after ingesting a 75-g oral glucose load after an overnight fast of at least 8 h, or • Symptoms of hyperglycemia (eg, polyuria, polydipsia, polyphagia) and a random (nonfasting) PG concentration ≥200 mg/dL, or • Hemoglobin A1c (A1C) level ≥6.5% Diagnosis of DM requires 2 abnormal test results, either from the same sample or two abnormal results on samples drawn on different days. However, a glucose level ≥200 mg/dL in the presence of symptoms for DM confirms the diagnosis of DM. Grade A; BEL 2 and expert opinion of task force |
| R 1.2 | Prediabetes is identified by the presence of impaired fasting glucose (IFG) (100 to 125 mg/dL), impaired glucose tolerance (IGT), which is a PG value of 140 to 199 mg/dL 2 h after ingesting 75 g of glucose, and/or A1C value between 5.7% and 6.4% (Table 4). A1C should be used only for screening for prediabetes. The diagnosis of prediabetes, which may manifest as either IFG or IGT, should be confirmed with glucose testing. Grade B; BEL 2 |
| R 1.3 | Type 1 diabetes (T1D) is characterized by marked insulin deficiency in the presence of hyperglycemia and positive autoantibody tests to glutamic acid decarboxylase (GAD65), pancreatic islet b cells (tyrosine phosphatase IA-2), and IA-2b zinc transporter (ZnT8), and/or insulin. The presence of immune markers and clinical presentation are needed to establish the correct diagnosis and to distinguish between T1D and type 2 diabetes (T2D) in children or adults, as well as to determine appropriate treatment. Grade A; BEL 2 |
| R 1.4 | T2D is characterized by progressive loss of b-cell insulin secretion and variable defects in insulin sensitivity. T2D is often asymptomatic and can remain undiagnosed for many years; therefore, all adults ≥35 y of age with risk factors should be screened for DM (Table 5). Grade A; BEL 1 |
| R 1.5 | Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance that begins or is first recognized during pregnancy and resolves postpartum. Pregnant women with risk factors for DM should be screened at the first prenatal visit for undiagnosed T2D using standard criteria (Table 4). Grade B; BEL 1 |
| R 1.6 | Screen all pregnant women for GDM at 24 to 28 weeks' gestation. Diagnose GDM with either the one-step or the two-step approach. • The one-step approach uses a 2-h 75-g oral glucose tolerance test (OGTT) after ≥8 h of fasting with diagnostic cutoffs of one or more FPG ≥92 mg/dL, 1-h PG ≥180 mg/dL, or 2-h PG ≥153 mg/dL. • The two-step approach uses a nonfasting 1-h 50-g glucose challenge test with 1-h PG screening threshold of 130 or 140 mg/dL. For women with a positive screening test, the 3-h 100-g OGTT is used for diagnosis with 2 or more PG tests that meet the following thresholds: FPG ≥95 mg/dL, 1-h ≥180 mg/dL, 2-h ≥155 mg/dL, 3-h ≥140 mg/dL. Grade A; BEL 1 |
| R 1.7 | Clinicians should consider evaluation for monogenic DM in any child or young adult with an atypical presentation, clinical course, or response to therapy. Monogenic DM includes neonatal diabetes and nonautoimmune diabetes of multiple genetic causes, also known as maturity-onset diabetes of the young. Most children with DM occurring under age 6 mo of age have a monogenic cause as autoimmune T1D rarely occurs before 6 mo of age. Other monogenic forms of diabetes are characterized by mutation of genes of transcription factors, genes regulating pancreatic development or atrophy, abnormal insulin genes, genes related to endoplasmic reticulum stress that impair insulin secretion or abnormal glucokinase genes that cause impaired insulin signaling. Grade B; BEL 2 |
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Q 2: What are the glycemic treatment goals for persons with diabetes mellitus? | |
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2.1 Outpatient Glucose Targets for Nonpregnant Adults
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| R 2.1.1 | An A1C level of ≤6.5% is recommended for most nonpregnant adults, if it can be achieved safely. To achieve this target A1C level, FPG may need to be <110 mg/dL, and the 2-h postprandial glucose (PPG) may need to be <140 mg/dL (Table 6). Glucose targets should be individualized with consideration for life expectancy, disease duration, presence or absence of micro- and macrovascular complications, cardiovascular disease (CVD) risk factors, comorbid conditions, and risk for hypoglycemia, as well as a person’s cognitive and psychological status. Grade A; BEL 1 |
| R 2.1.2 | Adopt less stringent glycemic goals (A1C 7% to 8%) in persons with a history of severe hypoglycemia, hypoglycemia unawareness, limited life expectancy, advanced renal disease, extensive comorbid conditions, or long-standing DM in which the A1C goal has been difficult to attain despite intensive efforts, so long as the person remains free of hyperglycemia-associated symptoms. Grade A; BEL 1 |
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2.2 Inpatient Glucose Targets for Nonpregnant Adults | |
| R 2.2 | For most hospitalized persons with hyperglycemia in both the intensive care unit (ICU) and non-ICU settings, a glucose range of 140 to 180 mg/dL is recommended, provided this target can be safely achieved (Table 6). Grade A; BEL 1 |
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2.3 Outpatient Glucose Targets for Pregnant Women | |
| R 2.3 | In women with GDM, the following glucose goals are recommended: fasting and preprandial glucose concentration ≤95 mg/dL and either a 1-h postmeal glucose value ≤140 mg/dL or a 2-h postmeal glucose value ≤120 mg/dL. In women with preexisting T1D or T2D who become pregnant, it is recommended that glucose be controlled to meet the following goals, but only if the goals can be safely achieved: premeal, bedtime, and overnight glucose values between 60 and 95 mg/dL; a 1-h PPG value between 110 and 140 mg/dL; a 2-h glucose 100 to 120 mg/dL. A secondary target would be an A1C level of <6% if it can be accomplished without significant hypoglycemia. Grade A; BEL 1 |
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Q 3: When and how should glucose monitoring be used? | |
| R 3.1 | A1C should be measured at least semiannually in all persons with DM and at least quarterly in persons not at their glycemic target. Grade B; BEL 2 |
| R 3.2 | All persons who use insulin should use continuous glucose monitoring (CGM) or perform blood glucose monitoring (BGM) a minimum of twice daily and ideally before any insulin injection. More frequent BGM may be needed by persons who are taking multiple daily injections (MDI) injections, persons not at A1C targets, or those with history of hypoglycemia. Persons who do not require insulin or insulin secretagogue therapy may often benefit from BGM, especially to provide feedback about the effects of their lifestyle choices (diet and physical activity), and to assess response to pharmacologic therapy. Grade A; BEL 1 |
| R 3.3 | Real-time continuous glucose monitoring (rtCGM) or intermittently scanned continuous glucose monitoring (isCGM) is recommended for all persons with T1D, regardless of insulin delivery system, to improve A1C levels and to reduce the risk for hypoglycemia and DKA (see Fig. 6). Grade A; BEL 1 |
| R 3.4 | rtCGM or isCGM is recommended for persons with T2D who are treated with insulin therapy, or who have high risk for hypoglycemia and/or with hypoglycemia unawareness (see Figure 6). Grade A; BEL 1 |
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Section 2. Comorbidities and Complications | |
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Q 4: How should hypertension be managed in persons with diabetes mellitus?
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| R 4.1 | The recommended blood pressure (BP) goal for most persons with T1D, T2D, or prediabetes is <130/80 mm Hg (Table 7). Grade A; BEL 1 |
| R 4.2 | Therapeutic lifestyle interventions in persons with hypertension are recommended to include consultation with a registered dietitian for education about an overall healthy diet (such as the Mediterranean diet), weight management, reduced sodium intake (such as the Dietary Approaches to Stop Hypertension [DASH] diet), daily physical activity and regular exercise (several times a week), and as-needed consultation with a psychologist or certified diabetes care and education specialist (CDCES) to support long-term behavior change. (See also R 11.2 to R 11.4 and R 12.1.1 to R 12.1.5 on nutrition and lifestyle.) Grade A; BEL 1 |
| R 4.3 | If BP goals are unattained with therapeutic lifestyle changes, use antihypertensive pharmacotherapy to achieve individual BP treatment goals. Grade A; BEL 1 |
| R 4.4 | Select antihypertensive agents based on their ability to reduce BP to goal and prevent or slow the progression of micro- and macrovascular disease. Use either an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) for BP control and to delay the progression of DKD or chronic kidney disease (CKD) in DM (see also R 6.1 to R 6.6 on DKD or CKD in DM). Grade A; BEL 1 |
| R 4.5 | Intensify pharmacotherapy as needed to achieve BP goals. Antihypertensive therapy may include combinations of either an ACE inhibitor or an ARB plus any of the following agents: diuretics, calcium channel antagonists, combined alpha-beta blockers, and newer-generation beta blockers. Consider a mineralocorticoid receptor antagonist for resistant hypertension. Grade A; BEL 1 |
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Q 5: How should dyslipidemia be managed in persons with diabetes mellitus? | |
| R 5.1 | All persons with prediabetes, T1D over the age of 40, or T2D should have a lipid panel (fasting or nonfasting) checked at diagnosis and annually to assess cardiovascular (CV) and metabolic disease risks, and at additional intervals as needed to monitor treatment to achieve lipid goals. Grade B; BEL 2 |
| R 5.2 | Therapeutic lifestyle interventions for dyslipidemia are recommended for all persons with prediabetes, T1D over the age of 40, or T2D, to include education with a registered dietitian about a healthy diet with emphasis on weight management, daily physical activity, and regular exercise (several times a week). Consultation with a psychologist or CDCES is recommended to support long-term behavior change. Grade A; BEL 1 |
| R 5.3 | Persons with prediabetes or T2D without atherosclerotic cardiovascular disease (ASCVD) and with less than 2 traditional risk factors should be assessed with the aid of ASCVD risk calculators to determine initiation and intensity of lipid-lowering therapy (Fig. 1 and Table 8). Grade A; BEL 1 |
| R 5.4 | Assess nontraditional ASCVD risk factors (Fig. 1) beyond a lipid panel to guide management when the initial shared decision is not self-evident. Grade B; BEL 2 |
| R 5.5 | Manage persons with prediabetes and persons with T1D over the age of 40 in the same manner as those with T2D. Grade A; BEL 1 |
| R 5.6 | In persons with high ASCVD risk, use a moderate-intensity statin regardless of DM type or status. In persons with very high ASCVD risk (T2D with 2 or more additional traditional ASCVD risk factors such as advancing age, hypertension, chronic kidney disease (CKD) stage 3a, cigarette smoking, family history of premature ASCVD in men <55 y and women <65 y, low high-density lipoprotein cholesterol (HDL-C), or high non-HDL-C), use a high-intensity statin regardless of baseline low-density lipoprotein cholesterol (LDL-C) level. For persons at extreme risk of ASCVD event (current ASCVD or target organ damage), use a high-intensity statin plus other therapies as needed to achieve lipid targets (Fig. 1 and Table 10). Grade A; BEL 1 |
| R 5.7 | Treatment targets for persons in a high ASCVD risk category are LDL-C <100 mg/dL, apolipoprotein B (apo B) <90 mg/dL, and non-HDL-C <130 mg/dL. Treatment targets for persons in a very high risk ASCVD category are LDL-C <70 mg/dL, apo B <80 mg/dL, and non-HDL-C <100 mg/dL. Treatment targets for persons with extreme risk of ASCVD include LDL-C <55 mg/dL, apo B <70 mg/dL, and non-HDL-C <90 mg/dL (Table 9 and Fig. 1). Grade A; BEL 1 |
| R 5.8 | Statins are recommended for the initial treatment of hypercholesterolemia. Monitor efficacy every 6 to 12 wk and increase the dose or intensity of statin as needed and tolerated to achieve LDL-C, apo B, and/or non-HDL-C goals based on individual ASCVD risk. Once lipid targets are achieved, lipid panel or apo B can be monitored less often (Fig. 1). Grade A; BEL 1 |
| R 5.9 | Combine the cholesterol absorption inhibitor ezetimibe with statin therapy when the desired lipid targets are not achieved with a maximally tolerated statin dose. If lipid targets are not achieved on this combination, add or substitute a proprotein convertase subtilisin/kexin type 9-lowering agent. Alternatively, add bempedoic acid to the maximally tolerated statin or consider adding icosapent ethyl (in persons with triglycerides 135 to 499 mg/dL) for ASCVD risk reduction. Grade A; BEL 1 |
| R 5.10 | Management of hypertriglyceridemia in persons with high ASCVD risk or very high ASCVD risk should begin with intensive lifestyle modification and statin therapy. In persons treated with a maximally tolerated statin who have triglyceride concentrations ≥200 mg/dL and HDL-C <40 mg/dL, add a fibrate or high-dose omega-3 fatty acid to achieve the desired apo B or non-HDL-C goal. Icosapent ethyl can be considered in persons with high or very high ASCVD risk (Fig. 2). Grade A; BEL 1 |
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Q 6: How should DKD or CKD in DM be managed? | |
| R 6.1 | Annual assessment of serum creatinine to determine the estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio is recommended to identify, stage, and monitor progression of DKD, also referred to as CKD in DM. Begin annual DKD assessment 5 y after diagnosis in persons with T1D or at diagnosis in persons with T2D. Grade B; BEL 2 |
| R 6.2 | Advise persons with CKD in DM about optimal glycemic control, BP control, lipid control, and smoking cessation to reduce risks of development and progression of CKD and CVD. (See also R 4.1 to R 4.5 on BP control, R 5.1 to R 5.10 on lipid management, and R 12.1.1 to R 12.2.19 on glycemic control.) Grade A; BEL 1 |
| R 6.3 | Renin-angiotensin-aldosterone system blockade with an ARB or an ACE inhibitor is recommended for persons with albuminuria (T1D or T2D) to reduce risk of DKD or CKD in DM progression (see Fig. 3 for category definitions). Grade A; BEL 1 |
| R 6.4 | A sodium glucose cotransporter 2 inhibitor (SGLT2i) with proven benefit is recommended as foundational therapy for persons with T2D and CKD with eGFR ≥20 mL/min/1.73 m2 to reduce progression of CKD and risk of CVD. Grade A; BEL 1 |
| R 6.5 | A glucagon-like peptide-1 receptor agonist (GLP-1 RA) with proven benefit is recommended for persons with T2D and DKD or CKD in DM with eGFR ≥15 mL/min/1.73 m2 for glycemic control and to reduce risk of ASCVD and progression of albuminuria. Grade A; BEL 1 |
| R 6.6 | A non-steroidal mineralocorticoid receptor antagonist (finerenone) with proven kidney and CVD benefit is recommended for persons with T2D, an eGFR ≥25 mL/min/1.73 m2, normal serum potassium concentration, and albuminuria (ACR ≥30 mg/g) despite a maximum tolerated dose of a renin-angiotensin-system inhibitor. Grade A; BEL 1 |
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Q 7: How should retinopathy be managed in persons with diabetes mellitus? | |
| R 7.1 | It is recommended that persons with T2D or adult-onset T1D should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of diagnosis or shortly after diagnosis. Individualized subsequent screening can be based on type and duration of DM, A1C or mean blood glucose (BG), BP, and the presence and grade of retinopathy. Grade A; BEL 2 and expert opinion of task force |
| R 7.2 | In persons with T1D, an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist should be performed within 5 y of diagnosis in children and adolescents. Grade B; BEL 4 and expert opinion of task force |
| R 7.3 | Women who are pregnant and have preexisting T1D or T2D should be monitored with eye examinations every trimester during pregnancy and in the postpartum period as determined by the severity of retinopathy during pregnancy. Grade B; BEL 2 |
| R 7.4 | Persons with greater than mild nonproliferative retinopathy should have examinations at least once a year and more frequently as advised by their eyecare specialist. Grade B; BEL 4 and expert opinion of task force |
| R 7.5 | Follow-up with eyecare specialists typically should occur on an annual basis, but persons with T1D or T2D who have had a normal ocular examination may be screened every 2 to 3 y. Grade B; BEL 2 and expert opinion of task force |
| R 7.6 | Optimal glucose, BP, weight, and lipid control should be implemented to slow the progression of retinopathy. Grade B; BEL 1 |
| R 7.7 | Artificial intelligence systems, authorized by the US Food and Drug Administration (FDA) for detecting greater than mild diabetic retinopathy, can be used as an alternative to traditional screening approaches. These systems can facilitate diagnosis of vision-threatening retinopathy and identification of persons who require ophthalmologic visits for treatment. Grade B; BEL 1 |
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Q 8: How should neuropathy be diagnosed and managed in persons with diabetes mellitus? | |
| R 8.1 | Diabetic peripheral neuropathy (DPN) is a clinical diagnosis. A comprehensive differential diagnosis should be considered to rule out nondiabetic neuropathies. Grade B; BEL 2 |
| R 8.2 | Screening for DPN should be done at diagnosis of T2D, within 5 y of the diagnosis of T1D, and subsequently annually or whenever symptoms occur, by performing a clinical history and physical exam. Grade B; BEL 2 |
| R 8.3 | Assessments for DPN should include a careful history to assess target symptoms, and a combination of at least two of the following: vibration sensation using a 128-Hz tuning fork, pinprick sensation, temperature discrimination, 10-g monofilament testing on the dorsal aspect of the great toe bilaterally, and ankle reflexes. All these assessments should follow the typical DPN pattern, starting distally (the dorsal aspect of the hallux) on both sides and move proximally until a sensory threshold is identified. Grade A; BEL 2, upgraded by expert opinion of task force |
| R 8.4 | Screening for cardiovascular autonomic neuropathy (CAN) should be considered at diagnosis of T2D and at 5 y after the diagnosis of T1D, including youth. Screening for CAN should also be considered in the presence of DPN, DKD, 2 or more CV risk factors, hypoglycemia unawareness, high glucose variability, in persons with heart failure (HF), perioperatively, or in individuals presenting with autonomic symptoms. A careful differential to exclude other comorbidities or drug effects/interactions that could mimic CAN should be performed. Grade B; BEL 2 |
| R 8.5 | CV reflex tests (deep breathing, Valsalva, supine to standing) remain the gold standard and are recommended for assessment of CAN. Indices of heart rate variability derived from electrocardiogram recordings could also be used as an easier alternative for screening for CAN. Grade A; BEL 2, upgraded by expert opinion of task force |
| R 8.6 | Diabetic foot exams should be performed at every visit (in person or virtual) to identify deformities and to identify those at risk for late complications such as ulcerations and amputations. Grade A; BEL 1 |
| R 8.7 | Intensive glucose control applied as early as possible is recommended to prevent the onset of DPN and CAN in T1D. Achieving optimal control of glucose, BP, and lipid levels along with lifestyle interventions, including weight loss and exercise, are recommended to prevent DPN and CAN in T2D. Lifestyle interventions are effective for DPN and CAN prevention in persons with prediabetes/metabolic syndrome. Grade A; BEL 2, upgraded by expert opinion of task force |
| R 8.8 | Pregabalin, duloxetine, and capsaicin 8% patch are recommended for the treatment of neuropathic pain due to DM and have received regulatory approval in the United States. Current evidence shows that these agents are effective in reaching 30% to 50% reduction in pain in many individuals (Grade A; BEL 1). However, gabapentin and some tricyclic antidepressants may be as effective to achieve a clinically meaningful reduction in diabetic neuropathic pain (Grade B; BEL 1). Combining two or more agents from different classes may have enhanced benefits with lower adverse effects and risks than maximizing the dose of one medication or using opioids. The use of opioids, including tapentadol or tramadol, is NOT RECOMMENDED due to high risk of addiction and other complications. Grade A; BEL 1 |
| R 8.9 | Lifestyle interventions including a combination of regular aerobic, strengthening, and balance exercises, reduction of sedentary behavior, and dietary modification aimed at reducing calorie intake and increasing plant-based and polyunsaturated fats are recommended. Neuromodulatory techniques such as high-frequency spinal cord stimulation and combining pharmacological with nonpharmacological approaches should be considered in those with refractory painful DPN. Grade B; BEL 1 |
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Q 9: How should antihyperglycemic agents be prioritized in persons with type 2 diabetes at high risk for or with established cardiovascular disease? | |
| R 9.1 | In persons with T2D and established ASCVD or at high risk for ASCVD, use GLP-1 RAs with proven CV benefits to reduce the risk of myocardial infarction, stroke, or CV death regardless of other glucose-lowering or CV therapies and independent of A1C. Grade A; BEL 1 |
| R 9.2 | In persons with T2D and established ASCVD or very high ASCVD risk, use SGLT2is with proven CV benefits to reduce the risk of hospitalization for HF, major adverse CV events, or CV death regardless of background glucose-lowering therapy, cardiovascular therapy, or A1C. Grade A; BEL 1 |
| R 9.3 | In persons with T2D and established HF (regardless of ejection fraction, background glucose-lowering or HF therapies, or A1C), use SGLT2is with proven HF benefits to reduce the risk of hospitalization for HF or CV death, and to improve HFerelated symptoms. Grade A; BEL 1 |
| R 9.4 | In persons with T2D and ASCVD or at high risk for ASCVD, use GLP-1 RAs with proven benefit for reduction in the risk of stroke. In persons with insulin resistance, prediabetes, or T2D and a prior transient ischemic attack or stroke, pioglitazone should be considered to reduce the risk of recurrent stroke. Grade A; BEL 1 |
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Q 10: How should obesity be managed in persons with diabetes mellitus? | |
| R 10.1 | Persons with prediabetes, T1D or T2D, and obesity/adiposity-based chronic disease (ABCD) have 2 diseases, and each should be treated effectively with the goal of optimizing their respective outcomes. Grade B; BEL 2 and expert opinion of task force |
| R 10.2 | The diagnosis and evaluation of ABCD in persons with prediabetes, T1D, or T2D should include both anthropometric and clinical components. The anthropometric evaluation should include body mass index (BMI), confirmed by physical examination that excludes excess muscle mass, edema, or sarcopenia. Waist circumference (WC) should be measured as a marker of cardiometabolic disease (CMD) risk. Grade B; BEL 2 and expert opinion of task force |
| R 10.3 | For most adults, BMI values that indicate excess body weight are 25 to 29.9 kg/m2 for overweight and ≥30 kg/m2 for obesity, and WC threshold values ≥102 cm for men and ≥88 cm for women. Grade B; BEL 4 and expert opinion of task force |
| R 10.4 | The clinical evaluation of persons with both prediabetes, T1D, or T2D and ABCD should assess the presence and severity of weight-related complications including cardiometabolic complications such as dyslipidemia, hypertension, nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH), CVD, HF, and CKD; biomechanical complications such as obstructive sleep apnea (OSA), osteoarthritis, gastroesophageal reflux disease, and urinary incontinence; abnormalities involving sex steroids, such as infertility, polycystic ovary syndrome, and hypogonadism; as well as impact on psychological disorders and quality of life (QoL). Grade B; BEL 2 and expert opinion of task force |
| R 10.5 | Persons with T2D and ABCD should be treated with weight-loss interventions which will both improve glycemic control and prevent or treat ABCD complications. The target for weight loss should be >5% to ≥10% of baseline body weight. Grade A; BEL 1 |
| R 10.6 | Persons with T2D and ABCD should be instructed and supported in therapeutic lifestyle interventions that include a reduced-calorie healthy diet generally designed to produce a ≥500 kilocalorie daily energy deficit, daily physical activity, regular exercise (several times a week), and behavioral health practices. Grade A; BEL 1 |
| R 10.7 | The Mediterranean, low-fat, low-carbohydrate, very lowecarbohydrate, vegetarian, vegan, and DASH diets are recommended, safe, and effective for short-term (1–2 y) weight loss, though evidence of long-term risk reduction for CVD events and mortality exists only for the Mediterranean diet. Grade A; BEL 1 |
| R 10.8 | Persons with T2D and obesity/ABCD with BMI ≥27 kg/m2 should be treated with DM medications associated with weight loss (GLP-1 RAs, SGLT2is). In addition, for persons with prediabetes, T1D, or T2D who have obesity/ABCD, consider FDAeapproved weight-loss medications as an adjunct to lifestyle intervention to achieve lowering of A1C, reduction of CVD risk factors, treatment or prevention of other ABCD complications, and improvement in QoL. Grade A; BEL 1 |
| R 10.9 | Persons with a BMI ≥35 kg/m2 and one or more severe obesity-related complications remediable by weight loss, including T2D, high risk for T2D (insulin resistance, prediabetes, and/or metabolic syndrome), poorly controlled hypertension, NAFLD/NASH, OSA, osteoarthritis of the knee or hip, and urinary stress incontinence, should be considered for a bariatric procedure (668). Grade C; BEL 3 |
| R 10.10 | Persons with BMI 30 to 34.9 kg/m2 and T2D with inadequate glycemic control despite optimal lifestyle and medical therapy should be considered for a bariatric procedure (668). Grade B; BEL 2 |
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Section 3. Management | |
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Q 11: How should prediabetes be managed?
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| R 11.1 | Prediabetes is a metabolic and vascular disorder, and clinicians should actively treat people with prediabetes in order to prevent or at least delay progression to T2D and development of CVD complications. Grade A; BEL 1 |
| R 11.2 | In persons with prediabetes and/or metabolic syndrome or identified to be at high risk of T2D based on validated risk-staging instruments, the prevention of T2D can be addressed by lifestyle modifications that include a healthy meal plan, regular physical activity, and behavioral health practices and weight loss in persons with ABCD. The Mediterranean diet should be considered to reduce progression to T2D and risk of CVD. Low-fat, vegetarian, and DASH meal patterns can also be considered for prevention of T2D. Grade A, BEL 1 |
| R 11.3 | Clinicians should manage and monitor CVD risk factors in prediabetes and metabolic syndrome, including elevated BP, dyslipidemia, and excessive weight, with the same targets as for a person with T2D. Grade B; BEL 2 |
| R 11.4 | Lifestyle intervention should include aerobic and resistance physical activity in all persons with prediabetes and/or metabolic syndrome. The initial aerobic prescription may require a progressive increase in the volume and intensity of exercise, and the ultimate goal should be ≥150 min/week of moderate exercise performed during 3 to 5 sessions per week (Grade A; BEL 1). Resistance exercise should consist of single-set exercises that use the major muscle groups 2 to 3 times per week (Grade A; BEL 1). An increase in nonexercise and active leisure activity should be encouraged to reduce sedentary behavior (Grade B; BEL 2). |
| R 11.5 | Obesity medications, namely phentermine/topiramate ER, liraglutide 3 mg, or weekly semaglutide 2.4 mg, in conjunction with lifestyle therapy should be considered in persons with prediabetes and/or metabolic syndrome with ABCD, whether overweight (BMI 27 to 29.9 kg/m2) or with obesity (BMI ≥30 kg/m2), when needed to achieve and sustain 7% to 10% weight loss for prevention of T2D. Grade A; BEL 1 |
| R 11.6 | Although no medications have been approved for the treatment of prediabetes, diabetes medications including metformin, acarbose, pioglitazone, or GLP-1 RA can be considered in persons with prediabetes or in persons who also have ABCD and remain glucose-intolerant following weight loss using lifestyle and/or weight-loss medications. Grade A; BEL 1 |
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Q 12: How can glycemic targets be achieved in persons with type 2 diabetes? | |
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12.1 Therapeutic Lifestyle Changes
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| R 12.1.1 | All persons with prediabetes or DM should be prescribed, instructed, and supported in lifestyle interventions that include a healthy meal plan, regular physical activity, and healthful behavior practices. Individualized medical nutrition therapy (MNT) should be provided at the time of diagnosis (with intermittent re-education as needed during continued care) via evaluation and counseling by a trained registered dietitian, certified nutritionist, or a clinician knowledgeable in nutrition. Grade A, BEL 1 |
| R 12.1.2 | MNT should consider the overall treatment plan including medications, DM complications, physical activity, body weight goals, and avoidance of hypoglycemia, as well as personal and cultural preferences, health literacy and numeracy, psychological factors, readiness for change, social determinants of health (SDOH), and support systems. For people on insulin therapy, insulin dosage adjustments should match carbohydrate intake (eg, with use of carbohydrate counting). Grade A; BEL 1 |
| R 12.1.3 | The meal plan should contribute to therapeutic goals for control of glycemia, BP, lipids, CVD risk factors, and the prevention of DM complications. In selecting optimal meal patterns, certain Mediterranean diets should be considered which, over the long term, can protect against CVD events and premature mortality. Although there is a lack of long-term studies addressing CVD outcomes, multiple other meal plans have been shown to be safe and can achieve short-term benefits (1–2 y) regarding glycemia, BP, lipids, and CVD risk factors. These meal plans include low-fat, low-carbohydrate, very low-carbohydrate, vegetarian, vegan, and DASH diets. Grade A, BEL 1 |
| R 12.1.4 | Given the variety of meal plans demonstrated to be beneficial in management of DM, nutritional recommendations should consider personal and cultural dietary preferences. Until there is conclusive evidence comparing the benefits of different meal patterns and the availability of long-term safety data, health care professionals should emphasize foods and nutrients that contribute to high “diet quality” scores as assessed by the Healthy Eating Index (HEI); high HEI is associated with reduced risks of DM, CVD, and mortality and includes fruits, nonstarchy vegetables, whole grains, nuts, legumes, and fish, with limited consumption of added sugars, refined grains, red meat, and processed meats. Grade B; BEL 1 |
| R 12.1.5 | Lifestyle intervention in persons with DM should include an individualized prescription for physical activity involving aerobic and resistance exercise and reduction in sedentary behavior. The initial prescription for aerobic physical activity may require a progressive increase in the volume and intensity of exercise, and the ultimate goal should be ≥150 min/week of moderate exercise performed during 3 to 5 sessions per week. (Grade A; BEL 1). Moderate exercise is considered to be activity that achieves a heart rate that is 50% to 60% higher than one’s basal heart rate. The physical activity prescription also should include resistance exercise that use the major muscle groups 2 to 3 times per week (Grade A; BEL 1). Individuals should also incorporate flexibility and range-of-motion training. An increase in nonexercise and/or active leisure activity should be encouraged to reduce sedentary behavior (Grade A; BEL 1). |
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12.2 Antihyperglycemic Pharmacotherapy for Persons with Type 2 Diabetes | |
| R 12.2.1 | Individualized pharmacotherapy for persons with T2D should be prescribed based on evidence for benefit that includes glucose lowering, avoidance of hypoglycemia and weight gain, and reduction of cardio-renal risk. Grade A; BEL 1 |
| R 12.2.2 | Persons with T2D and their health care professionals should use patient-centered shared decision-making to agree on therapy targets and treatments as well as a regimen for glucose monitoring (i.e., BGM, structured BGM, or CGM). Grade B; BEL 2 |
| R 12.2.3 | Glycemic targets include A1C, BGM, and, for those using CGM, achievement of CGM targets such as time in range (TIR), percentage in low and very low range, time above range, and glycemic variability (Table 6). Nonglycemic targets include avoidance of hypoglycemia, control of BP, lipids, other CVD risk factors, and achieving and maintaining a healthy body weight. Grade B; BEL 4 |
| R 12.2.4 | Independent of glycemic control, targets, or treatment, if there is established or high risk for ASCVD, HF, and/or CKD, clinicians should prescribe a GLP-1 RA or an SGLT2i with proven efficacy for the specific condition(s) of the person with T2D being treated (see also R 6.1 to R 6.6 on DKD or CKD in DM and R 9.1 to R 9.4 on ASCVD and HF). Grade A; BEL 1 |
| R 12.2.5 | DM therapy should be individualized based on level of glycemia and the presence of comorbidities, complications, and access. Metformin is often the preferred initial therapy. Other agents may be appropriate as first line or in addition to metformin to reduce BG and/or to address specific comorbidities (such as ASCVD, HF, CKD, obesity, NAFLD), independent of glucose-lowering effects. Grade A; BEL 1 |
| R 12.2.6 | For some recently diagnosed individuals with T2D and more severe hyperglycemia (A1C ≥7.5%), unlikely to attain the A1C target with a single agent, early combination pharmacotherapy should be considered, usually to include metformin plus another agent that does not cause hypoglycemia, especially a GLP-1 RA, SGLT2i, or dipeptidyl peptidase 4 (DPP-4) inhibitor. Grade A; BEL 1 |
| R 12.2.7 | For newly diagnosed persons with T2D and an entry A1C >9.0% and/or ≥1.5% above target, one should initiate, along with lifestyle modifications, dual- or possibly triple-combination pharmacotherapy usually including metformin. Basal insulin along with noninsulin therapy is recommended if there are significant signs or symptoms of hyperglycemia, especially including catabolism (eg, weight loss) or a very high A1C >10% (86 mmol/mol) or BG levels (≥300 mg/dL [16.7 mmol/L]). Grade A; BEL 1 |
| R 12.2.8 | Clinicians should discuss with persons with T2D the likelihood that most persons with T2D ultimately require a combination of multiple complementary antihyperglycemic agents, in addition to lifestyle interventions, to attain and maintain optimal glycemic control. Grade B; BEL 2 |
| R 12.2.9 | The DM care team should assess medication adherence and safety and glycemic control in persons with T2D quarterly or more frequently as needed. Subsequent visits will depend upon the metabolic targets achieved and the stability of metabolic control. Grade D; BEL 4 |
| R 12.2.10 | Persons with T2D who start on metformin should continue it unless intolerance or contraindications occur. When intensification of antihyperglycemic treatment is needed, other agents should be added to metformin. Grade B; BEL 2 |
| R 12.2.11 | Most persons with T2D who require intensification of antihyperglycemic therapy with a GLP-1 RA or insulin should initially be prescribed a GLP-1 RA. If further intensification is required, one should prescribe a basal insulin or a switch to a fixed-ratio combination of a basal insulin and a GLP-1 RA (insulin glargine U100 + lixisenatide [GlarLixi] or insulin degludec + liraglutide [IdegLira]). Grade A BEL 1 |
| R 12.2.12 | Insulin should be prescribed for persons with T2D when noninsulin antihyperglycemic therapy fails to achieve target glycemic control or when a person has symptomatic hyperglycemia. Grade A; BEL 1 |
| R 12.2.13 | Long-acting basal insulin analogs are the recommended initial choice of insulin therapy for persons with T2D. The insulin analogs glargine (U100 or U300), degludec (U100 or U200), or detemir are preferred over intermediate-acting Neutral Protamine Hagedorn (NPH) insulin because analog insulins have demonstrated less hypoglycemia in some studies. Glargine U300 and degludec can be associated with less hypoglycemia than glargine U100 or detemir. Grade A; BEL 1 |
| R 12.2.14 | Many persons with T2D receiving basal insulin and not at goal A1C can have significantly improved glycemia by the addition of a GLP-1 RA or being switched to a fixed-ratio combination basal insulineGLP-1 RA (GlarLixi or IdegLira). One of these changes should be considered before adding a meal-time insulin for postprandial glycemic control. Grade A; BEL 1 |
| R 12.2.15 | When control of postprandial hyperglycemia is needed and a basal insulin and a GLP-1 RA are already being used, preference should be given to rapid-acting insulins (the analogs lispro, aspart, and glulisine or the rapid-acting inhaled human insulin powder) over regular human insulin (see Table 18). The former have a more consistent and a more rapid onset and offset of action with less risk of hypoglycemia. Grade A; BEL 1 |
| R 12.2.16 | Ultra-rapid-acting insulins (faster-acting insulin aspart, lispro aabc, and [human insulin] inhalation powder) may allow a decrease in the time between insulin administration and food intake and reduce the postprandial peak of PG as compared with rapid-acting insulins. The significance of this on long-term complications is unknown. Grade A; BEL 1 |
| R 12.2.17 | Basal-bolus insulin regimens or continuous subcutaneous insulin infusion (CSII) (ie, insulin pump) allow for adjustment of insulin doses according to carbohydrate intake and activity levels and are recommended for intensive insulin therapy in persons with T2D. Grade C; BEL 1 |
| R 12.2.18 | Premixed insulin formulations (fixed combinations of shorter- and longer-acting components) of human or analog insulin may be considered for persons with T2D who have consistent dietary and exercise patterns and in whom adherence to more intensive insulin regimens is problematic. However, these preparations have reduced dosage flexibility and may increase the risk of hypoglycemia compared with basal insulin or basal-bolus regimens. Grade A; BEL 1 |
| R 12.2.19 | In persons with T2D who are treated with basal-bolus insulin therapy, adding a GLP-1 RA, or switching to a fixed-ratio combination of a GLP-1 RA and a basal insulin, or adding an SGLT2i or pramlintide (less commonly used) may be able to reduce postprandial hyperglycemia, A1C, and weight. GLP-1 RAs may also allow reduction or discontinuation of bolus insulin in some individuals. Grade A; BEL 1 |
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Q 13: How should insulin therapy be used for management of persons with type 1 diabetes? | |
| R 13.1 | Insulin must be used to treat all persons with T1D. Grade A; BEL 1 |
| R 13.2 | Physiologic insulin replacement regimens, which provide both basal and prandial (meal-related or bolus) insulin, are recommended for most persons with T1D. Grade A; BEL 1 |
| R 13.3 | Achievement of glucose targets using either MDI of insulin or CSII, is needed to prevent development of life-threatening crises, such as acute hyperglycemic crises (DKA and hyperglycemic hyperosmolar state) and catabolic state. Grade A; BEL 1 |
| R 13.4 | A multi-component self-management DM education program is recommended for persons with T1D. Ideally, this is provided by a professional with expertise (ie, CDCES) in the topics of healthy lifestyle, insulin technique including prandial insulin dosing guided by carbohydrate counting and diet adjustments for special situations, such as physical activity and prolonged fasting. Instruction is also needed in how to deal with sick days and prevention of DKA and hypoglycemia, and other relevant issues. Due to changes in DM self-management practices and each individual’s medical history, personal and cultural background, and educational needs, specific education topics may need to be repeated at regular intervals. Grade A; BEL 1 |
| R 13.5 | The ideal insulin regimen should be personalized to an individual’s needs and glycemic targets, attempting to better emulate physiological insulin replacement to maintain near normoglycemia, to prevent the development and progression of DM complications, while minimizing hypoglycemia and providing flexibility for specific daily life situations/scenarios such as: exercise, sleep, acute illness, psychological stress, etc. Grade A; BEL 1 |
| R 13.6 | Insulin regimens usually should involve the use of insulin analogs for most persons with T1D and include the following approaches: a. MDI, which usually involve 1 to 2 subcutaneous injections daily of basal insulin to suppress ketogenesis and gluconeogenesis and to control glycemia between meals and overnight, and subcutaneous injections of prandial insulin or use of inhaled insulin before each meal to control meal-related glycemic excursions. CGM is the preferred method of glucose monitoring for all individuals with T1D. Grade A; BEL 1 b. Insulin pump therapy (CSII) provides constant/continuous infusion of fast-acting insulin driven by mechanical force and delivered via a cannula inserted under the skin. CSII can improve (or enhance) glycemic control and should be an option for insulin delivery for appropriate persons with DM. Ideally, these individuals should also use CGM as stated in R13.6.a. Grade B; BEL 1 c. Automated insulin delivery systems (AIDs), which include an insulin pump, an integrated CGM, and computer software algorithm, aim to better emulate physiological insulin replacement and achieve glycemic targets. This technology is recommended for many persons with T1D since its use has been shown to increase TIR while often reducing hypoglycemia or at least without causing increased hypoglycemia. Grade A; BEL 1 d. Open-loop (use of a pump and sensor which do not communicate) and sensor-augmented pump (SAP) systems: (CGM communicates with pump facilitating needed adjustments to basal rate; temporary interruption of insulin delivery when glucose levels are low or forecast to be low within 30 min). Insulin pump with a CGM or an SAP is recommended to manage persons with DM treated with intensive insulin management who prefer not to use AIDs or have no access to them. Grade D; BEL 4 |
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Q 14: How should hypoglycemia be managed? | |
| R 14.1 | Oral intake of rapidly absorbed glucose (eg, glucose tablets or dietary sugar like fruit juice) followed by a snack or meal containing both protein and carbohydrates (eg, cheese and crackers or a peanut butter sandwich) should be used to treat hypoglycemia (measured glucose <70 mg/dL [3.9 mmol/L]) if a person is able to safely swallow. Grade A; BEL 1 |
| R 14.2 | Glucagon, in one of the currently available forms: intranasal, prefilled liquid stable nonaqueous formulation, prefilled aqueous liquid stable glucagon analogue or with reconstitution from powder, should be used to correct hypoglycemia if individuals are unable or unwilling to ingest carbohydrates orally. If there is no response after 15 min, an additional same dose may be administered. As soon as the individual is awake and able to swallow, they should receivea rapidly absorbed source of carbohydrate. Grade A; BEL 1 |
| R 14.3 | Persons with severe hypoglycemia with altered mental status or with prolonged hypoglycemia need to be hospitalized. If an individual has hypoglycemic unawareness and hypoglycemia-associated autonomic failure, several weeks of hypoglycemia avoidance may at least partially reverse hypoglycemia unawareness and may reduce the risk or prevent recurrence of severe hypoglycemia. Adjustment of an individual's long-term antihyperglycemic regimen may be necessary to further avoid recurrence of hypoglycemia. Grade B; BEL 1 |
| R 14.4 | In persons with T2D who develop hypoglycemia and are being treated with alpha-glucosidase inhibitors or with pancreatic diabetes, oral glucose or lactose-containing foods (dairy products) must be given because alpha-glucosidase inhibitors inhibit the breakdown and absorption of complex carbohydrates and disaccharides (eg, table sugars or starches). Grade A; BEL 1 |
| R 14.5 | Persons at risk for hypoglycemia should perform frequent BGM or preferably use CGM devices (see R 3.1 to R 3.4 on monitoring). Grade B; BEL 4 and expert opinion of task force |
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Q 15: How should diabetes mellitus be managed in the hospital? | |
| R 15.1 | All hospitalized persons should have laboratory glucose testing on admission. Persons with DM or with admission hyperglycemia >140 mg/dL should have glucose monitoring during hospitalization. Grade B; BEL 1 |
| R 15.2 | To guide inpatient therapy and inform discharge planning, clinicians should measure A1C in all persons with DM, unless their A1C is known and was tested within the previous 3 mo. Grade B; BEL 2 |
| R 15.3 | Hospitalized persons with hyperglycemia but without known DM should have A1C measured to identify preexisting DM and inform discharge planning. Grade B; BEL 2 |
| R 15.4 | Initiate bedside point-of-care (POC) capillary glucose monitoring at an appropriately chosen schedule to guide therapy for hyperglycemia during hospitalization in all persons with DM, persons without prior DM who have hyperglycemia, and persons receiving therapies with a high risk of hyperglycemia, such as corticosteroids and enteral or parenteral nutrition. Grade A; BEL 1 |
| R 15.5 | For hospitalized persons with DM eating on a regular schedule, check POC BG before each meal and at bedtime, if clinically indicated. In hospitalized persons who are not eating (eg, NPO [nothing by mouth] or continuous feeding), initially check POC BG at least every 4 to 6 h. Additional checks may be warranted for those at higher risk of hypoglycemia. For those on intravenous (IV) insulin, POC BG should be obtained from every 30 min to every 2 h. Grade A; BEL 1 |
| R 15.6 | Although inpatient CGM has not received regulatory approval, CGM may be useful in inpatient settings, while complying with institutional policies and safety precautions. CGM may improve detection of severe hypoglycemic and hyperglycemic events, identify glucose trends and patterns, and improve satisfaction in persons with DM. Grade C; BEL 2 |
| R 15.7 | CGM may be considered under special regulatory allowance during the time of coronavirus disease 2019 (COVID-19) to reduce staff exposure and use of personal protective equipment and assist with glycemic monitoring of persons in the hospital setting. Grade C; BEL 2 |
| R 15.8 | Specialized inpatient DM teams and/or CDCES, if available, should be used to improve outcomes in hospitalized persons with DM or hyperglycemia. The use of virtual consults may be considered an alternative to support hospitals lacking these services. Grade B; BEL 1 |
| R 15.9 | For critically ill persons, IV insulin infusion is recommended to treat persistent hyperglycemia in the ICU using validated protocols that allow adjustment of insulin dose for glycemic excursions based on prespecified glucose targets. For those receiving IV insulin, POC testing should be performed every 30 to 120 min. Grade A; BEL 1 |
| R 15.10 | A glucose target of 140 to 180 mg/dL is recommended for most critically ill persons in the hospital setting. More intensive targets between 110 to 140 mg/dL may be appropriate in select populations, particularly critically ill persons postcardiothoracic or other surgeries, while minimizing the risk of hypoglycemia. Grade A; BEL 1 |
| R 15.11 | For most noncritically ill persons in the hospital setting, a glucose target of 140 to 180 mg/dL is recommended. For hospitalized persons who are able to achieve and maintain glycemic control without hypoglycemia, a lower target range (100 to 140 mg/dL) may be reasonable. For persons in a hospital setting with high clinical complexity, terminal illness, limited life expectancy, or high risk for hypoglycemia, less stringent targets are appropriate. Grade B; BEL 1 |
| R 15.12 | Insulin therapy following approved protocols is recommended as the preferred therapy for managing hyperglycemia in the hospital. For noncritically ill hospitalized persons with T2D, an individualized approach is recommended for consideration of noninsulin agents alone or in combination with insulin (see also R 15.16). Grade A; BEL 1 |
| R 15.13 | The insulin regimen for hospitalized persons with satisfactory meal intake should include basal, prandial, and correction doses. For those without adequate food intake, a regimen of basal, prandial, and correction doses should be used as necessary for glycemic control. Exclusive use of “sliding-scale” insulin should only be used for those whose glucoses are in the target range most of the time, and only occasionally exceed it. Grade A; BEL 1 |
| R 15.14 | The management of hyperglycemic emergencies, including DKA and hyperosmolar state, should include fully adequate fluid resuscitation to correct fluid deficits, electrolyte replacement (potassium), and insulin therapy. Simultaneous continued infusion of insulin and dextrose solutions after correction of hyperglycemia is often required until DKA resolves to avoid hypoglycemia. Grade A; BEL 1 |
| R 15.15 | Transition from IV insulin in the ICU to a subcutaneous insulin regimen is typically required when acidosis is resolved, and a person is no longer critically ill. A proactive regimen with scheduled subcutaneous insulin therapy, with basal, nutritional/prandial, and/or correctional doses, is recommended for most persons. Grade A; BEL 1 |
| R 15.16 | For hospitalized persons with T2D and mild admission hyperglycemia (glucose <180 mg/dL), a personalized approach is recommended for the use of noninsulin agents alone or in combination with basal insulin, aiming for the most efficacious regimen with the lowest hypoglycemic risk. For some hospitalized persons with T2D, DPP-4 inhibitors plus correction doses with rapid-acting insulin, or basal insulin plus DPP-4 inhibitors may be sufficient. Grade A; BEL 1 |
| R 15.17 | A hospital-wide standardized plan should be in place to prevent hypoglycemia. Each hypoglycemic episode should be documented, and appropriate adjustments should be made to prevent recurrence. Grade B; BEL 2 |
| R 15.18 | It is recommended to start discharge planning soon after hospital admission and to provide and document appropriate individualized plans for transition to an ambulatory setting and follow-up care at discharge for all persons with DM or newly diagnosed hyperglycemia. Grade A; BEL 1 |
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Q 16: How should diabetes mellitus in pregnancy be managed? | |
| R 16.1 | For women with GDM, the following treatment goals are recommended: preprandial glucose concentration ≤95 mg/dL and either a 1-h postmeal glucose ≤140 mg/dL or a 2-h postmeal glucose ≤120 mg/dL to decrease adverse fetal outcomes. Grade C; BEL 4 and expert opinion of task force |
| R 16.2 | All women with preexisting DM (T1D, T2D, or previous GDM) need access to preconception care and counseling to ensure adequate nutrition, healthy weight, and glucose control before conception, during pregnancy, and in the postpartum period. Grade B; BEL 2 |
| R 16.3 | Rapid-acting insulin analogs (insulin-lispro, insulin-aspart) should be used to treat postprandial hyperglycemia in pregnant women. Grade B; BEL 1 |
| R 16.4 | Options for basal insulin include long-acting insulin (eg, NPH, detemir, or glargine) or rapid-acting insulin via a CSII. Regular insulin, although not recommended as first-line therapy, is acceptable to use in managing pregnant women with DM when rapid-acting insulin analogs are not available. Grade B; BEL 1 |
| R 16.5 | Insulin is the preferred therapeutic choice for pregnant women with GDM or T2D, but metformin has been given a category B for pregnancy with accumulating clinical evidence of metformin’s safety during the first trimester and beyond. Metformin has been shown to improve pregnancy and fetal outcomes except for increased rates of infants with SGA and later onset of obesity. The prescriber should discuss the potential risks and benefits of oral agent therapy during pregnancy as well as the need for longer-term outcome studies. Grade B; BEL 1 |
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Section 4. Education and Other Topics | |
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Q 17: What education interventions have been shown to be most effective in management of persons with diabetes mellitus?
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| R 17 | Comprehensive individualized DSMES is recommended at the time of DM diagnosis and subsequently as appropriate. Therapeutic lifestyle management must be discussed with all persons with DM or prediabetes at the time of diagnosis and throughout their lifetime. This includes MNT (with reduction and modification of caloric and fat intake to achieve weight loss in those who are overweight or obese), appropriately prescribed physical activity, avoidance of tobacco products, and adequate sleep quantity and quality. Additional topics commonly taught in DSMES programs outline principles of glycemia treatment options; BGM; insulin dosage adjustments; acute complications of DM; and prevention, recognition, and treatment of hypoglycemia. Grade A; BEL 1 |
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Q 18: What are the key nonpharmacological components of a comprehensive diabetes care plan for children and adolescents? | |
| R 18.1 | T1D and T2D in children and adolescents should be managed in close consultation with the patient and their family members, involving school and daycare personnel whenever possible. Grade B; BEL 2 |
| R 18.2 | It is recommended that all children and adolescents with DM should be given age and culturally appropriate education and guidance for physical activity and lifestyle modification. Grade A; BEL 1 |
| R 18.3 | Interventions by family and/or community are recommended to improve dietary behavior and increase physical activity in efforts to prevent childhood obesity and T2D (Grade A). Game-based interventions also can be incorporated to enhance healthy lifestyle habits (Grade B). BEL 1 |
| R 18.4 | Routine psychological assessment with consideration of family stressors and psychosocial factors that may impact glycemic control is recommended for all youth with DM. Grade A; BEL 1 |
| R 18.5 | With the risk of glycemic control worsening during adolescence, coordinated, individualized, planned transition from pediatric to adult DM care is recommended for all adolescents. Grade A; BEL 1 |
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Q 19.1: Should persons with infertility be screened for diabetes mellitus? | |
| R 19.1 | Men and women undergoing investigation for infertility and preparation for infertility interventions, including in vitro fertilization, should be screened for DM. Grade B; BEL 2 |
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Q 19.2: How should persons with preexisting diabetes mellitus and infertility be evaluated? | |
| R 19.2 | For all persons with DM and possible infertility, in addition to routine endocrine evaluation, further collaborative consultation with a reproductive specialist should be considered. For women with T2D and infertility, or those with T1D who desire to preserve or estimate their fertility, anti-Müllerian hormone and midluteal progesterone levels may be assessed and screened for ovulatory dysfunction including anovulation. For men with DM and infertility, a standard semen analysis may be assessed, and an endocrine evaluation be initiated. Grade B; BEL 2 |
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Q 19.3: Should men with diabetes mellitus and cardiometabolic disorders be assessed for hypogonadism? | |
| R 19.3 | All men with CMD including prediabetes, metabolic syndrome, obesity, and T2D should be assessed for hypogonadism by history and physical examination; test for testosterone deficiency in persons with loss of libido and/or loss of muscle strength or mass, erectile dysfunction, osteopenia, or infertility. Grade B; BEL 1 |
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Q 20.1: How should persons at risk for secondary diabetes be assessed? | |
| R 20.1 | Persons with risk factors for developing secondary DM, such as postorgan transplantation, cystic fibrosis, chronic pancreatitis/postpartial pancreatectomy, or on medication associated with hyperglycemia, should be monitored routinely for IFG, IGT, and/or overt DM. Grade A; BEL 1 |
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Q 20.2: What are the best treatment strategies for management of secondary diabetes, such as posttransplant diabetes, cystic fibrosis‒related diabetes, and other forms of secondary diabetes? | |
| R 20.2.1 | Select treatment for secondary DM based on the underlying pathophysiology. Insulin therapy is safe and effective, but alternative glucose-lowering agents may be considered in specific patient populations. Grade A; BEL 1 |
| R 20.2.2 | DPP-4 inhibitors can be safely used to improve glycemic control for posttransplant diabetes. Grade A; BEL 1 |
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Q 21: What is the role of sleep medicine in the care of persons with diabetes? | |
| R 21.1 | Health care professionals should assess persons with T2D for symptoms and signs of OSA, especially in the presence of obesity or suggestive clinical features of OSA. Grade B; BEL 2 |
| R 21.2 | Based on resources available locally, persons suspected to have OSA should be referred to an appropriate center for diagnosis and management of OSA. Grade B; BEL 4 and Expert Opinion of Task Force |
| R 21.3 | Weight loss is recommended as the predominant intervention to improve both OSA and insulin sensitivity. In addition, devices that provide positive airway pressure as prescribed by a sleep specialist are effective. Grade A; BEL 1 |
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Q 22: Should screening for depression be a routine component of clinical assessment in persons with diabetes mellitus? | |
| R 22 | Routine screening of adults with DM for depression and DM distress is recommended during each clinic encounter, if appropriate. Referral to mental health professionals should be made as soon as possible once depression is suspected or diagnosed. Grade A; BEL 1 |
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Q 23: Is the evaluation of social determinants of health in persons predisposed to or with diabetes mellitus useful in improving health outcomes? | |
| R 23 | Clinicians should assess the SDOH in persons with DM to better guide them to the most appropriate resources. Interventional trials addressing SDOH and health inequities in DM are needed to evaluate reversibility of their impact. Grade B; BEL 1 |
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Q 24: Is telehealth/virtual care an effective care-delivery model for the management of persons with diabetes mellitus? | |
| R 24 | Offer telehealth, if available and appropriate, to persons with DM as part of their wholistic health care. Grade A; BEL 1 |
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Q 25: Which occupations have specific public safetyerelated diabetes management considerations? | |
| R 25 | Persons with DM who are engaged in occupations with public safety implications, such as commercial drivers and pilots, have special management requirements for certification. CGM to predict hypoglycemia in real time and pharmacotherapy that minimizes hypoglycemia are recommended as effective strategies for persons with DM who work in these occupations. Grade A; BEL 1 and expert opinion of task force |
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Q 26: Is there a role for nutritional supplements in the management of diabetes and what might be the associated risks? | |
| R 26 | Nutritional supplements (ie, noncaloric oral supplements) have modest or neutral effects on glycemic control, lipids, and BP. Until proven scientifically, these supplements should not be used for managing DM or related CV risk factors among persons with DM. In view of potential harm, we recommend that persons with DM use caution and discuss with their physicians the use of unregulated nutritional supplements. Grade A; BEL 1 |
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Q 27: How should potential increased cancer risk be managed in persons with obesity/type 2 diabetes? | |
| R 27.1 | Clinicians should recommend age, sex, and risk-appropriate screening for common cancers, especially those associated with obesity and DM. Grade B; BEL 2 |
| R 27.2 | With the increased risk of certain cancers in persons with obesity or DM, clinicians should educate persons regarding cancer risk and encourage a healthy lifestyle, including weight reduction. Grade A; BEL 1 |
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Q 28: Which vaccinations should be given to persons with diabetes mellitus? | |
| R 28.1 | AACE supports the recommendations of the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) that all persons with DM receive age-appropriate vaccinations according to the CDC/ACIP schedule (7). Immunization recommendations for adults with DM are summarized in Table 21. Grade A; BEL 4 and expert opinion of task force |
| R 28.2 | An annual influenza vaccine is recommended for those with DM who are ≥6 mo old. Grade A; BEL 1 |
| R 28.3 | The 15- or 20-valent pneumococcal conjugate vaccine (PCV15 or PCV20) should be administered to all adults aged 19 to 64 y who have DM. When PCV15 is used, PPSV23 should be administered at least 12 mo following the dose of PCV15. A minimum interval of 8 wk may be used for adults with immunocompromising conditions. Grade B; BEL 3 |
| R 28.4 | For adults over 65 who have not previously received PCV or whose vaccination history is unknown, PCV15 or PCV20 should be administered. When PCV15 is used, it should be followed by a dose of PPSV23. Grade B; BEL 3 |
| R 28.5 | It is recommended to administer hepatitis B vaccinations to all individuals as soon after diagnosis of DM as possible up to age 59 y. Grade A; BEL 1 |
| R 28.6 | Consider hepatitis B vaccination of adults ≥60 y based on assessment of risk and likelihood of an adequate immune response. Grade C; BEL 4 |
| R 28.7 | Tetanus-diphtheria-pertussis (Tdap) vaccine is typically included with routine childhood vaccinations. However, all adults with DM should receive a tetanus-diphtheria (Td) booster every 10 y. Grade C; BEL 4 |
| R 28.8 | Health care professionals may consider recommending vaccines for the following diseases for persons with T2D based on individual needs: Tdap - tetanus, diphtheria, and pertussis (whooping cough); measles/mumps/rubella; varicella (chicken pox); and polio. In addition, persons traveling to other countries may require vaccines for endemic diseases. Grade D; BEL 4, expert opinion of task force |
| R 28.9 | Due to the increased risk for serious complications of COVID-19, persons with DM should be vaccinated against COVID-19 according to current guidelines. Grade B; BEL 2 |
| R 28.10 | Recombinant zoster vaccine is recommended for adults ≥50 y for protection against shingles according to the CDC/ACIP vaccination schedule. Grade A; BEL 1 |
| R 28.11 | Health care professionals should utilize interventions with demonstrated effectiveness in increasing vaccination rates to improve uptake of vaccination among persons with DM. Grade B; BEL 2 |