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1、STANDARDS OF MEDICAL CAREIN DIABETES2011Table of ContentsSectionSectionSlideNo.SlideNo.ADAEvidenceGradingSystemofClinicalRecommendations3I.ClassificationandDiagnosisofDiabetes4-11II.TestingforDiabetesinAsymptomaticPatients12-15III.DetectionandDiagnosisofGestationalDiabetesMellitus(GDM)16-19IV.Preven
2、tion/DelayofType2Diabetes20-21V.DiabetesCare22-50VI.PreventionandManagementofDiabetesComplications51-101VII.DiabetesCareinSpecificPopulations102-119VIII. DiabetesCareinSpecificSettings120-126IX.StrategiesforImprovingDiabetesCare127-130ADA Evidence Grading System for ADA Evidence Grading System for C
3、linical RecommendationsClinical RecommendationsLevelofLevelofEvidenceEvidenceDescriptionDescriptionAClearorsupportiveevidencefromadequatelypoweredwell-conducted,generalizable,randomizedcontrolledtrialsCompellingnonexperimentalevidenceBSupportiveevidencefromwell-conductedcohortstudiesorcase-controlst
4、udyCSupportiveevidencefrompoorlycontrolledoruncontrolledstudiesConflictingevidencewiththeweightofevidencesupportingtherecommendationEExpertconsensusorclinicalexperienceADA.Diabetes Care2011;34(suppl1):S12.Table1.I. CLASSIFICATION AND DIAGNOSIS OF DIABETESClassification of DiabetesType1diabetes-celld
5、estructionType2diabetesProgressiveinsulinsecretorydefectOtherspecifictypesofdiabetesGeneticdefectsin-cellfunction,insulinactionDiseasesoftheexocrinepancreasDrug-orchemical-inducedGestationaldiabetesmellitusADA.I.ClassificationandDiagnosis.Diabetes Care2011;34(suppl1):S12.Criteria for the Diagnosis o
6、f DiabetesA1C6.5%ORFastingplasmaglucose(FPG)126mg/dl(7.0mmol/l)ORTwo-hourplasmaglucose200mg/dl(11.1mmol/l)duringanOGTTORArandomplasmaglucose200mg/dl(11.1mmol/l)ADA.I.ClassificationandDiagnosis.Diabetes Care 2011;34(suppl1):S13.Table2.Criteria for the Diagnosis of DiabetesA1C6.5%Thetestshouldbeperfor
7、medinalaboratoryusinganNGSP-certifiedmethodstandardizedtotheDCCTassay*Intheabsenceofunequivocalhyperglycemia,resultshouldbeconfirmedbyrepeattesting.ADA.I.ClassificationandDiagnosis.Diabetes Care 2011;34(suppl1):S13.Table2.Criteria for the Diagnosis of DiabetesFastingplasmaglucose(FPG)126mg/dl(7.0mmo
8、l/l)Fasting:nocaloricintakeforatleast8h*Intheabsenceofunequivocalhyperglycemia,resultshouldbeconfirmedbyrepeattesting.ADA.I.ClassificationandDiagnosis.Diabetes Care 2011;34(suppl1):S13.Table2.Criteria for the Diagnosis of DiabetesTwo-hourplasmaglucose200mg/dl(11.1mmol/l)duringanOGTTThetestshouldbepe
9、rformedasdescribedbytheWorldHealthOrganization,usingaglucoseloadcontainingtheequivalentof75ganhydrousglucosedissolvedinwater*ntheabsenceofunequivocalhyperglycemia,resultshouldbeconfirmedbyrepeattesting.ADA.I.ClassificationandDiagnosis.Diabetes Care2011;34(suppl1):S13.Table2.Criteria for the Diagnosi
10、s of DiabetesInapatientwithclassicsymptomsofhyperglycemiaorhyperglycemiccrisis,arandomplasmaglucose200mg/dl(11.1mmol/l)ADA.I.ClassificationandDiagnosis.Diabetes Care 2011;34(suppl1):S13.Table2.Prediabetes: IFG, IGT, Increased A1CCategoriesofincreasedriskfordiabetes(Prediabetes)*FPG100-125mg/dl(5.6-6
11、.9mmol/l):IFGor2-hplasmaglucoseinthe75-gOGTT140-199mg/dl(7.8-11.0mmol/l):IGTorA1C5.7-6.4%*Forallthreetests,riskiscontinuous,extendingbelowthelowerlimitofarangeandbecomingdisproportionatelygreaterathigherendsoftherange.ADA.I.ClassificationandDiagnosis.Diabetes Care 2011;34(suppl1):S13.Table3.II. TEST
12、ING FOR DIABETES IN ASYMPTOMATIC PATIENTSRecommendations: Testing for Diabetes in Asymptomatic PatientsConsidertestingoverweight/obeseadultswithoneormoreadditionalriskfactorsInthosewithoutriskfactors,begintestingatage45years(B)IftestsarenormalRepeattestingatleastat3-yearintervals(E)UseA1C,FPG,or2-h7
13、5-gOGTT(B)InthosewithincreasedriskforfuturediabetesIdentifyand,ifappropriate,treatotherCVDriskfactors(B)ADA.II.TestinginAsymptomaticPatients.Diabetes Care 2011;34(suppl1):S13-S14.Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (1)PhysicalinactivityFirst-degreerelativewithdiabetes
14、High-riskrace/ethnicity(e.g.,AfricanAmerican,Latino,NativeAmerican,AsianAmerican,PacificIslander)Womenwhodeliveredababyweighing9lborwerediagnosedwithGDMHypertension(140/90mmHgorontherapyforhypertension)HDLcholesterollevel250mg/dl(2.82mmol/l)Womenwithpolycysticovariansyndrome(PCOS)A1C5.7%,IGT,orIFGon
15、previoustestingOtherclinicalconditionsassociatedwithinsulinresistance(e.g.,severeobesity,acanthosisnigricans)HistoryofCVD*At-riskBMImaybelowerinsomeethnicgroups.1. Testing should be considered in all adults who are overweight (BMI 25 kg/m2*) and have additional risk factors: ADA.TestinginAsymptomati
16、cPatients.Diabetes Care 2011;34(suppl1):S14.Table4.2. Intheabsenceofcriteria(riskfactorsonpreviousslide),testingfordiabetesshouldbeginatage45years3.Ifresultsarenormal,testingshouldberepeatedatleastat3-yearintervals,withconsiderationofmorefrequenttestingdependingoninitialresultsandriskstatusADA.Testi
17、nginAsymptomaticPatients.Diabetes Care 2011;34(suppl1):S14.Table4.Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (2)III. DETECTION AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUSRecommendations:Detection and Diagnosis of GDM (1)Screenforundiagnosedtype2diabetesatthefirstprenatalv
18、isitinthosewithriskfactors,usingstandarddiagnosticcriteria(B)Inpregnantwomennotpreviouslyknowntohavediabetes,screenforGDMat24-28weeksgestation,usinga75-gOGTTandthediagnosticcutpointsinTable6(B)ADA.III.DetectionandDiagnosisofGDM.Diabetes Care 2011;34(suppl1):S15.Screening for and Diagnosis of GDMPerf
19、orma75-gOGTT,withplasmaglucosemeasurementfastingandat1and2h,at24-28weeksofgestationinwomennotpreviouslydiagnosedwithovertdiabetesPerformOGTTinthemorningafteranovernightfastofatleast8hGDMdiagnosis:whenanyofthefollowingplasmaglucosevaluesareexceededFasting92mg/dl(5.1mmol/l)1h180mg/dl(10.0mmol/l)2h153m
20、g/dl(8.5mmol/l)ADA.III.DetectionandDiagnosisofGDM.Diabetes Care 2011;34(suppl1):S15.Table6.Recommendations:Detection and Diagnosis of GDM (2)ScreenwomenwithGDMforpersistentdiabetes6-12weekspostpartum(E)WomenwithahistoryofGDMshouldhavelifelongscreeningforthedevelopmentofdiabetesorprediabetesatleastev
21、erythreeyears(E)ADA.III.DetectionandDiagnosisofGDM.Diabetes Care 2011;34(suppl1):S15.IV. PREVENTION/DELAY OF TYPE 2 DIABETESRecommendations:Prevention/Delay of Type 2 DiabetesReferpatientswithIGT(A),IFG(E),orA1C5.7-6.4%(E)tosupportprogramWeightloss7%ofbodyweightAtleast150min/weekmoderateactivityFoll
22、ow-upcounselingimportant(B);third-partypayorsshouldcover(E)Considermetforminifmultipleriskfactors,especiallyifhyperglycemia(e.g.,A1C6%)progressesdespitelifestyleinterventions(B)Inthosewithprediabetes,monitorfordevelopmentofdiabetesannually(E)ADA.IV.Prevention/DelayofType2Diabetes.Diabetes Care 2011;
23、34(suppl1):S16.V. DIABETES CAREAcompletemedicalevaluationshouldbeperformedtoClassifythediabetesDetectpresenceofdiabetescomplicationsReviewprevioustreatment,glycemiccontrolinpatientswithestablisheddiabetesAssistinformulatingamanagementplanProvideabasisforcontinuingcarePerformlaboratorytestsnecessaryt
24、oevaluateeachpatientsmedicalconditionDiabetes Care: Initial EvaluationADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S16.Components of the Comprehensive Diabetes Evaluation (1)MedicalhistoryAgeandcharacteristicsofonsetofdiabetes(e.g.,DKA,asymptomaticlaboratoryfinding)Eatingpatterns,physicalactivit
25、yhabits,nutritionalstatus,andweighthistory;growthanddevelopmentinchildrenandadolescentsDiabeteseducationhistoryReviewofprevioustreatmentregimensandresponsetotherapy(A1Crecords)ADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S17.Table8.Components of the Comprehensive Diabetes Evaluation (2)ADA.V.Dia
26、betesCare.Diabetes Care 2011;34(suppl1):S17.Table8.Currenttreatmentofdiabetes,includingmedications,mealplan,physicalactivitypatterns,andresultsofglucosemonitoringandpatientsuseofdata(1)DKAfrequency,severity,andcauseHypoglycemicepisodesHypoglycemiaawarenessAnyseverehypoglycemia:frequencyandcauseCompo
27、nents of the Comprehensive Diabetes Evaluation (3)ADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S17.Table8.Currenttreatmentofdiabetes,includingmedications,mealplan,physicalactivitypatterns,andresultsofglucosemonitoringandpatientsuseofdata(2)Historyofdiabetes-relatedcomplicationsMicrovascular:reti
28、nopathy,nephropathy,neuropathySensoryneuropathy,includinghistoryoffootlesionsAutonomicneuropathy,includingsexualdysfunctionandgastroparesisMacrovascular:CHD,cerebrovasculardisease,PADOther:psychosocialproblems*,dentaldisease*Seeappropriatereferralsforthesecategories.Components of the Comprehensive D
29、iabetes Evaluation (4)ADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S17.Table8.Physicalexamination(1)Height,weight,BMIBloodpressuredetermination,includingorthostaticmeasurementswhenindicatedFundoscopicexamination*ThyroidpalpationSkinexamination(foracanthosisnigricansandinsulininjectionsites)*Seea
30、ppropriatereferralsforthesecategories.Components of the Comprehensive Diabetes Evaluation (5)ADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S17.Table8.*Seeappropriatereferralsforthesecategories.Physicalexamination(2)ComprehensivefootexaminationInspectionPalpationofdorsalispedisandposteriortibialpu
31、lsesPresence/absenceofpatellarandAchillesreflexesDeterminationofproprioception,vibration,andmonofilamentsensationLaboratoryevaluationA1C,ifresultsnotavailablewithinpast23monthsIfnotperformed/availablewithinpastyearFastinglipidprofile,includingtotal,LDL-andHDL-cholesterolandtriglyceridesLiverfunction
32、testsTestforurinealbuminexcretionwithspoturinealbumin/creatinineratioSerumcreatinineandcalculatedGFRTSHintype1diabetes,dyslipidemia,orwomen50yearsofageADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S17.Table8.Components of the Comprehensive Diabetes Evaluation (6)ReferralsAnnualdilatedeyeexamFamil
33、yplanningforwomenofreproductiveageRegistereddietitianforMNTDiabetesself-managementeducationDentalexaminationMentalhealthprofessional,ifneededADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S17.Table8.Components of the Comprehensive Diabetes Evaluation (7)Recommendations: Glucose MonitoringSelf-moni
34、toringofbloodglucoseshouldbecarriedout3+timesdailyforpatientsusingmultipleinsulininjectionsorinsulinpumptherapy(A)Forpatientsusinglessfrequentinsulininjections,noninsulintherapy,ormedicalnutritiontherapyaloneSMBGmaybeusefulasaguidetosuccessoftherapy(E)However,severalrecenttrialshavecalledintoquestio
35、nclinicalutility,cost-effectiveness,ofroutineSMBGinnoninsulin-treatedpatientsADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S17.Recommendations: A1CPerformA1Ctestatleasttwiceyearlyinpatientsmeetingtreatmentgoals(andhavestableglycemiccontrol)(E)PerformA1Ctestquarterlyinpatientswhosetherapyhaschange
36、dorwhoarenotmeetingglycemicgoals(E)Useofpoint-of-caretestingforA1Callowsfortimelydecisionsontherapychanges,whenneeded(E)ADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S18.Correlation of A1C with Estimated Average Glucose (eAG)MeanplasmaglucoseA1C(%)mg/dlmmol/l61267.071548.6818310.2921211.81024013.
37、41126914.91229816.5ADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S18.Table9.TheseestimatesarebasedonADAGdataof2,700glucosemeasurementsover3monthsperA1Cmeasurementin507adultswithtype1,type2,andnodiabetes.ThecorrelationbetweenA1Candaverageglucosewas0.92.AcalculatorforconvertingA1Cresultsintoestimat
38、edaverageglucose(eAG),ineithermg/dlormmol/l,isavailableathttp:/professional.diabetes.org/GlucoseCalculator.aspx.Recommendations:Glycemic Goals in Adults (1)ADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S19.LoweringA1Ctobeloworaround7%Showntoreducemicrovascularandneuropathiccomplicationsofdiabetes
39、Ifimplementedsoonafterdiagnosisofdiabetes,associatedwithlong-termreductioninmacrovasculardiseaseTherefore,areasonableA1Cgoalformanynon-pregnantadultsis7%(B)Recommendations:Glycemic Goals in Adults (2)ADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S19.Additionalanalysisfromseveralrandomizedtrialssu
40、ggestasmallbutincrementalbenefitinmicrovascularoutcomeswithA1CvaluesclosertonormalProvidersmightreasonablysuggestmorestringentA1Cgoalsforselectedindividualpatients,ifthiscanbeachievedwithoutsignificanthypoglycemiaorotheradverseeffectsoftreatmentSuchpatientsmightincludethosewithshortdurationofdiabete
41、s,longlifeexpectancy,andnosignificantcardiovasculardisease(B)Recommendations:Glycemic Goals in Adults (3)ADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S19.Conversely,lessstringentA1CgoalsmaybeappropriateforpatientswithHistoryofseverehypoglycemia,limitedlifeexpectancy,advancedmicrovascularormacrov
42、ascularcomplications,extensivecomorbidconditionsThosewithlongstandingdiabetesinwhomthegeneralgoalisdifficulttoattaindespitediabetesself-managementeducation,appropriateglucosemonitoring,andeffectivedosesofmultipleglucoseloweringagentsincludinginsulin(C)Intensive Glycemic Control and Cardiovascular Ou
43、tcomes: ACCORDGersteinHC,etal,fortheActiontoControlCardiovascularRiskinDiabetesStudyGroup.N Engl J Med 2008;358:2545-2559.2008 New England Journal of Medicine. Used with permission.Primary Outcome: Nonfatal MI, nonfatal stroke, CVD death HR=0.90 (0.78-1.04)Intensive Glycemic Control and Cardiovascul
44、ar Outcomes: ADVANCE2008 New England Journal of Medicine. Used with permission.Primary Outcome: Microvascular plus macrovascular (nonfatal MI, nonfatal stroke, CVD death)PatelA,etal,.fortheADVANCECollaborativeGroup.N Engl J Med 2008;358:2560-2572.HR=0.90 (0.82-0.98)Intensive Glycemic Control and Car
45、diovascular Outcomes: VADTDuckworthW,etal.,fortheVADTInvestigators.N Engl J Med2009;360:129-139.Primary Outcome: Nonfatal MI, nonfatal stroke, CVD death, hospitalization for heart failure, revascularizationHR=0.88 (0.74-1.05)2009 New England Journal of Medicine. Used with permission.Glycemic Recomme
46、ndations for Non-Pregnant Adults with Diabetes (1)A1C7.0%*Preprandialcapillaryplasmaglucose70130mg/dl*(3.97.2mol/l)Peakpostprandialcapillaryplasmaglucose180mg/dl*(35kg/m2andtype2diabetes(B)Aftersurgery,life-longlifestylesupportandmedicalmonitoringisnecessary(E)Insufficientevidencetorecommendsurgeryi
47、npatientswithBMI64yearspreviouslyimmunizedat5yearsagoOtherindicationsforrepeatvaccination:nephroticsyndrome,chronicrenaldisease,immunocompromisedstates(C)ADA.V.DiabetesCare.Diabetes Care 2011;34(suppl1):S27.VI. PREVENTION AND MANAGEMENT OFDIABETES COMPLICATIONSCVDisamajorcauseofmorbidity,mortalityfo
48、rthosewithdiabetesCommonconditionscoexistingwithtype2diabetes(e.g.,hypertension,dyslipidemia)areclearriskfactorsforCVDDiabetesitselfconfersindependentriskBenefitsobservedwhenindividualcardiovascularriskfactorsarecontrolledtoprevent/slowCVDinpeoplewithdiabetesCardiovascular Disease (CVD) in Individua
49、ls with DiabetesADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S27.Recommendations: Hypertension/Blood Pressure ControlScreeninganddiagnosisMeasurebloodpressureateveryroutinediabetesvisitIfpatientshavesystolicbloodpressure130mmHgordiastolicbloodpressure80mmHgConfirmbloodpr
50、essureonaseparatedayRepeatsystolicbloodpressure130mmHgordiastolicbloodpressure80confirmsadiagnosisofhypertension(C)ADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S27.Recommendations: Hypertension/Blood Pressure ControlGoalsAgoalsystolicbloodpressure130mmHgisappropriateform
51、ostpatientswithdiabetes(C)Basedonpatientcharacteristicsandresponsetotherapy,higherorlowersystolicbloodpressuretargetsmaybeappropriate(B)Patientswithdiabetesshouldbetreatedtoadiastolicbloodpressure80mmHg(B)ADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S27.Recommendations:
52、Hypertension/Blood Pressure ControlTreatment(1)Patientswithasystolicbloodpressure130139mmHgoradiastolicbloodpressure8089mmHgMaybegivenlifestyletherapyaloneforamaximumof3monthsIftargetsarenotachieved,patientsshouldbetreatedwiththeadditionofpharmacologicalagents(E)ADA.VI.Prevention,ManagementofComplic
53、ations.Diabetes Care 2011;34(suppl1):S27.Recommendations: Hypertension/Blood Pressure ControlTreatment(2)Patientswithmoreseverehypertension(systolicbloodpressure140mmHgordiastolicbloodpressure90mmHg)atdiagnosisorfollow-upShouldreceivepharmacologictherapyinadditiontolifestyletherapy(A)ADA.VI.Preventi
54、on,ManagementofComplications.Diabetes Care 2011;34(suppl1):S27.Recommendations: Hypertension/Blood Pressure ControlTreatment(3)LifestyletherapyforhypertensionWeightlossifoverweightDASH-styledietarypatternincludingreducingsodium,increasingpotassiumintakeModerationofalcoholintakeIncreasedphysicalactiv
55、ity(B)ADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S27.Recommendations: Hypertension/Blood Pressure ControlTreatment(4)PharmacologictherapyforpatientswithdiabetesandhypertensionPairwitharegimenthatincludeseitheranACEinhibitororangiotensinIIreceptorblockerIfoneclassisnott
56、olerated,theothershouldbesubstitutedIfneededtoachievebloodpressuretargetsThiazidediureticshouldbeaddedtothosewithestimatedGFR30mlxmin/1.73m2LoopdiureticforthosewithanestimatedGFR30mlxmin/1.73m2(C)ADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S27.Recommendations: Hypertens
57、ion/Blood Pressure ControlTreatment(5)Multipledrugtherapy(twoormoreagentsatmaximaldoses)Generallyrequiredtoachievebloodpressuretargets(B)IfACEinhibitors,ARBs,ordiureticsareusedKidneyfunction,serumpotassiumlevelsshouldbemonitored(E)ADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(sup
58、pl1):S27.Recommendations: Hypertension/Blood Pressure ControlTreatment(6)InpregnantpatientswithdiabetesandchronichypertensionBloodpressuretargetgoalsof110129/6579mmHgaresuggestedininterestoflong-termmaternalhealthandminimizingimpairedfetalgrowthACEinhibitors,ARBs,contraindicatedduringpregnancy(E)ADA
59、.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S27.Recommendations:Dyslipidemia/Lipid ManagementScreeningInmostadultpatientsMeasurefastinglipidprofileatleastannuallyInadultswithlow-risklipidvalues(LDLcholesterol50mg/dl,andtriglycerides40yearsofageandhaveoneormoreotherCVDriskf
60、actors(A)ADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S29.Recommendations:Dyslipidemia/Lipid ManagementTreatmentrecommendationsandgoals(3)Forpatientsatlowerrisk(e.g.,withoutovertCVDand100mg/dlInthosewithmultipleCVDriskfactorsADA.VI.Prevention,ManagementofComplications.Di
61、abetes Care 2011;34(suppl1):S29.Recommendations:Dyslipidemia/Lipid ManagementTreatmentrecommendationsandgoals(4)InindividualswithoutovertCVDPrimarygoalisanLDLcholesterol100mg/dl(2.6mmol/l)(A)InindividualswithovertCVDLowerLDLcholesterolgoalof70mg/dl(1.8mmol/l),usingahighdoseofastatin,isanoption(B)ADA
62、.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S29.Recommendations:Dyslipidemia/Lipid ManagementTreatmentrecommendationsandgoals(5)IftargetsnotreachedonmaximaltoleratedstatintherapyAlternativetherapeuticgoal:reduceLDLcholesterol3040%frombaseline(A)Triglyceridelevels40mg/dl(1.
63、0mmol/l)inmenand50mg/dl(1.3mmol/l)inwomen,aredesirableHowever,LDLcholesteroltargetedstatintherapyremainsthepreferredstrategy(C)ADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S29.Recommendations:Dyslipidemia/Lipid ManagementTreatmentrecommendationsandgoals(6)Iftargetsarenot
64、reachedonmaximallytolerateddosesofstatinsCombinationtherapyusingstatinsandotherlipidloweringagentsmaybeconsideredtoachievelipidtargetsHasnotbeenevaluatedinoutcomestudiesforeitherCVDoutcomesorsafety(E)StatintherapyiscontraindicatedinpregnancyADA.VI.Prevention,ManagementofComplications.Diabetes Care 2
65、011;34(suppl1):S29.Statins: Reduction in 10-Year Risk of Major CVD* in Patients with DiabetesStudyref.Statin dose and comparator Risk reductionRelative riskreductionAbsolute riskreductionLDLcholesterolreduction, mg/dl (%)4S-DM1Simvastatin20-40mgvs.placebo85.7to43.2%50%42.5%186to119(36%)ASPEN2Atorvas
66、tatin10mgvs.placebo39.5to24.5%34%12.7%112to79(29%)HPS-DM3Simvastatin40mgvs.placebo43.8to36.3%17%7.5%123to84(31%)CARE-DM4Pravastatin40mgvs.placebo40.8to35.4%13%5.4%136to99(27%)TNT-DM5Atorvastatin80mgvs.10mg26.3to21.6%18%4.7%99to77(22%)ADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(
67、suppl1):S30.Table11.*Endpoints=CHDdeath,nonfatalMISecondary PreventionStudyref.Statin dose and comparator Risk reductionRelative riskreductionAbsolute riskreductionLDLcholesterolreduction, mg/dl (%)HPS-DM1Simvastatin40mgvs.placebo17.5to11.5%34%6.0%124to86(31%)CARDS2Atorvastatin10mgvs.placebo11.5to7.
68、5%35%4.0%118to71(40%)ASPEN3Atorvastatin10mgvs.placebo9.8to7.9%19%1.9%114to80(30%)ASCOT-DM4Atorvastatin10mgvs.placebo11.1to10.2%8%0.9%125to82(34%)*Endpoints=CHDdeath,nonfatalMIADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S30.Table11.Primary PreventionStatins: Reduction in
69、 10-Year Risk of Major CVD* in Patients with DiabetesRecommendations: Glycemic, Blood Pressure, Lipid Control in AdultsA1C7.0%*Bloodpressure130/80mmHgLipidsLDLcholesterol100mg/dl(2.6mmol/l)*Moreorlessstringentglycemicgoalsmaybeappropriateforindividualpatients.Goalsshouldbeindividualizedbasedon:durat
70、ionofdiabetes,age/lifeexpectancy,comorbidconditions,knownCVDoradvancedmicrovascularcomplications,hypoglycemiaunawareness,andindividualpatientconsiderations.Basedonpatientcharacteristicsandresponsetotherapy,higherorlowersystolicbloodpressuretargetsmaybeappropriate.InindividualswithovertCVD,alowerLDLc
71、holesterolgoalof10%)Includesmostmen50yearsofageorwomen60yearsofagewhohaveatleastoneadditionalmajorriskfactorFamilyhistoryofCVDHypertensionSmokingDyslipidemiaAlbuminuriaADA.VI.Prevention,ManagementofComplications.Diabetes Care2011;34(suppl1):S31.Recommendations:Antiplatelet Agents (2)Aspirinshouldnot
72、berecommendedforCVDpreventionforadultswithdiabetesatlowCVDrisk,sincepotentialadverseeffectsfrombleedinglikelyoffsetpotentialbenefits(C)10-yearCVDrisk5%:men50andwomen1.5mg/dl)ARBshavebeenshowntodelayprogressionofnephropathy(A)Ifoneclassisnottolerated,theothershouldbesubstituted(E)ADA.VI.Prevention,Ma
73、nagementofComplications.Diabetes Care 2011;34(suppl1):S33.Recommendations:Nephropathy Treatment (4)Reductionofproteinintakemayimprovemeasuresofrenalfunction(urinealbuminexcretionrate,GFR)(B)To0.81.0gxkgbodywt1xday1inthosewithdiabetes,earlierstagesofCKDTo0.8gxkgbodywt1xday1inlaterstagesofCKDWhenACEin
74、hibitors,ARBs,ordiureticsareused,monitorserumcreatinine,potassiumlevelsfordevelopmentofacutekidneydisease,hyperkalemia(E)ADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S33.Recommendations:Nephropathy Treatment (5)Continuemonitoringurinealbuminexcretiontoassessbothresponset
75、otherapy,diseaseprogression(E)WheneGFR60ml/min/1.73m2,evaluate,managepotentialcomplicationsofCKD(E)Considerreferraltoaphysicianexperiencedincareofkidneydisease(B)UncertaintyaboutetiologyofkidneydiseaseDifficultmanagementissuesAdvancedkidneydiseaseADA.VI.Prevention,ManagementofComplications.Diabetes
76、Care 2011;34(suppl1):S33.Definitions of Abnormalities in Albumin ExcretionCategorySpotcollection(g/mgcreatinine)Normal30Microalbuminuria30-299Macroalbuminuria(clinical)300ADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S34.Table13.Stages of Chronic Kidney DiseaseStageDescri
77、ptionGFR(ml/minper1.73m2bodysurfacearea)1Kidneydamage*withnormalorincreasedGFR902Kidneydamage*withmildlydecreasedGFR60893ModeratelydecreasedGFR30594SeverelydecreasedGFR15295Kidneyfailure15ordialysis*Kidney damage defined as abnormalities on pathologic, urine, blood, or imaging tests. GFR = glomerula
78、r filtration rateADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S34.Table14.Management of CKD in Diabetes (1)GFR(ml/min/1.73m2)RecommendedAllpatientsYearlymeasurementofcreatinine,urinaryalbuminexcretion,potassium45-60Referraltonephrologyifpossibilityfornondiabetickidneydis
79、easeexistsConsiderdoseadjustmentofmedicationsMonitoreGFRevery6monthsMonitorelectrolytes,bicarbonate,hemoglobin,calcium,phosphorus,parathyroidhormoneatleastyearlyAssurevitaminDsufficiencyConsiderbonedensitytestingReferralfordietarycounsellingADA.VI.Prevention,ManagementofComplications.Diabetes Care 2
80、011;34(suppl1):S35.Table15;Adaptedfromhttp:/www.kidney.org/professionals/KDOQI/guideline_diabetes/.Management of CKD in Diabetes (2)ADA.VI.Prevention,ManagementofComplications.Diabetes Care 2011;34(suppl1):S35.Table15;Adaptedfromhttp:/www.kidney.org/professionals/KDOQI/guideline_diabetes/.GFR(ml/min
81、/1.73m2)Recommended30-44MonitoreGFRevery3monthsMonitorelectrolytes,bicarbonate,calcium,phosphorus,parathyroidhormone,hemoglobin,albumin,weightevery36monthsConsiderneedfordoseadjustmentofmedications130/80mmHg,if95%exceedsthatvalue)Initiateassoonasdiagnosisisconfirmed(E)ADA.VII.DiabetesCareinSpecificP
82、opulations.Diabetes Care.2011;34(suppl1):S39.Recommendations: Pediatric Hypertension (Type 1 Diabetes) (2)ACEinhibitorsConsiderforinitialtreatmentofhypertension,followingappropriatereproductivecounselingduetopotentialteratogeniceffects(E)GoaloftreatmentBloodpressureconsistently240mg/dl)oracardiovasc
83、ulareventbeforeage55years,oriffamilyhistoryisunknownPerformfastinglipidprofileonchildren2yearsofagesoonafterdiagnosis(afterglucosecontrolhasbeenestablished)ADA.VII.DiabetesCareinSpecificPopulations.Diabetes Care.2011;34(suppl1):S39.Screening(2)IffamilyhistoryisnotofconcernConsiderfirstlipidscreening
84、atpuberty(10years)AllchildrendiagnosedwithdiabetesatorafterpubertyPerformfastinglipidprofilesoonafterdiagnosis(afterglucosecontrolhasbeenestablished)(E)ADA.VII.DiabetesCareinSpecificPopulations.Diabetes Care.2011;34(suppl1):S39.Recommendations: Pediatric Dyslipidemia (Type 1 Diabetes) (2) Screening(
85、3)Forbothage-groups,iflipidsareabnormalAnnualmonitoringisrecommendedIfLDLcholesterolvaluesarewithinacceptedrisklevels(age10years,statinreasonableinthose(afterMNTandlifestylechanges)withLDLcholesterol160mg/dl(4.1mmol/l)orLDLcholesterol130mg/dl(3.4mmol/l)andOneormoreCVDriskfactors(E)Goaloftherapy:LDLc
86、holesterol100mg/dl(2.6mmol/l)(E)ADA.VII.DiabetesCareinSpecificPopulations.Diabetes Care.2011;34(suppl1):S40.MNT=medicalnutritiontherapyRecommendations: Pediatric Dyslipidemia (Type 1 Diabetes) (4) FirstophthalmologicexaminationObtainoncechildis10yearsofage;hashaddiabetesfor35years(E)Afterinitialexam
87、inationAnnualroutinefollow-upgenerallyrecommendedLessfrequentexaminationsmaybeacceptableonadviceofaneyecareprofessional(E)Recommendations: Pediatric Retinopathy (Type 1 Diabetes)ADA.VII.DiabetesCareinSpecificPopulations.Diabetes Care.2011;34(suppl1):S40.Recommendations: PediatricCeliac Disease (Type
88、 1 Diabetes) (1)Childrenwithtype1diabetesScreenforceliacdiseasebymeasuringtissuetransglutaminaseorantiendomysialantibodies,withdocumentationofnormaltotalserumIgAlevels,soonafterthediagnosisofdiabetes(E)RepeattestinginchildrenwithGrowthfailureFailuretogainweight,weightlossDiarrhea,flatulence,abdomina
89、lpain,orsignsofmalabsorptionFrequentunexplainedhypoglycemiaordeteriorationinglycemiccontrol(E)ADA.VII.DiabetesCareinSpecificPopulations.Diabetes Care.2011;34(suppl1):S40.ChildrenwithpositiveantibodiesRefertoagastroenterologistforevaluationwithendoscopyandbiopsy(E)Childrenwithbiopsy-confirmedceliacdi
90、seasePlaceonagluten-freedietConsultwithadietitianexperiencedinmanagingbothdiabetesandceliacdisease(E)ADA.VII.DiabetesCareinSpecificPopulations.Diabetes Care.2011;34(suppl1):S40.Recommendations: PediatricCeliac Disease (Type 1 Diabetes) (2)Recommendations: Pediatric Hypothyroidism (Type 1 Diabetes)Ch
91、ildrenwithtype1diabetesScreenforthyroidperoxidase,thyroglobulinantibodiesatdiagnosis(E)Thyroid-stimulatinghormone(TSH)concentrationsMeasureaftermetaboliccontrolestablishedIfnormal,recheckevery1-2years;orIfpatientdevelopssymptomsofthyroiddysfunction,thyromegaly,oranabnormalgrowthrateADA.VII.DiabetesC
92、areinSpecificPopulations.Diabetes Care.2011;34(suppl1):S40.Recommendations:Preconception Care (1)Beforeconceptionisattempted,A1ClevelsClosetonormalaspossible(95%)requiredmechanicalventilationADA.VIII.DiabetesCareinSpecificSettings.Diabetes Care.2011;34(suppl1):S44.Diabetes Care in the Hospital: NICE
93、-SUGAR Study (2)Inbothsurgical/medicalpatients,90-daymortalitysignificantlyhigherinintensivelytreatedvsconventionalgroup(target144-180mg/dl)78moredeaths(27.5%vs24.9%;P=0.02)76moredeathsfromcardiovascularcauses(41.6%vs35.8%;P=0.02)Severehypoglycemiamorecommon(6.8%vs0.5%;P0.001)ADA.VIII.DiabetesCarein
94、SpecificSettings.Diabetes Care.2011;34(suppl1):S44.IX. STRATEGIES FOR IMPROVINGDIABETES CAREObjective 1Provider and Team Behavior ChangeADA.IX.StrategiesforImprovingDiabetesCare.Diabetes Care.2010;33(suppl1):S47.Facilitatetimelyandappropriateintensificationoflifestyleand/orpharmaceuticaltherapyofpat
95、ientswhohavenotachievedbeneficiallevelsofbloodpressure,lipid,orglucosecontrolObjective 2Patient Behavior ChangeImplementasystematicapproachtosupportpatientsbehaviorchangeeffortsasneededincluding1)healthylifestyle(physicalactivity,healthyeating,nonuseoftobacco,weightmanagement,effectivecoping,medicat
96、iontakingandmanagement)2)preventionofdiabetescomplications(screeningforeye,foot,andrenalcomplications;immunizations)3)achievementofappropriatebloodpressure,lipid,andglucosegoalsADA.IX.StrategiesforImprovingDiabetesCare.Diabetes Care.2011;34(suppl1):S47.Objective 3Change the Systems of CareResearchon
97、thecomprehensivechroniccare(CCM)modelsuggestsadditionalstrategiestoimprovediabetescareConsistent,evidence-basedcareguidelinesCollaborative,multidisciplinaryteamsAuditandfeedbackofprocessandoutcomedatatoprovidersCaremanagementIdentifyingand/ordevelopingcommunityresourcesandpublicpolicythatsupportshealthylifestylesAlterationsinreimbursementADA.IX.StrategiesforImprovingDiabetesCare.Diabetes Care.2011;34(suppl1):S47.
