Am Fam Physician. 2010;82(2):206-208
Guideline source: American Diabetes Association
Literature search described? No
Evidence rating system used? Yes
Published source: Diabetes Care, January 2010
Available at: http://care.diabetesjournals.org/content/33/Supplement_1
The 2010 American Diabetes Association's (ADA) “Standards of Medical Care in Diabetes” includes revisions based on new evidence. Several sections have undergone major changes; these changes are outlined below.
Current criteria for the diagnosis of diabetes mellitus include a fasting plasma glucose level of 126 mg per dL (6.99 mmol per L) or greater; two-hour plasma glucose level of 200 mg per dL (11.10 mmol per L) or greater during an oral glucose tolerance test; or a random plasma glucose level of 200 mg per dL in a patient with hyperglycemia or hyperglycemic crisis symptoms. A1C level is now included in the diagnosis of diabetes, with a cut point of 6.5 percent or greater.
Categories of Increased Risk
An A1C level of 5.7 to 6.4 percent has been added as a category of increased risk of future diabetes. This is in addition to impaired fasting glucose (100 to 125 mg per dL [5.55 to 6.94 mmol per L]) and glucose tolerance (140 to 199 mg per dL [7.77 to 11.04 mmol per L]). Patients with any of these risk factors should be referred to a support program for weight loss and increased physical activity. Metformin (Glucophage) may also be considered in persons at very high risk of diabetes who are obese and younger than 60 years.
National standards suggest that persons with diabetes receive diabetes self-management education at diagnosis and on an as-needed basis, with the goals of improving effective self-management and quality of life. These outcomes should be monitored as part of standard care. Because emotional well-being is associated with positive diabetes outcomes, self-management education should also focus on psychosocial issues. Third-party payors should provide reimbursement for self-management education.
Treatment with Antiplatelet Agents
Aspirin (75 to 162 mg per day) should be considered as a primary prevention strategy in persons with type 1 or 2 diabetes and an increased cardiovascular risk (10-year risk greater than 10 percent), including most men older than 50 years and most women older than 60 years with at least one additional major risk factor (i.e., family history of cardiovascular disease, hypertension, smoking, dyslipidemia, or albuminuria). There is insufficient evidence to recommend aspirin therapy as a primary prevention strategy in persons with lower risk, including men younger than 50 years or women younger than 60 years without major risk factors. Clinical judgment should be used when patients in these age groups have multiple other risk factors.
Aspirin therapy should be used as a secondary prevention strategy in persons with diabetes and a history of cardiovascular disease. Clopidogrel (Plavix; 75 mg per day) should be used in persons with cardiovascular disease who have an allergy to aspirin. Combination therapy with aspirin and clopidogrel is reasonable for up to one year after acute coronary syndrome.
An initial dilated and comprehensive eye examination should be performed by an ophthalmologist or optometrist within five years of a type 1 diabetes diagnosis in persons at least 10 years of age; persons with type 2 diabetes should have the examination shortly after diagnosis. Subsequent examinations should be done annually; if retinopathy is progressing, examinations should be done more frequently. If the patient has one or more normal examinations, examinations may be considered every two to three years. Women with diabetes who are or may become pregnant should have a comprehensive eye examination and should be counseled about the risk of development or progression of retinopathy. The eye examination should be performed in the first trimester, with follow-up examinations throughout pregnancy and for one year postpartum.
The ADA now includes recommendations on the use of high-quality fundus photographs, which can detect most clinically significant diabetic retinopathy; however, even though photography can be used as a screening tool, it should not replace a comprehensive eye examination. A trained eye care professional should interpret the photographs.