Standards of Medical Care in Diabetes—2015 Abridged for Primary Care Providers

Recommendations

• Patient-centered communication that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care should be used. B

• Care should be aligned with components of the Chronic Care Model (CCM) to ensure productive interactions between a prepared proactive practice team and an informed activated patient. A

Recommendations

• Testing to detect type 2 diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 kg/m² or ≥23 kg/m² in Asian Americans) and who have one or more additional risk factors for diabetes. For all patients, particularly those who are overweight or obese, testing should begin at age 45 years. B

• If tests are normal, repeat testing carried out at a minimum of 3-year intervals is reasonable. C

• In patients with prediabetes or diabetes, identify and, if appropriate, treat other CVD risk factors. B

• Testing to detect prediabetes and type 2 diabetes should be considered in children and adolescents who are overweight or obese and who have two or more additional risk factors for diabetes. E

The modified recommendations of the ADA consensus report “Type 2 Diabetes in Children and Adolescents” (14) are summarized in Table 4.

Recommendations

• Test for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria. B

• Test for GDM at 24–28 weeks of gestation in pregnant women not previously known to have diabetes. A

• Screen women with GDM for persistent diabetes at 6–12 weeks postpartum, using the OGTT and clinically appropriate nonpregnancy diagnostic criteria. E

• Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years. B

• Women with a history of GDM found to have prediabetes should receive lifestyle interventions or metformin to prevent diabetes. A

Recommendations

• Consider screening those with type 1 diabetes for autoimmune diseases (e.g., thyroid dysfunction, celiac disease) as appropriate. E

• Consider assessing for and addressing common comorbid conditions (e.g., depression, obstructive sleep apnea) that may complicate diabetes management. B

Additional comorbid conditions to consider assessing include fatty liver disease, cancer, fractures, cognitive impairment, low testosterone in men, periodontal disease, and hearing impairment.

Recommendations

• People with diabetes should receive DSME and DSMS according to the national standards for DSME and DSMS when their diabetes is diagnosed and as needed thereafter. B

• Effective self-management and quality of life are the key outcomes of DSME and DSMS and should be measured and monitored as part of care. C

• DSME and DSMS should address psychosocial issues, as emotional well-being is associated with positive diabetes outcomes. C

• DSME and DSMS programs are appropriate venues for people with prediabetes to receive education and support to develop and maintain behaviors that can prevent or delay the onset of diabetes. C

• Because DSME and DSMS can result in cost-savings and improved outcomes B, DSME and DSMS should be adequately reimbursed by third-party payers. E

Recommendations

• Children with diabetes or prediabetes should be encouraged to engage in at least 60 min of physical activity each day. B

• Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise. A

• Evidence supports that all individuals, including those with diabetes, should be encouraged to reduce sedentary time, particularly by breaking up extended amounts of time (>90 min) spent sitting. B

• In the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week. A

Recommendations

• Advise all patients not to smoke or use tobacco products. A

• Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care. B

Recommendations

• Include assessment of the patient’s psychological and social situation as an ongoing part of the medical management of diabetes. B

• Psychosocial screening and follow-up may include, but are not limited to, attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional), and psychiatric history. E

• Routinely screen for psychosocial problems such as depression, diabetes-related distress, anxiety, eating disorders, and cognitive impairment. B

• Older adults (aged ≥65 years) with diabetes should be considered a high-priority population for depression screening and treatment. B

• Patients with comorbid diabetes and depression should receive astepwise collaborative care app-roach for the management of depression. A

Recommendations

• Provide routine vaccinations for children and adults with diabetes as for the general population. C

• Annually provide an influenza vaccine to all patients with diabetes ≥6 months of age. C

• Administer pneumococcal polysaccharide vaccine 23 (PPSV23) to all patients with diabetes ≥2 years of age. C

• Adults ≥65 years of age, if not previously vaccinated, should receive pneumococcal conjugate vaccine 13 (PCV13), followed by PPSV23 6–12 months after initial vaccination. C

• Adults ≥65 years of age, if previously vaccinated with PPSV23, should receive a follow-up ≥12 months with PCV13. C

• Administer hepatitis B vaccination to unvaccinated adults with diabetes who are aged 19–59 years. C

• Consider administering hepatitis B vaccination to unvaccinated adults with diabetes who are aged ≥60 years. C

Recommendations

• Patients with impaired glucose tolerance (IGT) A, impaired fasting glucose (IFG) E, or an A1C 5.7–6.4% E should be referred to an intensive diet and physical activity behavioral counseling program targeting loss of 7% of body weight and increasing moderate-intensity physical activity (such as brisk walking) to at least 150 min/week.

• Metformin therapy for prevention of type 2 diabetes may be considered in those with IGT A, IFG E, or an A1C 5.7–6.4% E, especially for those with BMI >35 kg/m², aged <60 years, and women with prior GDM. A

• At least annual monitoring for the development of diabetes in those with prediabetes is suggested. E

• Screening for and treatment of modifiable risk factors for CVD is suggested. B

Intensive lifestyle modification programs have been shown to be very effective (∼58% reduction after 3 years) (15–17), and pharmacological agents metformin, α-glucosidase inhibitors, orlistat, and thiazolidinediones (TZDs) have been shown to decrease incident diabetes to various degrees.

Individuals with an A1C of 5.7–6.4%, IGT, or IFG should be counseled on lifestyle changes with goals similar to those of the Diabetes Prevention Program (7% weight loss and moderate physical activity of at least 150 min/week). Metformin has demonstrated long-term safety as pharmacological therapy for diabetes prevention.

Recommendation

• Patients on multiple-dose insulin or insulin pump therapy should perform self-monitoring of blood glucose (SMBG) prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. B

Two primary techniques are available for health providers and patients to assess the effectiveness of the management plan on glycemic control: patient SMBG or interstitial glucose and A1C. Continuous glucose monitoring (CGM) may be a useful adjunct to SMBG in selected patients.

SMBG frequency and timing should be dictated by the patient’s specific needs and goals. SMBG is especially important for patients treated with insulin to monitor for and prevent asymptomatic hypoglycemia and hyperglycemia. For patients on nonintensive insulin regimens, such as those with type 2 diabetes on basal insulin, when to prescribe SMBG and the testing frequency are less established.

SMBG allows patients to evaluate their individual response to therapy and assess whether glycemic targets are being achieved. Results of SMBG can be useful in preventing hypoglycemia and adjusting medications (particularly prandial insulin doses), medical nutrition therapy, and physical activity. Evidence also supports a correlation between SMBG frequency and lower A1C (18).

SMBG accuracy is instrument and user dependent (19), so it is important to evaluate each patient’s monitoring technique, both initially and at regular intervals thereafter. The ongoing need for and frequency of SMBG should be reevaluated at each routine visit.

Recommendations

• Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). E

• Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. E

• Use of point-of-care testing for A1C provides the opportunity for more timely treatment changes. E

For patients in whom A1C/estimated average glucose and measured blood glucose appear discrepant, clinicians should consider the possibilities of hemoglobinopathy or altered red blood cell turnover and the options of more frequent and/or different timing of SMBG or use of CGM. Other measures of chronic glycemia such as fructosamine are available, but their linkage to average glucose and their prognostic significance are not as clear as for A1C.

Recommendations

• Lowering A1C to approximately 7% or less has been shown to reduce microvascular complications of diabetes, and, if implemented soon after the diagnosis of diabetes, it is associated with long-term reduction in macrovascular disease. Therefore, a reasonable A1C goal for many nonpregnant adults is <7%. B

• Providers might reasonably suggest more stringent A1C goals (such as <6.5%) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant CVD. C

• Less stringent A1C goals (such as <8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced micro- or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite DSME, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. B

See Figure 1 for patient and disease factors used to determine optimal A1C targets. Recommended glycemic targets are provided in Table 6. The recommendations are based on those for A1C values, with blood glucose levels that appear to correlate with achievement of an A1C of <7%.

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FIGURE 1.

Depicted are patient and disease factors used to determine optimal A1C targets. Characteristics and predicaments toward the left justify more stringent efforts to lower A1C; those toward the right suggest less stringent efforts. Adapted with permission from Inzucchi et al. (22).

Recommendations

• Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter. C

• Glucose (15–20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. Fifteen minutes after treatment, if SMBG shows continued hypoglycemia, the treatment should be repeated. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. E

• Glucagon should be prescribed for all individuals at an increased risk of severe hypoglycemia, and caregivers or family members of these individuals should be instructed on its administration. Glucagon administration is not limited to health care professionals. E

• Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger reevaluation of the treatment regimen. E

• Insulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. A

• Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if low cognition and/or declining cognition is found. B

Pure glucose is the preferred treatment, but any form of carbohydrate that contains glucose will raise blood glucose. Added fat may retard and then prolong the acute glycemic response. Ongoing insulin activity or insulin secretagogues may lead to recurrent hypoglycemia unless further food is ingested after recovery.

Family members, roommates, school personnel, child care providers, correctional institution staff, or coworkers should be instructed on use of glucagon kits. An individual does not need to be a health care professional to safely administer glucagon.

Recommendations

• Most people with type 1 diabetes should be treated with multiple-dose insulin injections (three to four injections per day of basal and prandial insulin) or continuous subcutaneous insulin infusion therapy. A

• Most people with type 1 diabetes should be educated in how to match prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated physical activity. E

• Most people with type 1 diabetes should use insulin analogs to reduce hypoglycemia risk. A

For patients with frequent noc-turnal hypoglycemia and/or hypo-glycemia unawareness, a sensor-augmented low glucose threshold suspend pump may be considered.

Recommendations

• Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacological agent for type 2 diabetes. A

• In patients with newly diagnosed type 2 diabetes and markedly symptomatic and/or elevated blood glucose levels or A1C, consider initiating insulin therapy (with or without additional agents). E

• If noninsulin monotherapy at maximum tolerated dose does not achieve or maintain the A1C target over 3 months, add a second oral agent, a glucagon-like peptide 1 (GLP-1) receptor agonist, or basal insulin. A

• A patient-centered approach should be used to guide choice of pharmacological agents. Considerations include efficacy, cost, potential side effects, weight, comorbidities, hypoglycemia risk, and patient preferences. E

• Due to the progressive nature of type 2 diabetes, insulin therapy is eventually indicated for many patients with type 2 diabetes. B

Figure 2 emphasizes drugs commonly used in the U.S. and/or Europe.

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FIGURE 2.

Antihyperglycemic therapy in type 2 diabetes: general recommendations (22). The order in the chart was determined by historical availability and the route of administration, with injectables to the right; it is not meant to denote any specific preference. Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, with the usual transition moving vertically from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). DPP-4-i, DPP-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1-RA, GLP-1 receptor agonist; GU, genitourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, sodium-glucose cotransporter 2 inhibitor; SU, sulfonylurea. *See ref. 22 for description of efficacy categorization. †Consider starting at this stage when A1C is ≥9%. ‡Consider starting at this stage when blood glucose is ≥300–350 mg/dL (16.7–19.4 mmol/L) and/or A1C is ≥10–12%, especially if symptomatic or catabolic features are present, in which case insulin + mealtime is the preferred initial regimen. §Usually a basal insulin (NPH, glargine, detemir, degludec). Adapted with permission from Inzucchi et al. (22).

A comprehensive list of the properties of available glucose-lowering agents in the U.S. and Europe that may guide individualized treatment choices in patients with type 2 diabetes is available in the complete 2015 Standards, reprinted from Inzucchi et al. (22).

Many patients with type 2 diabetes eventually require and benefit from insulin therapy. The progressive nature of type 2 diabetes and its therapies should be regularly and objectively explained to patients. Providers should avoid using insulin as a threat or describing it as a failure or punishment. Equipping patients with an algorithm for self-titration of insulin doses based on SMBG results improves glycemic control in patients with type 2 diabetes initiating insulin. Refer to the ADA–European Association for the Study of Diabetes (EASD) position statement (22) for more details on pharmacotherapy for hyperglycemia in type 2 diabetes.

Recommendations

• Bariatric surgery may be considered for adults with BMI >35 kg/m² and type 2 diabetes, especially if diabetes or associated comorbidities are difficult to control with lifestyle and pharmacological therapy. B

• Patients with type 2 diabetes who have undergone bariatric surgery need lifelong lifestyle support and medical monitoring. B

• Although small trials have shown glycemic benefit of bariatric surgery in patients with type 2 diabetes and BMI 30–35 kg/m², there is currently insufficient evidence to generally recommend surgery in patients with BMI <35 kg/m². E

Recommendations

• People with diabetes and hypertension should be treated to a systolic blood pressure (SBP) goal of <140 mmHg. A

• Lower systolic targets, such as <130 mmHg, may be appropriate for certain individuals, such as younger patients, if they can be achieved without undue treatment burden. C

• Individuals with diabetes should be treated to a diastolic blood pressure (DBP) <90 mmHg. A

• Lower diastolic targets, such as <80 mmHg, may be appropriate for certain individuals, such as younger patients, if they can be achieved without undue treatment burden. B

• Patients with blood pressure >120/80 mmHg should be advised on lifestyle changes to reduce blood pressure. B

• Patients with confirmed office-based blood pressure >140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve blood pressure goals. A

• Lifestyle therapy for elevated blood pressure consists of weight loss, if overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern including reducing sodium and increasing potassium intake; moderation of alcohol intake; and increased physical activity. B

• Pharmacological therapy for patients with diabetes and hypertension should comprise a regimen that includes either an ACE inhibitor or an angiotensin receptor blocker (ARB). B If one class is not tolerated, the other should be substituted. C

• Multiple-drug therapy (including a thiazide diuretic and ACE inhibitor/ARB, at maximal doses) is generally required to achieve blood pressure targets. B

Recommendations

• Optimize glucose control and blood pressure to reduce the risk or slow the progression of diabetic kidney disease (DKD). A

• At least once a year, quantitatively assess urinary albumin (e.g., urine albumin-to-creatinine ratio [UACR]) and estimated glomerular filtration rate (eGFR) in patients with type 1 diabetes duration of ≥5 years and in all patients with type 2 diabetes. B

Complications of CKD correlate with levels of kidney function (Table 8).

Intensive diabetes management with the goal of achieving near-normoglycemia has been shown in large prospective randomized studies to delay the onset and progression of increased urinary albumin excretion and reduced eGFR in patients with type 1 diabetes (1) and type 2 diabetes (34). Screening for increased urinary albumin excretion can be performed by UACR in a random spot urine collection; 24-h or timed collections are more burdensome and add little to prediction or accuracy (35,36). Two of three specimens collected within a 3- to 6-month period should be abnormal before considering a patient to have developed albuminuria.

ACE inhibitors and ARBs provide selective benefit in slowing decline in GFR in patients with higher levels of albumin (37–40). ACE inhibitors reduce major CVD outcomes in patients with diabetes, supporting their use in patients with elevated albuminuria (a CVD risk factor) (41). ARBs reduce progression of albuminuria and end-stage renal disease in patients with type 2 diabetes (42–44), but they do not reduce risk of CVD events or albuminuria in normotensive patients with type 1 or type 2 diabetes (41).

Additional blood pressure lowering can be accomplished with diuretics, calcium channel blockers, and β-blockers.

Combining an ACE inhibitor and an ARB provides no additional benefit for CVD or DKD and has a higher adverse event risk (45). Thus, combined use should be avoided.

Recommendations

• Optimize glycemic and blood pressure control to reduce the risk or slow the progression of retinopathy. A

• Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. B

• Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes. B

Intensive diabetes management with the goal of achieving near-normoglycemia has been shown in large prospective randomized studies to prevent and/or delay the onset and progression of diabetic retinopathy (34,46).

Because retinopathy is estimated to take at least 5 years to develop after the onset of hyperglycemia, patients with type 1 diabetes should have an initial dilated and comprehensive eye examination within 5 years after the diabetes diagnosis (47). These exams should be repeated annually. Photos are not a substitute for a comprehensive eye exam.

Recommendations

• All patients should be screened for diabetic peripheral neuropathy (DPN) starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter, using simple clinical tests, such as a 10-g monofilament. B

• Screening for signs and symptoms (e.g., orthostasis, resting tachycardia) of cardiovascular autonomic neuropathy (CAN) should be considered with more advanced disease. E

• Tight glycemic control is the only strategy convincingly shown to prevent or delay the development of DPN and CAN in patients with type 1 diabetes A and to slow the progression of neuropathy in some patients with type 2 diabetes. B

Clinical tests for DPN include pinprick sensation, vibration threshold using 128-Hz tuning fork, and 10-g monofilament and ankle reflexes.

DPN can be debilitating (48) but may be treated with pregabalin, duloxetine, and tapentadol. For persistent painful DPN, venlafaxine, amitriptyline, gabapentin, valproate, and opioids may be considered. A tailored and stepwise strategy is recommended (49).

Autonomic neuropathy, particularly CAN, is an independent risk factor for cardiovascular mortality (50,51). Major clinical manifestations of autonomic neuropathy include resting tachycardia, exercise intolerance, orthostatic hypotension, gastroparesis, constipation, erectile dysfunction, impaired neurovascular function, and autonomic failure in response to hypoglycemia. In men, diabetic autonomic neuropathy may cause erectile dysfunction or retrograde ejaculation.

Gastrointestinal neuropathies may involve any section of the gastrointestinal tract. Gastroparesis should be suspected in individuals with erratic glucose control and upper gastrointestinal symptoms. Constipation is the most common lower gastrointestinal symptom but can alternate with diarrhea.

Gastroparesis may improve with dietary changes and prokinetic agents such as erythromycin. Due to side effects, metoclopramide is reserved for the most severe and unresponsive case.

Recurrent urinary tract infections, pyelonephritis, incontinence, or palpable bladder should evoke evaluation of bladder dysfunction.

Control of lipids, blood pressure, smoking, and other lifestyle factors can reduce the progression and development of CAN (52).

Recommendation

• For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection and assessment of foot pulses. B

Previous amputation, prior foot ulcer, peripheral neuropathy, foot deformity, peripheral vascular disease, visual impairment, peripheral neuropathy (especially if on dialysis), poor glycemic control, and smoking all represent high risk.

Components of the screening exam include inspection of skin integrity and musculoskeletal deformity and assessment of pedal pulses. The exam should seek to identify loss of peripheral sensation (LOPS). Five simple tests (10-g monofilament, 128-Hz tuning fork, pinprick sensation, ankle reflexes, and testing vibration perception threshold with biothesiometer) can identify LOPS in the diabetic foot. Two of these tests should be performed annually. One or more abnormal tests would suggest LOPS and two or more normal tests would rule out LOPS.

Screening for peripheral arterial disease (PAD) (ankle-brachial index evaluation) should include a history of claudication and assessment of pedal pulses. Screening for PAD should start at age 50 years and be considered at <50 years of age in those with PAD risk factors.

Patients with high-risk foot conditions should be educated about their risk and appropriate management. This may be managed with well-fitted walking shoes that cushion the feet and redistribute pressure. Those with boney deformities may need extra wide or deep shoes. Some with more advanced disease may need custom fitted shoes.

Recommendations

• Older adults who are functional and cognitively intact and have significant life expectancy should receive diabetes care with goals similar to those developed for younger adults. E

• Glycemic goals for some older adults might reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. E

• Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. E

• Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. E

• Older adults (≥65 years of age) with diabetes should be considered a high-priority population for depression screening and treatment. B

The care of older adults with diabetes is complicated by their clinical and functional heterogeneity. Providers caring for older adults with diabetes must take this heterogeneity into consideration when setting and prioritizing treatment goals (Table 9).

Recommendations

• An A1C goal of <7.5% is recommended across all pediatric age-groups. E

• Blood pressure should be measured at each routine visit. Children found to have high-normal blood pressure (SBP or DBP ≥90th percentile for age, sex, and height) or hypertension (SBP or DBP ≥95th percentile for age, sex, and height) should have blood pressure confirmed on three separate days. B

The benefit of A1C control should be balanced against the risk of hypoglycemia and the developmental burden of intensive regimens for children and youth (58).

Blood pressure measurements should be determined using the appropriate size cuff and with the child seated and relaxed. ACE inhibitors or ARBs should be considered first line, following appropriate reproductive counseling due to teratogenic effects.

Recommendations

• Obtain a fasting lipid profile on children ≥2 years of age soon after the diagnosis (after glucose control has been established). E

• If lipids are abnormal, annual monitoring is reasonable. If LDL cholesterol values are within the accepted risk levels (<100 mg/dL [2.6 mmol/L]), a lipid profile repeated every 5 years is reasonable. E

Lipids should be obtained at diagnosis of type 2 diabetes due to the presence of increased comorbid conditions (59). Annual monitoring is recommended if LDL is <100 mg/dL.

For specific recommendations and additional guidance, refer to “Type 2 Diabetes in Children and Adolescents” (14).

Recommendations

• GDM should be managed first with diet and exercise, and medications should be added if needed. A

• Due to alterations in red blood cell turnover that lower the normal A1C level in pregnancy, the A1C target in pregnancy is <6% if this can be achieved without significant hypoglycemia. B

• Medications widely used in pregnancy include insulin, metformin, and glyburide; most oral agents cross the placenta or lack long-term safety data. B

Optimal glycemic goals for women with GDM and for women with preexisting type 1 or type 2 diabetes who become pregnant are available in the complete 2015 Standards (21).

Insulin is the preferred agent for management due to the lack of long-term safety data for noninsulin agents. In type 2 diabetes, care with weight gain and management of comorbid conditions remains paramount (60,61).

For women with GDM, screening for persistent diabetes at 6–12 weeks postpartum and every 1–3 years thereafter is recommended (62).

Recommendations

• Diabetes discharge planning should start at hospital admission, and clear diabetes management instructions should be provided at discharge. E

• The sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged. A

• All patients with diabetes admitted to the hospital should have their diabetes type clearly identified in the medical record. E