Position Statement

Standards of Medical Care in Diabetes—2018 Abridged for Primary Care Providers

  1. American Diabetes Association
  1. This is an abridged version of the American Diabetes Association’s Standards of Medical Care in Diabetes—2018. Diabetes Care 2018;41(Suppl. 1):S1–S159.
Clinical Diabetes 2018 Jan; 36(1): 14-37. https://doi.org/10.2337/cd17-0119

Article Figures & Tables

Figures

  • FIGURE 1.
    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. Diabetes Care 2015;38:140–149.

  • FIGURE 2.
    FIGURE 2.

    Antihyperglycemic therapy in type 2 diabetes: general recommendations. *If patient does not tolerate or has contraindications to metformin, consider agents from another class in Table 7. #GLP-1 receptor agonists and DPP-4 inhibitors should not be prescribed in combination. If a patient with ASCVD is not yet on an agent with evidence of cardiovascular risk reduction, consider adding.

  • FIGURE 3.
    FIGURE 3.

    Combination injectable therapy for type 2 diabetes. FBG, fasting blood glucose; hypo, hypoglycemia. Adapted with permission from Inzucchi et al. Diabetes Care 2015;38:140–149.

Tables

  • TABLE 1.

    Criteria for the Screening and Diagnosis of Diabetes

    PrediabetesDiabetes
    A1C5.7–6.4%*≥6.5%†
    FPG100–125 mg/dL (5.6–6.9 mmol/L)*≥126 mg/dL (7.0 mmol/L)†
    OGTT140–199 mg/dL (7.8–11.0 mmol/L)*≥200 mg/dL (11.1 mmol/L)†
    RPG—≥200 mg/dL (11.1 mmol/L)‡

    • ↵* For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at the higher end of the range.

    • ↵† In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing.

    • ↵‡ Only diagnostic in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis. RPG, random plasma glucose.

  • TABLE 2.

    Criteria for Testing for Diabetes or Prediabetes in Asymptomatic Adults

    Testing should be considered in overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) adults who have one or more of the following risk factors:
    First-degree relative with diabetes
    High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
    History of CVD
    Hypertension (≥140/90 mmHg or on therapy for hypertension)
    HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)
    Women with polycystic ovary syndrome
    Physical inactivity
    Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
    Patients with prediabetes (A1C ≥5.7% [39 mmol/mol], IGT, or IFG) should be tested yearly.
    Women who were diagnosed with GDM should have lifelong testing at least every 3 years.
    For all other patients, testing should begin at age 45 years.
    If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.
  • TABLE 3.

    Risk-Based Screening for Type 2 Diabetes or Prediabetes in Asymptomatic Children and Adolescents in a Clinical Setting*

    Criteria
    ● Overweight (BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height) A
    ● Plus one or more additional risk factors based on the strength of their association with diabetes as indicated by evidence grades:
    ● Maternal history of diabetes or GDM during the child’s gestation A
    ● Family history of type 2 diabetes in first- or second-degree relative A
    ● Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) A
    ● Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight) B

    • ↵* Persons aged <18 years.

  • TABLE 5.

    Situations That Warrant Referral of a Person With Diabetes to a Mental Health Provider for Evaluation and Treatment

    • If self-care remains impaired in a person with DD after tailored diabetes education

    • If a person has a positive screen on a validated screening tool for depressive symptoms

    • In the presence of symptoms or suspicions of disordered eating behavior, an eating disorder, or disrupted patterns of eating

    • If intentional omission of insulin or oral medication to cause weight loss is identified

    • If a person has a positive screen for anxiety or fear of hypoglycemia

    • If a serious mental illness is suspected

    • In youth and families with behavioral self-care difficulties, repeated hospitalizations for diabetic ketoacidosis, or significant distress

    • If a person screens positive for cognitive impairment

    • Declining or impaired ability to perform diabetes self-care behaviors

    • Before undergoing bariatric or metabolic surgery and after surgery if assessment reveals an ongoing need for adjustment support

  • TABLE 6.

    Summary of Glycemic Recommendations for Many Nonpregnant Adults With Diabetes

    A1C<7.0% (53 mmol/mol)*
    Preprandial capillary plasma glucose80–130 mg/dL (4.4–7.2 mmol/L)*
    Peak postprandial capillary plasma glucose†<180 mg/dL (10.0 mmol/L)*

    • ↵* More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.

    • ↵† Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals. Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.

  • TABLE 7.
  • TABLE 8.

    Recommendations for Statin and Combination Treatment in Adults With Diabetes

    AgeASCVDRecommended statin intensity^ and combination treatment*
    <40 yearsNoNone†
    YesHigh
    If LDL cholesterol ≥70 mg/dL (3.9 mmol/L) despite maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or PCSK9 inhibitor)#
    ≥40 yearsNoModerate‡
    YesHigh
    If LDL cholesterol ≥70 mg/dL (3.9 mmol/L) despite maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or PCSK9 inhibitor)

    • ↵* In addition to lifestyle therapy.

    • ↵^ For patients who do not tolerate the intended intensity of statin, the maximally tolerated statin dose should be used.

    • ↵† Moderate-intensity statin may be considered based on risk-benefit profile and presence of ASCVD risk factors. ASCVD risk factors include LDL cholesterol ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, CKD, albuminuria, and family history of premature ASCVD.

    • ↵‡ High-intensity statin may be considered based on risk-benefit profile and presence of ASCVD risk factors.

    • ↵# Adults aged <40 years with prevalent ASCVD were not well represented in clinical trials of nonstatin-based LDL reduction. Before initiating combination lipid-lowering therapy, consider the potential for further ASCVD risk reduction, drug-specific adverse effects, and patient preferences.

  • TABLE 9.

    High-Intensity and Moderate-Intensity Statin Therapy*

    High-intensity statin therapy (lowers LDL cholesterol by ≥50%)Moderate-intensity statin therapy (lowers LDL cholesterol by 30–50%)
    Atorvastatin 40–80 mgAtorvastatin 10–20 mg
    Rosuvastatin 20–40 mgRosuvastatin 5–10 mg
    Simvastatin 20–40 mg
    Pravastatin 40–80 mg
    Lovastatin 40 mg
    Fluvastatin XL 80 mg
    Pitavastatin 2–4 mg

    • ↵* Once-daily dosing. XL, extended release.

  • TABLE 10.

    CKD Stages and Corresponding Focus of Kidney-Related Care

    CKD Stage†Focus of Kidney-Related Care
    StageeGFR (ml/min/1.73 m2)Evidence of Kidney Damage*Diagnose Cause of Kidney InjuryEvaluate and Treat Risk Factors for CKD Progression**Evaluate and Treat CKD Complications***Prepare for Renal Replacement Therapy
    No clinical evidence of CKD≥60—
    1≥90+✓✓
    260–89+✓✓
    330–59+/–✓✓✓
    415–29+/–✓✓✓
    5<15+/–✓✓

    • ↵† CKD stages 1 and 2 are defined by evidence of kidney damage (+), while CKD stages 3–5 are defined by reduced eGFR with or without evidence of kidney damage (+/–).

    • ↵* Kidney damage is most often manifest as albuminuria (UACR ≥30 mg/g Cr) but can also include glomerular hematuria, other abnormalities of the urinary sediment, radiographic abnormalities, and other presentations.

    • ↵** Risk factors for CKD progression include elevated blood pressure, glycemia, and albuminuria.

    • ***See Table 10.2 in the full 2018 Standards of Care.

  • TABLE 11.

    Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older Adults With Diabetes

    Patient Characteristics/ Health StatusRationaleReasonable A1C Goal‡Fasting or Preprandial GlucoseBedtime GlucoseBlood PressureLipids
    Healthy (few coexisting chronic illnesses, intact cognitive and functional status)Longer remaining life expectancy<7.5% (58 mmol/mol)90–130 mg/dL (5.0–7.2 mmol/L)90–150 mg/dL (5.0–8.3 mmol/L)<140/90 mmHgStatin unless contraindicated or not tolerated
    Complex/intermediate (multiple coexisting chronic illnesses* or 2+ instrumental ADL impairments or mild-to-moderate cognitive impairment)Intermediate remaining life expectancy, high treatment burden, hypoglycemia vulnerability, fall risk<8.0% (64 mmol/mol)90–150 mg/dL (5.0–8.3 mmol/L)100–180 mg/dL (5.6–10.0 mmol/L)<140/90 mmHgStatin unless contraindicated or not tolerated
    Very complex/poor health (LTC or end-stage chronic illnesses** or moderate-to-severe cognitive impairment or 2+ ADL dependencies)Limited remaining life expectancy makes benefit uncertain<8.5%† (69 mmol/mol)100–180 mg/dL (5.6–10.0 mmol/L)110–200 mg/dL (6.1–11.1 mmol/L)<150/90 mmHgConsider likelihood of benefit with statin (secondary prevention more so than primary)

    • This represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes. The patient characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consideration of patient and caregiver preferences is an important aspect of treatment individualization. Additionally, a patient’s health status and preferences may change over time.

    • ↵‡ A lower A1C goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden.

    • ↵* Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, congestive heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. By “multiple,” we mean at least three, but many patients may have five or more.

    • ↵** The presence of a single end-stage chronic illness, such as stage 3–4 congestive heart failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer, may cause significant symptoms or impairment of functional status and significantly reduce life expectancy.

    • ↵† A1C of 8.5% (69 mmol/mol) equates to an estimated average glucose of ∼200 mg/dL (11.1 mmol/L). Looser A1C targets above 8.5% (69 mmol/mol) are not recommended as they may expose patients to more frequent higher glucose values and the acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing. ADL, activities of daily living.

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Standards of Medical Care in Diabetes—2018 Abridged for Primary Care Providers
American Diabetes Association
Clinical Diabetes Jan 2018, 36 (1) 14-37; DOI: 10.2337/cd17-0119
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