Standards of Care

Standards of Medical Care in Diabetes—2020 Abridged for Primary Care Providers

  1. American Diabetes Association
Clinical Diabetes 2020 Jan; 38(1): 10-38. https://doi.org/10.2337/cd20-as01

Article Figures & Tables

Figures

  • FIGURE 4.1
    FIGURE 4.1

    Decision cycle for patient-centered glycemic management in type 2 diabetes. HbA1c, glycated hemoglobin. Reprinted from Davies MJ, D’Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:2669–2701.

  • FIGURE 6.1
    FIGURE 6.1

    Sample AGP report. Adapted from Battelino T, Danne T, Bergenstal RM, et al. Diabetes Care 2019;42:1593–1603.

  • FIGURE 6.2
    FIGURE 6.2

    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. A1C 7%553 mmol/mol. Adapted with permission from Inzucchi SE, Bergenstal RM, Buse JB, et al. Diabetes Care 2015;38:140–149.

  • FIGURE 9.1
    FIGURE 9.1

    Glucose-lowering medication in type 2 diabetes: overall approach. For appropriate context, see Figure 4.1. CREDENCE, Evaluation of the Effects of Canagliflozin on Renal and Cardiovascular Outcomes in Participants With Diabetic Nephropathy. CVOTs, CV outcomes trials; DPP-4i, dipeptidyl peptidase 4 inhibitor; GLP-1 RA, GLP-1 receptor agonist; SGLT2i, SGLT2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione. Adapted from Davies MJ, D'Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:2669–2701 and Buse JB, Wexler DJ, Tsapas A, et al. Diabetes Care 19 December 2019 [Epub ahead of print]. DOI: 10.2337/dci19-0066.

  • FIGURE 9.2
    FIGURE 9.2

    Intensifying to injectable therapies. FPG, fasting plasma glucose; FRC, fixed-ratio combination; GLP-1 RA, GLP-1 receptor agonist; iDegLira, insulin degludec/liraglutide; iGlarLixi, insulin glargine/lixisenatide; max, maximum; PPG, postprandial glucose; Table 9.3 appears in the complete 2020 Standards of Care. Adapted from Davies MJ, D'Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:2669–2701.

  • FIGURE 10.1
    FIGURE 10.1

    Recommendations for the treatment of confirmed hypertension in people with diabetes. *An ACE inhibitor (ACEi) or ARB is suggested to treat hypertension for patients with a UACR 30–299 mg/g Cr and strongly recommended for patients with a UACR ≥300 mg/g Cr. **Thiazide-like diuretic; long-acting agents shown to reduce CV events, such as chlorthalidone and indapamide, are preferred. ***Dihydropyridine CCB. BP, blood pressure. Adapted from de Boer IH, Bangalore S, Benetos A, et al. Diabetes Care 2017;40:1273–1284.

  • FIGURE 11.1
    FIGURE 11.1

    Risk of CKD progression, frequency of visits, and referral to nephrology according to GFR and albuminuria. The GFR and albuminuria grid depicts the risk of progression, morbidity, and mortality by color, from best to worst (green, yellow, orange, red, dark red). The numbers in the boxes are a guide to the frequency of visits (number of times per year). Green can reflect CKD with normal eGFR and UACR only in the presence of other markers of kidney damage, such as imaging showing polycystic kidney disease or kidney biopsy abnormalities, with follow-up measurements annually; yellow requires caution and measurements at least once per year; orange requires measurements twice per year; red requires measurements three times per year; and dark red requires measurements four times per year. These are general parameters only, based on expert opinion, and underlying comorbid conditions and disease state as well as the likelihood of impacting a change in management for any individual patient must be taken into account. “Refer” indicates that nephrology services are recommended. *Referring clinicians may wish to discuss with their nephrology service, depending on local arrangements regarding treating or referring. Reprinted with permission from Vassalotti JA, Centor R, Turner BJ, Greer RC, Choi M, Sequist TD; National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Am J Med 2016;129:153–162.e7.

Tables

  • TABLE 2.2/2.5

    Criteria for the screening and diagnosis of prediabetes and diabetes

    PrediabetesDiabetes
    A1C5.7–6.4% (39–47 mmol/mol)*≥6.5% (48 mmol/mol)†
    Fasting plasma glucose100–125 mg/dL (5.6–6.9 mmol/L)*≥126 mg/dL (7.0 mmol/L)†
    Oral glucose tolerance test140–199 mg/dL (7.8–11.0 mmol/L)*≥200 mg/dL (11.1 mmol/L)†
    Random plasma glucose≥200 mg/dL (11.1 mmol/L)‡

    • Adapted from Tables 2.2 and 2.5 in the complete Standards of Care. *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, diagnosis requires two abnormal test results from the same sample or in two separate samples. ‡Only diagnostic in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis.

  • TABLE 2.3

    Criteria for testing for diabetes or prediabetes in asymptomatic adults

    1. Testing should be considered in adults with overweight or obesity (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) 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)
    2. Patients with prediabetes (A1C ≥5.7% [39 mmol/mol], impaired glucose tolerance, or impaired fasting glucose) should be tested yearly.
    3. Women who were diagnosed with GDM should have lifelong testing at least every 3 years.
    4. For all other patients, testing should begin at age 45 years.
    5. 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 2.4

    Risk-based screening for type 2 diabetes or prediabetes in asymptomatic children and adolescents in a clinical setting

    Testing should be considered in youth* with overweight (≥85th percentile) or obesity (≥95th percentile) A who have one or more additional risk factors based on the strength of their association with diabetes:

    • • 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

    • ↵* After the onset of puberty or after 10 years of age, whichever occurs earlier. If tests are normal, repeat testing at a minimum of 3-year intervals, or more frequently if BMI is increasing, is recommended. Reports of type 2 diabetes before age 10 years exist, and this can be considered with numerous risk factors.

  • TABLE 6.3

    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 6.4

    Classification of hypoglycemia

    Glycemic criteria/description
    Level 1Glucose <70 mg/dL (3.9 mmol/L) and ≥54 mg/dL (3.0 mmol/L)
    Level 2Glucose <54 mg/dL (3.0 mmol/L)
    Level 3A severe event characterized by altered mental and/or physical status requiring assistance for treatment of hypoglycemia

    • Reprinted from Agiostratidou G, Anhalt H, Ball D, et al. Diabetes Care 2017;40:1622–1630.

  • TABLE 7.3

    CGM devices

    Real-time CGMCGM systems that measure glucose levels continuously and provide the user automated alarms and alerts at specific glucose levels and/or for changing glucose levels.
    Intermittently scanned CGMCGM systems that measure glucose levels continuously but only display glucose values when swiped by a reader or a smart phone that reveals the glucose levels.
    Blinded (professional) CGMCGM devices that measure glucose levels that are not displayed to the patient in real time. These devices are generally initiated in a clinic, using a reader that is owned by the clinic. They are removed after a period of time (generally 10–14 days) and analyzed by the patient and provider to assess glycemic patterns and trends.
    Unblinded CGMCGM devices that measure glucose levels that are displayed to the patient.
  • TABLE 9.1
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Standards of Medical Care in Diabetes—2020 Abridged for Primary Care Providers
American Diabetes Association
Clinical Diabetes Jan 2020, 38 (1) 10-38; DOI: 10.2337/cd20-as01
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