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Standards of care for diabetes: What's new?

Funnell, Martha M. MS, RN, CDE

doi: 10.1097/01.NURSE.0000388314.83393.bd
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Make sure you're current by reviewing this quick update on recent changes in clinical practice guidelines.

Martha M. Funnell is a research investigator at the University of Michigan Medical School in Ann Arbor, Mich., and a member of the Nursing2010 editorial board.

EACH YEAR, the American Diabetes Association (ADA) publishes standards of medical care for people with diabetes.1 The ADA updates these standards based on the latest evidence so that healthcare professionals can incorporate this evidence into their care. The standards also summarize and rate the levels of evidence on which the recommendations are based. This article describes new recommendations in the 2010 Standards of Medical Care in Diabetes (the 2010 Standards).

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Diagnosing diabetes

In previous versions of the standards, the diagnoses of diabetes and prediabetes were made based on fasting plasma glucose (FPG) levels, or signs and symptoms of hyperglycemia and a casual (random) plasma glucose, or oral glucose tolerance test results. The 2010 Standards now also include the hemoglobin A1C (A1C) test for diagnosis, due in part to the increased standardization of the assay, which allows the results to be applied consistently across populations.2,3 A1C results represent an integrated measurement of hyperglycemia during a 2- to 3-month period and are more reproducible than glucose readings.

An A1C level of 6.5% or higher has been added as one method for diagnosing diabetes.1 Point-of-care A1C testing isn't recommended for making the diagnosis. Plasma glucose levels of 126 mg/dL or higher when fasting (defined as no caloric intake for at least 8 hours), 200 mg/dL or higher 2 hours after a 75-g glucose load, or a random glucose of 200 mg/dL or higher with classic signs and symptoms of hyperglycemia (such as polyuria, polydipsia, or unexplained weight loss) continue to be diagnostic of diabetes.

The A1C and plasma glucose levels used to diagnose diabetes were determined based on the presence of retinopathy at these thresholds.1–3 If clear signs and symptoms aren't present, the same diagnostic test should be repeated on a different day to confirm the diagnosis.

Prediabetes is diagnosed when the FPG is 100 to 125 mg/dL or from 140 to 199 mg/dL 2 hours after a 75-g glucose load. Although these criteria haven't changed, an A1C of 5.7% to 6.4% has been added to indicate increased risk of type 2 diabetes. The term prediabetes is used for people who have these levels.

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Blood glucose goals

The general goal for A1C levels among nonpregnant adults is still less than 7%. According to the 2010 Standards, a normal A1C may further reduce the risk of long-term complications, although the risk of hypoglycemia is greater.1 Among people with a history of severe hypoglycemia, limited life expectancy, advanced diabetes-related complications, and extensive comorbid complications, an A1C level at or above 7% may be more reasonable and prudent.1

Table. C

Table. C

Treatment goals for patients with diabetes include an FPG of 70 to 130 mg/dL and peak postprandial (usually 1 to 2 hours after the start of a meal) capillary plasma glucose levels of less than 180 mg/dL. Specific guidelines for children and older adults and specific care settings are also defined in the 2010 Standards.

The 2009 Standards included a correlation between A1C levels and mean plasma glucose levels.4 (See Correlating A1C with average blood glucose.) Some labs now report both an A1C level and an estimated average glucose (eAG) level. Additional tools for calculating eAG are available at http://www.diabetes.org and other diabetes websites.5

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Preventing complications

Because myocardial infarction and stroke are the leading causes of death among people with diabetes, low-dose aspirin therapy had been recommended as part of the ADA standards in previous years. In the 2010 Standards, the aspirin guidelines were revised based on recent studies that question the benefit of aspirin for primary prevention among low-risk adults.6 The revised standards recommend considering low-dose aspirin therapy as primary prevention among those with type 1 or type 2 diabetes at increased cardiovascular risk, which includes most men older than age 50 and women older than age 60 who have at least one additional risk factor, such as family history of cardiovascular disease (CVD), hypertension, smoking, dyslipidemia, or albuminuria (ADA). Aspirin therapy is still recommended as a secondary prevention strategy among people with diabetes and a history of CVD.

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In the hospital

The section on managing hyperglycemia among hospitalized patients has been revised, particularly in the area of blood glucose goals for critically ill patients. These revisions are based on evidence of potentially negative effects of very stringent goals, such as severe hypoglycemia.

The 2010 Standards recommend that I.V. insulin be started for patients with blood glucose levels of 180 mg/dL or higher. Once I.V. insulin is initiated, the recommended maintenance range for blood glucose is 140 to 180 mg/dL.7

No clear-cut evidence exists for specific blood glucose goals for patients who aren't critically ill.7 When patients are treated with insulin, however, their premeal blood glucose target should generally be less than 140 mg/dL and random blood glucose values should generally be less than 180 mg/dL.

More stringent targets may be appropriate for stable patients who've previously maintained tight levels of blood glucose control. Less stringent targets may be appropriate for patients with multiple comorbid conditions.

Scheduled subcutaneous insulin regimens that include basal (intermediate or long-acting insulin), nutritional, and correction (rapid or short-acting insulin) doses are the preferred treatment for achieving and maintaining the recommended blood glucose levels among noncritically ill patients with diabetes.

The standards also continue to address recommendations for the care of hospitalized patients with diabetes, including clear documentation of their diabetes in the medical record, blood glucose testing including self-monitoring of blood glucose, and the treatment of hypoglycemia.

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New areas receive attention

Cystic fibrosis-related diabetes is the most common comorbidity experienced by people with cystic fibrosis and results in greater morbidity and mortality than in patients with cystic fibrosis and no diabetes, particularly among women. A section on this topic has been added to the new standards. Diabetes and cystic fibrosis experts have convened a consensus conference that will issue recommendations later this year.1

The sections on diabetes self-management education (DSME), strategies for improving diabetes care, and psychosocial assessment and care have been revised to reflect newer evidence. As identified in the national standards for DSME published in 2007, the importance of both DSME and the need for ongoing diabetes self-management support continues to be stressed. In addition, strong support for both the effectiveness and cost-effectiveness of DSME continues to grow and adds to the evidence that served as the basis for DSME standards.8,9

The 2010 Standards contain a larger section on approaches for improving the quality of diabetes care delivery based on the implementation of multiple strategies from the Chronic Care Model.10 Of particular interest to nurses is the emphasis on case or care management services and the importance of interventions to provide DSME.11

The psychosocial issues section, which previously focused on depression and anxiety, has been expanded to reflect growing recognition of diabetes-related distress (such as anger, fear, frustration, and guilt) that occurs among most patients at the time of diagnosis and continues for a lifetime for almost half of all patients with diabetes.12 Although no one instrument is recommended to assess psychosocial issues, several diabetes-specific validated and reliable measures that are useful in practice are readily available.13

A section on bariatric surgery and diabetes was added in 2009.14 In general, bariatric surgery should be considered for adults who have type 2 diabetes and a BMI greater than 35. Bariatric surgery results in a complete or near normalization of glucose levels and has also been used successfully among patients at high risk for diabetes.14

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Put diabetes in the limelight

Nurses in every setting encounter diabetes among patients of all ages. Managing diabetes is critical for patients' optimal overall health and quality of life, no matter what other chronic or acute illnesses they may have. Along with providing high-quality care to hospitalized patients, nurses also need to use evidence-based educational and behavioral strategies to educate patients about how to be effective self-managers and advocates for quality diabetes care.

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REFERENCES

1. American Diabetes Association. Standards of medical care in diabetes—2010. Diabetes Care. 2010;33(suppl 1):S11–S61.
2. Fowler MJ. Diagnosis, classification, and lifestyle treatment of diabetes. ClinDiabetes. 2010;28(2):79–86.
3. International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care. 2009;32(7):1327–1334.
4. American Diabetes Association. Standards of medical care in diabetes—2009. Diabetes Care. 2009;32(suppl 1):S13–S61.
5. American Diabetes Association. Estimated Average Glucose, eAG .
6. Calvin AD, Aggarwal NR, Murad MH, et al. Aspirin for the primary prevention of cardiovascular events: a systematic review and meta-analysis comparing patients with and without diabetes. Diabetes Care. 2009;32(12):2300–2306.
7. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119–1131.
8. Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes Care. 2007;30(6):1630–1637.
9. Duncan I, Birkmeyer C, Coughlin S, Li QE, Sherr D, Boren S. Assessing the value of diabetes education. Diabetes Educ. 2009;35(5):752–760.
10. Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA. 2006;296(4):427–440.
11. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood). 2009;28(1):75–85.
12. Skovlund SE, Peyrot M, on behalf of the DAWN International Advisory Panel. The Diabetes Attitudes, Wishes, and Needs (DAWN) program: a new approach to improving outcomes of diabetes care. Diabetes Spectrum. 2005;18(3):136–142 .
13. Patient-Reported Outcome and Quality of Life Instruments Database ProQolid Endocrine system disease instruments .
14. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122(3):248–256.
© 2010 Lippincott Williams & Wilkins, Inc.