DIABETES MANAGEMENT


















ADA Blood Sugar Goals for Adults

Blood sugar goals
  • Preprandial (before meal): 80 - 130 mg/dl
  • Peak post-meal blood sugar (within 1 - 2 hours after the start of a meal): < 180 mg/dl
  • †Fasting blood sugar (after 8 hours of no calorie consumption): 70 - 100 mg/dl
  • †The ADA does not give specific goals for fasting blood sugars, but 70 - 100 mg/dl is typically considered a normal range
A1C goals
  • Most diabetics: < 7%
  • More stringent: < 6.5%
    • If this can be achieved without significant hypoglycemia or other adverse effects of treatment (i.e., polypharmacy). 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 cardiovascular disease.
  • Less stringent: < 8.0%
    • Appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin.

ADA Blood Sugar Goals for Youth with Type 1 DM

Blood sugar goals
  • Preprandial (before meal): 90 - 130 mg/dl
  • Bedtime: 90 - 150 mg/dl
A1C goals
  • Most youth: < 7.5%
  • More stringent: < 7.0%
    • A lower goal is reasonable if it can be achieved without excessive hypoglycemia [48]

ADA Blood Sugar Goals for Youth with Type 2 DM

Blood sugar goals†
  • Preprandial (before meal): 80 - 130 mg/dl
  • Peak post-meal blood sugar (within 1 - 2 hours after the start of a meal): < 180 mg/dl
  • Fasting blood sugar (after 8 hours of no calorie consumption): 70 - 100 mg/dl
  • †The ADA does not give specific blood sugar goals for youth patients with T2DM, but they can be assumed to be similar to that of most adults
A1C goals
  • Most youth: < 7%
  • More stringent: < 6.5%
    • May be appropriate 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 and lesser degrees of b-cell dysfunction and patients treated with lifestyle or metformin only who achieve significant weight improvement.

ADA Blood Sugar Goals for Elderly

Healthy (few coexisting chronic illnesses, intact cognitive and functional status)
  • A1C goal: < 7.5%
  • Preprandial (before meal): 90 - 130 mg/dl
  • Fasting blood sugar (after 8 hours of no calorie consumption): 90 - 130 mg/dl
  • Bedtime: 90 - 150 mg/dl
Complex / intermediate (multiple coexisting chronic illnesses or 21 instrumental ADL impairments or mild-to-moderate cognitive impairment)
  • A1C goal: < 8.0%
  • Preprandial (before meal): 90 - 150 mg/dl
  • Fasting blood sugar (after 8 hours of no calorie consumption): 90 - 150 mg/dl
  • Bedtime: 100 - 180 mg/dl
Very complex / poor health (LTC or end-stage chronic illnesses or moderate-to-severe cognitive impairment or 21 ADL dependencies)
  • A1C goal: < 8.5%
  • Preprandial (before meal): 100 - 180 mg/dl
  • Fasting blood sugar (after 8 hours of no calorie consumption): 100 - 180 mg/dl
  • Bedtime: 110 - 200 mg/dl
ADL - Activities of daily living | LTC - Long-term care


  • Severe low blood sugar episodes (hypoglycemia) were more common in the intensive group in all the trials
  • Average length of time subjects had been diagnosed with diabetes upon enrollment: UKPDS < 1 year; ACCORD 10 years; ADVANCE 8 years; VADT 12 years [3]
  • Kidney disease defined as incidence of proteinuria. For kidney failure, there was no significant difference between intensive and standard therapy in any of the trials. [4]
  • The following is a synopsis of 4 large trials that compared significant clinical outcomes in Type 2 diabetics

    • In each trial, patients were divided into 2 groups:
      • 1. Intensive treatment - group with a lower A1C goal, typically ≤ 7%
      • 2. Standard treatment - group with A1C goal around 7 - 8%
  • Legend:
    • Intensive A1C = average A1C achieved in intensive therapy group
    • Standard A1C = average A1C achieved in standard treatment group
    • I = Intensive therapy group was significantly better
    • S = Standard therapy group was significantly better
    • NS = No Significant difference between groups
Trial
(trial length)
Intensive
A1C
Standard
A1C
Overall
mortality
Heart
disease
Eye
disease
Kidney
disease
Neuropathy
UKPDS
(11 yrs)
7.0 7.9 NS NS I I I
ACCORD
(3.5 yrs)
6.4 7.5 S S I I I
ADVANCE
(5 yrs)
6.4 7.0 NS NS NS I NS
VADT
(5.6 yrs)
6.9 8.5 NS NS NS I NS



Reference [36]
A1C values (%) Average blood sugar
(mg/dl)
5 97
6 126
7 154
8 183
9 212
10 240
11 269
12 298
13 326
14 355
15 384










  • Reference [43]
Small nerve fibers
Function
  • Pain sensation (nociception)
  • Hot/cold sensation
Symptoms
  • Pain, burning, electric shocks, tingling
  • Exaggerated response to painful stimuli (hyperalgesia)
  • Pain from minimal contact (e.g. socks, shoes, bed sheets) (allodynia)
  • Pain is typically worse at night
Exam findings
  • Loss of thermal discrimination (hot/cold)
  • Loss of pinprick sensation
  • Hyperalgesia

  • Reference [43]
Large nerve fibers
Function
  • Pressure
  • Balance and position sense (proprioception)
Symptoms
  • Numbness
  • Tingling
  • Poor balance
Exam findings
  • Loss of ankle reflexes
  • Loss of sense of vibration
  • Loss of proprioception
  • Loss of light touch sensation (10-g monofilament)


  • Reference [43]
System Symptoms
Cardiovascular
  • Resting tachycardia
  • Orthostatic hypotension
  • Abnormal blood pressure regulation
  • Hypoglycemia unawareness
Gastrointestinal
  • Gastroparesis
  • Esophageal dysfunction (dysphagia, GERD)
  • Diarrhea and constipation
  • Fecal incontinence
  • Hypoglycemia unawareness
Urogenital
  • Bladder dysfunction (incontinence, frequency, etc.)
  • Erectile dysfunction
  • Female sexual dysfunction
Sudomotor (sweat glands)
  • Gustatory sweating (face and neck sweating when eating)
  • Dry skin
  • Hypoglycemia unawareness

  • Reference [43,48]
FDA-approved therapies for DM neuropathy
Drug Dosing
(ADA recommended)
Other
Pregabalin (Lyrica®)
  • Starting: 25 - 75 mg one to three times a day
  • Effective: 300 - 600 mg a day
  • FDA-approved for diabetic peripheral neuropathy
  • Preferred first-line agent by ADA
  • See pregabalin for more
Duloxetine (Cymbalta®)
  • Starting: 20 - 30 mg once daily
  • Effective: 60 - 120 mg/day
  • May be given in one or two divided doses
  • FDA-approved for diabetic peripheral neuropathy
  • Preferred first-line agent by ADA
  • See duloxetine for more
Other therapies (non FDA-approved)
Gabapentin (Neurontin®)
  • Starting: 100 - 300 mg one to three times a day
  • Target: 900 - 3600 mg/day
  • Efficacy has been mixed in clinical trials
  • Preferred first-line agent by ADA
  • See gabapentin for more
Venlafaxine (Effexor XR®)
  • Starting: 37.5 mg once daily
  • Target: 75 - 225 mg/day
  • Has shown some effectiveness in clinical trials
  • See venlafaxine for more
Amitriptyline (Elavil®)
  • Starting: 10 - 25 mg once daily
  • Target: 25 - 100 mg/day
  • Has shown some effectiveness in small trials
  • See amitriptyline for more






Blood pressure in diabetes

Overview
  • The ideal blood pressure (BP) range in diabetics has not been completely determined
  • The ACCORD study compared outcomes between diabetics who were treated to a target SBP of < 120 to those treated to a target of < 140

Studies
ACCORD Study - Intensive vs Standard Blood Pressure Control in DM, NEJM (2010) [PubMed abstract]
  • The ACCORD study enrolled 4733 type 2 diabetics with an average SBP of 139 mmHg
  • Main inclusion criteria: SBP 130 - 180; type 2 diabetes; HgA1C 7.5% - 11%; ≥ 40 years old with cardiovascular disease or ≥ 55 years old with atherosclerosis, albuminuria, left ventricular hypertrophy, or at least two additional risk factors for cardiovascular disease (dyslipidemia, hypertension, smoking, or obesity)
  • Main exclusion criteria: BMI ≥ 45; serum creatinine > 1.5 mg/dl; significant liver disease; cardiovascular event within last 3 months
  • Baseline characteristics: average age 62 years; previous cardiovascular event - 34%; average BMI - 32; average BP - 139/76; median duration of diabetes - 10 years; average HgA1C - 8.3%; average LDL - 110 mg/dl; average GFR - 92 ml/min
Patients were randomized to 1 of 2 groups:
  • Group 1 (2362 patients) - Target SBP < 120 mmHg (intensive therapy)
  • Group 2 (2371 patients) - Target SBP < 140 mmHg (standard therapy)
  • Blood pressure medications used were ACE/ARBs, thiazide diuretics, beta blockers, calcium channel blockers, reserpine, and/or alpha blockers
  • No specific treatment regimen or drug was required
PRIMARY OUTCOME: Composite of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes
After an average follow-up of 4.7 years, the following was seen:
  • Average SBP at 1 year (mmHg): Group 1 - 119.3, Group 2 - 133.5 (diff 14.2, 95%CI [13.7 - 14.7])
  • Average DBP at 1 year (mmHg): Group 1 - 64.4, Group 2 - 70.5 (diff 6.1, 95%CI [5.7 - 6.5])
  • Primary outcome: Group 1 - 1.87%/year, Group 2 - 2.09%/year (HR 0.88, 95%CI [0.73 - 1.06], p=0.20)
  • Overall mortality: Group 1 - 1.28%/year, Group 2 - 1.19%/year (HR 1.07, 95%CI [0.85 - 1.35], p=0.55)
  • Stroke: Group 1 - 0.32%/year, Group 2 - 0.53%/year (HR 0.59, 95%CI [0.39 - 0.89], p=0.01)
  • Nonfatal myocardial infarction: Group 1 - 1.13%/year, Group 2 - 1.28%/year (HR 0.87, 95%CI [0.68 - 1.10], p=0.25)
  • Hypokalemia (< 3.2 mEq/L): Group 1 - 2.1%, Group 2 - 1.1% (p=0.01)
  • Estimated GFR < 30 ml/min: Group 1 - 4.2%, Group 2 - 2.2% (p<0.001)
  • Macroalbuminuria: Group 1 - 6.6%, Group 2 - 8.7% (p=0.009)
  • Average # of BP meds after first year: Group 1 - 3.4, Group 2 - 2.1 [8]
Findings: In patients with type 2 diabetes at high risk for cardiovascular events, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, did not reduce the rate of a composite outcome of fatal and nonfatal major cardiovascular events

StraightHealthcare analysis:
  • The ACCORD trial found that intensive blood pressure therapy did not improve CVD outcomes in type two diabetics when compared to standard therapy
  • Intensive therapy increased the risk of hypokalemia and GFR < 30 ml/min while decreasing the risk of macroalbuminuria
  • For years, it had been recommended that all diabetics be treated to a blood pressure goal of < 130/80. After the ACCORD trial, the recommendation was changed to < 140/90.

ADA BP Recommendations for Adults with Diabetes

Blood pressure goals
  • Diabetics at lower risk of CVD: < 140/90 mmHg
    • Lower risk defined as 10-year atherosclerotic CVD risk < 15%
  • Diabetics at higher risk of CVD: < 130/80 mmHg
    • Higher risk defined as existing CVD or 10-year atherosclerotic CVD risk > 15%

Blood pressure medications
  • If BP is ≥ 160/100 mmHg, a two-drug regimen may be initiated
  • Drugs of choice include ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers
  • Do not combine ACE inhibitors, ARBs, and/or direct renin inhibitors
  • ACE or ARB is indicated in patients with urinary albumin-to-creatinine ratio ≥ 30 mg/g
  • Patients with resistant hypertension should be be considered for mineralocorticoid receptor antagonist therapy [48]

Other guidelines

ADA BP Recommendations for Youth with Diabetes

Blood pressure goals
  • SBP and DBP < 90th percentile for age, sex, and height
  • Elevated BP should be confirmed on 3 separate days

Blood pressure treatment
  • BP > 90th percentile but < 95th percentile: Initial treatment should be diet and exercise for 3 - 6 months. If goal BP is not achieved, medications should be considered.
  • BP ≥ 95th percentile: Diet, weight loss, and medication. ACE inhibitors and ARBs are preferred, but their potential for teratogenic effects should be considered with females. [48]



ADA 2018 Lipid Treatment Recommendations in Adults

Age < 40 years
  • No ASCVD and no ASCVD risk factors: No statin recommended
  • No ASCVD with ASCVD risk factors: Moderate-intensity statin may be considered
  • ASCVD present: High-intensity statin recommended. If LDL ≥ 70 mg/dl despite maximally tolerated statin, consider adding ezetimibe or PCSK9 inhibitor
  • Lipid levels should be monitored annually or as needed [46]
  • See statin intensity chart

Age ≥ 40 years
  • No ASCVD and no ASCVD risk factors: Moderate-intensity statin
  • No ASCVD with ASCVD risk factors: At the least, moderate-intensity statin. High-intensity statin should be considered.
  • ASCVD present: High-intensity statin recommended. If LDL ≥ 70 mg/dl despite maximally tolerated statin, consider adding ezetimibe or PCSK9 inhibitor
  • Lipid levels should be monitored annually or as needed [46]
  • See statin intensity chart

ADA ASCVD Risk Factors

  • LDL ≥ 100 mg/dl
  • Hypertension
  • Chronic kidney disease (GFR < 60 ml/min)
  • Albuminuria ≥30 mcg of albumin/mg creatinine
  • Smoking
  • History of premature ASCVD in a first-degree relative (ASCVD in males < 55 years and females < 65 years) [46]

ADA Lipid Treatment Recommendations in Youth with T1DM

Screening
  • Obtain a fasting lipid profile in children ≥ 10 years of age soon after the diagnosis of diabetes (after glucose control has been established)
  • If LDL cholesterol values are within the accepted risk level (< 100 mg/dL), a lipid profile repeated every 3 – 5 years is reasonable

Treatment
  • If lipids are abnormal, initial therapy should consist of optimizing glucose control and medical nutrition therapy using a Step 2 American Heart Association diet to decrease the amount of saturated fat to 7% of total calories and dietary cholesterol to 200 mg/day, which is safe and does not interfere with normal growth and development.
  • After the age of 10 years, addition of a statin is suggested in patients who, despite medical nutrition therapy and lifestyle changes, continue to have LDL cholesterol > 160 mg/dL or LDL cholesterol > 130 mg/dL and one or more cardiovascular disease risk factor, following reproductive counseling because of the potential teratogenic effects of statins
  • The goal of therapy is an LDL cholesterol value < 100 mg/dL [48]

ADA Lipid Treatment Recommendations in Youth with T2DM

Screening
  • Lipid testing should be performed when initial glycemic control has been achieved and annually thereafter

Treatment
  • Optimal goals are LDL cholesterol < 100mg/dL, HDL cholesterol > 35 mg/dL, and triglycerides < 150 mg/dL
  • If LDL cholesterol is > 130 mg/dL, blood glucose control should be maximized and dietary counseling should be provided using the American Heart Association Step 2 diet
  • If LDL cholesterol remains above goal after 6 months of dietary intervention, initiate therapy with statin, with goal of LDL < 100 mg/dL [48]

ADA Recommendations for HDL and Triglyceride Levels in Adults

  • Triglycerides ≥ 150 mg/dl and/or HDL cholesterol < 40 mg/dL for men, < 50 mg/dL for women - intensify lifestyle therapy and optimize glycemic control
  • Fasting triglycerides ≥ 500 mg/dl - evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce risk of pancreatitis [46]

ADA Recommendations for Triglyceride Levels in Youth with T2DM

  • If triglycerides are > 400 mg/dL fasting or > 1,000 mg/dL nonfasting, optimize glycemia and begin fibrate, with a goal of < 400 mg/dL fasting (to reduce risk for pancreatitis) [48]










  • Reference [48]
ADA Classification of Hypoglycemia
Level Blood sugar (mg/dl)
I 54 - 69
II < 54
III A severe event characterized by altered mental and/or physical status requiring assistance



ADA recommendations for daily aspirin in diabetes

Secondary prevention
  • Use aspirin therapy (75 – 162 mg/day) as a secondary prevention strategy in those with diabetes and a history of atherosclerotic cardiovascular disease.
  • For patients with atherosclerotic cardiovascular disease and documented aspirin allergy, clopidogrel (75 mg/day) should be used
  • Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary syndrome and may have benefits beyond this period

Primary prevention
  • Aspirin therapy (75 – 162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased cardiovascular risk, after a discussion with the patient on the benefits versus increased risk of bleeding

StraightHealthcare analysis