Bab Ii Fix 6

Global Prevalence of Diabetes Expected to Increase
by 54% by 2045
Standards of Medical 2017 U.S. Statistics:

LARGER THAN
THE POPULATION
OF THE UNITED
WORLD
693M +54%
Care in Diabetes – 2018 • 1 in 11 Americans has diabetes. STATES
54%
• 1 of every four adults ≥ 65 has WORLD
451M
diabetes or prediabetes.
William T. Cefalu, MD
Chief Scientific, Medical and Mission Officer
American Diabetes Association • Type 2 diabetes accounts for 90
to 95% of all diabetes cases in
the U.S.2
1.IDF Diabetes Atlas, 8th edition. 2017. International Diabetes Foundation.

2.http://www.cdc.gov/chronicdisease/resources/publications/aag/ddt.htm.
Morbidity And Mortality Due To Diabetes The Heavy Cost Burden Of Diabetes Threatens
Complications Continue At An Alarming Rate The Economy
4 Million Deaths/Year Opioid Overdose Crisis
IN THE US, DIABETESa
CONTRIBUTES TO, ON AVERAGE1: WORLDWIDE, 1 PERSON DIES IN THE UNITED STATES, IN 2016, 1 PERSON Almost half of all adults with diabetes are between the ages of 45 and 64 years 1.
EVERY 8 SECONDS FROM DIABETESa DIES EVERY 52 MINUTES FROM OPIOD
1 stroke every AND ITS COMPLICATIONS2 OVERDOSE3 Productivity
2 minutes lost2 Global health
1 case of ischemic heart
Reduced labor force expenditure
130 million days
disease every participation due to disability due to diabetes
80 seconds
estimated to be
Reduced performance at
1 case of kidney failure
every 00:08 52:00 work
113 million days US $727 billion
10 minutes in 2017
Workdays absent 25 million days
1 lower limb amputation
every Reduced productivity for 20 million days
5 minutes those not in labor force
That’s more than That’s more than
11,000 people a day 46 people a day
aType 1 or Type 2 diabetes.

1. CDC. National Diabetes Statistics Report 2017. www.cdc.gov/statistics. 2. American Diabetes
1. CDC. National Diabetes Statistics Report 2017. www.cdc.gov/statistics. 2. . IDF Diabetes Atlas, 8th edition.
Association Economic Cost of Diabetes in 2012. Diabetes Care 36: 1033-1046, 2013. IDF Diabetes Atlas,
2017. International Diabetes Foundation ; https://www.cdc.gov/drugoverdose/data/overdose.html
8th Edition, 2017
OUR VISION OUR MISSION
To prevent and
Life free of cure diabetes
diabetes and and to improve
all its burdens. the lives of all
people affected
by diabetes.
5
Significant Therapeutic Advances in Diabetes Standards of Care
Care Over Past 20 Years
• Funded by ADA’s general revenues, without industry support
SGLT-2
Inhibitor
Bromocriptine
DPP-4
• Slides correspond with sections within the Standards of
ADA Standards of Care inhibitor
1989 Pramlintide Medical Care in Diabetes - 2018.
GLP-1R agonist
Meglitinide
• Review of scientific literature led by Professional Practice
TZD
Basal insulin
Rapid-acting
Committee
insulin
αGlucosidase
Insulin SFU
inhibitor
Metformin
• PPC recommendations reviewed and approved by ADA’s
1920 1960 1970 1980 1990 2000 2010 2014 Board of Directors
Professional Practice Committee Process

Members of the PPC
ADA Staff
• Rita R. Kalyani, MD, MHS, FACP (Chair)
• Christopher P. Cannon, MD
• Erika Gebel Berg, PhD • ADA’s Professional Practice Committee (PPC) conducts annual
• Andrea L. Cherrington, MD, MPH • Matthew P. Petersen review & revisions.
• Donald R. Coustan, MD • Sacha Uelmen, RDN, CDE
• Ian H. de Boer, MD, MS • William T. Cefalu, MD • Literature search of human studies related to each diabetes
• Hope Feldman, CRNP, FNP-BC subsection and published since January 1 of the previous year.
• Judith Fradkin, MD ACC Designated Representatives
• Recommendations are revised based on new evidence, for clarity, or
• David Maahs, MD, PhD (Section 9)
• Melinda Maryniuk, MEd, RD, CDE
to update the text to match the strength of evidence.
• Sandeep Das, MD, MPH, FACC
• Medha N. Munshi, MD • Mikhail Kosiborod, MD, FACC
• Joshua J. Neumiller, PharmD, CDE, FASCP
• Guillermo E. Umpierrez, MD, CDE, FACE, FACP professional.diabetes.org/SOC
Evidence Grading System Trend Toward Higher Level of Evidence

Trend from 2005 to 2014 in number and proportion of recommendations made each year in the
ADA Standards of Care that were based on higher-level evidence vs. lower-level evidence.
Richard W. Grant, and M. Sue Kirkman Dia Care 2015;38:6-8

©2015 by American Diabetes Association
Trend Toward Higher Level of Evidence Standards of Care: Table of Contents
Trends from 2005 to 2014 in annual proportion of recommendations based on 1. Improving Care and Promoting Health in Populations
higher-level evidence, stratified into four mutually exclusive categories 2. Classification and Diagnosis of Diabetes
3. Comprehensive Medical Evaluation and Assessment of Co-morbidities
4. Lifestyle Management
5. Prevention and Delay of Type 2 Diabetes
6. Glycemic Targets
7. Obesity Management for the Treatment of Type 2 Diabetes
8. Pharmacologic Approaches to Glycemic Treatment
9. Cardiovascular Disease and Risk Management
10. Microvascular Complications and Foot Care
11. Older Adults
12. Children and Adolescents
13. Management of Diabetes in Pregnancy
14. Diabetes Care in the Hospital
15. Diabetes Advocacy
Classification and Diagnosis of Diabetes:
Richard W. Grant, and M. Sue Kirkman Dia Care 2015;38:6-8 Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S13-S27
Changes are needed to Improve Care Quality in

Diabetes: Type 2 Diabetes Trends in the U.S. 2006-2013
DPP-4 and Increased adoption of Affordable Care Act Meaningful Use SGLT-2 inhibitor
GLP-1 Rx EHRs, HITECH Act, becomes law, Implementation, PCMH, Rx approved
1. Improving Care and Promoting approved iPhone and apps

introduced
proliferation of
“personal tech”
ACO formations
N=424,348*
*Subset of 1.66M
100 patients with an
Health in Populations
Proportion of patients
with Type 2 Diabetes
90
Advances in health technology, drug therapies and policy have NOT A1c available
80 translated to improvements in diabetes care quality

70
60
50
40 A1c ≥ 9%
30
A1c < 7%
20
10
0
Adapted from: Lipska KJ, Yao X, Herrin J, et al. Trends in drug utilization, glycemic control, and rates of severe hypoglycemia, 2006–
2013 [published online September 22, 2016]. Diabetes Care. doi:10.2337/dc16-0985.
Care Delivery Systems Diabetes and Population Health: Recommendations
• 33-49% of patients still do not meet targets for A1C, blood pressure, or
lipids. • Care systems should facilitate team-based care, patient registries, decision
support tools, and community involvement to meet patient needs. B
• Only 14% of patients meet targets for all A1C, BP, lipids, and nonsmoking
status. • Efforts to assess the quality of diabetes care and create quality
improvement strategies should incorporate reliable data metrics, to promote
• Progress in CVD risk factor control is slowing.
improved processes of care and health outcomes, with simultaneous
• Substantial system-level improvements are needed. emphasis on costs. E
• Delivery system is fragmented, lacks clinical information capabilities,

duplicates services, and is poorly designed.
Improving Care and Promoting Health in Population: Improving Care and Promoting Health in Population:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S7-S12 Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S7-S12
Health Inequities Tailoring Treatment for Social Context
• Health inequities related to diabetes and its complications are well Key Recommendations:
documented and are heavily influenced by social determinants of health
• Providers should assess social context, including potential food insecurity,
housing stability, and financial barriers, and apply that information to treatment
decisions. A
• Social determinants of health are defined as:
o The economic, environmental, political, and social conditions in which • Refer patients to local community resources when available. B
people live
• Provide patients with self-management support from lay health coaches,
o Responsible for a major part of health inequality worldwide navigators, or community health workers when available. A
Improving Care and Promoting Health in Population: Improving Care and Promoting Health in Population:
Classification of Diabetes
1. Type 1 diabetes
o β-cell destruction
2. Classification and Diagnosis of 2. Type 2 diabetes

o Progressive insulin secretory defect
Diabetes 3. Gestational Diabetes Mellitus (GDM)
4. Other specific types of diabetes due to other causes:

o Monogenic diabetes syndromes
o Diseases of the exocrine pancreas, e.g., cystic fibrosis
o Drug- or chemical-induced diabetes
Classification and Diagnosis of Diabetes:

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S13-S27
Criteria for the Diagnosis of Diabetes Categories of Increased Risk for Diabetes
(Prediabetes)
Classification and Diagnosis of Diabetes: Classification and Diagnosis of Diabetes:

A1C: New Recommendations Testing for Diabetes or Prediabetes in
Asymptomatic Adults
• To avoid misdiagnosis or missed diagnosis, the A1C test should be performed
using a method that is certified by the NGSP and standardized to the Diabetes
Control and Complications Trial (DCCT) assay. B
• Marked discordance between measured A1C and plasma glucose levels should
raise the possibility of A1C assay interference due to hemoglobin variants (i.e.,
hemoglobinopathies) and consideration of using an assay without interference or
plasma blood glucose criteria to diagnose diabetes. B
• In conditions associated with increased red blood cell turnover, such as sickle cell
disease, pregnancy (second and third trimesters), hemodialysis, recent blood loss
or transfusion, or erythropoietin therapy, only plasma blood glucose criteria
should be used to diagnose diabetes. B
Classification and Diagnosis of Diabetes: Classification and Diagnosis of Diabetes:

Patient-Centered Collaborative Care
• A patient-centered communication style that uses person-centered

3. Comprehensive Medical Evaluation and strength-based language, active listening, elicits patient
preferences and beliefs, and assesses literacy, numeracy, and
and Assessment of Comorbidities potential barriers to care should be used to optimize patient health
outcomes and health-related quality of life. B
Comprehensive Medical Evaluation and Assessment of Comorbidities:

Components of the Comprehensive Diabetes Components of the Comprehensive Diabetes

Evaluation Evaluation
Comprehensive Medical Evaluation and Assessment of Comorbidities: Comprehensive Medical Evaluation and Assessment of Comorbidities:

† May be needed more frequently in patients with known chronic kidney disease or with changes in medications that
affect kidney function and serum potassium.
# May also need to be checked after initiation or dose changes of medications that affect these laboratory values (i.e.,
†May be needed more frequently in patients with known chronic kidney disease or with changes in medications that
diabetes medications, blood pressure medications, cholesterol medications, or thyroid medications),.
˄ In people without dyslipidemia and not on cholesterol-lowering therapy, testing may be less frequent. affect kidney function and serum potassium.
Lifestyle Management
▪ Diabetes self-management education and support

(DSMES)
4. Lifestyle Management
▪ Medical nutrition therapy (MNT)
▪ Physical activity
▪ Smoking cessation counseling
▪ Psychosocial care
Lifestyle Management:
Diabetes Self-Management Education and Support Nutrition: Recommendations
Four critical time points for DSMES delivery:
1. At diagnosis
2. Annually for assessment of education, nutrition, and emotional
needs
3. When new complicating factors (health conditions, physical
limitations, emotional factors, or basic living needs) arise that
influence self-management; and
4. When transitions in care occur
Lifestyle Management: Lifestyle Management:

Physical Activity: Recommendations

Diabetes Food Hub
• Children and adolescents with diabetes or prediabetes should engage in
• Diabetes Food Hub allows users to
60 min/day or more of moderate- or vigorous-intensity aerobic activity,
customize recipes to meet individual
with vigorous muscle-strengthening and bone-strengthening activities at
needs:
least 3 days/week. C
• adjust the number of servings to
make or the portion to eat, and • Most adults with type 1 C and type 2 B diabetes should engage in 150
• nutrition facts and ingredient lists min or more of moderate-to-vigorous intensity aerobic activity per week,
are recalculated based on the spread over at least 3 days/week, with no more than 2 consecutive days
servings and portions chosen. without activity. Shorter durations (minimum 75 min/week) of vigorous-
intensity or interval training may be sufficient for younger and more
physically fit individuals.
42
Diabetes Distress Mental Health Provider Diabetes Education
Program (MHDEP)
• Diabetes distress ADA and the American Psychological
o Very common and distinct from other psychological disorders Association (APA) partnered to create the
o Negative psychological reactions related to emotional burdens of first ever, diabetes-focused continuing
managing a demanding chronic disease education (CE) program for licensed mental
health providers.
• Recommendation: Upon successful completion of the program, the provider can:
o Routinely monitor people with diabetes for diabetes distress, • Become an ADA member at the Associate level
particularly when treatment targets are not met and/or at the onset of • Receive 12 CE credits from the APA
diabetes complications. B • Become eligible for inclusion on the Mental Health Provider Referral Directory
• Access the ADA’s new listserv for behavioral health and psychosocial topics
• Access monthly “mentoring” calls with experts in the field
Prevention or Delay of T2DM: Recommendations
• Patients with prediabetes should be referred to an intensive behavioral

lifestyle intervention program modeled on the Diabetes Prevention Program
to achieve and maintain 7% loss of initial body weight and increase
5. Prevention or Delay of Type 2 Diabetes moderate-intensity physical activity (such as brisk walking) to at least 150
min/week. A
• Metformin therapy for prevention of type 2 diabetes should be considered in

those with prediabetes, especially for those with BMI ≥35 kg/m2, those aged
<60 years, and women with prior GDM. A
Prevention or Delay of Type 2 Diabetes:

Summary of Glycemic Recommendations
6. Glycemic Targets
Glycemic Targets:
Treatment of Type 2 Diabetes
Published new algorithm for

the treatment of T2D, as
7. Obesity Management for the Treatment recommended by DSS-II
of Type 2 Diabetes voting delegates.
Algorithm for the Treatment of T2D Overweight/Obesity Treatment Options in T2DM
Body Mass Index (BMI) Category (kg/m2)
25.0-26.9 27.0-29.9 30.0-34.9 35.0-39.9 ≥40
(or 23.0- (or 27.5- (or 32.5-37.4*) (or ≥37.5*)
Treatment 26.9*) 32.4*)
Diet,
physical activity
& behavioral ┼ ┼ ┼ ┼ ┼
therapy
Pharmacotherapy
┼ ┼ ┼ ┼
Metabolic surgery
┼ ┼ ┼
* Cutoff points for Asian-American individuals.
┼ Treatment may be indicated for selected, motivated patients.
Francesco Rubino et al. Dia Care 2016;39:861-877 Obesity Management for the Treatment of Type 2 Diabetes:
©2016 by American Diabetes Association Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S65-S72
Pharmacologic Therapy For Type 1 Diabetes:

Recommendations
• Most people with T1DM should be treated with multiple daily

8. Pharmacologic Approaches to injections of prandial insulin and basal insulin or continuous
subcutaneous insulin infusion (CSII). A
Glycemic Treatment
• Most individuals with T1DM should use rapid-acting insulin
analogs to reduce hypoglycemia risk. A
Pharmacologic Approaches to Glycemic Treatment:

Mortality and Cardiovascular Disease in Type 1 and Type 2 Diabetes

Management Approach for Hyperglycemia Patients with Type 1 DM
Death from any cause Death from Cardiovascular Disease
more A1C less

Patient/Disease Features stringent 7% stringent “…data from 1998 to 2014 showed marked
Risk of hypoglycemia/drug adverse effects reductions in mortality and in the incidence of
low high
Disease Duration cardiovascular complications among adults with
newly diagnosed long-standing either type 1 diabetes or type 2 diabetes”.
Life expectancy
long short “Residual Risk”
Important comorbidities Patients with Type 1 DM
absent Few/mild severe Death from any cause Death from Cardiovascular Disease
“There remains a substantial excess
Established vascular complications overall rate of all outcomes analyzed
absent Few/mild severe
among persons with either type 1 diabetes
Patient attitude & expected or type 2 diabetes as compared with the
highly motivated, adherent, less motivated, nonadherent,
treatment efforts excellent self-care capabilities poor self-care capabilities general population.
Resources & support system
readily available limited
Rawshani A, Rawshani A, Franzén S, et al. . N Engl J Med.
2017 Apr 13;376(15):1407-1418.
Glycemic Targets:
Completed and Ongoing CVOTs Risk Reduction & Evidence of CV Benefit
William T. Cefalu et al. Dia Care 2018;41:14-31

William T. Cefalu et al. Dia Care 2018;41:14-31
Antihyperglycemic Therapy in Adults with T2DM Antihyperglycemic Therapy in Adults with T2DM
Pharmacologic Approaches to Glycemic Treatment: Pharmacologic Approaches to Glycemic Treatment:

Antihyperglycemic Therapy in Adults with T2DM Pharmacologic Therapy For T2DM: Recommendations
• In patients with T2DM and established ASCVD, antihyperglycemic
therapy should begin with lifestyle management and metformin and
subsequently incorporate an agent proven to reduce major adverse
CV events and CV mortality (currently empagliflozin and liraglutide),
after considering drug-specific and patient factors (Table 8.1). A
• In patients with T2DM and established ASCVD, after lifestyle

management and metformin, the antihyperglycemic agent
canagliflozin may be considered to reduce major adverse CV events,
based on drug-specific and patient factors (Table 8.1). C

Words Still Relevant Today
“Doctors prescribe medicine of which

they know little, to cure diseases of
which they know less, in human
beings of which they know nothing.
Francois-Marie Voltaire, 250 years ago
New Paradigm for Managing Blood Glucose in Informing the Future Standards of Care:
Type 2 Diabetes Digital Treatment
Precision Health Ecosystem for Diabetes Control
Initialization
CVD Risk Established History of Recent Recent Asymptomatic History Symptomatic HF/ End Stage Update
Factors Only CAD MI/Stroke ACS Stroke LV Dysfunction of HF HF Hospitalization HF
Database
Treatment: Virtual Image of the Patient (VIP)
? Event forecast;
Decision Support;
Digital patient profile based on a well-established
in silico model of the human metabolic system.
Closed-Loop Control (artificial
pancreas)
GLP-1 ? Metformin SGLT2 Pioglitazone Not Adequately
Agonists ? GLP-1 Inhibitors Studied Data: real-time CGM; body sensors
Data: electronic medical records
Data: genetic profile
Frequency: every few minutes Frequency: once
Metformin ?DPP-4i SGLT2i Methods: system dynamics & optimal
Frequency: every few months
Methods: Bayesian update
Methods: probability
control distribution
or SGLT2i
seem promising
Modify based on co-morbidities, contraindications, HBA1C

control preferably with agents that have proven safety Physician
expertise
Consumer Health Care System Research
Future trials should target combination therapies
Diabetes and Cardiovascular Disease

• ASCVD is the leading cause of morbidity & mortality for those with diabetes.
• Largest contributor to direct/indirect costs
• Common conditions coexisting with type 2 diabetes (e.g., hypertension,
9. Cardiovascular Disease and Risk dyslipidemia) are clear risk factors for ASCVD.
• Diabetes itself confers independent risk
Management
• Control individual cardiovascular risk factors to prevent/slow CVD in people
with diabetes.
• Systematically assess all patients with diabetes for cardiovascular risk
factors.
Cardiovascular Disease and Risk Management:

Recommendations for Statin and Combination Tx
Diabetic Retinopathy: Recommendations

Treatment:
• The traditional standard treatment, panretinal laser photocoagulation therapy,

10. Microvascular Complications is indicated to reduce the risk of vision loss in patients with high-risk PDR
and Foot Care and, in some cases, severe NPDR. A
• Intravitreous injections of anti-vascular endothelial growth factor ranibizumab

are not inferior to traditional panretinal laser photocoagulation and are also
indicated to reduce the risk of vision loss in patients with PDR. A
Microvascular Complications and Foot Care:

Older Adults: Recommendations

Pharmacologic Therapy:
• In older adults at increased risk of hypoglycemia, medication classes
with low risk of hypoglycemia are preferred. B
11. Older Adults
• Overtreatment of diabetes is common in older adults and should be
avoided. B
• Deintensification (or simplification) of complex regimens is
recommended to reduce the risk of hypoglycemia, if it can be
achieved within the individualized A1C target. B
Older Adults:
Framework for Considering Treatment Goals in
Older Adults with Diabetes
12. Children and Adolescents
Older Adults:
Type 2 Diabetes in Youth Risk-Based Screening in Asymptomatic Children

and Adolescents
• T2DM in youth has increased over the past 20 years
o ~5,000 new cases per year in the U.S.
• T2DM in youth is different from both T1DM in youth and T2DM in adults
• Disproportionally impacts youth of ethnic and racial minorities
• Additional risk factors include:
o Adiposity, family history of diabetes, female sex, and low socioeconomic
status
Children and Adolescents: Classification and Diagnosis of Diabetes:

SOC Overview Living Standards of Care

Provide new, effective resources for health care professionals and offer
those resources when, where and how they are needed
• Provides all of ADA’s current clinical practice recommendations
o The Standards supersedes all previous position statements on clinical
Strategy: ADA will enhance the Standards of Care
and aggressively implement innovative approaches to
topics within the purview of the Standards
reach critical audiences and expand the integration of
the standards of care into clinical practices,
particularly primary care providers. • Annual review process remains the same, but mid-year updates become
“Event-Driven”
Standards of Care:
o Option to update the Standards mid-year should the PPC determine
• “Living” event-driven SOC updates
timely incorporation of new evidence as it becomes available throughout the year that new evidence or regulatory changes merit immediate incorporation
• Increasing reach and adoption of clinical recommendations through user-friendly tools: o Updates may be suggested by PPC members, ADA staff, or members
• Specialty-focused executive summaries published in partner journals (PCP, Cardiology, JAMA, of the diabetes community
etc.) (MOU with American College of Cardiology to provide reviewers)
• Mobile App
o Updates must be reviewed and approved by the PPC
• Micromodules
• Diabetes is Primary
General Process Changes Living Standards of Care
• SOC are now the sole source of ADA’s clinical practice
Examples of Evidence-Based Updates:
recommendations
• The PPC will continue to update the Standards annually, and now • FDA makes a decision to approve metformin for
has the option to update throughout the year, online, if the PPC prevention in people with prediabetes
determines that new evidence or regulatory changes merit
immediate updates or inclusion. • Approval, clinical use and new indications of
technology and devices
• ADA will begin taking proposals from the community for statements,
consensus reports, scientific reviews, and clinical/research • New drug approval or new indication: ertugliflozin
conferences and semaglutide
professional.diabetes.org/SOC
Taxonomy of ADA Documents & Conferences Standards of Care Scope and Impact
• ADA Statements: represent the official ADA position and
are in line to with the Standards of Care.
The following do not represent the official ADA position and

are not tied to the SOC:
• Expert Consensus Reports
• Scientific Reviews
• Evolving Clinical Concepts Conferences
• Research Symposia
• Conference Proceedings
2018 Standards of Care: Resources
• Full version available

Resources • Abridged version for PCPs
• Free app (launching Spring 2018)
• Pocket cards with key figures
• Free webcast for continuing education
credit
Professional Education Diabetes Self-Management Education
• Find a recognized Diabetes Self-

Management program
• Live programs • Become a recognized DSME
• Online self-assessment program
programs • Tools and resources for DSME
programs
• Online webcasts
• Online education documentation
tools
professional.diabetes.org/CE professional.diabetes.org/ERP
Professional Membership
Thank you.
• Journals
• Meeting, book and journal discounts
• Career center
• Quarterly member newsletter
professional.diabetes.org/Membership

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Global Prevalence of Diabetes Expected to Increase

Standards of Medical 2017 U.S. Statistics:

1.IDF Diabetes Atlas, 8th edition. 2017. International Diabetes Foundation.

aType 1 or Type 2 diabetes.

OUR VISION OUR MISSION

Professional Practice Committee Process

Evidence Grading System Trend Toward Higher Level of Evidence

Richard W. Grant, and M. Sue Kirkman Dia Care 2015;38:6-8

Changes are needed to Improve Care Quality in

1. Improving Care and Promoting approved iPhone and apps

80 translated to improvements in diabetes care quality

Care Delivery Systems Diabetes and Population Health: Recommendations

• Delivery system is fragmented, lacks clinical information capabilities,

2. Classification and Diagnosis of 2. Type 2 diabetes

4. Other specific types of diabetes due to other causes:

Classification and Diagnosis of Diabetes:

Classification and Diagnosis of Diabetes: Classification and Diagnosis of Diabetes:

Classification and Diagnosis of Diabetes: Classification and Diagnosis of Diabetes:

Patient-Centered Collaborative Care

• A patient-centered communication style that uses person-centered

Comprehensive Medical Evaluation and Assessment of Comorbidities:

Components of the Comprehensive Diabetes Components of the Comprehensive Diabetes

Components of the Comprehensive Diabetes Components of the Comprehensive Diabetes

▪ Diabetes self-management education and support

Lifestyle Management: Lifestyle Management:

Physical Activity: Recommendations

• Patients with prediabetes should be referred to an intensive behavioral

• Metformin therapy for prevention of type 2 diabetes should be considered in

Prevention or Delay of Type 2 Diabetes:

Summary of Glycemic Recommendations

Treatment of Type 2 Diabetes

Published new algorithm for

Pharmacologic Therapy For Type 1 Diabetes:

• Most people with T1DM should be treated with multiple daily

Pharmacologic Approaches to Glycemic Treatment:

Mortality and Cardiovascular Disease in Type 1 and Type 2 Diabetes

more A1C less

William T. Cefalu et al. Dia Care 2018;41:14-31

Pharmacologic Approaches to Glycemic Treatment: Pharmacologic Approaches to Glycemic Treatment:

• In patients with T2DM and established ASCVD, after lifestyle

Pharmacologic Approaches to Glycemic Treatment:

“Doctors prescribe medicine of which

Francois-Marie Voltaire, 250 years ago

Modify based on co-morbidities, contraindications, HBA1C

Diabetes and Cardiovascular Disease

Cardiovascular Disease and Risk Management:

Diabetic Retinopathy: Recommendations

• The traditional standard treatment, panretinal laser photocoagulation therapy,

and Foot Care and, in some cases, severe NPDR. A

• Intravitreous injections of anti-vascular endothelial growth factor ranibizumab

Microvascular Complications and Foot Care:

Older Adults: Recommendations

12. Children and Adolescents

Type 2 Diabetes in Youth Risk-Based Screening in Asymptomatic Children

Children and Adolescents: Classification and Diagnosis of Diabetes:

SOC Overview Living Standards of Care

The following do not represent the official ADA position and

2018 Standards of Care: Resources

• Full version available

• Find a recognized Diabetes Self-

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