Clinical Question

P Patients suspected to have T2DM

I HbA1c
O Diagnosis of T2DM
M Clinical Practice Guideline
http://professional.diabetes.org/
 Were all important options and
outcomes considered?
Current Criteria for the Diagnosis of Hypoglycemia Nephropathy
Diabetes

Immunization Hypertension
Testing for Pre-Diabetes in
Asymptomatic Patients
Hypertension/Blood Pressure Contro Dyslipidemia

Testing for T2DM in Children

Dyslipidemia/Lipid Management Retinopaty

Detection and Diagnosis of GDM

Treatment Recommendations and Goals Celiac Disease

Prevention/Delay of T2DM
Antiplatelet Agents Hypothyroidism

Glucose Monitoring
Smoking Cesation Preconception Care

A1C
Coronary Heart Disease Screening and Older Adults
Treatment
Glycemic Controls in Adults
Diabetes Care in the Hospital, School and Day Setting,
Nephropathy Screening and Treatment Diabetes Camps, Correctional Institutions
Medical Nutrition Therapy

Retinopathy Screning and Treatment Emergency and Disaster Preparedness

Bariatric Surgery

Neuropathy Screening and Treatment Diabetes and Employment

Diabetes Self-Management Education

Foot Care Third-Party Reimbursement for Diabetes Care, Self-

Phyical Activity Management Education, and Supplies

Children and Adolscents

Pyschosocial Assessment and Care
 Were all important options and
outcomes considered?
Current Criteria for the Diagnosis of Hypoglycemia Nephropathy
Diabetes

Immunization Hypertension
Testing for Pre-Diabetes in
Asymptomatic Patients
Hypertension/Blood Pressure Contro Dyslipidemia

Testing for T2DM in Children

Dyslipidemia/Lipid Management Retinopaty

Detection and Diagnosis of GDM

Treatment Recommendations and Goals Celiac Disease

Prevention/Delay of T2DM
Antiplatelet Agents Hypothyroidism

Glucose Monitoring
Smoking Cesation Preconception Care

A1C
Coronary Heart Disease Screening and Older Adults
Treatment
Glycemic Controls in Adults
Diabetes Care in the Hospital, School and Day Setting,
Nephropathy Screening and Treatment Diabetes Camps, Correctional Institutions
Medical Nutrition Therapy

Retinopathy Screning and Treatment Emergency and Disaster Preparedness

Bariatric Surgery

Neuropathy Screening and Treatment Diabetes and Employment

Diabetes Self-Management Education

Foot Care Third-Party Reimbursement for Diabetes Care, Self-

Phyical Activity Management Education, and Supplies

Children and Adolscents

Pyschosocial Assessment and Care
 A1C for the diagnosis of diabetes has
“The use of the
previously not been recommended due to lack of global
standardization and uncertainty about diagnostic
thresholds. However, with a world-wide move toward a standardized
assay and with increasing observational evidence about the prognostic
significance of A1C, an Expert Committee on the Diagnosis of Diabetes was
convened in 2008. This joint committee of ADA, the European Association for
the Study of Diabetes, and the International Diabetes Federation will likely
recommend that the A1C become the preferred diagnostic test for diabetes.
Diagnostic cut-points are being discussed at the
time of publication of this statement. Updated
recommendations will be published in Diabetes Care and will be available at
diabetes.org”
Because A1C is thought to reflect average
glycemia over several months (37), and
has strong predictive value for diabetes
complications (10,39), A1C testing should
be performed routinely in all patients with
diabetes at initial assessment and then as
part of continuing care….

The A1C test is subject to certain

limitations. Conditions that affect
erythrocyte turnover (hemolysis, blood
loss) and hemoglobin variants must be
considered, particularly when the A1C
result does not correlate with the patient's
clinical situation (37).
Was an explicit and sensible process used

to identify, select, and combine evidence?

ADA Clinical Practice Recommendations consist of
position statements that represent official ADA
opinion as denoted by formal review and approval by
the Professional Practice Committee and the
Executive Committee of the Board of Directors.
Consensus statements and technical reviews are not
official ADA recommendations; however, they are
produced under the auspices of the Association by
invited experts. These publications may be used by
the Professional Practice Committee as source
documents to update the “Standards.”
ADA POSITION STATMENT

An official point of view or belief of the ADA. Position

statements are issued on scientific or medical issues
related to diabetes. They may be authored or unauthored
and are published in ADA journals and other
scientific/medical publications as appropriate. Position
statements must be reviewed and approved by the
Professional Practice Committee and, subsequently, by
the Executive Committee of the Board of Directors. ADA
position statements are typically based on a technical
review or other review of published literature. They are
reviewed on an annual basis and updated as needed. A list
of recent position statements is included on p. S98 of this
supplement.
TECHNICAL REVIEW

A balanced review and analysis of the literature on

a scientific or medical topic related to diabetes.
The technical review provides a scientific
rationale for a position statement and undergoes
critical peer review before submission to the
Professional Practice Committee for approval. A
list of recent technical reviews is included on
page S95 of this supplement.
CONSENSUS STATMENT

A comprehensive examination by a panel of experts (i.e., consensus

panel) of a scientific or medical issue related to diabetes. A
consensus statement is typically developed immediately following a
consensus conference at which presentations are made on the issue
under review. The statement represents the panel's collective
analysis, evaluation, and opinion at that point in time based in part on
the conference proceedings. The need for a consensus statement
arises when clinicians or scientists desire guidance on a subject for
which the evidence is contradictory or incomplete. Once written by
the panel, a consensus statement is not subject to subsequent
review or approval and does not represent official Association
opinion. A list of recent consensus statements is included on p. S96
of this supplement.
Was an explicit and sensible process used

to identify, select, and combine evidence?

No mention of how literature was searched and

what database was used.
Is the guideline likely to account for
important recent developments?
The guideline is updated annually. It cites 64
reference articles published between 1950 to
2009.
Has the guideline been subjected
to peer review and testing?
No.
Are practical, clinically important,
recommendations made?
I. CLASSIFICATION AND DIAGNOSIS

II. TESTING FOR PRE-DIABETES AND DIABETES IN ASYMPTOMATIC PATIENTS

III. DETECTION AND DIAGNOSIS OF GDM

IV. PREVENTION/DELAY OF TYPE 2 DIABETES

V. DIABETES CARE

VI. PREVENTION AND MANAGEMENT OF DIABETES COMPLICATIONS

VII. DIABETES CARE IN SPECIFIC POPULATIONS

VIII. DIABETES CARE IN SPECIFIC SETTINGS

IX. DIABETES AND EMPLOYMENT (360)

X. THIRD-PARTY REIMBURSEMENT FOR DIABETES CARE, SELF-MANAGEMENT EDUCATION, AND SUPPLIES (361)

XI. STRATEGIES FOR IMPROVING DIABETES CARE

How strong are the
recommendations?
The crtieria for diagnosis was the only topic
without a grade.

HbA1c recommendations were all grade E.

Is the primary objective of the guideline

consistent with your objective?

My question may be too specific

Are the recommendations
applicable to your patients?
In terms of diagnosing patients, YES. The lab
tests are readily available and standardized.
An International Expert Committee with members appointed
by the American Diabetes Association, the European
Association for the Study of Diabetes, and the International
Diabetes Federation was convened in 2008 to consider the
current and future means of diagnosing diabetes in
nonpregnant individuals. The report of the International
Expert Committee represents the consensus view of its
members and not necessarily the view of the organizations
that appointed them. The International Expert Committee
hopes that its report will serve as a stimulus to the
international community and professional organizations to
consider the use of the A1C assay for the diagnosis of
diabetes.
Advantages of HbA1c
Testing
Standardized and aligned to the DCCT/UKPDS; measurement of glucose is less well
standardized

Better index of overall glycemic exposure and risk for long-term complications

Substantially less biologic variability

Substantially less preanalytic instability

No need for fasting or timed samples

Relatively unaffected by acute (e.g., stress or illness related) perturbations in glucose

levels

Currently used to guide management and adjust therapy

What would be the most appropriate
cut off point for HbA1c?
Limitations of HbA1c in
the diagnosis of diabetes
Cost

Cannot be used in patients with blood

dyscrasias

Appears to increase with age and varies among

races

“Rapidly evolving T1DM”