ADA GUIDELINE.pptx

Diabetes guidelines

1. Standards of Care in Diabetes—2023

2. Intended to provide clinicians, patients, researchers, payers, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. The Standards.

3. Introduction: Standards of Medical Care in Diabetes - 2019 . Diabetes Care 2019;42(Suppl. 1):S1-S2 3 Introduction: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S1-S4

4. Table of Contents . Improving Care and Promoting Health in Populations Classification and Diagnosis of Diabetes Prevention or Delay of T2D and Associated Comorbidities Comprehensive Medical Evaluation and Assessment of Comorbidities Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes Glycemic Targets Diabetes Technology Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes Pharmacologic Approaches to Glycemic Treatment CVD and Risk Management CKD and Risk Management Retinopathy, Neuropathy, and Foot Care Older Adults Children and Adolescents Management of Diabetes in Pregnancy Diabetes Care in the Hospital Diabetes and Advocacy

5. Section 2 . Classification and Diagnosis of Diabetes

6. Classification Classification and Diagnosis of Diabetes Diabetes can be classified into the following general categories: Type 1 diabetes (due to autoimmune ß-cell destruction, usually leading to absolute insulin deficiency, including latent autoimmune diabetes of adulthood) Type 2 diabetes (due to a non-autoimmune progressive loss of adequate ß-cell insulin secretion frequently on the background of insulin resistance and metabolic syndrome) Specific types of diabetes due to other causes , e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young), diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (such as with glucocorticoid use, in the treatment of HIV/AIDS, or after organ transplantation) Gestational diabetes mellitus (diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation)

7. Classification and Diagnosis of Diabetes Introduction and Methodology: ElSayed NA, Aleppo G, Aroda VR, et al., American Diabetes Association. Introduction and methodology: Standards of Care in Diabetes—2023. Diabetes Care 2023;46(Suppl. 1):S1–S4 7 Hold for table 2.1 Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S19-S40

8. No mention of hybride forms of diabetes ADA vs WHO classification of DM

9. Classification and Diagnosis of Diabetes Introduction and Methodology: ElSayed NA, Aleppo G, Aroda VR, et al., American Diabetes Association. Introduction and methodology: Standards of Care in Diabetes—2023. Diabetes Care 2023;46(Suppl. 1):S1–S4 9 Table 2.2 Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S19-S40

10. Classic symptoms of hyperglycemia Polyuria Polydipsia Weight loss Polyphagia no longer considered a classic symptom

11. Screening for type 2 DM

12. Classification and Diagnosis of Diabetes Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S19-S40

13. Classification and Diagnosis of Diabetes Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S19-S40

14. HBA1C maintained < 6.5 % for 3 months without use of OHA and INSULIN Remission of DM

15. 2.1b Point-of-care A1C testing for diabetes screening and diagnosis should be restricted to U.S. Food and Drug Administration – approved devices at laboratories pro fi cient in performing testing of moderate complexity or higher by trained personnel . B UPDATE 2023

16. Section 3 . Prevention or Delay of Type 2 Diabetes and Associated Comorbidities

17. Prevention of DM

18. 3.1 Monitor for the development of type 2 diabetes in those with prediabetes at least annually ; modified based on individual risk/benefit assessment. E 3.9 Statin therapy may increase the risk of type 2 diabetes in people at high risk of developing type 2 diabetes. In such individuals, glucose status should be monitored regularly and diabetes prevention approaches reinforced. It is not recommended that statins be discontinued . B 3.10 In people with a history of stroke and evidence of insulin resistance and prediabetes, pioglitazone may be considered to lower the risk of stroke or myocardial infarction. However, this benefit needs to be balanced with the increased risk of weight gain, edema, and fracture. A Lower doses may mitigate the risk of adverse effects . C UPDATE 2023

19. Section 4 . Comprehensive Medical Evaluation and Assessment of Comorbidities

20. Comordities in DM

21. Immunizations Comprehensive Medical Evaluation and Assessment of Comorbidities

22. Immunizations Comprehensive Medical Evaluation and Assessment of Comorbidities

23. Immunizations Comprehensive Medical Evaluation and Assessment of Comorbidities

24. Section 5 . Facilitating Positive Behaviors and Well-being to Improve Health Outcomes

25. Should engage in 150 min or more of moderate – to vigorous intensity activity weekly , spread over atleast 3 days / week No more than 2 consecutive days without activity Resistance training in 2 -3 sessions / week on non consecutive days Flexibility training and balance training are recommended 2-3 times / week for older adult with DM EXERCISE PLAN

26. Facilitating POSITIVE HEALTH Behaviors and Well-being to Improve Health Outcomes Medical Nutrition Therapy Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S68-S96

27. Facilitating POSITIVE HEALTH Behaviors and Well-being to Improve Health Outcomes Medical Nutrition Therapy (continued) Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S68-S96

28. Facilitating POSITIVE HEALTH Behaviors and Well-being to Improve Health Outcomes Medical Nutrition Therapy (continued) Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S68-S96

29. Time restricted eating and intermittent fasting Time restricted eating is generally easier to follow compared with alternative day fasting or the 5:2 plan No significant difference in weight loss when compared with contious calorie restriction Update 2023

30. Section 6 . Glycemic Targets

31. Glycemic targets

32. TIME IN RANGE

33. Section 8 . Obesity and Weight Management for the Treatment of Type 2 Diabetes

34. Obesity management

35. Obesity Management for the Treatment of Type 2 Diabetes Obesity Management for the Treatment of Type 2 Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S128-S139

36. Pharmacotherapy

37. Section 9 . Pharmacologic Approaches to Glycemic Treatment

38. Insulin as default

39. Pharmacologic Approaches to Glycemic Treatment Pharmacologic Approaches to Glycemic Management: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S140-S157

40. Section 10 . Cardiovascular Disease and Risk Management

41. Cardiovascular Disease and Risk Management Cardiovascular Disease and Risk Management: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S158-S190

42. Hypertension management

43. Cardiovascular Disease and Risk Management Recommendations for the Treatment of Confirmed Hypertension in People with Diabetes (1 of 2) Cardiovascular Disease and Risk Management: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S158-S190

44. Cardiovascular Disease and Risk Management Recommendations for the Treatment of Confirmed Hypertension in People with Diabetes (2 of 2) Cardiovascular Disease and Risk Management: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S158-S190

45. Lipid management – statins for primary prevention Age CV risk factors 40 - 75 nil Moderate intensity statin LDL < 100 mg/dl 40 -75 1 or more High intensity statin LDL < 70 Reduce LDL 50% from base line 20- 39 + Reasonable to initiate statin > 75 Nil Reasonable to initiate moderate intensity statin > 75 + Continue statin therapy

46. For people of all age with diabetes and ASCVD , high intensity statin therapy should be added to lifestyle therapy Target LDL < 55mg / dl ( add ezetimibe / PCSK9 inhibitors if target not achieved ASCVD or other CV risk factors on a statin with controlled LDL cholesterol but elevated triglycerides ( 135 – 499) the addition of icosapent ethyl can be considered to reduce CV risk Lipid management – statins for secondary prevention

47. Cardiovascular Disease and Risk Management Cardiovascular Disease and Risk Management: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S158-S190

48. Reduce cardiovascular risk

49. Reduce cardiovascular risk

50. Aspirin in DM

51. Section 11 . Chronic Kidney Disease and Risk Management

52. ACEI/ARB recommended in moderately increased albuminuria ( 30 -299 mg/g cr ) strongly recommened in severly increased albuminuria ( >300 mg/g cr ) and or e GFR < 60 SGLT2i In all patients with DKD , recommended to reduce CKD progression and CV events in patient with an e GFR > 20 Ml /min/1.73m2 and urinary albumin > 200mg/g cr CKD and risk management

53. FINERENONE used if e GFR > 25 Ml /min/1,73m2 and k+ < 5 mEq/L 10 mg / 20 mg once weekly weekly e GFR , K + monitoring CKD and risk management

54. Section 12 . Retinopathy, Neuropathy, and Foot Care

55. 12.20 Gabapentinoids , serotoninnorepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers are recommended as initial pharmacologic treatments for neuropathic pain in diabetes. A Refer to neurologist or pain specialist when pain control is not achieved within the scope of practice of the treating physician . E SNRI – duloxetine , venlafaxine , all selective SNRI TCA – amitriptyline Capsaicin – FDA approved for pain as 8% patch Neuropathy

56. Sodium channel blockers – lamotrigine , lacosamide , oxcarbamazepine , and valproic acid Carbamazepine not approved Neuropathy

57. Fatty infiltration of > 5 % Hepatic steatosis associated with inflammation and hepatocyte injury with or without fibrosis – NASH ASSESSMENT FIB 4 SCORE – age , SGOT, SGPT, platelet count Fibroelastography NAFLD

58. THANK YOU