The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, ...diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.
The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.
This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.
This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
... recent trials in critically ill patients have failed to show a significant improvement in mortality with intensive glycemic control (12,13) or have even shown increased mortality risk (14). ... ...these recent RCTs have highlighted the risk of severe hypoglycemia resulting from such efforts (12-17). A sixfold increase in severe hypoglycemic events (BG <40 mg/dl 2.2 mmol/1) was observed in the intensively treated group (18.7 vs. 3.1%), and hypoglycemia was identified as an independent risk factor for mortality (16).\n * Less stringent targets may be appropriate in terminally ill patients or in patients with severe comorbidities. * Scheduled subcutaneous administration of insulin, with basal, nutritional, and correction components, is the preferred method for achieving and maintaining glucose control. * Prolonged therapy with SSI as the sole regimen is discouraged. * Noninsulin antihyperglycemic agents are not appropriate in most hospitalized patients who require therapy for hyperglycemia. * Clinical judgment and ongoing assessment of clinical status must be incorporated into day-to-day decisions regarding treatment of hyperglycemia.
Aims Recent trials (EMPA-REG OUTCOME and Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results LEADER) have shown improved cardiovascular (CV) mortality with ...specific currently available glucose-lowering medications (empagliflozin and liraglutide, respectively), but were limited to selected patient populations. We sought to evaluate the current use and potential real-world impact of empagliflozin (and other sodium-glucose co-transporter 2 inhibitors SGLT2is) and liraglutide (and other glucagonlike peptide-1 receptor agonist GLP-1 RAs) among patients in the Diabetes Collaborative Registry (DCR). Methods and results We evaluated 182,525 patients from the DCR - a large, US-based outpatient registry of individuals with type 2 diabetes from 313 sites that included cardiology, endocrinology and primary care practices. Among these patients, 26.2% met major eligibility criteria for EMPA-REG OUTCOME and 48.0% met major eligibility criteria for LEADER. Of these potentially eligible patients, only a small minority were actually prescribed these agents: 5.2% on an SGLT2i and 6.0% on a GLP-1 RA, respectively. Patients receiving these studied medications or medication classes, in general, had lower CV disease burden compared with those not on these agents. Assuming similar risk reductions as in the clinical trials, if all potentially trial-eligible patients in the DCR were treated for 1 year with empagliflozin (or other SGLT2is, assuming a class effect) or liraglutide (or other GLP-1 RAs, assuming a class effect), this may have prevented 354 CV deaths, 231 heart failure hospitalizations, 329 CV deaths and 247 myocardial infarctions, respectively. Conclusion In a large, US-based outpatient registry, we found a significant number of patients would have been potentially eligible for glucose-lowering agents that demonstrated CV benefit in recent clinical trials. In view of these findings, a broader and better-targeted use of these medications in evidence-based patient populations should be considered.
This report presents an algorithm to assist primary care physicians, endocrinologists, and others in the management of adult, nonpregnant patients with type 2 diabetes mellitus. In order to minimize ...the risk of diabetes-related complications, the goal of therapy is to achieve a hemoglobin A1c (A1C) of 6.5% or less, with recognition of the need for individualization to minimize the risks of hypoglycemia. We provide therapeutic pathways stratified on the basis of current levels of A1C, whether the patient is receiving treatment or is drug naïve. We consider monotherapy, dual therapy, and triple therapy, including 8 major classes of medications (biguanides, dipeptidyl-peptidase-4 inhibitors, incretin mimetics, thiazolidinediones, alpha-glucosidase inhibitors, sulfonylureas, meglitinides, and bile acid sequestrants) and insulin therapy (basal, premixed, and multiple daily injections), with or without orally administered medications. We prioritize choices of medications according to safety, risk of hypoglycemia, efficacy, simplicity, anticipated degree of patient adherence, and cost of medications. We recommend only combinations of medications approved by the US Food and Drug Administration that provide complementary mechanisms of action. It is essential to monitor therapy with A1C and self-monitoring of blood glucose and to adjust or advance therapy frequently (every 2 to 3 months) if the appropriate goal for each patient has not been achieved. We provide a flow-chart and table summarizing the major considerations. This algorithm represents a consensus of 14 highly experienced clinicians, clinical researchers, practitioners, and academicians and is based on the American Association of Clinical Endocrinologists/American College of Endocrinology Diabetes Guidelines and the recent medical literature.
Screening for sleep apnea may be useful in a number of settings, such as preoperative testing, clinical research, and evaluation for referral to a sleep center. The purpose of the study was to ...validate the ApneaLink device (ResMed Corporation, Poway, Calif) for use as a screening tool for sleep apnea in clinical practice.
The ApneaLink device is a single-channel screening tool for sleep apnea that measures airflow through a nasal cannula connected to a pressure transducer, providing an apnea-hypopnea index (AHI) based on recording time. We compared the AHI from the ApneaLink device to that obtained during simultaneously conducted attended sleep-laboratory polysomnography to assess the sensitivity and specificity of the device in consecutive subjects with type 2 diabetes mellitus referred from a diabetes clinic. We also compared the AHI obtained from the ApneaLink device during a study in the subjects' homes to that obtained during the in-laboratory study. The laboratory study was performed within 2 weeks of the home study.
Fifty-nine subjects completed the study. Mean age of subjects was 57 years; mean body mass index was 33 kg/m2. The results demonstrate a high sensitivity and specificity of the at-home ApneaLink AHI compared with the AHI from the simultaneous polysomnographic study at all AHI levels, with the best results at an AHI of > or =15 events per hour (sensitivity 91%, specificity 95%). The AHI comparison from the home and laboratory studies also demonstrates good sensitivity and specificity at AHI levels of > or =15 and > or =20 events per hour (sensitivity 76%, specificity 94%, for both).
Given the prevalence of sleep apnea in the adult population and in specific comorbid conditions, a screening tool may be useful in many diagnostic settings. This study demonstrates that the ApneaLink device provides reliable information, is a simple, easy-to-use device, and is highly sensitive and specific in calculating AHI, when compared with the AHI obtained from full polysomnography.
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