Because glucose management is dynamic, more frequent monitoring provides a more complete picture. As discussed in Section 9 “Pharmacologic Approaches to Glycemic Treatment,” addition of specific sodium–glucose cotransporter 2 inhibitors (SGLT2i) or glucagon-like peptide 1 receptor agonists (GLP-1 RA) to improve cardiovascular outcomes in patients with established CVD is indicated with consideration of glycemic goals. Diabetes Care Print ISSN: 0149-5992, Online ISSN: 1935-5548. For Suggested citation: American Diabetes Association. The A1C is a blood test that gives doctors an estimate of your blood sugar level average over the past few months. Classification and diagnosis of diabetes. Medicare, Dexcom G5, & Smartphone Access: Whos to Blame and What Can We Do? 6. 2. This Chef Lost 50 Pounds And Reversed Prediabetes With A Digital Program Some studies have shown that people who have aggressively pushed to lower their blood sugar are at somewhat higher risk of premature death. Also, with longer duration of disease, diabetes may become more difficult to control, with increasing risks and burdens of therapy. In type 2 diabetes, there is evidence that more intensive treatment of glycemia in newly diagnosed patients may reduce long-term CVD rates. 2021 Highlights Webcast . Continue reading >>, The American Diabetes Association (ADA) publishes the Standards of Medical Care in Diabetes annually, based on the latest medical research. However, 10-year follow-up of the VADT cohort (33) showed a reduction in the risk of cardiovascular events (52.7 [control group] vs. 44.1 [intervention group] events per 1,000 person-years) with no benefit in cardiovascular or overall mortality. The revised guidelines, published in Diabetes Care, also created new specifications for applying the HbA1c test. Whether there are clinically meaningful differences in how A1C relates to average glucose in children or in different ethnicities is an area for further study (8,14,15). New guidelines incorporate the use of diabetes drugs with known cardiovascular benefit. Epidemiologic analyses of the DCCT (16) and UKPDS (23) demonstrate a curvilinear relationship between A1C and microvascular complications. If already on dual therapy or multiple glucose-lowering therapies and not on an SGLT2i or GLP-1 RA, consider switching to one of these agents with proven cardiovascular benefit. For many people with diabetes, glucose monitoring is key for the achievement of glycemic targets. "There are harms associated with overzealous treatment or inappropriate treatment focused on A1C targets," says Dr. Jack Ende , president of the ACP. What Are the ADA Standards of Care and Why Should You Care? Details of these studies are reviewed extensively in “Intensive Glycemic Control and the Prevention of Cardiovascular Events: Implications of the ACCORD, ADVANCE, and VA Diabetes Trials” (31). The American Diabetes Association (ADA) 2020 Guideline revisions are available. Objective: To compare recent diabetes guideline updates from the American Diabetes Association-European Association for the Study of Diabetes (ADA/EASD) and the American Association of Clinical Endocrinologists-American College of Endocrinology (AACE/ACE). Screening patients before signs and symptoms develop leads to earlier diagnosis and treatment, but may not reduce rates of end-organ damage. Continue reading >>, Living with poorly controlled blood sugar levels may lead to potentially serious health complications for people with diabetes — including diabetic neuropathy, diabetic retinopathy, amputations, depression, sexual issues, heart disease, stroke, and even death. 2. The use of point-of-care A1C testing may provide an opportunity for more timely treatment changes during encounters between patients and providers. A, 6.5 Providers might reasonably suggest more stringent A1C goals (such as <6.5% [48 mmol/mol]) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment (i.e., polypharmacy). Most patients using intensive insulin regimens (multiple-dose insulin or insulin pump therapy) should perform self-monitoring of blood glucose (SMBG) prior to meals and snacks, at bedtime, occasionally postprandially, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. You will not develop type 2 diabetes automatically if you have prediabetes. The American Diabetes Association’s goals for blood glucose control in individuals with diabetes mellitus are 70 to 130 mg/dL prior to dishes, as well as less compared to 180 mg/dL … Ongoing insulin activity or insulin secretagogues may lead to recurrent hypoglycemia unless more food is ingested after recovery. B, 6.7 Reassess glycemic targets over time based on the criteria in Fig. For example: When you have type 1 diabetes you are treated with insulin replacement therapy. We will learn that target ranges can be individualized based on the factors above. You may or may not understand what blood sugar ranges are for people without diabetes. A small study comparing A1C to CGM data in children with type 1 diabetes found a highly statistically significant correlation between A1C and mean blood glucose, although the correlation (r = 0.7) was significantly lower than in the ADAG trial (13). An individual does not need to be a health care professional to safely administer glucagon. For some people with prediabetes, early treatment can actually … American Diabetes Association 2451 Crystal Drive, Suite 900, Arlington, VA 22202 1-800-DIABETES Follow us on Twitter, Facebook, YouTube and LinkedIn DBP Footer Main There is evidence for a cardiovascular benefit of intensive glycemic control after long-term follow-up of cohorts treated early in the course of type 1 diabetes. "Diabetes is such a prevalent problem, and there are so many guidelines and conflicting information out there, we wanted to do an assessment that would give our members the best possible advice," Ende said. An analysis of data from 470 participants in the ADAG study (237 with type 1 diabetes and 147 with type 2 diabetes) found that actual average glucose levels associated with conventional A1C targets were higher than older DCCT and ADA targets (Table 6.1) (7,43). Blood glucose targets are individualized based on: duration of diabetes; age/life expectancy; conditions a person may have; cardiovascular disease or diabetes complications; hypoglycemia unawareness; individual patient considerations; The American Diabetes Association suggests the following targets for most nonpregnant adults with diabetes. Patient self-monitoring of blood glucose (SMBG) may help with self-management and medication adjustment, particularly in individuals taking insulin. Following a review of the latest evidence — including a range of recent trials of drug and lifestyle interventions — the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) have produced an updated consensus statement on how to manage hyperglycaemia (high blood sugar) in patients with type 2 diabetes. Can You Reverse a Type-2 Diabetes Diagnosis? An association of level 3 hypoglycemia with mortality was also found in the ADVANCE trial (51). Keywords: physical activity, exercise, diabetes, guidelines, American Diabetes Association This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). E Patients on multiple-dose insulin or insulin pump therapy should perform SMBG prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. As discussed further below, severe hypoglycemia is a potent marker of high absolute risk of cardiovascular events and mortality (38). The American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes is updated and published annually in a supplement to the January issue of Diabetes Care . Lastly, level 3 hypoglycemia is defined as a severe event characterized by altered mental and/or physical functioning that requires assistance from another person for recovery. Major clinical trials of insulin-treated patients have included SMBG as part of multifactorial interventions to demonstrate the benefit of intensive glycemic control on diabetes complications (16). In general: An A1C level below 5.7 percent is considered normal An A1C level between 5.7 and 6.4 percent is considered prediabetes An A1C level of 6.5 percent or higher on two separate tests indicates type 2 diabetes Certain conditions can make the A1C test inaccurate — such as if you are pregnant or have an uncommon form of hemoglobin (hemoglobin variant). The American Diabetes Association (ADA) has released their annualStandards of Medical Care in Diabetesfor 2018, highlighting several updated recommendations for diabetes care and management. She was diagnosed in her mid-40s and put on an aggressive treatment regime. Propose solutions and resources accordingly. Caregivers, school personnel, or family members of these individuals should know where it is and when and how to administer it. These findings support that premeal glucose targets may be relaxed without undermining overall glycemic control as measured by A1C. Long-term follow-up of the UKPDS cohorts showed enduring effects of early glycemic control on most microvascular complications (22). Although such variability is less on an intraindividual basis than that of blood glucose measurements, clinicians should exercise judgment when using A1C as the sole basis for assessing glycemic control, particularly if the result is close to the threshold that might prompt a change in medication therapy. Yet, it woul... How can diabetes affect feet and skin? Providers should continue to counsel patients to treat hypoglycemia with fast-acting carbohydrates at the hypoglycemia alert value of 70 mg/dL (3.9 mmol/L) or less. However, on the basis of physician judgment and patient preferences, select patients, especially those with little comorbidity and long life expectancy, may benefit from adopting more intensive glycemic targets (e.g., A1C target <6.5% [48 mmol/mol]) if they can achieve it safely without hypoglycemia or significant therapeutic burden. For example, the ADA (American Diabetes Association) numbers are different from that of the ACE (American College of Endocrinology). Any condition leading to deterioration in glycemic control necessitates more frequent monitoring of blood glucose; ketosis-prone patients also require urine or blood ketone monitoring. More than 29 million Americans have diabetes. The American Diabetes Association (ADA) and the American Association for Clinical Chemistry have determined that the correlation (r = 0.92) in the ADAG trial is strong enough to justify reporting both the A1C result and the estimated average glucose (eAG) result when a clinician orders the A1C test. The American Diabetes Association (ADA) 2020 Guideline revisions are available. Unstable or intensively managed patients (e.g., pregnant women with type 1 diabetes) may require testing more frequently than every 3 months (4). Given the substantially increased risk of hypoglycemia in type 1 diabetes trials and with polypharmacy in type 2 diabetes, the risks of lower glycemic targets may outweigh the potential benefits on microvascular complications. The ACP, which represents internists, recommends that doctors aim for an A1C in the range of 7 to 8 percent, not the lower levels that other groups recommend. Added fat may retard and then prolong the acute glycemic response. For glycemic goals in older adults, please refer to Section 12 “Older Adults.” For glycemic goals in children, please refer to Section 13 “Children and Adolescents.” For glycemic goals in pregnant women, please refer to Section 14 “Management of Diabetes in Pregnancy.”, 6.4 A reasonable A1C goal for many nonpregnant adults is <7% (53 mmol/mol). C, 6.9 Glucose (15–20 g) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL [3.9 mmol/L]), although any form of carbohydrate that contains glucose may be used. ADA-Recommended Glycemic Targets for Nonpregnant Adults3 Parameter Treatment Goal Hemoglobin A1C <6.5% for patients If accompanied by ketosis, vomiting, or alteration in the level of consciousness, marked hyperglycemia requires temporary adjustment of the treatment regimen and immediate interaction with the diabetes care team. Heterogeneity of mortality effects across studies was noted, which may reflect differences in glycemic targets, therapeutic approaches, and population characteristics (34). The new revisions include changes for screening, nutrition and assessing blood glucose management and more. If the patient is not at A1C target, continue metformin unless contraindicated and add SGLT2i or GLP-1 RA with proven cardiovascular benefit. SMBG is thus an integral component of effective therapy of patients taking insulin. This change reflects the results of the ADAG study, which demonstrated that higher glycemic targets corresponded to A1C goals (7). This includes sodium-glucose cotransporter 2 (SGLT-2) … An additional goal of raising the lower range of the glycemic target was to limit overtreatment and provide a safety margin in patients titrating glucose-lowering drugs such as insulin to glycemic targets. AACE-Recommended Glycemic Targets for Nonpregnant Adults1,2 Parameter Treatment Goal Hemoglobin A1C Individualize on the basis of age, comorbidities, and duration of disease ≤6.5 for most Closer to normal for healthy Less stringent for “less healthy” Fasting plasma glucose (FPG) <110 mg/dL 2-hour postprandial glucose (PPG) <140 mg/dL The American Diabetes Association (ADA) also recommends individualizing glycemic targets (Table 2) based on patient-specific characteristics3: Patient attitude and expected treatment efforts Risks potentially associated with hypoglycemia as well as other adverse events Disease duration Life expectancy Important comorbidities Established vascular complications Resources and support system Table 2. Click here to view more. The factors to consider in individualizing goals are depicted in Fig. The issue of preprandial versus postprandial SMBG targets is complex (41). Initiate insulin therapy for American Diabetes Association releases 2019 Guidelines for Diabetes Care in the Hospital (BG) levels ≥180 mg/dL in most hospitalized patients, … Glycemic management is primarily assessed with the A1C test, which was the measure studied in clinical trials demonstrating the benefits of improved glycemic control. B. Hypoglycemia is the major limiting factor in the glycemic management of type 1 and type 2 diabetes. Analysis of the ACCORD data did not identify a clear explanation for the excess mortality in the intensive treatment arm (27). For adults with type 2 diabetes and heart disease, the ADA recommends that, after lifestyle management and metformin, health care providers should include a medication proven to improve heart health. How did I get so unhealthy? The standards reflect the latest evidence available to help improve care and health outcomes in people with diabetes, says William T. Cefalu, MD, the chief scientific, medical, and mission officer at the ADA who is based in New Orleans, Louisiana. The performance of the test is generally excellent for NGSP-certified assays (www.ngsp.org). Purchased content. Download adobe Acrobat or click here to download the PDF file. 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The benefit of intensive glycemic control in this cohort with type 1 diabetes has been shown to persist for several decades (29) and to be associated with a modest reduction in all-cause mortality (30). Reconsider/lower individualized A1C target and introduce SGLT2i or GLP-1 RA. BLOOD GLUCOSE MONITORING IN DIABETES MANAGEMENT 2020. C Given variable adherence to CGM, assess individual readiness for continuing use of CGM prior to prescribing. A fasting blood sugar level of 126 mg/dL (7.0 mmol/L) or higher indicates type 2 diabetes. Over time, high blood sugar levels can lead to vision loss , nerve problems, heart attacks, strokes and kidney failure. E, 6.11 Hypoglycemia unawareness or one or more episodes of level 3 hypoglycemia should trigger reevaluation of the treatment regimen. 3. A must-read every morning. For most adults, the American Diabetes Association recommends a target A1C of below 7 percent. This syndrome is characterized by deficient counterregulatory hormone release, especially in older adults, and a diminished autonomic response, which both are risk factors for, and caused by, hypoglycemia. The updated guidelines address the use of the medications with potential cardiovascular (CV) benefit. Lancet 1998; 352(9131): 837-53. If you have prediabetes, you should be checked for type 2 diabetes every one to two years. Self-monitoring of blood glucose (SMBG) is an important component of modern therapy for diabetes mellitus. Continue reading >>, Understanding blood sugar target ranges to better manage your diabetes As a person with diabetes, you may or may not know what your target ranges should be for your blood sugars first thing in the morning, before meals, after meals, or at bedtime. More stringent control (such as an A1C of 6.5% [48 mmol/mol] or <7% [53 mmol/mol]) may be recommended if it can be achieved safely and with acceptable burden of therapy and if life expectancy is sufficient to reap benefits of tight control. Adequate fluid and caloric intake must be ensured. As with any laboratory test, there is variability in the measurement of A1C. Mean glucose levels for specified A1C levels (6,7). In a recent report, mean glucose measured with CGM versus central laboratory–measured A1C in 387 participants in three randomized trials demonstrated that A1C may underestimate or overestimate mean glucose (5). The new revisions include changes for screening, nutrition and assessing blood glucose management and more. Technological innovations are shaping the way people manage diabetes, experts say. The recommendations include blood glucose levels that appear to correlate with achievement of an A1C of <7% (53 mmol/mol). Conclusions: A single RBG ≥ 100 mg/dL is more strongly associated with undiagnosed diabetes than traditional risk factors. Figure 6.1 is not designed to be applied rigidly but to be used as a broad construct to guide clinical decision making (40) in both type 1 and type 2 diabetes. Clinicians should note that the mean plasma glucose numbers in the table are based on ∼2,700 … Success correlates with adherence to ongoing use of the device. If you think you may have diabetes or prediabetes, check with your doctor and get tested. Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia. Glycemic Targets. The ADA has long recommended that treatment goals be individualized based on factors both modifiable and nonmodifiable, such as age, life expectancy, duration of disease, resources and support, and comorbid conditions. To minimize this risk, many providers will recommend that individuals treated with insulin target a pre Although the Standards of Medical Care are primarily geared toward the healthcare community, your diabetes management can benefit if you know about them, says Robert A. Gabbay, MD, PhD, the chief medical officer of the Joslin Diabetes Center in Boston. Numerous factors must be considered when setting glycemic targets. The Diabetes Control and Complications Trial (DCCT) (16), a prospective randomized controlled trial of intensive (mean A1C about 7% [53 mmol/mol]) versus standard (mean A1C about 9% [75 mmol/mol]) glycemic control in patients with type 1 diabetes, showed definitively that better glycemic control is associated with 50–76% reductions in rates of development and progression of microvascular (retinopathy, neuropathy, and diabetic kidney disease) complications.

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