Joslin 2010

2-4 routine visits/ year.

who fail to keep scheduled appointments, have frequent hospitalizations or missed days of work/school.

• engage patients in identifying and resolving contributing factors or barriers to under-utilization or over-utilization of healthcare services • consider referral to a diabetes educator (DE), social services or a mental health professional to address possible barriers and/or psychosocial problems • establish a process of follow-up communication regarding achievement (progress) of the treatment plan, sustaining behaviors and identifying obstacles to care A1C

An A1C* level of 6.5% or higher on 2 separate days is acceptable for diagnosis of diabetes. However, some individuals may have an A1C < 6.5% with diabetes diagnosed by previously established blood glucose criteria.

Those with an A1C of 5.7-6.4% are at increased risk for

Pt's with an A1C of 5.7-6.4% should be treated with lifestyle changes and follow more frequently.

2-4 times a year as part of the scheduled medical visit, with frequency dependent upon revision of the treatment program and the need to reinforce behavior changes.

therapy has changed and/or when glycemic goals are not met.

having the A1C result at the time of the visit can be useful in making timely treatment decisions.

< 7%

presence or absence of microvascular and/or cardiovascular complications,

≤ 6.5%.

consider revising A1C goals to maintain safety.

3-4 months, more frequently as the situation dictates.

• Review and clarify the management plan with the patient with attention to

1-nutrition and meal planning 2- physical activity 3- medication administration schedule, technique 4 and practices 5- self-monitoring blood glucose (SMBG) schedule and technique 6- treatment of hypoglycemia and hyperglycemia 7- sick day management practices

1 Review and clarify the plan as previously noted. 2 Assess for psychosocial stress. 3 Establish and reinforce individualized glycemic goals

1 assess for changes in daily routine such as decreased food intake or increased activity 2 refer to DE for evaluation, DSME and hypoglycemia prevention

7 consider and screen for other medical causes 8 consider referral for blood glucose awareness training, if available 9• consider use of continuous glucose monitoring (CGM) 10• schedule follow-up appointment within 1-2 months.

gauge treatment efficacy, help in

glucose goals,

4-6 times per day. Some patients may need to monitor even more frequently.

mode of

for several consecutive

2-3 hours postprandially, as postprandial

• have an elevated A1C but fasting glucose is at target • are initiating intensive (physiologic) insulin treatment programs • are experiencing problems with glycemic control • are using glucose-lowering agents targeted at postprandial glucose levels • are making meal planning or activity adjustments

• during pregnancy• for those patients using alpha-glucosidase inhibitors Encourage the patient to bring SMBG results (written records or meter for downloading) to each visit for review with provider/educator.

lag

exercise,

• when the blood glucose may be changing rapidly• for patients using intensive insulin treatment

SMBG to document hypoglycemia

administer a

hypoglycemic.

15-20 grams

20-30 grams

15 minutes.

15 minutes.

additional carbohydrate or snack if next meal is more than one hour away.

patient or companion should be instructed to contact healthcare provider.

For patients with hypoglycemia unawareness, the

check 15 minutes

diabetes

• Identify possible causes of hypoglycemia in order to prevent it.

modified treatment goals

• an annual assessment of the need for DSME and MNT, and referral, as appropriate, to a trained DE • initial and ongoing assessment of psychosocial issues

• Physical activity should be an integral component of the diabetes care plan to optimize glucose control, decrease cardiovascular risk factors, and achieve or maintain optimal body weight.

physical activity minimum of 30 minutes (min) 5 days per

10 or more minutes.

60-90 minutes, 6-7 days per week

resistance training should be incorporated into the activity plan 3-4 days per week, and include upper, core and lower body

muscles are

physical

physical activity for a

10 or more minutes.

resistance training should be incorporated into the activity plan 3-4 days per week, as feasible, and include upper, core and lower

balance exercises

• Family history of premature** CAD or stroke • HTN

• History of MI, angina, or documented CAD • Vascular revascularization • Non-hemorrhagic stroke • TIA • PAD

allergy, bleeding tendency, anticoagulant therapy, recent gastrointestinal bleeding and clinically active

beta-blocker in all patients with a history of

known CAD or

NYHA classes III and IV

an increased risk of myocardial

asymptomatic ischemia and therefore warrant

rMPI or echocardiography with ECG monitoring

pharmacologic stress testing

annually

• <100 if no diagnosed CVD

• <70 if diagnosed CVD

• >40 (men)

<150 (fasting)

All patients should receive information about a meal plan designed to lower blood glucose and improve lipids,physical activity recommendations, and risk reduction strategies. Consultation with appropriate education

• optimize glycemic control • refer to RD for intensive dietary modification and therapeutic lifestyle changes (TLC) • consider referral to exercise specialist or DE for exercise prescription • recheck lipids within 6 weeks

<100, preferably with a statin, or by ~30-40% if goal not achieved by maximally

statin therapy if age >40 yrs and one more CVD risk factor is present (hypertension, smoking, albuminuria or family history of premature CVD).

• optimize glycemic control• refer to RD for intensive dietary modification and therapeutic lifestyle changes (TLC)• consider referral to exercise specialist or DE for

initiate/titrate medication

• optimize glycemic control• refer to RD for dietary modification and therapeutic

calculate non-HDL-C (total cholesterol minus

>200 and/or HDL-C ≤40 mg/dl after

rule-out other secondary causes

the

A1C should be performed in a laboratory using a method that is National Glycohemoglobin Standardization Program (NGSP) certified and standardized to the Diabetes Control and Complications Trial (DCCT) assay.