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Overview of medical care in adults with diabetes mellitus

Official reprint from UpToDate www.uptodate.com 2012 UpToDate

Overview of medical care in adults with diabetes mellitus

Author David K McCulloch, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan 2012. | This topic last updated: Jan 30, 2012. INTRODUCTION The estimated prevalence of diabetes among adults in the United States ranges from 4.4 to 17.9 percent (median 8.2 percent) [1]. However, because of the associated microvascular and macrovascular disease, diabetes accounts for almost 14 percent of US health care expenditures, at least one-half of which are related to complications such as myocardial infarction, stroke, end-stage renal disease, retinopathy, and foot ulcers [2,3]. Numerous factors, in addition to directly related medical complications, contribute to the impact of diabetes on quality of life and economics. Diabetes is associated with a high prevalence of affective illness [4] and adversely impacts employment, absenteeism, and work productivity [5]. This review will provide an overview of the medical care for patients with diabetes (table 1). Detailed discussions relating to screening, evaluation, and treatment of the individual complications of diabetes are discussed separately. Guidelines from the American Diabetes Association for health maintenance in diabetics are published yearly [6]. Consensus recommendations for the management of glycemia in type 2 diabetes were published in 2006 and updated in 2009 [7,8]. EVALUATION FOR DIABETIC COMPLICATIONS Morbidity from diabetes is a consequence of both macrovascular disease (atherosclerosis) and microvascular disease (retinopathy, nephropathy, and neuropathy). In type 2 diabetes, disease onset is insidious, and diagnosis is often delayed. As a result, diabetic microvascular complications may be present at the time of diagnosis of diabetes [9], and their frequency increases over time (figure 1). The progression of these complications can be slowed, but probably not stopped, with interventions such as aggressive management of glycemia, laser therapy for retinopathy, and administration of an angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) for nephropathy. (See "Prevention and treatment of diabetic retinopathy" and "Microalbuminuria in type 1 diabetes mellitus" and "Microalbuminuria in type 2 diabetes mellitus" and "Treatment of diabetic nephropathy".) Routine eye examination Patients with diabetes are at increased risk for visual loss, related both to refractive errors (correctable visual impairment) and to retinopathy. Screening for diabetic retinopathy The efficacy of laser photocoagulation surgery in preventing loss of vision is the major reason to screen regularly for diabetic retinopathy. (See "Prevention and treatment of diabetic retinopathy", section on 'Panretinal photocoagulation'.) Recommendations for the type and frequency of routine eye examinations vary, based upon the type of diabetes mellitus and the presence of specific eye findings (table 2) [6]. Serial
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Section Editor David M Nathan, MD

Deputy Editor Jean E Mulder, MD

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Overview of medical care in adults with diabetes mellitus

examinations are indicated because of the increased incidence of retinopathy over time in patients with either type 1 or type 2 diabetes (figure 2). Screening for diabetic retinopathy is reviewed in detail separately. (See "Screening for diabetic retinopathy".) Correctable visual impairment A study using data from the National Health and Nutrition Examination Survey (NHANES) in the US found that 11 percent of patients aged 20 years and older with diabetes had visual impairment (visual acuity <20/40 in their best eye with glasses) [10]. The impairment was correctable with an adequate corrective prescription for glasses or contact lenses in over two-thirds of the patients. These data indicate the need for visual acuity and refractive error assessment in addition to dilated eye examinations for retinopathy in diabetic patients to reduce injury risk and improve quality of life. Routine foot examination Foot problems due to vascular and neurologic disease are a common and important source of morbidity in diabetic patients. Systematic screening examinations for neuropathic and vascular involvement of the lower extremities and careful inspection of feet may substantially reduce morbidity from foot problems. (See "Evaluation of the diabetic foot".) Guidelines from the American Diabetes Association recommend performing a comprehensive foot examination annually on patients with diabetes to identify risk factors predictive of ulcers and amputation [6]. The comprehensive foot examination can be accomplished in the primary care setting and should include inspection, assessment of foot pulses, and testing for loss of protective sensation, as follows: Perform a visual inspection of the feet at each routine visit. The skin should be assessed for integrity, especially between the toes and under the metatarsal heads. The presence of erythema, warmth, or callus formation may indicate areas of tissue damage. Bony deformities, joint mobility, and gait and balance should also be assessed. Screen for peripheral artery disease by asking about a history of claudication and assessing the pedal pulses. Consider obtaining an ankle brachial index as many patients with peripheral artery disease are asymptomatic. The presence of peripheral artery disease also suggests a high likelihood of cardiovascular disease. (See "Noninvasive diagnosis of arterial disease", section on 'Ankle-brachial index'.) Test for loss of protective sensation using a Semmes-Weinstein 5.07 (10-g) monofilament at specific sites to detect loss of sensation in the foot (figure 3), plus any one of the following: vibration using a 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold with a biothesiometer. (See "Evaluation of the diabetic foot", section on 'Screening tests for peripheral neuropathy'.) Advice for prophylactic foot care should be given to all patients (see "Patient information: Foot care in diabetes mellitus (Beyond the Basics)"): Avoid going barefoot, even in the home. Test water temperature before stepping into a bath. Trim toenails to shape of the toe; remove sharp edges with a nail file. Do not cut cuticles. Wash and check feet daily. Shoes should be snug but not tight and customized if feet are misshapen or have ulcers. Socks should fit and be changed daily. Patients who may have neuropathy, based on abnormal results from a microfilament and one other
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Overview of medical care in adults with diabetes mellitus

test, or who have callus or other foot deformities should be referred to clinicians with expertise in diabetic foot care (podiatrist, nurse, diabetes foot clinic, or other, depending on available local resources). Screening for microalbuminuria Increased urinary protein excretion is the earliest clinical finding of diabetic nephropathy. The routine urine dipstick, however, is a relatively insensitive marker for proteinuria, not detecting protein until excretion exceeds 300 to 500 mg/day. (See "Treatment of diabetic nephropathy" and "Microalbuminuria in type 1 diabetes mellitus" and "Microalbuminuria in type 2 diabetes mellitus".) The normal rate of albumin excretion is less than 20 mg/day (15 mcg/min); persistent values between 30 and 300 mg/day (20 to 200 mcg/min) in a patient with diabetes is called microalbuminuria and is usually indicative of diabetic nephropathy (unless there is some coexistent renal disease) [11]. Values above 300 mg/day (200 mcg/min) are considered to represent overt proteinuria [12]. Microalbumin may be tested by screening with either a specifically sensitive dipstick or a laboratory assay on a spot urine sample, to determine an albumin-to-creatinine ratio. Abnormal results should be repeated at least two or three times over a three- to six-month period because of the large number of false positives that can occur [13]. Establishing the diagnosis of microalbuminuria requires the demonstration of a persistent (at least two abnormal tests) elevation in albumin excretion. Fever, exercise, heart failure, and poor glycemic control are among the factors that can cause transient microalbuminuria [13]. The availability of effective therapy for diabetic nephropathy with angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARB) is the rationale for yearly screening of all patients with either type 1 or type 2 diabetes for microalbuminuria [14]. Screening for microalbuminuria can be deferred for five years after the onset of disease in patients with type 1 diabetes because microalbuminuria is uncommon before this time; some recommend that screening should begin at diagnosis in patients with type 2 diabetes because many have had diabetes for several years before diagnosis [6]. The optimal therapy of diabetic nephropathy continues to evolve. In patients with type 1 diabetes who have microalbuminuria or overt nephropathy, ACE inhibitors both lower urinary protein excretion and slow the rate of disease progression (figure 4A-B) [15]. It seems reasonable, therefore, to institute therapy with an ACE inhibitor or angiotensin receptor blocker (ARB), even if the patient is normotensive, in those patients who have microalbuminuria or overt nephropathy. Since these drugs do not completely prevent progression, additional interventions may be required, the most important of which is maintenance of strict glycemic control. Similar considerations apply to patients with type 2 diabetes. The treatment of microalbuminuria is reviewed in detail elsewhere. (See "Microalbuminuria in type 1 diabetes mellitus" and "Microalbuminuria in type 2 diabetes mellitus" and "Treatment of diabetic nephropathy".) Screening for coronary heart disease Patients with diabetes have an increased risk for atherosclerosis due both to diabetes and to the frequent presence of other risk factors. Furthermore, diabetic patients with CHD are more likely to be asymptomatic or have atypical symptoms than nondiabetic patients with CHD. (See "Prevalence of and risk factors for coronary heart disease in diabetes mellitus", section on 'Silent ischemia and infarction'.) Despite the frequency of silent ischemia, however, it has not been proven that identifying asymptomatic disease or providing early intervention will improve outcomes in this population. In addition, CHD risk factors (dyslipidemia, hypertension, smoking, positive family history of early coronary disease, and presence of micro- or macroalbuminuria) [6] do not predict the likelihood of
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having ischemic findings on stress testing or coronary angiography [16,17]. Thus, the American Diabetes Association guidelines recommend annual assessment of risk criteria to identify patients who might benefit from interventions such as aspirin, ACE inhibitors, and statin therapy, but no longer recommend that these criteria be used to identify patients for stress testing [6]. There are no randomized trial data to support the routine performance of exercise stress testing in asymptomatic patients with diabetes who are planning to begin an exercise program [6,18]. The vast majority of patients, particularly those with a sedentary lifestyle, are encouraged to begin a gentle exercise program and to gradually progress to a more vigorous program as tolerated. In addition, all CVD risk factors should be treated. (See 'Blood pressure control' below and 'Dyslipidemia' below.) Thus, exercise testing is not necessary for most patients. However, it may be indicated for asymptomatic individuals at high risk for CHD (eg, evidence of peripheral or carotid atherosclerotic vascular disease, renal disease, abnormal resting electrocardiogram, multiple diabetes complications). The decision to perform stress testing prior to beginning an exercise program should be individualized. We do not typically perform exercise stress testing in asymptomatic patients as long as they are beginning a gentle exercise program with gradual progression as tolerated. However, the increased risk for asymptomatic coronary artery disease in those with diabetes and other risk factors suggests that an exercise tolerance test be considered prior to changing exercise levels in patients with diabetes who also have peripheral or carotid or coronary artery disease. (See "Screening for coronary heart disease in patients with diabetes mellitus".) Treatment of diabetic patients with known CHD is reviewed in detail elsewhere. (See "Treatment of acute myocardial infarction in diabetes mellitus" and "Coronary artery revascularization in patients with diabetes mellitus".) REDUCING THE RISK OF MACROVASCULAR DISEASE Men and women with diabetes are at increased risk for developing and dying from cardiovascular disease (CVD) [19,20]. Compared with nondiabetics, men and women with diabetes have decreased life expectancy (six to eight years less). At the time of diagnosis of type 2 diabetes, many patients already have one or more risk factors for macrovascular disease (obesity, hypertension, dyslipidemia, smoking) and many have evidence of overt atherosclerosis (past myocardial infarction, ischemic changes on electrocardiogram, or peripheral vascular disease) [9,21,22]. (See "The metabolic syndrome (insulin resistance syndrome or syndrome X)".) A number of modifiable risk factors for coronary heart disease were identified in a cohort of over 3000 type 2 diabetics from the United Kingdom Prospective Diabetes Study (UKPDS) [23]. Estimated hazard ratios from this study for the upper third relative to the lower third were 2.3 for serum LDL cholesterol, 0.6 for serum high-density-lipoprotein (HDL) cholesterol, 1.5 for hemoglobin A1C, 1.8 for systolic blood pressure, and 1.4 for smokers. These and other observations suggest that a substantial reduction in cardiovascular mortality could be achieved by smoking cessation, aggressive treatment of hypertension and dyslipidemia, and possibly daily low-dose aspirin (figure 5) [24]. (See 'Multifactorial risk factor reduction' below.) With regard to cardiovascular disease risk reduction among patients with type 2 diabetes, the benefit of good blood pressure control has been confirmed, whereas benefit from strict glycemic control has not been conclusively demonstrated [25]. Among patients with type 1 diabetes, the DCCT/EDIC study demonstrated long-term benefit of intensive glycemic management on cardiovascular outcomes, reducing fatal and nonfatal heart disease and stroke by 57 percent compared with conventional diabetes management [26]. (See "Glycemic control and vascular complications in type 1 diabetes mellitus" and "Glycemic control and vascular complications in type
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2 diabetes mellitus" and "Treatment of hypertension in patients with diabetes mellitus".) Smoking cessation A survey in the United States found that the prevalence of cigarette smoking was higher among diabetic patients than nondiabetic subjects, even after adjusting for age, sex, race, and educational level [27]. Over 25 percent of newly diagnosed diabetic patients were smokers. A meta-analysis of many of the cardiovascular risk reduction trials showed that cessation of smoking had a much greater benefit on survival than most other interventions (figure 5) [24]. These findings suggest that discontinuation of smoking is one of the most important aspects of therapy in diabetic patients who smoke. (See "Smoking and cardiovascular risk in diabetes mellitus" and "Patterns of tobacco use".) Aspirin The merits of daily aspirin therapy in patients with macrovascular disease are widely accepted. A meta-analysis from the Antithrombotic Trialists' Collaboration of randomized trials of antiplatelet therapy for the secondary prevention of cardiovascular disease in high-risk patients showed that aspirin produced statistically significant and clinically important reductions in the risk of subsequent myocardial infarction (MI), stroke, and vascular death among a wide range of highrisk patients (acute MI or ischemic stroke, unstable angina, prior MI or stroke, peripheral artery disease, and other high-risk groups) [28]. (See "Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease".) In the subset of patients with diabetes, there was a nonsignificant 7 percent decrease in serious cardiovascular events [28]. Similarly, in The Primary Prevention Project, aspirin (100 mg/day) was associated with a nonsignificant 10 percent reduction in total cardiovascular events in the subset of patients with diabetes (RR 0.89, 95% CI 0.62-1.26) compared with a 30 percent reduction in nondiabetic subjects (RR 0.69, 95% CI 0.53-0.90) [29]. (See "Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease".) These trials suggest that aspirin may be less effective in the prevention of cardiovascular events in patients with diabetes. Trials that assess the benefit of daily aspirin therapy specifically in patients with diabetes show the following: In the Early Treatment of Diabetic Retinopathy Study (ETDRS), patients with diabetes with and without cardiovascular disease were randomly assigned to aspirin (650 mg daily) or placebo [30]. The relative risk among all aspirin-treated patients was 0.91 (99% CI 0.751.11) for death and 0.83 (99% CI 0.66-1.04) for fatal and nonfatal myocardial infarction. In a trial of aspirin for the prevention of cardiovascular disease in 2539 Japanese patients with type 2 diabetes (no history of atherosclerotic heart disease), patients were randomly assigned to low-dose aspirin (80 to 100 mg daily) or to a nonaspirin group. After a median follow-up of 4.4 years, there were 13.6 and 17.0 cardiovascular events per 1000 personyears in the aspirin and nonaspirin groups, respectively (HR for primary composite endpoint of any cerebrovascular, coronary, or peripheral vascular atherosclerotic event 0.80 [95% CI 0.58-1.10]) [31]. The lower than expected event rate in this trial decreased the power of the analysis to assess the primary composite outcome or individual outcomes, such as fatal and nonfatal coronary events. In addition, the generalizability of this study to Western populations with higher cardiovascular risk is unknown. In the Prevention of Progression of Arterial Disease and Diabetes (POPADAD) trial, 1276 UK adults with type 1 or type 2 diabetes with asymptomatic peripheral artery disease (ankle brachial pressure index of 0.99) were randomly assigned to aspirin (100 mg daily) plus an antioxidant, aspirin alone, antioxidant alone, or double placebo [32]. During a median 6.7
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years of follow-up, there were 116 and 117 fatal and nonfatal cardiovascular events in the aspirin and nonaspirin groups, respectively (HR for primary composite endpoint of death from coronary heart disease or stroke, nonfatal myocardial infarction or stroke, or aboveankle amputation for critical limb ischemia 0.98, 95% CI 0.76-1.26). Thus, trials in patients with diabetes do not show a significant benefit of aspirin for the primary prevention of cardiovascular events. However, both the Japanese trial and ETDRS suggest benefit. Larger trials with longer follow-up are required to clarify this issue. Two large trials investigating the role of aspirin for the prevention of cardiovascular events in patients with diabetes are underway [33,34]. Bleeding One of the main adverse effects of aspirin is bleeding. The United States Physicians' Health Study found a nonsignificant trend toward an increase in hemorrhagic stroke and an increased risk of gastrointestinal bleeding in those who took aspirin [35]. In the Japanese trial described above, there was no difference in the incidence of hemorrhagic stroke (0.4 and 0.2 events per 1000 person-years in those assigned to the aspirin and nonaspirin groups, respectively). However, gastrointestinal and retinal bleeding occurred more commonly in the aspirin group, and four patients in the aspirin group required transfusion. Nevertheless, while diabetes is associated with several platelet and coagulation abnormalities, the majority of strokes in diabetic patients are thrombotic, not hemorrhagic in nature [36]. (See "Prevalence of and risk factors for coronary heart disease in diabetes mellitus".) Guidelines Based upon these data, the American Diabetes Association and American Heart Association recommend the following approach [6,37]. Aspirin (75 to 162 mg/day) is recommended for secondary prevention in diabetic patients with a history of myocardial infarction, vascular bypass, stroke or transient ischemic attack, peripheral vascular disease, claudication, or angina. Aspirin (75 to 162 mg/day) is recommended for primary prevention in any patient with diabetes at increased cardiovascular risk (10 year risk >10 percent), which would include most men >50 years and women >60 years who have at least one additional cardiovascular risk factor (eg, cigarette smoking, hypertension, obesity, albuminuria, dyslipidemia, or a family history of coronary heart disease). The ADA recognizes that the evidence to support this recommendation is weak. Aspirin is not recommended for diabetic patients under the age of 30 years due to a lack of evidence of benefit, and aspirin is contraindicated under the age of 21 years because of an increased risk of Reye's syndrome. Clopidogrel (75 mg/day) is recommended for patients with cardiovascular disease and documented aspirin allergy. (See "Secondary prevention of cardiovascular disease: Risk factor reduction", section on 'Aspirin'.) In spite of these recommendations, aspirin use in patients with diabetes is quite low: 74 and 38 percent in patients with or without cardiovascular disease, respectively [38]. Blood pressure control Hypertension is a common problem in type 1 and especially in type 2 diabetes. The American Diabetes Association recommends measuring blood pressure at every routine diabetes visit [6,39]. Early and effective treatment of blood pressure is important, both to prevent cardiovascular disease and to minimize the rate of progression of diabetic nephropathy and retinopathy. Among patients with diabetes, there is moderate evidence supporting a goal blood pressure less
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than 140/90 mmHg in all patients and weaker evidence supporting a goal blood pressure less than 130/80 mmHg. These issues and the choice of antihypertensive drugs are discussed in detail separately. (See "Treatment of hypertension in patients with diabetes mellitus", section on 'Goal blood pressure' and "Treatment of diabetic nephropathy".) Dyslipidemia Lipid abnormalities are common in patients with diabetes mellitus, and undoubtedly contribute to the increase in risk of cardiovascular disease. The American Diabetes Association (ADA) recommends screening for lipid disorders at least annually in diabetic patients, and more often if needed to achieve goals [6,39]. Adults with low-risk lipid values (LDL <100 mg/dL [2.6 mmol/L], HDL >50 mg/dL [1.3 mmol/L], and triglycerides <150 mg/dL [1.7 mmol/L]) may be screened every two years. The ADA recommends lifestyle intervention (diet, weight loss, increased physical activity) to improve the lipid profile in all patients with diabetes [6]. In patients with clinical cardiovascular disease (CVD) or over age 40 years with other CVD risk factors, statin therapy should be added to lifestyle intervention regardless of baseline lipid levels. For patients without clinical CVD and under age 40 years, statin therapy can be considered in addition to lifestyle intervention if LDL cholesterol remains above 100 mg/dL or in those with multiple CVD risk factors. In individuals without overt cardiovascular disease, the goal LDL is <100 mg/dL (2.6 mmol/L), whereas in patients with overt CVD, a lower LDL goal (<70 mg/dL [1.8 mmol/L]) is an option [6]. Triglyceride levels <150 mg/dL (1.7 mmol/L) and HDL levels >40 mg/dL (1.0 mmol/L) for men and >50 mg/dL (1.3 mmol/L) for women are preferable. The optimal therapy of dyslipidemia is discussed in detail separately. (See "Treatment of lipids (including hypercholesterolemia) in secondary prevention", section on 'Treatment in diabetes' and "Intensity of lipid lowering therapy in secondary prevention of coronary heart disease", section on 'Summary and recommendations' and "Clinical trials of cholesterol lowering in patients with coronary heart disease or coronary risk equivalents", section on 'ACCORD Lipid trial'.) Metformin Metformin has been suggested to reduce the risk of macrovascular complications, independently of its effects on glycemic control. However, this effect is far from established [40]. These issues are discussed in detail elsewhere. (See "Glycemic control and vascular complications in type 2 diabetes mellitus", section on 'UKPDS'.) Multifactorial risk factor reduction The benefit of multiple risk factor intervention to reduce coronary risk in type 2 diabetes was demonstrated in the relatively small Steno-2 trial of 160 subjects with microalbuminuria who were randomly assigned to either conventional therapy or an intensive therapy regimen, which included the following [41]: Reduced dietary fat Light to moderate exercise Smoking cessation Tight glycemic control (target A1C <6.5 percent with intensive therapy) Tight blood pressure control (target <140/85 mmHg for most of the study and <130/80 mmHg for the last two years) Angiotensin converting enzyme (ACE) inhibitor therapy regardless of blood pressure Lipid-lowering therapy (target total cholesterol <190 mg/dL [4.9 mmol/L] for most of the study and <175 mg/dL [4.5 mmol/L] for the last two years; target fasting serum triglyceride <150 mg/dL [1.7 mmol/L]) Aspirin Vitamin C, vitamin D, folate, and chrome picolinate The attained differences between the two groups revealed significantly greater improvements with intensive therapy in glycemic control (A1C -0.5 versus +0.2 percent with conventional therapy),
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blood pressure control (-14/12 versus -3/8 mmHg), and total cholesterol (-50 versus -3 mg/dL [-1.3 versus -0.08 mmol/L]). At a mean of 7.8 years, patients on intensive therapy had a significant reduction in the primary aggregate end point of cardiovascular death, nonfatal MI, coronary artery bypass grafting, percutaneous coronary intervention, stroke, amputation, or peripheral vascular surgery (18 versus 38 percent, HR 0.47, 95% CI 0.22-0.74). Significant reductions were also seen in progression of nephropathy, retinopathy, and autonomic neuropathy. After the intervention study ended, 130 remaining patients participated in an observational followup study (5.5 years), during which time all participants were encouraged to follow intensive multifactorial treatment regimens [42]. At the end of the follow-up period, A1C values were similar in the groups previously assigned to intensive and conventional therapy (7.7 and 8.0 percent, respectively). Blood pressure, body mass index (BMI), and fasting serum cholesterol and triglycerides were also similar. During the entire follow-up period (13.3 years), there were fewer deaths (30 versus 50 percent) in the intensive therapy group (hazard ratio for death 0.54, 95% CI 0.32-0.89). Intensive therapy was also associated with a lower risk of cardiovascular deaths (HR 0.43, 95% CI 0.19-0.94), which was a predefined secondary endpoint. Progression of diabetic retinopathy, nephropathy, and autonomic neuropathy occurred less frequently in the intensive group. These results suggest a sustained benefit of multifactorial risk reduction. In spite of evidence that aggressive risk factor reduction lowers the risk of both micro- and macrovascular complications in patients with diabetes, the vast majority of patients do not achieve recommended goals for A1C, blood pressure control, and management of dyslipidemia. It is notable that only one patient in the observational Steno study described above reached all five treatment goals at the end of follow-up. Thus, renewed efforts to implement multifactorial risk factor reduction strategies early in the course of type 2 diabetes are necessary. (See 'Adequacy of care' below.) GLYCEMIC CONTROL Monitoring and target A1C Prospective, randomized clinical trials such as the Diabetes Control and Complications Trial (DCCT), the United Kingdom Prospective Diabetes Study (UKPDS), and the Kumamoto Study have demonstrated that intensive therapy aimed at lower levels of glycemia results in decreased rates of retinopathy, nephropathy, and neuropathy [43-46]. Every 1 percent drop in A1C was associated with improved outcomes and there was no threshold effect. These benefits have to be weighed against an increased risk of severe hypoglycemia associated with intensive therapy (particularly in type 1 diabetes). Although the goal of the intensive interventions in these studies was normoglycemia, with an A1C less than 6.1 percent, the average A1C achieved in the intensive therapy groups of these trials was around 7 percent. (See "Glycemic control and vascular complications in type 1 diabetes mellitus" and "Glycemic control and vascular complications in type 2 diabetes mellitus", section on 'Hyperglycemia and Microvascular disease'.) The importance of tight glycemic control for protection against cardiovascular disease in diabetes has been established in the DCCT/EDIC study for type 1 diabetes [26]. The role of glycemic control in reducing cardiovascular risk has not been established for patients with long-standing type 2 diabetes. (See "Glycemic control and vascular complications in type 2 diabetes mellitus", section on 'Macrovascular disease'.) Based upon these data, the American Diabetes Association recommends the following [6]: Aim to achieve normal or near normal glycemia with an A1C goal of <7 percent. More
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stringent goals (ie, a normal A1C, <6.1 percent) can be considered in individual patients. Less stringent treatment goals (ie, <8 percent) may be appropriate for patients with a history of severe hypoglycemia, patients with limited life expectancies, older adults, and individuals with comorbid conditions. (See "Treatment of type 2 diabetes mellitus in the elderly patient", section on 'Glycemic targets' and "Glycemic control and vascular complications in type 2 diabetes mellitus", section on 'Glycemic targets'.) Obtain an A1C at least twice yearly in patients who are meeting treatment goals and who have stable glycemic control, and quarterly in patients whose therapy has changed or who are not meeting glycemic goals. Nonpharmacologic therapy in type 2 diabetes There are three major components to nonpharmacologic therapy of blood glucose in type 2 diabetes (see "Initial management of blood glucose in type 2 diabetes mellitus", section on 'Intensive lifestyle modification'): Dietary modification Exercise Weight reduction In addition to improving glycemic control, these changes in lifestyle also slow progression of impaired glucose tolerance to overt diabetes [47]. (See "Prediction and prevention of type 2 diabetes mellitus".) Diet and exercise are important components of therapy in patients with type 1 diabetes. (See "Nutritional considerations in type 1 diabetes mellitus" and "Nutritional considerations in type 2 diabetes mellitus" and "Effects of exercise in diabetes mellitus in adults".) Surgical treatment of obese patients with diabetes results in the largest degree of sustained weight loss and, in parallel, the largest improvements in blood glucose control. (See "Surgical management of severe obesity".) Pharmacotherapy for weight loss may also be used for patients with type 2 diabetes, but may not be effectively sustained due to side effects. (See "Drug therapy of obesity".) Pharmacologic therapy for type 2 diabetes The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) issued a 2006 consensus statement for the management of glycemia in type 2 diabetes, which was updated in 2009 [7,8]. Because of the difficulty in achieving and sustaining goal glycemia and significant weight loss, the consensus group concluded that metformin therapy should be initiated concurrent with lifestyle intervention at the time of diagnosis. (See "Initial management of blood glucose in type 2 diabetes mellitus".) The therapeutic options for patients who fail initial therapy with lifestyle intervention and metformin are to add a second oral or injectable agent, including insulin, or to switch to insulin (algorithm 1). (See "Management of persistent hyperglycemia in type 2 diabetes mellitus" and "Insulin therapy in type 2 diabetes mellitus".) Regardless of the initial response to therapy, the natural history of most patients with type 2 diabetes is for blood glucose concentrations and A1C to rise over time (figure 6) [43,48]. The UKPDS suggested that worsening beta cell dysfunction with decreased insulin release was primarily responsible for disease progression [48]. More severe insulin resistance or decreased compliance with the dietary regimen also may contribute to progression. Type 2 diabetic patients often need large daily doses of insulin (>65 units per day, and often much more) to achieve acceptable glycemic control. Most patients with type 2 diabetes can be treated with one or two daily injections, in contrast to patients with type 1 diabetes for whom intensive insulin therapy with multiple daily injections is indicated. (See "Insulin therapy in type 2 diabetes mellitus" and "Insulin therapy in adults with type 1 diabetes mellitus".)
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OTHER ASPECTS OF HEALTH MAINTENANCE Routine health maintenance The potential exists for the clinician to overlook health maintenance not specifically targeted at diabetes, given the intensity and complexity of care required for prevention and treatment of complications in diabetic patients [49]. (See "Overview of preventive medicine in adults".) Cancer screening Some studies have suggested an increased risk of cancer in patients with diabetes, possibly related to the coincident obesity [50-53]. As examples: In a 10-year prospective study of 98,000 Japanese persons aged 40 to 69, the hazard ratio (HR) for any cancer among men with diabetes was 1.27 (95% CI 1.14-1.42) [50]. In comparison, the association of cancer risk and diabetes for women was only borderline (HR 1.21, 95% CI 0.99-1.47). In a prospective cohort study of 64,000 Swedish men and women aged 29 to 61, rising levels of fasting and post oral glucose challenge glucoses were associated with an increase in cancer risk for women in the highest quartile versus lowest quartile of fasting glucose (RR 1.26, 95% CI 1.09-1.47) [51]. The most common cancers associated with high glucose values were pancreatic, endometrial, and melanoma. There was no significant increased risk in men. Diabetes mellitus and insulin resistance may also be associated with an increased risk of colon cancer, hepatocellular carcinoma, renal cancer, bladder cancer, and pancreatic cancer, although causation is not well established. (See "Colorectal cancer: Epidemiology, risk factors, and protective factors" and "Epidemiology and etiologic associations of hepatocellular carcinoma" and "Epidemiology, pathology, and pathogenesis of renal cell carcinoma", section on 'Diabetes mellitus' and "Epidemiology and etiology of urothelial (transitional cell) carcinoma of the bladder" and "Epidemiology and risk factors for exocrine pancreatic cancer".) A retrospective study of over 700,000 Canadian women aged 50 to 67 years, including 69,168 with diabetes, found that women with diabetes, despite having more frequent physician visits, were less likely to have a mammogram within a two-year period than non-diabetics (odds ratio [OR] 0.68, 95% CI 0.67-0.70) [54]. This is of concern because in some, but not all studies, women with type 2 diabetes had a slightly higher risk of breast cancer than non-diabetic women [55]. Adults with type 2 diabetes also have an increased risk of cancer mortality. In a systematic review of individual patient data from 97 prospective studies (820,900 patients), adults with diabetes compared to those without had an increased risk of death from cancer (HR 1.25, 95% CI 1.191.31) [20]. The increased risk of death was associated specifically with cancers of the liver, pancreas, ovary, colorectum, lung, bladder, and breast. In addition, the relative risk was substantially reduced when A1C levels were considered in multivariate analyses, consistent with a direct effect of hyperglycemia on cancer risk. Elevated serum alanine aminotransferase (ALT) concentrations occur commonly in patients with diabetes [56,57]. Although the etiology may be multifactorial, nonalcoholic fatty liver disease rather than cancer is a common cause. (See "Epidemiology, clinical features, and diagnosis of nonalcoholic steatohepatitis".) Dental screening Periodontal disease is a common complication of diabetes and itself contributes to poor glycemic control. Severe periodontal disease was shown to be an independent risk factor for mortality from ischemic heart disease and nephropathy in one longitudinal study of Pima Indians with type 2 diabetes (RR 3.6, 95% CI 1.1-9.3) [58]. Annual dental examination is recommended in both dentate and non-dentate diabetic patients [59]. In a 2004 US survey, 67
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percent of respondents with diabetes reported a dental visit in the preceding 12 months [60]. Vaccination Patients with diabetes mellitus should receive influenza vaccination yearly and pneumococcal vaccination, repeating the pneumococcal vaccine once after age 65 years if the initial vaccination was prior to age 65. Tetanus and diphtheria vaccinations should also be updated. (See "Tetanus-diphtheria toxoid vaccination in adults".) Women of childbearing age Contraception and pregnancy planning should be discussed with all diabetic women who are premenopausal. For women who do not wish to become pregnant, ADA guidelines state that the selection of a contraceptive method for an individual patient should use the same guidelines that apply to women without diabetes. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) are more cautious and recommend "on theoretical concerns" that use of oral contraception be limited to nonsmoking diabetic women who are younger than 35 years and are without hypertension, nephropathy, retinopathy, or other vascular disease [61]. (See "Risks and side effects associated with estrogen-progestin contraceptives".) We recommend that the most reliable method of contraception be used, when not contraindicated by other health concerns, because the risk of unplanned pregnancy is significant. For women with diabetes who are contemplating pregnancy, prepregnancy counseling and planning is important. Prior to pregnancy, glycemic control should be optimized, and both ACE inhibitor and statin medications should be discontinued (table 3). (See "Pregnancy risks in women with type 1 and type 2 diabetes mellitus" and "Prepregnancy evaluation and management of women with type 1 or type 2 diabetes mellitus".) ADEQUACY OF CARE Despite extensive data suggesting large benefits with preventive and treatment strategies, and despite increasing media attention, there has been little improvement in diabetes management in the US. Surveys of patients aged 18 to 75 years with diabetes, comparing the US NHANES databases for 1988 to 1994 and 1999 to 2002, indicate that glycemic control has improved only minimally (nonsignificant decrease in proportion of patients with A1C >9 percent, no change in mean A1C, increase in patients with A1C between 6 and 8 percent), and blood pressure distribution has remained unchanged. Improvements were seen in the proportion of patients with LDL cholesterol <130 mg/dL (3.4 mmol/L); using aspirin; and receiving annual influenza vaccination, lipid testing, eye examination, and foot examination [62]. About 20 percent of patients in 1999 to 2002 had A1C >9 percent, 33 percent had blood pressure >140/90 mm, and 40 percent had LDL cholesterol >130 mg/dL (>3.4 mmol/L). Even when patients are achieving goals for individual components of diabetes care, the proportion of patients who are simultaneously at goal for all measured targets is low. In a study of 80,000 diabetic patients receiving care in a VA system, only 4 percent were simultaneously at ADA goal for A1C, LDL cholesterol, and blood pressure, though rates for individual targets ranged from 23 to 41 percent [63]. Nevertheless, small improvements in diabetes management and cardiovascular risk factor reduction have decreased cardiovascular and all-cause mortality rates in some patients [64]. Data from the National Health and Nutrition Examination Surveys (NHANES I, II, III), however, suggest that mortality rates are decreasing in diabetic men but not in women [65]. The reason for this discrepancy is unknown but may be related to gender differences in the pathophysiology of coronary artery disease, less accurate diagnosis of CVD in women, and disparities in access to care and targeting of risk factor reduction [64]. Overall, the majority of diabetic patients are not receiving recommended levels of healthcare [6671], particularly patients under age 45 years [72] and women [73,74]. Even when recommended
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screening data are obtained, rates of medication adjustment to address abnormal results are low [75]. There are several reasons for the large discrepancy between what should be done and what is being done: Treatment of acute and chronic disease Traditional medical practice is organized to respond quickly to acute patient problems, but does not adequately serve the needs of those with a chronic illness such as diabetes mellitus [76]. Clinical inertia Failure to make adjustments in a therapeutic regimen in response to an abnormal clinical result has been termed "clinical inertia" [77]. Multiple factors may be contributory: lack of awareness of therapeutic goals, reluctance to treat asymptomatic conditions, concern about patient's pill burden, time limitations, or attention to acute medical issues that take priority over risk factor management [78]. In one study of modifications in therapy for various cardiovascular risk conditions, medication adjustments were made for 66 percent of patients whose A1C level was >8 percent [78]. Lack of an organized system for care Outcomes are better when diabetic patients are seen in the context of organized programs [79,80]. One study, as an example, examined the fiveyear mortality of 3288 patients with diabetes who received medical care exclusively from generalists and of 4200 patients who received care from generalists and also had examinations in a diabetes clinic [80]. The relative risk of all-cause mortality was 0.82 for patients who received care from both diabetes clinics and generalists as compared with those who received care only from generalists. Who should take care of the patient The majority of diabetic patients (greater than 90 percent) receive their care from primary care providers. A major unresolved controversy is the place of the generalist and the specialist in the treatment of patients with type 2 diabetes. Studies comparing care by specialists and generalists have generated conflicting findings: A large observational study (the Medical Outcomes Study) found little advantage for patients under the care of endocrinologists, when compared with family practitioners, except for improved foot care and lower infection risk [81,82]. Overall functional status at four years and mortality at seven years were similar. A retrospective study of 112 patients (primarily type 2 diabetes) at a Veteran Administration Medical Center found that patients seen in a diabetes clinic, compared with those seen in a general medicine clinic, were more likely to have had an eye examination and A1C test in the past year (73 versus 52 percent) [83]. However, the mean A1C value (9.7 percent) in the two clinics was similar and suboptimal. Lower risks of neuropathy and nephropathy were reported in association with specialist care for type 1 diabetes [84]. It is difficult to distinguish how much of the difference in care is due to expert knowledge or to the application of a systematic and organized approach. In one study, although diabetes-specific tests were performed more often in a diabetes clinic, diabetic patients were more likely to get inquiries about the presence of cardiac symptoms if they received their care in a general internal medicine clinic [81]. These reports have generated much discussion and disagreement [85], and the place of the specialist remains unsettled. Other strategies for improving the routine care of diabetic patients
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are reviewed below. Strategies to improve diabetes primary care Several approaches have been tried in order to improve the care of diabetic patients within a primary care setting. These include the following: "Diabetes miniclinics" [86,87] Better organization and delivery of patient education [88,89] Structured behavioral intervention [90,91] Management by nurse specialists under the supervision of a diabetologist [92,93] Multidisciplinary disease management programs [94-96] The optimal intervention strategy to improve diabetes care in the primary care setting has not been established, and the effects of intervention may be short-lived [97,98]. Processes of care (performance of retinal examination, foot exam, A1C measurements, lipid testing, nephropathy screening, flu vaccination, aspirin therapy) may be more readily improved by disease management interventions than intermediate outcomes (blood pressure control, lipid control, or A1C level) [96]. A meta-analysis reviewing 66 publications of trials evaluating the impact of 11 different strategies for improving diabetes care found study limitations and likely publication bias [99]. Strategies incorporating team changes (expanded roles for non-MD clinicians and shared care) or case management programs (multidisciplinary coordinated care for patient scheduling and follow-up) were most effective. Across all trials, the mean A1C reduction was 0.42 percent (95% CI 0.290.34) over a median of 13 months follow-up. A1C improvement was greatest for strategies that allowed medication dose adjustments without awaiting physician approval. Several organizations are encouraging adherence to routine standards of care for diabetic patients by auditing charts, or by asking for data on random samples of diabetic patients. The most comprehensive set of diabetes measures has recently been launched by the American Diabetes Association (ADA), cosponsored by the National Committee for Quality Assurance. Individual providers or groups of providers may apply to receive recognition that they are delivering a certain standard of diabetes care. Recognition requires review of the medical chart, laboratory data, and a patient survey and measures eye, foot, and renal care; cardiac risk reduction; glycemic control; and patient satisfaction (table 4). Further information is available through the National Committee for Quality Assurance. INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Basics topics (see "Patient information: The ABCs of diabetes (The Basics)" and "Patient information: Type 1 diabetes (The Basics)" and "Patient information: Type 2 diabetes (The Basics)" and "Patient information: Treatment for type 2 diabetes (The Basics)" and "Patient information: Diabetic retinopathy (The Basics)" and "Patient information: Reducing the costs of medicines (The Basics)")
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Beyond the Basics topics (see "Patient information: Diabetes mellitus type 1: Overview (Beyond the Basics)" and "Patient information: Diabetes mellitus type 2: Overview (Beyond the Basics)" and "Patient information: Diabetes mellitus type 2: Treatment (Beyond the Basics)" and "Patient information: Reducing the costs of medicines (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Morbidity from diabetes involves both macrovascular (atherosclerosis) and microvascular disease (retinopathy, nephropathy, and neuropathy). Interventions can limit end organ damage and are the focus of care for the diabetic patient. Monitoring recommendations for patients with diabetes are presented in the table (table 1). (See 'Evaluation for diabetic complications' above and 'Reducing the risk of macrovascular disease' above.) Prevention of cardiovascular morbidity is a major priority for patients with diabetes, especially type 2. Smoking cessation is essential for patients who smoke. Cardiovascular morbidity can also be significantly reduced with aggressive management of hypertension, cholesterol (goal LDL less than 100 mg/dL [2.6 mmol/L]) and use of aspirin (75 to 162 mg/day) in patients with or at high risk for cardiovascular disease. (See 'Reducing the risk of macrovascular disease' above and "Treatment of hypertension in patients with diabetes mellitus", section on 'Goal blood pressure'.) Glycemic control can minimize risks for retinopathy, nephropathy, and neuropathy in both type 1 and type 2 diabetes, and has been shown to decrease the risk for cardiovascular disease for type 1 diabetes. (See 'Glycemic control' above.) A1C goal is <7 percent for most patients; more stringent control (A1C <6 percent) may be indicated for individual patients with type 1 diabetes and during pregnancy. (See "Glycemic control in women with type 1 and type 2 diabetes mellitus during pregnancy", section on 'Target blood glucose values'.) A higher target A1C (ie, <8 percent) may be preferable for some type 2 patients with comorbidities or with an anticipated lifespan, owing to advanced age or other factors, that is too brief to benefit from the effects of intensive therapy on long-term complications. (See 'Monitoring and target A1C' above and "Glycemic control and vascular complications in type 1 diabetes mellitus" and "Glycemic control and vascular complications in type 2 diabetes mellitus".) The majority of diabetic patients are not receiving recommended levels of healthcare and development of systems of care, involving disease management principles, may be important in delivering improved care. (See 'Adequacy of care' above.)

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GRAPHICS
Monitoring in patients with diabetes mellitus
Intervention
Smoking cessation counseling Blood pressure Dilated eye examination Foot examination Laboratory studies Fasting serum lipid profile A1C Microalbuminuria Annually Every 3 to 6 months Annually May obtain every two years if profile is low risk Goal <7% (may be lower or higher in selected patients) Begin 3 to 5 years after onset of type 1 diabetes; protein excretion and serum creatinine should also be monitored if persistent albuminuria is present

Frequency
Every visit For smokers only

Notes

History and physical examination

Every visit Annually*

Goal <130/80 Begin at onset of type 2 diabetes, 3 to 5 years after onset of type 1 diabetes. Examine more than annually if significant retinopathy Every visit if peripheral vascular disease or neuropathy

Annually

Serum creatinine Vaccinations Pneumococcus

Initially, as indicated

One time

Patients over age 65 need a second dose if vaccine was received 5 years previously and age was <65 at time of vaccination

Influenza Education, self management review

Annually Annually

* Less frequent screening (every two to three years) may be appropriate for some patients.

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Onset of retinopathy precedes diagnosis of type 2 diabetes

Prevalence of retinopathy in relation to years after onset of diabetes among patients in southern Wisconsin (blue circles) and rural western Australia (red squares). At diagnosis (year zero), retinopathy was already present in 10 to 20 percent of patients. The lines extrapolate back to an estimated onset of retinopathy four to seven years before the clinical diagnosis was made. Data from Harris, MI, Klein, R, Welborn, TA, Knuiman, MW,
Diabetes Care 1992; 15:815.

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Ophthalmologic examination schedule

Patient group
Type 1 diabetes Type 2 diabetes Pregnancy in preexisting diabetes

Recommended first examination

Within 5 years after diagnosis of diabetes once patient is age 10 years or older At time of diagnosis of diabetes Prior to conception and during first trimester. Counsel on the risk of development and/or progression of retinopathy.

Minimum routine follow-up*

Yearly Yearly Close follow-up throughout pregnancy and for one year postpartum.

* Abnormal findings necessitate more frequent follow-up. Some evidence suggests that the prepubertal duration of diabetes may be important in the development of microvascular complications; therefore, clinical judgment should be used when applying these recommendations to individual patients. Copyright 2004 American Diabetes Association From Diabetes Care Vol 27, Supplement 1, 2004. Reprinted with permission from The American Diabetes Association. Modifications from Standards of Medical Care in Diabetes--2009. Diabetes Care Vol 32, Supplement 1, 2009.

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Incidence of diabetic retinopathy increases over time

Percent of diabetic patients with retinopathy according to duration of disease in patients under the age of 30 years who were treated with insulin (primarily type 1 diabetes) and patients over the age of 30 years who were not treated with insulin (primarily type 2 diabetes). Retinopathy increased over time in both groups, affecting virtually all patients with type 1 diabetes by 20 years. The increased incidence in type 2 diabetes at three years is a probable reflection of the difficulty in determining the time of onset of that disease. Data from Klein,
R, Klein, BE, Moss, SE, et al, Arch Ophthalmol 1984; 102:520,527.

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Testing sites for pressure sensation in evaluation of diabetic foot

The monofilament used to evaluate pressure sensation should be tested at each of the 12 sites shown, which represent the most common sites of ulcer formation. Failure to detect cutaneous pressure at any site indicates that the patient is at high risk for future ulceration.

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Captopril delays progression of microalbuminuria in diabetes

Effect of captopril or placebo in 225 patients with type 1 diabetes mellitus, normal blood pressure, and microalbuminuria. At two years, captopril slowed the rate of progression to overt, dipstick-positive proteinuria and lowered the albumin excretion rate (AER) compared to placebo. Data
from The Microalbuminuria Study Group, Diabetologia 1996; 39:587.

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ACE inhibitor slows progression of diabetic nephropathy

The effect of the administration of placebo or captopril to patients with type 1 diabetes with overt proteinuria and a plasma creatinine concentration equal to or greater than 1.5 mg/dL (132 mol/L). The likelihood of a doubling of the plasma creatinine concentration (Pcr) was reduced by more than 50 percent in the captopril group. Data from Lewis, EJ,
Hunsicker, LG, Bain, RP, Rohde, RD, N Engl J Med 1993; 329:1456.

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Increased cardiovascular risk in type 2 diabetes

Calculated effects of different interventions on coronary and total deaths in 1000 normal and 1000 men with type 2 diabetes aged 35 to 57 years without a history of myocardial infarction. Although risk was reduced by the therapeutic interventions (particularly cessation of smoking), there was a residual three to four fold increase in mortality in the diabetic men, due presumably to the effects of hyperglycemia or hyperinsulinemia. Data
from Yudkin, JS, BMJ 1993; 306:1313.

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Initiation and adjustment of insulin regimens

Insulin regimens should be designed taking lifestyle and meal schedule into account. The algorithm can only provide basic guidelines for initiation and adjustment of insulin. bg: blood glucose.
* Premixed insulins are not recommended during adjustment of doses; however, they can be used conveniently, usually before breakfast and/or dinner if proportion of rapidand intermediate-acting insulins is similar to the fixed proportions available. Reproduced with permission from: Nathan, DM, Buse, JB, Davidson, MB, et al. Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009; 32: 193. Copyright 2009 American Diabetes Association.

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Glycemic control in type 2 diabetes

Glycemic control, estimated from the median hemoglobin A1C value, in patients with type 2 diabetes mellitus in the United Kingdom Prospective Diabetes Study (UKPDS) who were randomly assigned to receive intensive therapy with a sulfonylurea or insulin or to conventional treatment with diet; drugs were added if there were hyperglycemic symptoms or if the fasting blood glucose concentration was greater than 270 mg/dL (15 mmol/L). The HbA1c values were lower in the intensive therapy group but rose in both groups over time. The circles represent data for all patients, while the lines represent data for patients followed for ten years. Data from UK Prospective Diabetes Study (UKPDS) Group, Lancet
1998; 352:837.

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Preconception evalaution and management of women with type 1 or type 2 diabetes

History and physical examination
Hypertension goal blood pressure less than 140/90 mmHg except goal blood pressure less than 130/80 mmHg in patients with diabetic nephropathy and proteinuria stop antihypertensive drugs, if possible, or switch to agents with fewest risks to fetus Retinopathy ophthalmology consult treat active proliferative retinopathy before pregnancy Cardiac screen for coronary heart disease as per guidelines for nonpregnant women with diabetes Renal measure serum creatinine concentration and total protein-to-creatinine ratio women with an elevated serum creatinine concentration are at risk for deterioration of renal status Thyroid obtain serum thyrotropin and free thyroxine

Diabetes
Achieve good glucose control before conception. If A1c is above the normal range for women without diabetes, intensive insulin therapy is warranted. 3-4 injections/day of short and long acting insulin subcutaneously are usually required to achieve good glycemic control. Either subcutaneous insulin injections or an insulin infusion pump is acceptable Self-blood glucose monitoring is performed before and after each meal and at bedtime Repeat A1c one month after initiation of this program. Retest every month until target A1c value is achieved. Once in the target range, the patient can try to conceive. A pregnancy test is done 1 week after a missed period to confirm pregnancy.

Psychosocial
Assess "readiness" of patient for pregnancy

Other
Advise patient to stop smoking and stop use of illicit drugs Review medications. Discontinue those that are associated with potential fetal risks or change to medications with fewer fetal effects, if possible.

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American Diabetic Association provider recognition measures

Measure
HbA1c test (calculate proportion of patients with HbA1c value of less than 8 and 10 percent) Retinal examination Foot care evaluation Blood pressure measurement (calculate proportion of patients with diastolic pressures of less than 90 mm Hg) Measurement of urinary protein/microalbumineria Lipid profile evaluation Tobacco smoking status and counseling referral (document in chart) Assessment of patient monitoring of blood glucose (obtained from patient survey) Patient satisfaction questions (obtained from patient survey)

Frequency
At least once a year At least once a year At least once a year At least twice a year Once a year Once a year

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