DM Guidelines

STANDARDS OF CARE
Standards of Medical Care in Diabetes—2022 Abridged

for Primary Care Providers
American Diabetes Association
The American Diabetes Association’s (ADA’s) Standards of health (SDOH)—often out of direct control of the
of Medical Care in Diabetes (the Standards) is updated individual and potentially representing lifelong risk—
and published annually in a supplement to the January contribute to medical and psychosocial outcomes and
issue of Diabetes Care. The Standards are developed by must be addressed to improve all health outcomes.
the ADA’s multidisciplinary Professional Practice Com-
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mittee, which comprises expert diabetes health care Recommendations
professionals. The Standards include the most current 1.1 Ensure treatment decisions are timely, rely on
evidence-based recommendations for diagnosing and evidence-based guidelines, include social com-
treating adults and children with all forms of diabetes. munity support, and are made collaboratively
ADA’s grading system uses A, B, C, or E to show the with patients based on individual preferences,
evidence level that supports each recommendation. prognoses, and comorbidities, and informed
A—Clear evidence from well-conducted, generaliz- financial considerations. B
able randomized controlled trials that are ade- 1.2 Align approaches to diabetes management with
quately powered the Chronic Care Model. This model emphasizes
B—Supportive evidence from well-conducted cohort person-centered team care, integrated long-term
studies treatment approaches to diabetes and comorbid-
C—Supportive evidence from poorly controlled or ities, and ongoing collaborative communication
uncontrolled studies and goal setting between all team members. A
E—Expert consensus or clinical experience 1.3 Care systems should facilitate team-based care,
including those knowledgeable and experienced
This is an abridged version of the current Standards of
in diabetes management as part of the team and
Care containing the evidence-based recommendations
utilization of patient registries, decision support
most pertinent to primary care. The recommendations,
tools, and community involvement to meet
tables, and figures included here retain the same num- patient needs. B
bering used in the complete Standards. All of the rec-
ommendations included here are substantively the Strategies for System-Level Improvement
same as in the complete Standards. The abridged ver-
Care Teams
sion does not include references. The complete 2022
Collaborative, multidisciplinary teams are best suited to
Standards of Care, including all supporting references,
provide care for people with chronic conditions such as
is available at professional.diabetes.org/standards.
diabetes and to facilitate patients’ self-management
with emphasis on avoiding therapeutic inertia to
1. IMPROVING CARE AND PROMOTING HEALTH achieve the recommended metabolic targets.
IN POPULATIONS
Diabetes and Population Health Telemedicine
Patient-centered care is defined as care that considers Telemedicine may increase access to care for people
individual patient comorbidities and prognoses; is with diabetes. Increasingly, evidence suggests that vari-
respectful of and responsive to patient preferences, ous telemedicine modalities may be effective at reduc-
needs, and values; and ensures that patient values ing A1C in people with type 2 diabetes compared with
guide all clinical decisions. Further, social determinants or in addition to usual care. Interactive strategies that
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©2022 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational
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10 D IA B E TE SJ OUR N A L S.OR G/ C L IN IC A L
AMERICAN DIABETES ASSOCIATION
facilitate communication between providers and Type 1 diabetes (due to autoimmune b-cell destruc-
patients appear more effective. tion, usually leading to absolute insulin deficiency
including latent autoimmune diabetes of adulthood)
Behaviors and Well-Being Type 2 diabetes (due to a progressive loss of b-cell
insulin secretion frequently on the background of
Successful diabetes care requires a systematic approach
insulin resistance)
to supporting patients’ behavior-change efforts, includ- Specific types of diabetes due to other causes, e.g.,
ing high-quality diabetes self-management education monogenic diabetes syndromes (such as neonatal
and support (DSMES). diabetes and maturity-onset diabetes of the young),
diseases of the exocrine pancreas (such as cystic
Tailoring Treatment for Social Context
fibrosis and pancreatitis), and drug- or chemical-
Recommendations induced diabetes (such as with glucocorticoid use,

1.5 Assess food insecurity, housing insecurity/ in the treatment of HIV/AIDS, or after organ
homelessness, financial barriers, and social transplantation)
capital/social community support to inform Gestational diabetes mellitus (GDM; diabetes diag-
treatment decisions, with referral to appropriate nosed in the second or third trimester of pregnancy
local community resources. A that was not clearly overt diabetes prior to
1.6 Provide patients with self-management support from gestation)
lay health coaches, navigators, or community health It is important for providers to realize that classification
workers when available. A of diabetes type is not always straightforward at presen-
Health inequities related to diabetes and its complications tation, and misdiagnosis may occur. Children with type
are well documented and have been associated with greater 1 diabetes typically present with polyuria/polydipsia,
risk for diabetes, higher population prevalence, and poorer and approximately half present with diabetic ketoacido-
sis (DKA). Adults with type 1 diabetes may not present
diabetes outcomes. SDOH are defined as the economic,
with classic symptoms and may have a temporary
environmental, political, and social conditions in which peo-
remission from the need for insulin. The diagnosis may
ple live and are responsible for a major part of health
become more obvious over time and should be reeval-
inequality worldwide. In addition, cost-related medication
uated if there is concern.
nonadherence continues to contribute to health disparities.
Screening and Diagnostic Tests for Prediabetes

2. CLASSIFICATION AND DIAGNOSIS OF
and Type 2 Diabetes
DIABETES
The diagnostic criteria for diabetes and prediabetes
Classification are shown in Table 2.2/2.5. Screening criteria for
Diabetes can be classified into the following general adults and children are listed in Table 2.3 and
categories: Table 2.4, respectively. Screening for prediabetes
TABLE 2.2/2.5 Criteria for the Screening and Diagnosis of Prediabetes and Diabetes
Prediabetes Diabetes
A1C 5.7–6.4% (39–47 mmol/mol)* $6.5% (48 mmol/mol)†
Fasting plasma glucose 100–125 mg/dL (5.6–6.9 mmol/L)* $126 mg/dL (7.0 mmol/L)†
2-hour plasma glucose during 75-g OGTT 140–199 mg/dL (7.8–11.0 mmol/L)* $200 mg/dL (11.1 mmol/L)†
Random plasma glucose — $200 mg/dL (11.1 mmol/L)‡
Adapted from Tables 2.2 and 2.5 in the complete 2022 Standards of Care. *For all three tests, risk is continuous, extending below the lower
limit of the range and becoming disproportionately greater at the higher end of the range. †In the absence of unequivocal hyperglycemia,
diagnosis requires two abnormal test results from the same sample or in two separate samples ‡Only diagnostic in a patient with classic
symptoms of hyperglycemia or hyperglycemic crisis.
VO L UM E 40 , N U MB E R 1, W IN TE R 20 22 11
ABRIDGED STANDARDS OF CARE 2022
TABLE 2.3 Criteria for Screening for Diabetes or Prediabetes in Asymptomatic Adults
1. Testing should be considered in adults with overweight or obesity (BMI $25 kg/m2 or $23 kg/m2 in Asian Americans) who have one or more
of the following risk factors:
First-degree relative with diabetes
High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
History of CVD
Hypertension ($140/90 mmHg or on therapy for hypertension)
HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)
Women with polycystic ovary syndrome
Physical inactivity
Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
2. Patients with prediabetes (A1C $5.7% [39 mmol/mol], impaired glucose tolerance, or impaired fasting glucose]) should be tested yearly.

3. Women who were diagnosed with GDM should have lifelong testing at least every 3 years.
4. For all other patients, testing should begin at age 35 years.
5. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on
initial results and risk status.
6. People with HIV
and type 2 diabetes risk through an informal assess- Certain medications such as glucocorticoids, thiazide
ment of risk factors or with an assessment tool, such diuretics, some HIV medications, and atypical antipsy-
as the ADA’s risk test (diabetes.org/socrisktest) is chotics are known to increase the risk of diabetes and
recommended. should be considered when deciding whether to
screen.
Marked discrepancies between measured A1C and
plasma glucose levels should prompt consideration that
the A1C assay may not be reliable for that individual,
3. PREVENTION OR DELAY OF TYPE 2 DIABETES
and one should consider using an A1C assay without
AND ASSOCIATED COMORBIDITIES
interference or plasma blood glucose criteria for diagno- Recommendation
sis. (An updated list of A1C assays with interferences is 3.1 Monitor for the development of type 2 diabetes in
available at ngsp.org/interf.asp.) those with prediabetes at least annually, modified
If the patient has a test result near the margins of the based on individual risk/benefit assessment. E
diagnostic threshold, the clinician should follow the
Lifestyle Behavior Change for Diabetes
patient closely and repeat the test in 3–6 months. If
Prevention
using the oral glucose tolerance test (OGTT), fasting
or carbohydrate restriction 3 days prior to the test Recommendations
should be avoided, as it can falsely elevate glucose 3.2 Refer adults with overweight/obesity at high risk
levels. of type 2 diabetes, as typified by the Diabetes
TABLE 2.4 Risk-Based Screening for Type 2 Diabetes or Prediabetes in Asymptomatic Children and Adolescents in a
Clinical Setting
Screening should be considered in youth* who have overweight ($85th percentile) or obesity ($95th percentile) A and who have one or more
additional risk factors based on the strength of their association with diabetes:
Maternal history of diabetes or GDM during the child’s gestation A
Family history of type 2 diabetes in first- or second-degree relative A
Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) A
Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary
syndrome, or small-for-gestational-age birth weight) B
*After the onset of puberty or after 10 years of age, whichever occurs earlier. If tests are normal, repeat testing at a minimum of 3-year inter-
vals, or more frequently if BMI is increasing or risk factor profile deteriorating, is recommended. Reports of type 2 diabetes before age 10
years exist, and this can be considered with numerous risk factors.
Prevention Program (DPP), to an intensive life- evidence base. However, no agents have been approved
style behavior change program consistent with by the U.S. Food and Drug Administration (FDA) for
the DPP to achieve and maintain 7% loss of initial diabetes prevention.
body weight, and increase moderate-intensity
physical activity (such as brisk walking) to at
Prevention of Vascular Disease and Mortality
least 150 minutes/week. A
3.3 A variety of eating patterns can be considered Recommendation
to prevent diabetes in individuals with pre- 3.8 Prediabetes is associated with heightened cardio-
diabetes. B vascular (CV) risk; therefore, screening for and
3.5 Based on patient preference, certified technology- treatment of modifiable risk factors for cardiovas-
assisted diabetes prevention programs may be cular disease (CVD) are suggested. B
effective in preventing type 2 diabetes and should
be considered. B

Patient-Centered Care Goals
The strongest evidence supporting lifestyle intervention Recommendation
for diabetes prevention in the U.S. comes from the 3.9 In adults with overweight/obesity at high risk of
DPP trial, which demonstrated that intensive
type 2 diabetes, care goals should include weight
lifestyle intervention could reduce the risk of incident
loss or prevention of weight gain, minimizing pro-
type 2 diabetes by 58% over 3 years. Evidence
gression of hyperglycemia, and attention to CV
suggests that there is not an ideal percentage of
risk and associated comorbidities. B
calories from carbohydrate, protein, and fat to prevent
diabetes.
4. COMPREHENSIVE MEDICAL EVALUATION
Delivery and Dissemination of Lifestyle Behavior Change AND ASSESSMENT OF COMORBIDITIES
for Diabetes Prevention Patient-Centered Collaborative Care
The Centers for Disease Control and Prevention (CDC) Recommendations
developed the National DPP, a resource designed to
4.1 A patient-centered communication style that uses
bring evidence-based lifestyle change programs for pre-
person-centered and strength-based language and
venting type 2 diabetes to communities, including eligi-
ble Medicare patients. An online resource includes active listening; elicits patient preferences and
locations of CDC-recognized diabetes prevention life- beliefs; and assesses literacy, numeracy, and
style change programs (cdc.gov/diabetes/prevention/ potential barriers to care should be used to opti-
find-a-program.html). mize patient health outcomes and health-related
quality of life. B
Pharmacologic Interventions A successful medical evaluation depends on beneficial
interactions between the patient and the care team.
Recommendations
Individuals with diabetes must assume an active role
3.6 Metformin therapy for prevention of type 2 diabe- in their care. The person with diabetes, family or sup-
tes should be considered in adults with prediabe- port people, and health care team should together for-
tes, as typified by the DPP, especially those aged
mulate the management plan, which includes lifestyle
25–59 years with BMI $35 kg/m2, higher fasting
management, to improve disease outcomes and well-
plasma glucose (e.g., $110 mg/dL), and higher
being.
A1C (e.g., $6.0%), and in women with prior
The goals of treatment for diabetes are to prevent or
GDM. A
delay complications and optimize quality of life
3.7 Long-term use of metformin may be associated
(Figure 4.1). The use of person-centered, strength-
with biochemical vitamin B12 deficiency; consider
based, empowering language that is respectful and free
periodic measurement of vitamin B12 levels in
of stigma in diabetes care and education can help to
metformin-treated patients, especially in those
inform and motivate people. Language that shames
with anemia or peripheral neuropathy. B
and judges may undermine this effort. Use language
Various pharmacologic agents have been evaluated for that is person-centered (e.g., “person with diabetes” is
diabetes prevention, and metformin has the strongest preferred over “diabetic”).

FIGURE 4.1 Decision cycle for patient-centered glycemic management in type 2 diabetes. HbA1c, glycated hemoglobin. Adapted from
Davies MJ, D’Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:2669–2701.
Comprehensive Medical Evaluation disease 2019 (COVID-19) pandemic. Preventing avoid-

Recommendations able infections not only directly prevents morbidity but
also reduces hospitalizations, which may additionally
4.3 A complete medical evaluation should be per-
reduce risk of acquiring infections such as COVID-19.
formed at the initial visit to:
Children and adults with diabetes should receive vacci-
Confirm the diagnosis and classify diabetes. A nations according to age-appropriate
Evaluate for diabetes complications and poten- recommendations.
tial comorbid conditions. A
Review previous treatment and risk factor con-
trol in patients with established diabetes. A Cancer
Begin patient engagement in the formulation Patients with diabetes should be encouraged to undergo
of a care management plan. A recommended age- and sex-appropriate cancer screen-
Develop a plan for continuing care. A
ings and to reduce their modifiable cancer risk factors
4.4 A follow-up visit should include most components
(obesity, physical inactivity, and smoking).
of the initial comprehensive medical evaluation (see
Table 4.1 in the complete 2022 Standards of Care). A
4.5 Ongoing management should be guided by the Cognitive Impairment/Dementia
assessment of overall health status, diabetes compli- See “13. OLDER ADULTS.”
cations, CV risk, hypoglycemia risk, and shared deci-
sion-making to set therapeutic goals. B
Nonalcoholic Fatty Liver Disease
Immunizations Recommendation
The importance of routine vaccinations for people living 4.10 Patients with type 2 diabetes or prediabetes and
with diabetes has been elevated by the coronavirus elevated liver enzymes or fatty liver on
ultrasound should be evaluated for presence of collaborative development of an individualized eating

nonalcoholic steatohepatitis and liver fibrosis. C plan. MNT delivered by a registered dietitian nutritionist
is associated with A1C absolute decreases of 1.0–1.9% for
5. FACILITATING BEHAVIOR CHANGE AND people with type 1 diabetes and 0.3–2.0% for people with
WELL-BEING TO IMPROVE HEALTH OUTCOMES type 2 diabetes. See Table 5.1 in the complete 2022
Standards of Care for specific nutrition recommendations
Building positive health behaviors and maintaining psycho-
and refer to the ADA consensus report “Nutrition Therapy
logical well-being are foundational for achieving diabetes
for Adults With Diabetes or Prediabetes: A Consensus
treatment goals and maximizing quality of life. Essential to
Report” for more information on nutrition therapy.
achieving these goals are DSMES, medical nutrition ther-
apy (MNT), routine physical activity, smoking cessation Goals of Nutrition Therapy for Adults With Diabetes
counseling when needed, and psychosocial care
1. To promote and support healthful eating patterns,

emphasizing a variety of nutrient-dense foods in
DSMES
appropriate portion sizes, to improve overall
Recommendations health and:
5.1 In accordance with the national standards for Achieve and maintain body weight goals
DSMES, all people with diabetes should partici- Attain individualized glycemic, blood pressure,
pate in diabetes self-management education and and lipid goals
receive the support needed to facilitate the Delay or prevent the complications of diabetes
knowledge, decision-making, and skills mastery 2. To address individual nutrition needs based on
for diabetes self-care. A personal and cultural preferences, health literacy
5.2 There are four critical times to evaluate the need and numeracy, access to healthful foods, willing-
for diabetes self-management education to pro- ness and ability to make behavioral changes, and
mote skills acquisition in support of regimen existing barriers to change
implementation, MNT, and well-being: at diagno- 3. To maintain the pleasure of eating by providing
sis, annually and/or when not meeting treatment nonjudgmental messages about food choices while
targets, when complicating factors develop (medi- limiting food choices only when indicated by sci-
cal, physical, psychosocial), and when transitions entific evidence
in life and care occur. E 4. To provide a person with diabetes the practical
5.4 DSMES should be patient-centered, may be offered tools for developing healthy eating patterns rather
in group or individual settings, and should be com- than focusing on individual macronutrients,
municated with the entire diabetes care team. A micronutrients, or single foods
5.5 Digital coaching and digital self-management
interventions can be effective methods to deliver Weight Management
DSMES. B Studies have demonstrated that a variety of eating plans,
varying in macronutrient composition, can be used effec-
Evidence for the Benefits tively and safely in the short term (1–2 years) to achieve
Studies have found that DSMES is associated with weight loss in people with diabetes. The importance of pro-
improved diabetes knowledge and self-care behaviors, viding guidance on an individualized meal plan containing
lower A1C, lower self-reported weight, improved qual- nutrient-dense foods such as vegetables, fruits, legumes,
ity of life, reduced all-cause mortality risk, positive cop- dairy, lean sources of protein (including plant-based sour-
ing behaviors, and reduced health care costs. Better ces as well as lean meats, fish, and poultry), nuts, seeds,
outcomes were reported for DSMES interventions that and whole grains, as well as guidance on achieving the
were >10 hours over the course of 6–12 months. desired energy deficit, cannot be overemphasized.
MNT Physical Activity

Nutrition therapy plays an integral role in overall diabetes Recommendations
management, and people with diabetes should be actively 5.27 Children and adolescents with type 1 or type 2
engaged in education, self-management, and treatment diabetes or prediabetes should engage in 60
planning with their health care team, including the minutes/day or more of moderate- or vigorous-
intensity aerobic activity, with vigorous muscle- to decreased pain sensation. They should wear proper
strengthening and bone-strengthening activities footwear and examine their feet daily to detect
at least 3 days/week. C lesions early. Anyone with a foot injury or open sore
5.28 Most adults with type 1 C and type 2 B diabetes should be restricted to non–weight-bearing activities.
should engage in 150 minutes or more of moder- Diabetes is associated with autonomic neuropathy,
ate- to vigorous-intensity aerobic activity per which can increase the risk of exercise-induced
week, spread over at least 3 days/week, with no injury or adverse events through decreased cardiac
more than 2 consecutive days without activity. responsiveness to exercise, postural hypotension,
Shorter durations (minimum 75 minutes/week) impaired thermoregulation, and greater susceptibil-
of vigorous-intensity or interval training may be ity to hypoglycemia.
sufficient for younger and more physically fit
individuals. Smoking Cessation: Tobacco and e-Cigarettes
5.29 Adults with type 1 C and type 2 B diabetes should

Recommendations
engage in 2–3 sessions/week of resistance exer-
cise on nonconsecutive days. 5.33 Advise all patients not to use cigarettes and other
5.30 All adults, and particularly those with type 2 dia- tobacco products or e-cigarettes. A
betes, should decrease the amount of time spent 5.34 After identification of tobacco or e-cigarette use,
in daily sedentary behavior. B Prolonged sitting include smoking cessation counseling and other
should be interrupted every 30 minutes for blood forms of treatment as a routine component of dia-
glucose benefits. C betes care. A
5.31 Flexibility training and balance training are rec-
ommended 2–3 times/week for older adults with Psychosocial Issues
diabetes. Yoga and tai chi may be included based
Recommendations
on individual preferences to increase flexibility,
muscular strength, and balance. C 5.36 Psychosocial care should be integrated with a collab-
5.32 Evaluate baseline physical activity and sedentary orative, patient-centered approach and provided to
time. Promote increase in nonsedentary activities all people with diabetes, with the goals of optimizing
above baseline for sedentary individuals with health outcomes and health-related quality of life. A
type 1 E and type 2 B diabetes. Examples include 5.37 Psychosocial screening and follow-up may include,
walking, yoga, housework, gardening, swimming, but are not limited to, attitudes about diabetes,
and dancing. expectations for medical management and out-
comes, affect or mood, general and diabetes-related
Hypoglycemia quality of life, available resources (financial, social,
In individuals taking insulin and/or insulin secreta- and emotional), and psychiatric history. E
gogues, physical activity may cause hypoglycemia if the 5.38 Providers should consider assessment for symp-
medication dose or carbohydrate consumption is not toms of diabetes distress, depression, anxiety, dis-
adjusted for the exercise bout and post-bout impact on ordered eating, and cognitive capacities using
glucose. Patients need to be educated to check blood age-appropriate standardized and validated tools
glucose levels before and after periods of exercise and at the initial visit, at periodic intervals, and when
about the potential prolonged effects of exercise, there is a change in disease, treatment, or life cir-
depending on its intensity and duration. cumstance. Including caregivers and family mem-
bers in this assessment is recommended. B
Exercise in the Presence of Microvascular Complications
Refer to the ADA’s Mental Health Resources for assess-
For individuals with proliferative diabetic retinopa-
ment tools and additional resources (professional.
thy or severe nonproliferative diabetic retinopathy,
diabetes.org/mentalhealthsoc).
vigorous-intensity aerobic or resistance exercise
may be contraindicated because of the risk of trig- Diabetes Distress
gering vitreous hemorrhage or retinal detachment.
Individuals with peripheral neuropathy are at an Recommendation
increased risk of skin breakdown, infection, and Char- 5.40 Routinely monitor people with diabetes for diabe-
cot joint destruction with some forms of exercise, due tes distress, particularly when treatment targets
are not met and/or at the onset of diabetes com- year in patients who are meeting treatment goals
plications. B (and who have stable glycemic control). E
6.2 Assess glycemic status at least quarterly and as
Diabetes distress refers to significant negative psy- needed in patients whose therapy has recently
chological reactions related to emotional burdens changed and/or who are not meeting glycemic
and worries specific to an individual’s experience in goals. E
having to manage a severe, complicated, and
demanding chronic disease such as diabetes. The Glucose Assessment by CGM
constant behavioral demands of diabetes self-man-
Recommendations
agement and the potential or actuality of disease pro-
gression are directly associated with reports of 6.3 Standardized, single-page glucose reports from
diabetes distress. CGM devices with visual cues, such as the ambula-
tory glucose profile (AGP), should be considered as

a standard summary for all CGM devices. E
6. GLYCEMIC TARGETS 6.4 TIR is associated with the risk of microvascular
Assessment of Glycemic Control complications and can be used for assessment of
glycemic control. Additionally, time below target
Glycemic control is assessed by A1C measurement,
and time above target are useful parameters
continuous glucose monitoring (CGM), and blood
for the evaluation of the treatment regimen
glucose monitoring (BGM). Clinical trials primarily
(Table 6.2). C
use A1C to demonstrate the benefits of improved gly-
cemic control. CGM serves an increasingly important For many people with diabetes, glucose monitoring is
role in managing the effectiveness and safety of key for achieving glycemic targets. It allows patients
treatment in many patients with type 1 diabetes and to evaluate their individual response to therapy and
selected patients with type 2 diabetes. assess whether glycemic targets are being safely
achieved.
Glycemic Assessment
CGM technology has grown rapidly in accuracy, afford-
Recommendations ability, and accessibilitiy. The GMI and data on TIR,
6.1 Assess glycemic status (A1C or other glycemic mea- hypoglycemia, and hyperglycemia are available to pro-
surement such as time in range [TIR] or glucose viders and patients via the AGP report (Figure 6.1),
management indicator [GMI]) at least two times a which offers visual cues and recommendations to assist
TABLE 6.2 Standardized CGM Metrics for Clinical Care

1. Number of days CGM device is worn (recommend 14 days)
2. Percentage of time CGM device is active (recommend 70% of data from 14 days)
3. Mean glucose
4. GMI
5. Glycemic variability (%CV) target #36%*
6. TAR: % of readings and time >250 mg/dL (>13.9 mmol/L) Level 2 hyperglycemia
7. TAR: % of readings and time 181–250 mg/dL (10.1–13.9 mmol/L) Level 1 hyperglycemia
8. TIR: % of readings and time 70–180 mg/dL (3.9–10.0 mmol/L) In range
9. TBR: % of readings and time 54–69 mg/dL (3.0–3.8 mmol/L) Level 1 hypoglycemia
10. TBR: % of readings and time <54 mg/dL (<3.0 mmol/L) Level 2 hypoglycemia
%CV, percentage coefficient of variation; TAR, time above range; TBR, time below range. *Some studies suggest that lower %CV targets
(<33%) provide additional protection against hypoglycemia for those receiving insulin or sulfonylureas. Adapted from Battelino T, Danne T,
Bergenstal RM, et al. Diabetes Care 2019;42:1593–1603.
AGP Report: Continuous Glucose Monitoring

Time in Ranges Goals for Type 1 and Type 2 Diabetes Test Patient DOB: Jan 1, 1970
Goal: <5% 14 Days: August 8–August 21, 2021
Very High 20%
Time CGM Active: 100%
44% Goal: <25%
250
High 24% Glucose Metrics
180 Average Glucose ........................................... 175 mg/dL

Goal: <154 mg/dL
mg/dL Target 46% Goal: >70%

Glucose Management Indicator (GMI) ............... 7.5%
Goal: <7%

70 Low 5%
54
10% Goal: <4% Glucose Variability ............................................ 45.5%
Very Low 5%
Goal: <36%
Goal: <1% Each 1% time in range = ~15 minutes
AGP is a summary of glucose values from the report period, with median (50%) and other percentiles shown as if they occurred in a single day.
350
mg/dL
95%
75%
250
50%
25%
180
Target
Range
70 5%
54
0
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
Sunday Monday Tuesday Wednesday Thursday Friday Saturday

8 9 10 11 12 13 14
mg/dL
180
70
12pm 12pm 12pm 12pm 12pm 12pm 12pm

15 16 17 18 19 20 21
mg/dL
180
70
FIGURE 6.1 Key points included in standard AGP report. Reprinted from Holt RIG, DeVries JH, Hess-Fischl A, et al. Diabetes Care
2021;44:2589–2625.
in data interpretation and treatment decision-making. 6.11 Glucagon should be prescribed for all individuals
Table 6.2 summarizes CGM-derived metrics for assess- at increased risk of level 2 or 3 hypoglycemia, so
ment and glycemic management. that it is available should it be needed. Care-
givers, school personnel, or family members pro-
viding support to these individuals should know
Glycemic Goals
where it is and when and how to administer it.
Recommendations Glucagon administration is not limited to health
6.5a An A1C goal for many nonpregnant adults of care professionals. E
<7% (53 mmol/mol) without significant hypogly- 6.12 Hypoglycemia unawareness or one or more epi-
cemia is appropriate. A sodes of level 3 hypoglycemia should trigger
6.5b If using AGP/GMI to assess glycemia, a parallel hypoglycemia avoidance education and reevalua-
goal for many nonpregnant adults is TIR of tion and adjustment of the treatment regimen to
decrease hypoglycemia. E

>70% with time below range <4% and time
<54 mg/dL <1% (Figure 6.1 and Table 6.2). B 6.13 Insulin-treated patients with hypoglycemia
6.6 On the basis of provider judgment and patient pref- unawareness, one level 3 hypoglycemic event, or a
erence, achievement of lower A1C levels than the pattern of unexplained level 2 hypoglycemia should
goal of 7% may be acceptable and even beneficial if be advised to raise their glycemic targets to strictly
it can be achieved safely without significant hypo- avoid hypoglycemia for at least several weeks in
glycemia or other adverse effects of treatment. B order to partially reverse hypoglycemia unaware-
6.7 Less stringent A1C goals (such as <8% [64 mmol/ ness and reduce risk of future episodes. A
mol]) may be appropriate for patients with limited 6.14 Ongoing assessment of cognitive function is sug-
life expectancy or where the harms of treatment are gested with increased vigilance for hypoglycemia
greater than the benefits. B by the clinician, patient, and caregivers if
impaired or declining cognition is found. B
Table 6.3 summarizes glycemic recommendations for
many nonpregnant adults. For specific guidance, see “6. 7. DIABETES TECHNOLOGY
Glycemic Targets,” “14. Children and Adolescents,” and
Diabetes technology includes the hardware, devices,
“15. Management of Diabetes in Pregnancy” in the com-
and software that people with diabetes use to help
plete 2022 Standards of Care. For information about
manage their diabetes. This includes insulin delivery
glycemic targets for older adults, see Table 13.1 in “13.
technology such as insulin pumps (also called continu-
OLDER ADULTS.”
ous subcutaneous insulin infusion [CSII]) and con-
nected insulin pens, as well as glucose monitoring via
Hypoglycemia CGM system or glucose meter. More recently, diabetes
The classification of hypoglycemia level is summarized technology has expanded to include hybrid devices that
in Table 6.4. both monitor glucose and deliver insulin, some with
varying degrees of automation. Apps can also provide
Recommendations diabetes self-management support.
6.9 Occurrence and risk for hypoglycemia should be
reviewed at every encounter and investigated as General Device Principles
indicated. C Recommendations
6.10 Glucose (approximately 15–20 g) is the preferred 7.1 The type(s) and selection of devices should be indi-
treatment for the conscious individual with blood vidualized based on a person’s specific needs,
glucose <70 mg/dL (3.9 mmol/L), although any desires, skill level, and availability of devices. In the
form of carbohydrate that contains glucose may setting of an individual whose diabetes is partially
be used. Fifteen minutes after treatment, if BGM or wholly managed by someone else (e.g., a young
shows continued hypoglycemia, the treatment child or a person with cognitive impairment), the
should be repeated. Once the BGM or glucose caregiver’s skills and desires are integral to the deci-
pattern is trending up, the individual should con- sion-making process. E
sume a meal or snack to prevent recurrence of 7.2 When prescribing a device, ensure that people with
hypoglycemia. B diabetes/caregivers receive initial and ongoing
7.9 Although BGM in individuals on noninsulin thera-

TABLE 6.3 Summary of Glycemic Recommendations for
pies has not consistently shown clinically signifi-
Many Nonpregnant Adults With Diabetes
cant reductions in A1C, it may be helpful when
A1C <7.0% (53 mmol/mol)*# altering diet, physical activity, and/or medica-
Preprandial capillary 80–130 mg/dL* (4.4–7.2 mmol/L) tions (particularly medications that can cause
plasma glucose hypoglycemia) in conjunction with a treatment
adjustment program. E
Peak postprandial capillary <180 mg/dL* (10.0 mmol/L)
plasma glucose†
*More or less stringent glycemic goals may be appropriate for indi-

CGM
vidual patients. #CGM may be used to assess glycemic target as Table 6.2 summarizes CGM-derived glycemic metrics,
noted in Recommendation 6.5b and Figure 6.1. Goals should be and Table 7.3 defines the available types of CGM devices.
individualized based on duration of diabetes, age/life expectancy,

comorbid conditions, known CVD or advanced microvascular com-
plications, hypoglycemia unawareness, and individual patient con-
Recommendations
siderations. †Postprandial glucose may be targeted if A1C goals are 7.11 Real-time CGM (rtCGM) A or intermittently
not met despite reaching preprandial glucose goals. Postprandial scanned CGM (isCGM) B should be offered for
glucose measurements should be made 1–2 hours after the begin-
ning of the meal, generally peak levels in patients with diabetes.
diabetes management in adults with diabetes on
multiple daily injections (MDI) or CSII who are
capable of using devices safely (either by them-
TABLE 6.4 Classification of Hypoglycemia selves or with a caregiver). The choice of device
Glycemic Criteria/Description should be made based on patient circumstances,
Level 1 Glucose <70 mg/dL (3.9 mmol/L) and $54 mg/dL desires, and needs.
(3.0 mmol/L) 7.12 rtCGM A or isCGM C can be used for diabetes
management in adults with diabetes on basal
Level 2 Glucose <54 mg/dL (3.0 mmol/L)
insulin who are capable of using devices safely
Level 3 A severe event characterized by altered mental and/or (either by themselves or with a caregiver). The
physical status requiring assistance for treatment of choice of device should be made based on patient
hypoglycemia
circumstances, desires, and needs.
Reprinted from Agiostratidou G, Anhalt H, Ball D, et al. Diabetes 7.15 In patients on MDI and CSII, rtCGM devices should
Care 2017;40:1622–1630. be used as close to daily as possible for maximal
benefit. A is CGM devices should be scanned fre-
education and training, either in-person or
remotely, and regular evaluation of technique, quently, at a minimum once every 8 hours. A
7.16 When used as an adjunct to pre- and postprandial
results, and their ability to use data, including
uploading/sharing data (if applicable), to adjust BGM, CGM can help to achieve A1C targets in
therapy. C diabetes and pregnancy. B
7.5 Initiation of CGM, CSII, and/or automated insulin 7.17 Periodic use of rtCGM or isCGM or use of profes-
delivery (AID) early in the treatment of diabetes sional CGM can be helpful for diabetes manage-
can be beneficial depending on a person’s/care- ment in circumstances where continuous use of
giver’s needs and preferences. C CGM is not appropriate, desired, or available. C
7.18 Skin reactions, either due to irritation or allergy,
should be assessed and addressed to aid in suc-
BGM
cessful use of devices. E
Recommendations
7.7 People who are on insulin using BGM should be Inpatient Care
encouraged to check when appropriate based on
their insulin regimen. This may include checking Recommendation
when fasting, prior to meals and snacks, at bedtime, 7.29 Patients who are in a position to safely use
prior to exercise, when low blood glucose is sus- diabetes devices should be allowed to continue
pected, after treating low blood glucose levels until using them in an inpatient setting or during
they are normoglycemic, and prior to and while outpatient procedures when proper supervision is
performing critical tasks such as driving. B available. E
TABLE 7.3 CGM Devices

Real-time CGM (rtCGM) CGM systems that measure and display glucose levels continuously
Intermittently scanned CGM (isCGM) CGM systems that measure glucose levels continuously but only
display glucose values when swiped by a reader or a smartphone
Professional CGM CGM devices that are placed on the patient in the provider’s office (or
with remote instruction) and worn for a discrete period of time
(generally 7–14 days). Data may be blinded or visible to the
person wearing the device. The data are used to assess glycemic
patterns and trends. These devices are not fully owned by the
patient—they are clinic-based devices, as opposed to the patient-
owned rtCGM or isCGM CGM devices.

Other Technologies Assessment
See “7. Diabetes Technology” in the complete 2022 Recommendations
Standards of Care for more information on insulin 8.1 Use person-centered, nonjudgmental language that
delivery, including insulin syringes, pens, connected fosters collaboration between patients and pro-
pens, pumps, and AID systems, which combine insulin viders, including people-first language (e.g., “person
pump and CGM with software automating varying degrees with obesity” rather than “obese person”). E
of insulin delivery; software systems; and digital health sys- 8.2 Measure height and weight and calculate
tems that combine technology with online coaching. BMI at annual visits or more frequently. Assess
weight trajectory to inform treatment considera-
The Future tions. E
The most important component in the rapid pace of 8.3 Based on clinical considerations such as the pres-
technology development is the patient. Having a device ence of comorbid heart failure (HF) or significant
or application does not change outcomes unless the unexplained weight gain or loss, weight may
individual engages with it to create positive health ben- need to be monitored and evaluated more fre-
efits. The health care team should assist the patient in quently. B If deterioration of medical status is
device/program selection and support its use through associated with significant weight gain or loss,
inpatient evaluation should be considered, espe-
ongoing education. Although there is not yet technology
cially focused on associations between medication
that completely eliminates the self-care tasks necessary
use, food intake, and glycemic status. E
for treating diabetes, the tools described in this section
8.4 Accommodations should be made to provide pri-
can make diabetes easier to manage.
vacy during weighing. E
8. OBESITY AND WEIGHT MANAGEMENT FOR Table 8.1 summarizes treatment options for overweight
THE PREVENTION AND TREATMENT OF TYPE 2 and obesity in type 2 diabetes.
DIABETES
Strong evidence exists that obesity management can
Diet, Physical Activity, and Behavioral Therapy
delay the progression from prediabetes to type 2 diabe- Recommendations
tes and is highly beneficial in the treatment of type 2 8.5 Diet, physical activity, and behavioral therapy to
diabetes. Modest weight loss improves glycemic control achieve and maintain $5% weight loss is recom-
and reduces the need for glucose-lowering medications, mended for most people with type 2 diabetes and
and more intensive dietary energy restriction can sub- overweight or obesity. Additional weight loss usu-
stantially reduce A1C and fasting glucose and promote ally results in further improvements in control of
sustained diabetes remission through at least 2 years. diabetes and CV risk. B
Metabolic surgery strongly improves glycemic control 8.6 Such interventions should include a high frequency of
and often leads to remission of diabetes, improved qual- counseling ($16 sessions in 6 months) and focus on
ity of life, improved CV outcomes, and reduced dietary changes, physical activity, and behavioral strate-
mortality. gies to achieve a 500–750 kcal/day energy deficit. A
8.9 Evaluate systemic, structural, and socioeconomic months’ use) or if there are significant safety or
factors that may impact dietary patterns and food tolerability issues, consider discontinuation of
choices, such as food insecurity and hunger, the medication and evaluate alternative medica-
access to healthful food options, cultural circum- tions or treatment approaches. A
stances, and SDOH. C
8.10 For those who achieve weight loss goals, long-term Approved Weight Loss Medications
($1 year) weight maintenance programs are rec- Nearly all FDA-approved medications for weight loss have
ommended when available. Such programs should, been shown to improve glycemic control in patients with
at minimum, provide monthly contact and support, type 2 diabetes and delay progression to type 2 diabetes
recommend ongoing monitoring of body weight in patients at risk. Medications approved by the FDA for
(weekly or more frequently) and other self-monitor- the treatment of obesity are summarized in Table 8.2 in
ing strategies, and encourage regular physical activ- the complete 2022 Standards of Care.

ity (200–300 minutes/week). A
8.11 Short-term dietary intervention using structured,
Metabolic Surgery
very-low-calorie diets (800–1,000 kcal/day) may be
prescribed for carefully selected individuals by Recommendations
trained practitioners in medical settings with close 8.19 Metabolic surgery should be performed in high-
monitoring. Long-term, comprehensive weight volume centers with multidisciplinary teams
maintenance strategies and counseling should be knowledgeable about and experienced in the
integrated to maintain weight loss. B management of obesity, diabetes, and gastroin-
8.12 There is no clear evidence that dietary supple- testinal surgery. E
ments are effective for weight loss. A 8.20 People being considered for metabolic surgery should
be evaluated for comorbid psychological conditions
Pharmacotherapy and social and situational circumstances that have
the potential to interfere with surgery outcomes. B
Recommendations
8.21 People who undergo metabolic surgery should receive
8.13 When choosing glucose-lowering medications for long-term medical and behavioral support and routine
people with type 2 diabetes and overweight or obe- monitoring of micronutrient, nutritional, and meta-
sity, consider the medication’s effect on weight. B bolic status. B
8.14 Whenever possible, minimize medications for 8.22 If postbariatric hypoglycemia is suspected, clinical
comorbid conditions that are associated with evaluation should exclude other potential disor-
weight gain. E ders contributing to hypoglycemia, and manage-
8.16 If a patient’s response to weight loss medication ment includes education, MNT with a dietitian
is effective (typically defined as >5% weight experienced in postbariatric hypoglycemia, and
loss after 3 months’ use), further weight loss is medication treatment, as needed. A CGM should
likely with continued use. When early response be considered as an important adjunct to improve
is insufficient (typically <5% weight loss after 3 safety by alerting patients to hypoglycemia,
TABLE 8.1 Treatment Options for Overweight and Obesity in Type 2 Diabetes
BMI Category, kg/m2
Treatment 25.0–26.9 (or 23.0–24.9*) 27.0–29.9 (or 25.0–27.4*) $30.0 (or $27.5*)
Diet, physical activity, and behavioral counseling † † †
Pharmacotherapy † †
Metabolic surgery †
*Recommended cut points for Asian-American individuals (expert opinion). †Treatment may be indicated for select motivated patients.
especially for those with severe hypoglycemia or 9.9 Among individuals with type 2 diabetes who have
hypoglycemia unawareness. E established ASCVD or indicators of high CV risk,
established CKD, or HF, an SGLT2 inhibitor and/or
9. PHARMACOLOGIC APPROACHES TO GLP-1 receptor agonist with demonstrated CVD
GLYCEMIC TREATMENT benefit (Table 9.2 and Figure 9.3) is recommended
as part of the glucose-lowering regimen and com-
Pharmacologic Therapy for Adults With Type 1 prehensive CV risk reduction, independent of A1C
Diabetes and in consideration of patient-specific factors. A
See “9. Pharmacologic Approaches to Glycemic 9.10 In patients with type 2 diabetes, a GLP-1 receptor
Treatment” in the complete 2022 Standards of Care for agonist is preferred to insulin when possible. A
detailed information on pharmacologic approaches to 9.11 If insulin is used, combination therapy with a GLP-1
type 1 diabetes management in adults. receptor agonist is recommended for greater effi-
cacy and durability of treatment effect. A

Pharmacologic Therapy for Adults With Type 2 9.13 Medication regimen and medication-taking behav-
Diabetes ior should be reevaluated at regular intervals (every
3–6 months) and adjusted as needed to incorporate
Table 9.2 and Figure 9.3 provide details for informed
specific factors that impact choice of treatment (Fig-
decision-making on pharmacologic treatment for the
ure 4.1 and Table 9.2). E
management of glycemia in type 2 diabetes.
9.14 Clinicians should be aware of the potential for
overbasalization with insulin therapy. Clinical sig-
Recommendations
nals that may prompt evaluation of overbasaliza-
9.4a First-line therapy depends on comorbidities, patient- tion include basal dose more than ~0.5 IU/kg/
centered treatment factors, and management needs day, high bedtime-morning or post-preprandial
and generally includes metformin and comprehen- glucose differential, hypoglycemia (aware or
sive lifestyle modification. A unaware), and high glycemic variability. Indica-
9.4b Other medications (glucagon-like peptide 1 tion of overbasalization should prompt reevalua-
[GLP-1] receptor agonists, sodium–glucose tion to further individualize therapy. E
cotransporter 2 [SGLT2] inhibitors), with or with-
out metformin based on glycemic needs, are Both comprehensive lifestyle modifications and pharma-
appropriate initial therapy for individuals with cotherapy should begin at diagnosis. Glycemic status
type 2 diabetes with or at high risk for atheroscle- should be assessed, with treatment modified regularly
rotic cardiovascular disease (ASCVD), HF, and/or (e.g., at least twice yearly if stable and more often if not at
chronic kidney disease (CKD) (Figure 9.3). A goal) to achieve treatment goals and to avoid therapeutic
9.5 Metformin should be continued upon initiation of inertia. Not all treatment modifications involve sequential
insulin therapy (unless contraindicated or not toler- add-on therapy, but may involve switching therapy or
weaning current therapy to accommodate for changes in
ated) for ongoing glycemic and metabolic benefits. A
9.6 Early combination therapy can be considered in the patient’s overall goals (e.g., the initiation of agents for
reasons beyond glycemic benefit). See “9. Pharmacologic
some patients at treatment initiation to extend
Approaches to Glycemic Treatment” in the complete 2022
the time to treatment failure. A
Standards of Care for more detailed information on phar-
9.7 The early introduction of insulin should be con-
macologic approaches to type 2 diabetes management in
sidered if there is evidence of ongoing catabolism
adults, including Figure 9.4 for guidance on intensifying
(weight loss), if symptoms of hyperglycemia are
to injectable therapies in type 2 diabetes.
present, or when A1C levels (>10% [86 mmol/
mol]) or blood glucose levels ($300 mg/dL [16.7
mmol/L]) are very high. E 10. CVD AND RISK MANAGEMENT
9.8 A patient-centered approach should guide the ASCVD—defined as coronary heart disease, cerebrovascu-
choice of pharmacologic agents. Consider the lar disease, or peripheral arterial disease (PAD) presumed
effects on CV and renal comorbidities, efficacy, to be of atherosclerotic origin—is the leading cause of
hypoglycemia risk, impact on weight, cost and morbidity and mortality for individuals with diabetes.
access, risk for side effects, and patient preferences Controlling individual CV risk factors helps prevent or
(Table 9.2 and Figure 9.3). E slow ASCVD in people with diabetes. HF is another major
TABLE 9.2 Drug-Specific and Patient Factors to Consider When Selecting Antihyperglycemic Treatment in Adults With Type 2 Diabetes
24
CV effects Renal effects
Weight
Efficacy (60) Hypoglycemia Cost Oral/SQ Additional considerations
change (109)
ASCVD HF Progression of DKD Dosing/use considerations*
Metformin High No Neutral Potential Neutral Low Oral Neutral Contraindicated with eGFR Gastrointestinal side effects common
2
(potential for benefit <30 mL/min/1.73 m (diarrhea, nausea)
modest loss) Potential for B12 deficiency
See labels for renal dose Should be discontinued before any

SGLT2 inhibitors Intermediate No Loss Benefit: Benefit: High Oral Benefit:
considerations of individual scheduled surgery to avoid potential
empagliflozin†, empagliflozin‡, canagliflozin§,
agents risk for DKA
canagliflozin† canagliflozin, empagliflozin,
dapagliflozin‡, dapagliflozin§ Glucose-lowering effect is DKA risk (all agents, rare in T2D)
ertugliflozin lower for SGLT2 inhibitors Risk of bone fractures (canagliflozin)
at lower eGFR Genitourinary infections
Risk of volume depletion,
hypotension
nLDL cholesterol
Risk of Fournier’s gangrene
GLP-1 RAs High No Loss Benefit: dulaglutide†, Neutral High SQ; oral Benefit on renal end FDA Black Box: Risk of thyroid C-cell
(semaglutide)
See labels for renal dose
liraglutide†, points in CVOTs, tumors in rodents; human relevance
considerations of individual
semaglutide (SQ)† driven by albuminuria not determined (liraglutide,
agents
outcomes: liraglutide, dulaglutide, exenatide
semaglutide (SQ), No dose adjustment for extended release, semaglutide)
Neutral: exenatide dulaglutide dulaglutide, liraglutide, Gl side effects common
once weekly, semaglutide (nausea, vomiting, diarrhea)
lixisenatide Caution when initiating or Injection site reactions

increasing dose due to Pancreatitis has been reported in clinical
potential risk of nausea, trials but causality has not been
vomiting, diarrhea, or established. Discontinue if pancreatitis
dehydration. Monitor renal is suspected.
function in patients
reporting severe adverse Gl
reactions when initiating or
increasing dose of therapy.
DPP-4 inhibitors Intermediate No Neutral Neutral Potential risk: High Oral Neutral Renal dose adjustment Pancreatitis has been reported in clinical
saxagliptin required (sitagliptin, trials but causality has not been
saxagliptin, alogliptin); established. Discontinue if pancreatitis
can be used in renal is suspected.
impairment
Joint pain
No dose adjustment
required for linagliptin
Thiazolidinediones High No Gain Potential benefit: Increased risk Low Oral Neutral No dose adjustment FDA Black Box: Congestive heart
pioglitazone required failure (pioglitazone, rosiglitazone)
Generally not Fluid retention (edema; heart
recommended in renal failure)
impairment due to Benefit in NASH
potential for Risk of bone fractures
fluid retention Bladder cancer (pioglitazone)
LDL cholesterol (rosiglitazone)
Sulfonylureas High Yes Gain Neutral Neutral Low Oral Neutral Glyburide: generally not FDA Special Warning on increased
(2nd generation) recommended in chronic risk of cardiovascular mortality
kidney disease based on studies of an older
Glipizide and glimepiride: sulfonylurea (tolbutamide)
initiate conservatively to
avoid hypoglycemia
Insulin Human High Yes Neutral SQ; Neutral Lower insulin doses Injection site reactions
Gain Neutral Low (SQ)
insulin inhaled required with a Higher risk of hypoglycemia with
decrease in eGFR; titrate human insulin (NPH or premixed
Analogs per clinical response formulations) vs. analogs
High SQ
*For agent-specific dosing recommendations, please refer to the manufacturers’ prescribing information. †FDA-approved for CVD benefit. ‡FDA-approved for HF indication. §FDA-approved
for CKD indication. CVOT, cardiovascular outcomes trial; DPP-4, dipeptidyl peptidase 4; GLP-1 RA, glucagon-like peptide 1 receptor agonist; NASH, nonalcoholic steatohepatitis; SQ, sub-
D IA B E TE SJ OUR N A L S.OR G/ C L IN IC A L
cutaneous; T2D, type 2 diabetes.

VO L UM E 40 , N U MB E R 1, W IN TE R 20 22
FIGURE 9.3 Pharmacologic treatment of hyperglycemia in adults with type 2 diabetes. 2022 ADA Professional Practice Committee (PPC) adaptation of Davies MJ, D’Alessio DA,
Fradkin J, et al. Diabetes Care 2018;41:2669–2701 and Buse JB, Wexler DJ, Tsapas A, et al. Diabetes Care 2020;43:487–493. For appropriate context, see Figure 4.1. The 2022 ADA
PPC adaptation emphasizes incorporation of therapy rather than sequential add-on, which may require adjustment of current therapies. Therapeutic regimen should be tailored to
comorbidities, patient-centered treatment factors, and management needs. Refer to sections 10 and 11 in the complete 2022 Standards of Care for detailed discussions of CVD and
CKD risk management. CVOT, cardiovascular outcomes trial; DPP-4i, dipeptidyl peptidase 4 inhibitor; GLP-1 RA, glucagon-like peptide 1 receptor agonist; SGLT2i, sodium–glucose
25
cotransporter 2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione.

cause of morbidity and mortality from CVD. Studies show 10.5 For individuals with diabetes and hypertension
HF (with preserved ejection fraction [HFpEF] or reduced at lower risk for CVD (10-year ASCVD risk
ejection fraction [HFrEF]) is twofold higher in people <15%), treat to a blood pressure target of
with diabetes compared to those without. <140/90 mmHg. A
Risk factors, including duration of diabetes, obesity/ Treatment Strategies

overweight, hypertension, dyslipidemia, smoking, a
Lifestyle Intervention
family history of premature coronary disease, CKD, and
the presence of albuminuria, should be assessed at least Recommendation
annually in all patients with diabetes to prevent and 10.7 For patients with blood pressure >120/80 mmHg,
manage both ASCVD and HF. lifestyle intervention consists of weight loss when
indicated, a Dietary Approaches to Stop Hyperten-
The Risk Calculator sion (DASH)-style eating pattern, including reduc-

The American College of Cardiology/American Heart ing sodium and increasing potassium intake,
Association ASCVD risk calculator (Risk Estimator Plus) moderation of alcohol intake, and increased physi-
is generally a useful tool to estimate 10-year risk of an cal activity. A
individual’s first ASCVD event (available online at tools.
acc.org/ASCVD-Risk-Estimator-Plus). Pharmacologic Interventions
Recommendations
Hypertension/Blood Pressure Control 10.8 Patients with confirmed office-based blood pres-
Hypertension, defined as a sustained blood pressure sure $140/90 mmHg should, in addition to life-
$140/90 mmHg, is common among patients with style therapy, have prompt initiation and timely
either type 1 or type 2 diabetes. titration of pharmacologic therapy to achieve
blood pressure goals. A
Screening and Diagnosis 10.9 Patients with confirmed office-based blood pres-
Recommendations sure $160/100 mmHg should, in addition to
lifestyle therapy, have prompt initiation and
10.1 Blood pressure should be measured at every
timely titration of two drugs or a single-pill
routine clinical visit. When possible, patients
combination of drugs demonstrated to reduce
found to have elevated blood pressure ($140/
CV events in patients with diabetes. A
90 mmHg) should have blood pressure con-
10.10 Treatment for hypertension should include drug
firmed using multiple readings, including meas-
classes demonstrated to reduce CV events in
urements on a separate day, to diagnose
patients with diabetes. A ACE inhibitors or
hypertension. A Patients with blood pressure
angiotensin receptor blockers (ARBs) are recom-
$180/110 mmHg and CVD could be diagnosed
mended first-line therapy for hypertension in
with hypertension at a single visit. E
people with diabetes and coronary artery dis-
10.2 All hypertensive patients with diabetes should
ease (CAD). A
monitor their blood pressure at home. A
10.11 Multiple-drug therapy is generally required
to achieve blood pressure targets. However,
Treatment Goals
combinations of ACE inhibitors and ARBs
Recommendations and combinations of ACE inhibitors or ARBs
10.3 For patients with diabetes and hypertension, blood with direct renin inhibitors should not be
pressure targets should be individualized through used. A
a shared decision-making process that addresses 10.12 An ACE inhibitor or ARB, at the maximum tol-
CV risk, potential adverse effects of antihyperten- erated dose indicated for blood pressure treat-
sive medications, and patient preferences. B ment, is the recommended first-line treatment
10.4 For individuals with diabetes and hypertension for hypertension in patients with diabetes and
at higher CV risk (existing ASCVD or 10-year urinary albumin-to-creatinine ratio (UACR)
ASCVD risk $15%), a blood pressure target of $300 mg/g creatinine A or 30–299 mg/g cre-
<130/80 mmHg may be appropriate, if it can atinine. B If one class is not tolerated, the
be safely attained. B other should be substituted. B
10.13 For patients treated with an ACE inhibitor, Statin Treatment

ARB, or diuretic, serum creatinine/estimated Primary Prevention
glomerular filtration rate (eGFR) and serum
Recommendations
potassium levels should be monitored at least
annually. B 10.19 For patients with diabetes aged 40–75 years with-
out ASCVD, use moderate-intensity statin therapy
Resistant Hypertension in addition to lifestyle therapy. A
10.20 For patients with diabetes aged 20–39 years
Recommendation
with additional ASCVD risk factors, it may be
10.14 Patients with hypertension who are not meeting reasonable to initiate statin therapy in addition
blood pressure targets on three classes of to lifestyle therapy. C
antihypertensive medications (including a 10.21 In patients with diabetes at higher risk, espe-
diuretic) should be considered for mineral- cially those with multiple ASCVD risk factors or

ocorticoid receptor antagonist (MRA) aged 50–70 years, it is reasonable to use high-
therapy. B intensity statin therapy. B
10.22 In adults with diabetes and 10-year ASCVD risk of
20% or higher, it may be reasonable to add ezeti-
Lipid Management
mibe to maximally tolerated statin therapy to
Lifestyle Intervention reduce LDL cholesterol levels by 50% or more. C
Recommendations
Secondary Prevention
10.15 Lifestyle modification focusing on weight loss
(if indicated); application of a Mediterranean Recommendations
style or DASH eating pattern; reduction of 10.23 For patients of all ages with diabetes and ASCVD,
saturated fat and trans fat; increase of dietary high-intensity statin therapy should be added to
n-3 fatty acids, viscous fiber, and plant sta- lifestyle therapy. A
nols/sterols intake; and increased physical 10.24 For patients with diabetes and ASCVD considered
activity should be recommended to improve very high risk using specific criteria, if LDL choles-
the lipid profile and reduce the risk of devel- terol is $70 mg/dL on maximally tolerated statin
oping ASCVD in patients with diabetes. A dose, consider adding additional LDL-lowering
10.16 Intensify lifestyle therapy and optimize glyce- therapy (such as ezetimibe or PCSK9 inhibitor). A
mic control for patients with elevated triglyc- 10.25 For patients who do not tolerate the intended
eride levels ($150 mg/dL [1.7 mmol/L]) intensity, the maximally tolerated statin dose
and/or low HDL cholesterol (<40 mg/dL should be used. E
[1.0 mmol/L] for men, <50 mg/dL 10.26 In adults with diabetes aged >75 years already
[1.3 mmol/L] for women). C on statin therapy, it is reasonable to continue
statin treatment. B
Ongoing Therapy and Monitoring With Lipid Panel 10.27 In adults with diabetes aged >75 years, it may
be reasonable to initiate statin therapy after dis-
Recommendations
cussion of potential benefits and risks. C
10.17 In adults not taking statins or other lipid-lower-
ing therapy, it is reasonable to obtain a lipid See “10. Cardiovascular Disease and Risk Man-
profile at the time of diabetes diagnosis, at an agement” in the complete 2022 Standards of Care for
initial medical evaluation, and every 5 years detailed guidance on statin therapy in patients with
thereafter if under the age of 40 years, or more diabetes.
frequently if indicated. E
Treatment of Other Lipoprotein Fractions or Targets
10.18 Obtain a lipid profile at initiation of statins or
other lipid-lowering therapy, 4–12 weeks after Recommendations
initiation or a change in dose, and annually 10.29 For patients with fasting triglyceride levels
thereafter, as it may help to monitor the $500 mg/dL, evaluate for secondary causes of
response to therapy and inform medication hypertriglyceridemia and consider medical ther-
adherence. E apy to reduce the risk of pancreatitis. C
10.30 In adults with moderate hypertriglyceridemia and low bleeding risk to prevent major adverse
(fasting or nonfasting triglycerides 175–499 cardiovascular (MACE) events. A
mg/dL), clinicians should address and treat 10.38 Combination therapy with aspirin plus low-dose
lifestyle factors (obesity and metabolic syn- rivaroxaban should be considered for patients
drome), secondary factors (diabetes, chronic with stable CAD and/or PAD and low bleeding
liver or kidney disease and/or nephrotic syn- risk to prevent major adverse limb and CV
drome, hypothyroidism), and medications events. A
that raise triglycerides. C 10.39 Aspirin therapy (75–162 mg/day) may be con-
10.31 In patients with ASCVD or other CV risk factors on sidered as a primary prevention strategy in
a statin with controlled LDL cholesterol but elevated those with diabetes who are at increased CV
triglycerides (135–499 mg/dL), the addition of ico- risk, after a comprehensive discussion with the
sapent ethyl can be considered to reduce CV patient on the benefits versus the comparable
risk. A

increased risk of bleeding. A
Other Combination Therapy

CVD
Recommendations
Screening
10.32 Statin plus fibrate combination therapy has not
been shown to improve ASCVD outcomes and is Recommendations
generally not recommended. A 10.40 In asymptomatic patients, routine screening for
10.33 Statin plus niacin combination therapy has not CAD is not recommended as it does not
been shown to provide additional CV benefit improve outcomes as long as ASCVD risk fac-
above statin therapy alone, may increase the tors are treated. A
risk of stroke with additional side effects, and is 10.41 Consider investigations for CAD in the pres-
generally not recommended. A ence of any of the following: atypical cardiac
symptoms (e.g., unexplained dyspnea, chest
Diabetes Risk With Statin Use discomfort); signs or symptoms of associated
Although several studies have reported a modestly increased vascular disease, including carotid bruits, tran-
risk of incident diabetes with statin use, the CV event rate sient ischemic attack, stroke, claudication, or
reduction with statins far outweighs the risk of incident PAD; or electrocardiogram abnormalities (e.g.,
diabetes even for patients at highest risk for diabetes. Q waves). E
Lipid-Lowering Agents and Cognitive Function Treatment

Although concerns have been raised regarding a potential Recommendations
adverse impact of lipid-lowering agents on cognitive func- 10.42a In patients with type 2 diabetes and established
tion, several lines of evidence point against this association. ASCVD, multiple ASCVD risk factors, or diabetic
kidney disease (DKD), an SGLT2 inhibitor with
Antiplatelet Agents demonstrated CV benefit is recommended to
Recommendations reduce the risk of MACE and/or HF hospitaliza-
10.34 Use aspirin therapy (75–162 mg/day) as a section. A
ondary prevention strategy in those with diabe- 10.42b In patients with type 2 diabetes and established
tes and a history of ASCVD. A ASCVD or multiple risk factors for ASCVD, a
10.35 For patients with ASCVD and documented aspirin GLP-1 receptor agonist with demonstrated CV
allergy, clopidogrel (75 mg/day) should be used. B benefit is recommended to reduce the risk of
10.36 Dual antiplatelet therapy (with low-dose aspi- MACE. A
rin and a P2Y12 inhibitor) is reasonable for a 10.42c In patients with type 2 diabetes and estab-
year after an acute coronary syndrome and lished ASCVD or multiple risk factors for
may have benefits beyond this period. A ASCVD, combined therapy with an SGLT2
10.37 Long-term treatment with dual antiplatelet inhibitor with demonstrated CV benefit and a
therapy should be considered for patients with GLP-1 receptor agonist with demonstrated
prior coronary intervention, high ischemic risk, CV benefit may be considered for additive
reduction in the risk of adverse CV and kid- and in all patients with type 2 diabetes regard-
ney events. A less of treatment. B
10.43 In patients with type 2 diabetes and estab- 11.1b Patients with diabetes and urinary albumin
lished HFpEF or HFrEF, an SGLT2 inhibitor $300 mg/g creatinine and/or an eGFR 30–60
with proven benefit in this patient population mL/min/1.73 m2 should be monitored twice
is recommended to reduce risk of worsening annually to guide therapy. B
HF, hospitalizations for HF, and CV death. A
10.44 For patients with type 2 diabetes and CKD treated Treatment
with maximum tolerated doses of ACE inhibitors
Recommendations
or ARBs, addition of finerenone should be consid-
ered to improve CV outcomes and reduce the risk 11.2 Optimize glucose control to reduce the risk or
of CKD progression. A slow the progression of CKD. A
11.3a For patients with type 2 diabetes and DKD, use

10.45 In patients with known ASCVD, particularly CAD,
ACE inhibitor or ARB therapy is recommended to of an SGLT2 inhibitor in patients with an eGFR
reduce the risk of CV events. A $20 mL/min/1.73 m2 and urinary albumin
10.46 In patients with prior myocardial infarction, $300 mg/g creatinine is recommended to
b-blockers should be continued for 3 years reduce CKD progression and CV events. A
after the event. B 11.3b In patients with type 2 diabetes and CKD,
10.47 Treatment of patients with HFrEF should include consider use of SGLT2 inhibitors additionally
a b-blocker with proven CV outcomes benefit, for CV risk reduction when eGFR and urinary
unless otherwise contraindicated. A albumin creatinine are $25 mL/min/1.73 m2 or
10.48 In patients with type 2 diabetes with stable HF, $300 mg/g, respectively (Figure 9.3). A
metformin may be continued for glucose low- 11.3c In patients with CKD who are at increased risk for
ering if eGFR remains >30 mL/min/1.73 m2 CV events or CKD progression or are unable to use
but should be avoided in unstable or hospital- an SGLT2 inhibitor, a nonsteroidal MRA (finere-
ized patients with HF. B none) is recommended to reduce CKD progression
and CV events (Table 9.2). A
Cardiac Testing 11.4 Optimization of blood pressure control and reduc-
tion in blood pressure variability to reduce the risk
Candidates for advanced or invasive cardiac testing
or slow the progression of CKD is recommended. A
include those with 1) typical or atypical cardiac symp-
11.5 Do not discontinue renin-angiotensin system block-
toms and 2) an abnormal resting electrocardiogram.
ade for minor increases in serum creatinine
(#30%) in the absence of volume depletion. A
11. CKD AND RISK MANAGEMENT 11.6 For people with nondialysis-dependent stage 3 or
Epidemiology of Diabetes and CKD higher CKD, dietary protein intake should be a
CKD is diagnosed by the persistent elevation of urinary maximum of 0.8 g/kg body weight per day (the
albumin excretion (albuminuria), low eGFR, or other recommended daily allowance). A For patients on
manifestations of kidney damage. CKD attributable to dialysis, higher levels of dietary protein intake
diabetes (DKD) typically develops after diabetes dura- should be considered, since malnutrition is a
tion of 10 years in type 1 diabetes but may be present at major problem in some dialysis patients. B
diagnosis of type 2 diabetes. CKD can progress to end- 11.9 An ACE inhibitor or an ARB is not recommended
stage renal disease (ESRD) requiring dialysis or kidney for the primary prevention of CKD in patients with
transplantation and is the leading cause of ESRD in the diabetes who have normal blood pressure, normal
United States. CKD also markedly increases CV risk. UACR (<30 mg/g creatinine), and normal eGFR. A
11.10 Patients should be referred for evaluation by a
nephrologist if they have an eGFR <30 mL/
Screening
min/1.73 m2. A
Recommendations 11.11 Promptly refer to a nephrologist for uncertainty
11.1a At least annually, urinary albumin (e.g., spot about the etiology of kidney disease, difficult
UACR) and eGFR should be assessed in patients management issues, and rapidly progressing
with type 1 diabetes with duration of $5 years kidney disease. A
Diagnosis and Staging of DKD levels is advised due to the risk of hyperkalemia. It may
DKD is a clinical diagnosis made and staged based be used together with SGLT2 inhibitors.
on the presence and degree of albuminuria and/or
reduced eGFR in the absence of signs or symptoms of 12. RETINOPATHY, NEUROPATHY, AND FOOT
other primary causes of kidney damage. Two of three CARE
specimens of UACR collected within a 3- to 6-month
period should be abnormal before considering a Diabetic Retinopathy
patient to have albuminuria. eGFR should be calcu- Recommendations
lated from serum creatinine using a validated for- 12.1 Optimize glycemic control to reduce the risk or
mula. The Chronic Kidney Disease Epidemiology slow the progression of diabetic retinopathy. A
Collaboration (CKD-EPI) equation is generally 12.2 Optimize blood pressure and serum lipid control
preferred. to reduce the risk or slow the progression of dia-

betic retinopathy. A
Interventions
Selection of Glucose-Lowering Medications for Patients Screening
With CKD Recommendations
Metformin may be considered as the initial glucose-lowering 12.4 Patients with type 2 diabetes should have an ini-
medication in the setting of CKD. However, it is contraindi- tial dilated and comprehensive eye examination
cated in patients with an eGFR <30 mL/min/1.73 m2; by an ophthalmologist or optometrist at the
eGFR should be monitored while taking metformin; the ben- time of the diabetes diagnosis. B
efits and risks of continuing treatment should be reassessed 12.5 If there is no evidence of retinopathy for one
when eGFR falls to <45 mL/min/1.73 m2; metformin or more annual eye exams and glycemia is
should not be initiated for patients with an eGFR <45 mL/ well controlled, then screening every 1–2
min/1.73 m2; and metformin should be temporarily discon- years may be considered. If any level of dia-
tinued at the time of or before iodinated contrast imaging betic retinopathy is present, subsequent
procedures in patients with eGFR 30–60 mL/min/1.73 m2.
dilated retinal examinations should be
SGLT2 inhibitors should be given to all patients with stage repeated at least annually by an ophthalmolo-
3 CKD or higher and type 2 diabetes regardless of glycemic gist or optometrist. If retinopathy is progress-
control, as they slow CKD progression and reduce HF risk ing or sight-threatening, then examinations
independent of glycemic control. Randomized clinical out- will be required more frequently. B
come trials have not demonstrated increased risk of acute 12.6 Programs that use retinal photography (with
kidney injury with SGLT2 inhibitor use. Empagliflozin and remote reading or use of a validated assess-
dapagliflozin are approved by the FDA for use with eGFR ment tool) to improve access to diabetic reti-
25–45 mL/min/1.73 m2 for kidney/HF outcomes. Empagli- nopathy screening can be appropriate
flozin can be started with eGFR >30 mL/min/1.73 m2 screening strategies for diabetic retinopathy.
(though pivotal trials for each included participants with Such programs need to provide pathways for
eGFR $30 mL/min/1.73 m2 and demonstrated benefit in timely referral for a comprehensive eye exami-
subgroups with low eGFR). Canagliflozin is approved to be nation when indicated. B
initiated to eGFR levels of 30 mL/min/1.73 m2.
Treatment
GLP-1 receptor agonists are suggested for CV risk reduc-
tion if such risk is a predominant problem, as they reduce Recommendations
risks of CVD events and hypoglycemia and appear to possi- 12.9 Promptly refer patients with any level of dia-
bly slow CKD progression. Some GLP-1 receptor agonists betic macular edema, moderate or worse non-
require dose adjustment for reduced eGFR (the majority— proliferative diabetic retinopathy (a precursor
liraglutide, dulaglutide, semaglutide—do not require it). of proliferative diabetic retinopathy), or any
proliferative diabetic retinopathy to an oph-
MRAs in CKD thalmologist who is knowledgeable and expe-
Finerenone may reduce CKD progression and CVD in rienced in the management of diabetic
patients with CKD, although monitoring of potassium retinopathy. A
12.14 The presence of retinopathy is not a contraindi- disease and assess current symptoms of neurop-
cation to aspirin therapy for cardioprotection, as athy (pain, burning, numbness) and vascular
aspirin does not increase the risk of retinal hem- disease (leg fatigue, claudication). B
orrhage. A 12.24 The examination should include inspection of
the skin, assessment of foot deformities, neuro-
For more information about treatment of proliferative
logical assessment (10-g monofilament testing
diabetic retinopathy, see “12. Retinopathy, Neuropathy,
with at least one other assessment: pinprick,
and Foot Care” in the complete 2022 Standards of
temperature, vibration), and vascular assess-
Care.
ment, including pulses in the legs and feet. B
12.25 Patients with symptoms of claudication or
Neuropathy decreased or absent pedal pulses should be
Screening referred for ankle-brachial index and for further
vascular assessment as appropriate. C

Recommendations
12.26 A multidisciplinary approach is recommended
12.15 All patients should be assessed for diabetic periph-
for individuals with foot ulcers and high-risk
eral neuropathy starting at diagnosis of type 2 dia-
feet (e.g., dialysis patients and those with Char-
betes and 5 years after the diagnosis of type 1
cot foot or prior ulcers or amputation). B
diabetes and at least annually thereafter. B
12.27 Refer patients who smoke or who have histories
12.16 Assessment for distal symmetric polyneuropathy
should include a careful history and assessment of prior lower-extremity complications, loss of
of either temperature or pinprick sensation protective sensation, structural abnormalities, or
(small-fiber function) and vibration sensation PAD to foot care specialists for ongoing preven-
using a 128-Hz tuning fork (for large-fiber func- tive care and lifelong surveillance. C
tion). All patients should have annual 10-g 12.28 Provide general preventive foot self-care educa-
monofilament testing to identify feet at risk for tion to all patients with diabetes. B
ulceration and amputation. B 12.29 The use of specialized therapeutic footwear is
12.17 Symptoms and signs of autonomic neuropathy recommended for high-risk patients with diabe-
should be assessed in patients with microvascu- tes, including those with severe neuropathy,
lar complications. E foot deformities, ulcers, callous formation,
poor peripheral circulation, or history of ampu-
Treatment tation. B
Recommendations See “12. Retinopathy, Neuropathy, and Foot Care” in
12.18 Optimize glucose control to prevent or delay the the complete 2022 Standards of Care for specifics
development of neuropathy in patients with regarding comprehensive foot exams.
type 1 diabetes A and to slow the progression of
neuropathy in patients with type 2 diabetes. B 13. OLDER ADULTS
12.20 Pregabalin, duloxetine, or gabapentin are rec-
ommended as initial pharmacologic treatments Recommendations
for neuropathic pain in diabetes. A 13.1 Consider the assessment of medical, psychologi-
cal, functional (self-management abilities), and
Foot Care social domains in older adults to provide a
framework to determine targets and therapeutic
Recommendations
approaches for diabetes management. B
12.21 Perform a comprehensive foot evaluation at least 13.2 Screen for geriatric syndromes (i.e., polyphar-
annually to identify risk factors for ulcers and macy, cognitive impairment, depression, urinary
amputations. B incontinence, falls, and persistent pain and frailty)
12.22 Patients with evidence of sensory loss or prior in older adults, as they may affect diabetes self-
ulceration or amputation should have their feet management and diminish quality of life. B
inspected at every visit. B
12.23 Obtain a prior history of ulceration, amputation, Over one-fourth of people >65 years of age have diabe-
Charcot foot, angioplasty or vascular surgery, tes, and one-half of older adults have prediabetes. Older
cigarette smoking, retinopathy, and renal adults with diabetes have higher rates of premature
TABLE 13.1 Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older
Adults With Diabetes
Fasting or
Patient Reasonable A1C Preprandial Bedtime
Characteristics/ Goal, % Glucose, mg/dL Glucose, mg/dL Blood Pressure,
Health Status Rationale (mmol/mol)‡ (mmol/L) (mmol/L) mmHg Lipids
Healthy (few Longer remaining <7.0–7.5 (53–58) 80–130 (4.4–7.2) 80–180 <140/90 Statin unless
coexisting chronic life expectancy (4.4–10.0) contraindicated
illnesses, intact or not tolerated
cognitive and
functional status)
Complex/ Intermediate <8.0 (64) 90–150 (5.0–8.3) 100–180 <140/90 Statin unless

intermediate remaining life (5.6–10.0) contraindicated
(multiple expectancy, high or not tolerated
coexisting chronic treatment burden,
illnesses* or 2+ hypoglycemia
instrumental ADL vulnerability, fall
impairments or risk
mild-to-moderate
cognitive
impairment)
Very complex/poor Limited remaining Avoid reliance on 100–180 110–200 <150/90 Consider
health (LTC or life expectancy A1C; glucose (5.6–10.0) (6.1–11.1) likelihood of
end-stage chronic makes benefit control decisions benefit with
illnesses** or uncertain should be based statin
moderate-to- on avoiding
severe cognitive hypoglycemia and
impairment or 2+ symptomatic
ADL impairments) hyperglycemia
This table represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults
with diabetes. The patient characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consid-
eration of patient and caregiver preferences is an important aspect of treatment individualization. Additionally, a patient’s health status and
preferences may change over time. ADL, activities of daily living. ‡A lower A1C goal may be set for an individual if achievable without recur-
rent or severe hypoglycemia or undue treatment burden. *Coexisting chronic illnesses are conditions serious enough to require medications
or lifestyle management and may include arthritis, cancer, HF, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse
CKD, myocardial infarction, and stroke. “Multiple” means at least three, but many patients may have five or more. **The presence of a single
end-stage chronic illness, such as stage 3–4 HF or oxygen-dependent lung disease, CKD requiring dialysis, or uncontrolled metastatic cancer,
may cause significant symptoms or impairment of functional status and significantly reduce life expectancy. Adapted from Kirkman MS, Bris-
coe VJ, Clark N, et al. Diabetes Care 2012;35:2650–2664.
death, functional disability, accelerated muscle loss, People with diabetes have higher incidences of all-cause
and coexisting illnesses, such as hypertension, coronary dementia, Alzheimer disease, and vascular dementia
heart disease, and stroke than those without diabetes. than people with normal glucose tolerance. Ongoing
Screening for diabetes complications in older adults studies are evaluating whether preventing or delaying
should be individualized and periodically revisited, as diabetes onset may help to maintain cognitive function
the results of screening tests may impact targets and in older adults. However, studies examining the effects
therapeutic approaches. of intensive glycemic and blood pressure control to
achieve specific targets have not demonstrated a reduc-
tion in brain function decline.
Neurocognitive Function
Recommendation
Hypoglycemia
13.3 Screening for early detection of mild cognitive
impairment or dementia should be performed Recommendations
for adults 65 years of age or older at the initial 13.4 Because older adults with diabetes have a greater
visit and annually as appropriate. B risk of hypoglycemia than younger adults,
episodes of hypoglycemia should be ascertained Special care is required in prescribing and monitoring
and addressed at routine visits. B pharmacologic therapies in older adults. Metformin is
13.5 For older adults with type 1 diabetes, CGM the first-line agent for older adults with type 2 diabetes,
should be considered to reduce hypoglycemia. A although it can cause gastrointestinal side effects and a
reduction in appetite that can be problematic for some
Older adults are at higher risk of hypoglycemia for many
older adults. See Figure 9.3 for general recommenda-
reasons, including insulin deficiency necessitating insulin
tions regarding glucose-lowering treatment for adults
therapy and progressive renal insufficiency. Glycemic tar-
with type 2 diabetes and Table 9.2 for patient- and
gets and pharmacologic regimens may need to be adjusted
drug-specific factors to consider when selecting glucose-
to minimize the occurrence of hypoglycemic events.
lowering agents.
Patients and their caregivers should be routinely queried
about hypoglycemia and hypoglycemia unawareness. Many older adults with diabetes struggle to maintain the
frequent BGM and insulin injection regimens they previ-

Treatment Goals ously followed. MDI insulin therapy may be too complex
for older patients with advanced diabetes complications,
Providers caring for older adults with diabetes must
life-limiting coexisting chronic illnesses, or limited func-
take clinical, cognitive, and functional heterogeneity
tional status. Simplification of the insulin regimen to
into consideration when setting and prioritizing treat-
match an individual's self-management abilities has been
ment goals. See Table 13.1 for treatment goal
shown to reduce hypoglycemia and disease-related dis-
framework.
tress without worsening glycemic control. Figure 13.1 in
the complete 2022 Standards of Care provides an
Lifestyle Management approach to insulin regimen simplification.
Recommendation
13.11 Optimal nutrition and protein intake is recom- Treatment in Skilled Nursing Facilities and
mended for older adults; regular exercise, Nursing Homes
including aerobic activity, weight-bearing exer- Recommendations
cise, and/or resistance training, should be
13.17 Consider diabetes education for the staff of long-
encouraged in all older adults who can safely
term care (LTC) and rehabilitation facilities to
engage in such activities. B
improve the management of older adults with dia-
13.12 For older adults with type 2 diabetes, overweight/
betes. E
obesity, and capacity to safely exercise, an inten-
13.18 Patients with diabetes residing in LTC facilities
sive lifestyle intervention focused on dietary
need careful assessment to establish individual-
changes, physical activity, and modest weight loss
ized glycemic goals and to make appropriate
(e.g., 5–7%) should be considered for its benefits
choices of glucose-lowering agents based on
on quality of life, mobility and physical function-
their clinical and functional status. E
ing, and cardiometabolic risk factor control. A
Special management considerations in the LTC setting
Pharmacologic Therapy include the need to avoid both hypoglycemia and the
complications of hyperglycemia. Older adults may have
Recommendations
irregular and unpredictable meal consumption, undernu-
13.13 In older adults with type 2 diabetes at increased trition, anorexia, or impaired swallowing. Diets tailored
risk of hypoglycemia, medication classes with to patients’ culture, preferences, and personal goals may
low risk of hypoglycemia are preferred. B increase quality of life, satisfaction with meals, and nutri-
13.14 Overtreatment of diabetes is common in older tion status. It may be helpful to give insulin after meals
adults and should be avoided. B to ensure that the dose is appropriate for the amount of
13.15 Deintensification (or simplification) of complex carbohydrate consumed in the meal.
regimens is recommended to reduce the risk of
hypoglycemia and polypharmacy, if it can be
End-of-Life Care
achieved within the individualized A1C target. B
13.16 Consider costs of care and insurance coverage Recommendation
rules when developing treatment plans in order 13.20 Overall comfort, prevention of distressing symp-
to reduce risk of cost-related nonadherence. B toms, and preservation of quality of life and
dignity are primary goals for diabetes manage- Most youth with type 2 diabetes come from racial/eth-
ment at the end of life. C nic minority groups, have low socioeconomic status,
and often experience multiple psychosocial stressors.
Overall, palliative care should promote comfort, symp-
Consideration of the sociocultural context and efforts to
tom control, prevention (e.g., of pain, hypoglycemia,
personalize diabetes management are of critical impor-
hyperglycemia, and dehydration), and preservation of
tance to minimize barriers to care, enhance adherence,
dignity and quality of life.
and maximize response to treatment.
14. CHILDREN AND ADOLESCENTS Glycemic Targets

The management of diabetes in children and adoles- Recommendations
cents cannot simply be derived from care routinely pro-
14.63 A reasonable A1C target for most children and
vided to adults with diabetes. The epidemiology,
adolescents with type 2 diabetes is <7% (53

pathophysiology, developmental considerations, and
mmol/mol). More stringent A1C targets (such as
response to therapy in pediatric-onset diabetes are dif-
<6.5% [48 mmol/mol]) may be appropriate for
ferent from adult diabetes.
selected individual patients if they can be
See “14. Children and Adolescents” in the complete 2022 achieved without significant hypoglycemia or
Standards of Care for specific recommendations regarding other adverse effects of treatment. Appropriate
the comprehensive treatment of type 1 and type 2 diabe- patients might include those with short duration
tes in children and adolescents. The ADA position state- of diabetes and lesser degrees of b-cell dysfunc-
ments “Type 1 Diabetes in Children and Adolescents” and tion and patients treated with lifestyle or metfor-
“Evaluation and Management of Youth-Onset Type 2 Dia- min only who achieve significant weight
betes” provide additional information. improvement. E
14.64 Less stringent A1C goals (such as 7.5%
Type 1 Diabetes [58 mmol/mol]) may be appropriate if there is
increased risk of hypoglycemia. E
Type 1 diabetes is the most common form of diabetes in
youth. A multidisciplinary team of specialists trained in
Pharmacologic Management
pediatric diabetes management and sensitive to the chal-
lenges of children and adolescents with type 1 diabetes and Recommendations
their families, as well as the unique aspects of pediatric dia- 14.66 Initiate pharmacologic therapy, in addition to
betes management, should provide care for this population. behavioral counseling for healthful nutrition
and physical activity changes, at diagnosis of
Type 2 Diabetes type 2 diabetes. A
Type 2 diabetes in youth has increased over the past 20 14.74 Use of medications not approved by the FDA
years, and recent estimates suggest an incidence 5,000 for youth with type 2 diabetes is not recom-
new cases per year in the United States. Evidence suggests mended outside of research trials. B
that type 2 diabetes in youth is different not only from type In the complete 2022 Standards of Care, see recommen-
1 diabetes, but also from type 2 diabetes in adults, with a dations 14.67–14.73 for detailed guidance on pharma-
more rapid, progressive decline in b-cell function and cologic management of type 2 diabetes in youth and
accelerated development of diabetes complications. Tables 14.1A and 14.1B for screening and treatment
recommendations for type 1 and type 2 diabetes in
Management
youth.
Treatment of youth-onset type 2 diabetes by a multidis-
ciplinary team should include lifestyle management,
Transition From Pediatric to Adult Care
diabetes self-management education, and pharmaco-
logic treatment. Current pharmacologic treatment Recommendations
options for youth-onset type 2 diabetes are limited to 14.111 Pediatric diabetes providers should begin to pre-
three classes of drugs: insulin, metformin, and, in those pare youth for transition to adult health care in
$10 years of age with no contraindications, GLP-1 early adolescence and, at the latest, at least 1
receptor agonists indicated for use in youth. year before the transition. E
14.112 Both pediatric and adult diabetes care monitored every trimester and for 1 year post-
providers should provide support and resour- partum as indicated by the degree of retinopa-
ces for transitioning young adults. E thy and as recommended by the eye care
provider. B
15. MANAGEMENT OF DIABETES IN The preconception care of women with diabetes is
PREGNANCY detailed in Table 15.1 in the complete 2022 Standards
The prevalence of diabetes in pregnancy has been of Care.
increasing in the United States in parallel with the
worldwide epidemic of obesity. Specific risks of diabetes Management of GDM
in pregnancy include spontaneous abortion, fetal anom-
Recommendations
alies, preeclampsia, fetal demise, macrosomia, neonatal
hypoglycemia, hyperbilirubinemia, and neonatal respi- 15.13 Lifestyle behavior change is an essential compo-

ratory distress syndrome, among others. Diabetes in nent of management of GDM and may suffice
pregnancy may increase the risk of obesity, hyperten- for the treatment of many women. Insulin
sion, and type 2 diabetes in offspring later in life. should be added if needed to achieve glycemic
targets. A
15.14 Insulin is the preferred medication for treating
Preconception Counseling
hyperglycemia in GDM. Metformin and glybur-
Recommendations ide should not be used as first-line agents, as
15.1 Starting at puberty and continuing in all women both cross the placenta to the fetus. A Other
with diabetes and reproductive potential, pre- oral and noninsulin injectable glucose-lowering
conception counseling should be incorporated medications lack long-term safety data.
into routine diabetes care. A 15.15 Metformin, when used to treat polycystic ovary
15.2 Family planning should be discussed, and effective syndrome and induce ovulation, should be dis-
contraception (with consideration of continued by the end of the first trimester. A
long-acting, reversible contraception) should be 15.16 Telehealth visits for pregnant women with GDM
prescribed and used until a woman's treatment improve outcomes compared with standard in-
regimen and A1C are optimized for pregnancy. A person care. A
15.3 Preconception counseling should address the
importance of achieving glucose levels as close to Pregnancy and Drug Considerations
normal as is safely possible, ideally A1C <6.5%
Recommendations
(48 mmol/mol), to reduce the risk of congenital
anomalies, preeclampsia, macrosomia, preterm 15.20 In pregnant patients with diabetes and chronic
birth, and other complications. A hypertension, a blood pressure target of
110–135/85 mmHg is suggested in the interest
Preconception Care of reducing the risk for accelerated maternal
hypertension A and minimizing impaired fetal
Recommendations
growth. E
15.4 Women with preexisting diabetes who are plan- 15.21 Potentially harmful medications in pregnancy (i.e.,
ning a pregnancy should ideally be managed ACE inhibitors, ARBs, statins) should be stopped
beginning in preconception in a multidisciplin- at conception and avoided in sexually active
ary clinic including an endocrinologist, mater- women of childbearing age who are not using reli-
nal-fetal medicine specialist, registered dietitian able contraception. B
nutritionist, and diabetes care and education
specialist, when available. B
Postpartum Care
15.6 Women with preexisting type 1 or type 2 diabe-
tes who are planning pregnancy or who have Recommendations
become pregnant should be counseled on the 15.22 Insulin resistance decreases dramatically imme-
risk of development and/or progression of dia- diately postpartum, and insulin requirements
betic retinopathy. Dilated eye examinations need to be evaluated and adjusted, as they are
should occur ideally before pregnancy or in the often roughly half the prepregnancy require-
first trimester, and then patients should be ments for the initial few days postpartum. C
15.23 A contraceptive plan should be discussed and (7.8–10.0 mmol/L) is recommended for the
implemented with all women with diabetes of majority of critically ill and noncritically ill
reproductive potential. A patients. A
15.24 Screen women with a recent history of GDM at 16.5 More stringent goals, such as 110–140 mg/dL
4–12 weeks postpartum using the 75-g OGTT (6.1–7.8 mmol/L), may be appropriate for
and clinically appropriate nonpregnancy diag- selected patients if they can be achieved without
nostic criteria. B significant hypoglycemia. C
15.25 Women with a history of GDM found to have
Hyperglycemia in hospitalized patients is defined as
prediabetes should receive intensive lifestyle
blood glucose levels >140 mg/dL (7.8 mmol/L). Glu-
interventions and/or metformin to prevent dia-
cose levels persistently above this level should receive
betes. A
prompt conservative interventions to correct the hyper-
15.26 Women with a history of GDM should have life-
glycemia, such as changes to diet or medications caus-

long screening for the development of type 2
ing hyperglycemia.
diabetes or prediabetes every 1–3 years. B
15.27 Women with a history of GDM should seek pre- Hypoglycemia in the hospital is classified the same as in
conception screening for diabetes and precon- any setting (Table 6.4).
ception care to identify and treat hyperglycemia
and prevent congenital malformations. E Bedside BGM
15.28 Postpartum care should include psychosocial
In patients who are eating, bedside glucose monitoring
assessment and support for self-care. E
should be performed before meals; in those not eating,
glucose monitoring is advised every 4–6 hours. More
16. DIABETES CARE IN THE HOSPITAL frequent bedside glucose testing, every 30 minutes to
Among hospitalized patients, hyperglycemia, hypogly- every 2 hours, is required for intravenous insulin
cemia, and glucose variability are associated with infusion.
adverse outcomes, including death. Therefore, careful
Although CGM has theoretical advantages over point-
management of inpatients with diabetes has direct and of-care glucose testing in detecting and reducing the
immediate benefits. When caring for hospitalized incidence of hypoglycemia, it has not been approved by
patients with diabetes, consult with a specialized the FDA for inpatient use. However, some hospitals
diabetes or glucose management team when with established glucose management teams allow the
possible. use of CGM in selected patients.
Hospital Care Delivery Standards Glucose-Lowering Treatment in Hospitalized

Recommendations Patients
16.1 Perform an A1C test on all patients with diabetes Recommendations
or hyperglycemia (blood glucose >140 mg/dL 16.6 Basal insulin or a basal plus bolus correction
[7.8 mmol/L]) admitted to the hospital if not insulin regimen is the preferred treatment for
performed in the prior 3 months. B noncritically ill hospitalized patients with poor
16.2 Insulin should be administered using validated oral intake or those who are taking nothing by
written or computerized protocols that allow for mouth. A
predefined adjustments in the insulin dosage 16.7 An insulin regimen with basal, prandial, and
based on glycemic fluctuations. B correction components is the preferred treat-
ment for noncritically ill hospitalized patients
Glycemic Targets in Hospitalized Patients with good nutritional intake. A
Recommendations 16.8 Use of only a sliding scale insulin regimen in
the inpatient hospital setting is strongly
16.4 Insulin therapy should be initiated for treatment
discouraged. A
of persistent hyperglycemia starting at a thresh-
old $180 mg/dL (10.0 mmol/L) (checked on In certain circumstances, it may be appropriate to con-
two occasions). Once insulin therapy is started, tinue home regimens including oral glucose-lowering
a target glucose range of 140–180 mg/dL medications. If oral medications are withheld in the
hospital, there should be a protocol for resuming them MNT in the Hospital
1–2 days before discharge. The goals of MNT in the hospital are to provide ade-
quate calories to meet metabolic demands, optimize
Insulin Therapy
glycemic control, address personal food preferences,
In the critical care setting, continuous intravenous insu- and facilitate creation of a discharge plan.
lin infusion is the best method for achieving glycemic
targets. Outside of critical care units, scheduled insulin Self-Management in the Hospital
regimens as described above are recommended.
Diabetes self-management in the hospital may be
For patients who are eating, insulin injections should appropriate for specific patients. Sufficient cognitive
align with meals. In patients with unpredictable oral and physical skills, adequate oral intake, proficiency in
intake, a safer procedure is to administer prandial insu- carbohydrate estimation, and knowledge of sick-day
lin immediately after the patient eats with the dose management are some of the requirements. Self-

adjusted for the amount ingested. administered insulin with a stable MDI regimen or CSII
may be considered. A protocol should exist for these
An insulin regimen with basal and correction compo-
situations.
nents is necessary for all hospitalized patients with type
1 diabetes, with the addition of prandial insulin if
Standards for Special Situations
patients are eating. A transition protocol from insulin
infusion to subcutaneous insulin with the administra- See “16. Diabetes Care in the Hospital” in the com-
tion of basal insulin 2 hours before discontinuing the plete 2022 Standards of Care for guidance on
intravenous insulin drip is recommended. enteral/parenteral feedings, glucocorticoid therapy,
perioperative care, and DKA and hyperosmolar hyper-
Noninsulin Therapies glycemic state.
The safety and efficacy of noninsulin glucose-lower-
ing therapies in the hospital setting is an area of Transition From the Hospital to the Ambulatory
active research. See “16. Diabetes Care in the Hospi- Setting
tal” in the complete 2022 Standards of Care for a Recommendation
comprehensive review of the inpatient use of these
16.11 There should be a structured discharge plan tai-
medications.
lored to the individual patient with diabetes. B
Hypoglycemia Medication Reconciliation

Recommendations The patient’s medications must be cross-checked to
16.9 A hypoglycemia management protocol should ensure that no chronic medications were stopped
be adopted and implemented by each hospital and to ensure the safety of new prescriptions.
or hospital system. A plan for preventing and Prescriptions for new or changed medication should
treating hypoglycemia should be established for be filled and reviewed with the patient and family
each patient. Episodes of hypoglycemia in the at or before discharge.
hospital should be documented in the medical Discharge planning should begin at admission and be
record and tracked for quality improvement/ updated as patient needs change. An outpatient follow-
quality assessment. E up visit 1 month after discharge is recommended. An
16.10 For individual patients, treatment regimens should earlier appointment (in 1–2 weeks) is preferred, and
be reviewed and changed as necessary to prevent frequent contact may be needed avoid hyperglycemia
further hypoglycemia when a blood glucose value
and hypoglycemia.
of <70 mg/dL (3.9 mmol/L) is documented. C
Patients with or without diabetes may experience hypo- Structured Discharge Communication
glycemia in the hospital setting. Insulin is one of the Information on medication changes, pending tests
most common drugs causing adverse events in hospital- and studies, and follow-up needs must be accurately
ized patients, and insulin dosing/administration errors and promptly communicated to outpatient pro-
occur relatively frequently. viders, including transmission of the discharge
summary to the primary care provider as soon as ACKNOWLEDGMENTS

possible after discharge. This abridged version of the Standards of Medical Care in
Scheduling follow-up appointments prior to dis- Diabetes—2022 was created by the ADA’s Primary Care
charge increases the likelihood that patients will Advisory Group (PCAG), with special thanks to PCAG chair
attend. Hope Feldman, CRNP, FNP-BC, of Philadelphia, PA; ADA
lead Nuha Ali El Sayed, MD, MMSc; RaShaye Freeman,
It is important that patients be provided with appropri- DNP, FNP-BC, CDCES, BC-ADM, of Nashville, TN; Rozalina
ate durable medical equipment, medications, supplies, G. McCoy, MD, MS of Rochester, MN; Joy Moverley, DHSc,
MPH, PA-C, of Vallejo, CA; Sean M. Oser, MD, MPH, of
and prescriptions along with education at the time of
Aurora, CO; Alissa Segal, PharmD, CDCES, CDTC, FCCP, of
discharge.
Boston, MA; Neil Skolnik, MD, of Jenkintown, PA; and
Jennifer Trujillo, PharmD, FCCP, BCPS, CDCES, BC-ADM,
Preventing Admissions and Readmissions of Aurora, CO; with ADA staff support from Sarah Bradley.
Strategies aimed at reducing readmission include tar-

The complete Standards of Medical Care in Diabetes—2022
geting ketosis-prone type 1 diabetes, treating patients was developed by the ADA’s Professional Practice Commit-
with admission A1C >9% (75 mmol/mol) with insulin, tee: Boris Draznin, MD, PhD (Chair); Vanita R. Aroda, MD;
George Bakris, MD; Gretchen Benson, RDN, CDCES;
and using collaborative patient-centered medical homes
Florence M. Brown, MD; RaShaye Freeman, DNP, FNP-BC,
for people with DKD.
CDCES, BC-ADM; Jennifer Green, MD; Elbert Huang, MD,
Age is an important risk factor in hospitalization and MPH, FACP; Diana Isaacs, PharmD, BCPS, BC-ADM,
CDCES; Scott Kahan, MD, MPH; Jose Leon, MD, MPH;
readmission among patients with diabetes.
Sarah K. Lyons, MD; Anne L. Peters, MD; Priya Prahalad,
MD, PhD; Jane E.B. Reusch, MD; and Deborah Young-
17. DIABETES ADVOCACY Hyman, PhD, CDCES. American College of Cardiology—
Designated Representatives (Section 10) include Sandeep
For a list of ADA advocacy position statements, includ- Das, MD, MPH, FACC; and Mikhail Kosiborod, MD, FACC.
ing “Diabetes and Driving” and “Diabetes and Employ- ADA Staff are Mindy Saraco, MHA; Malaika I. Hill, MA;
ment,” see “17. Diabetes Advocacy” in the complete Robert A. Gabbay, MD, PhD; and Nuha Ali El Sayed, MD,
2022 Standards of Care. MMSc.

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STANDARDS OF CARE

Standards of Medical Care in Diabetes—2022 Abridged

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Screening and Diagnostic Tests for Prediabetes

Random plasma glucose — $200 mg/dL (11.1 mmol/L)‡

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4. For all other patients, testing should begin at age 35 years.

6. People with HIV

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Comprehensive Medical Evaluation disease 2019 (COVID-19) pandemic. Preventing avoid-

ultrasound should be evaluated for presence of collaborative development of an individualized eating

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MNT Physical Activity

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TABLE 6.2 Standardized CGM Metrics for Clinical Care

5. Glycemic variability (%CV) target #36%*

8. TIR: % of readings and time 70–180 mg/dL (3.9–10.0 mmol/L) In range

AGP Report: Continuous Glucose Monitoring

High 24% Glucose Metrics

180 Average Glucose ........................................... 175 mg/dL

mg/dL Target 46% Goal: >70%

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Sunday Monday Tuesday Wednesday Thursday Friday Saturday

12pm 12pm 12pm 12pm 12pm 12pm 12pm

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7.9 Although BGM in individuals on noninsulin thera-

*More or less stringent glycemic goals may be appropriate for indi-

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TABLE 7.3 CGM Devices

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See labels for renal dose Should be discontinued before any

lixisenatide Caution when initiating or Injection site reactions

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Risk factors, including duration of diabetes, obesity/ Treatment Strategies

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10.13 For patients treated with an ACE inhibitor, Statin Treatment

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Other Combination Therapy

Lipid-Lowering Agents and Cognitive Function Treatment

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14. CHILDREN AND ADOLESCENTS Glycemic Targets

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Hospital Care Delivery Standards Glucose-Lowering Treatment in Hospitalized

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Hypoglycemia Medication Reconciliation

summary to the primary care provider as soon as ACKNOWLEDGMENTS