Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2]; Tarek Nafee, M.D. [3]
2016 ADA Standards of Medical Care in Diabetes Guidelines[1]
DIABETIC KIDNEY DISEASE
Screening
| "1. At least once a year, assess urinary albumin (e.g., spot urinary albumin–to– creatinine ratio) and estimated glomerular filtration rate in patients with type 1 diabetes with duration of ≥5 years, in all patients with type 2 diabetes, and in all patients with comorbid hypertension. (Level of Evidence: B)"
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Treatment
| "1. Optimize glucose control to reduce the risk or slow the progression of diabetic kidney disease. (Level of Evidence: A)"
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| "2. Optimize blood pressure control (,140/90 mmHg) to reduce the risk or slow the progression of diabetic kidney disease. (Level of Evidence: A)"
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| "3. For people with nondialysis-dependent diabetic kidney disease, dietary protein intake should be 0.8 g/kg body weight per day (the recommended daily allowance). For patients on dialysis, higher levels of dietary protein intake should be considered. (Level of Evidence: A)"
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| "4. Either an ACE inhibitor or an angiotensin receptor blocker is recommended for the treatment of nonpregnant patients with diabetes and modestly elevated urinary albumin excretion (30–299 mg/day) B and is strongly recommended for those with urinary albumin excretion $300 mg/day and/or estimated glomerular filtration rate ,60 mL/min/1.73 m2. (Level of Evidence: A)"
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| "5. Periodically monitor serum creatinine and potassium levels for the development of increased creatinine or changes in potassium when ACE inhibitors, angiotensin receptor blockers, or diuretics are used. (Level of Evidence: E)"
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| "6. Continued monitoring of urinary albumin–to–creatinine ratio in patients with albuminuria treated with an ACE inhibitor or an angiotensin receptor blocker is reasonable to assess the response to treatment and progression of diabetic kidney disease. (Level of Evidence: E)"
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| "7. An ACE inhibitor or an angiotensin receptor blocker is not recommended for the primary prevention of diabetic kidney disease in patients with diabetes who have normal blood pressure, normal urinary albumin–to–creatinine ratio (<30 mg/g), and normal estimated glomerular filtration rate. (Level of Evidence: B)"
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| "8. When estimated glomerular filtration rate is <60 mL/min/1.73 m2, evaluate and manage potential complications of chronic kidney disease. (Level of Evidence: E)"
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| "9. Patients should be referred for evaluation for renal replacement treatment if they have estimated glomerular filtration rate <30 mL/min/1.73 m2. (Level of Evidence: A)"
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| "10. Promptly refer to a physician experienced in the care of kidney disease for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease. (Level of Evidence: B)"
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DIABETIC RETINOPATHY
| "1. Optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy. (Level of Evidence: A)"
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| "2. Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy. (Level of Evidence: A)"
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Screening
| "1. Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. '(Level of Evidence: B)"
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| "2. Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. (Level of Evidence: B)"
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| "3. If there is no evidence of retinopathy for one or more annual eye exams, then exams every 2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations for patients with type 1 or type 2 diabetes should be re- peated at least annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight-threatening, then examinations will be required more frequently. (Level of Evidence: B)"
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| "4. While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional. (Level of Evidence: E)"
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| "5. Eye examinations should occur before pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy. (Level of Evidence: B)"
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Treatment
| "1. Promptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy (a precursor of proliferative diabetic retinopathy), or any proliferative diabetic retinopathy to an ophthalmologist who is knowledgeable and experienced in the management and treatment of diabetic retinopathy. (Level of Evidence: A)"
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| "2. Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with high-risk proliferative diabetic retinopathy and, in some cases, severe nonproliferative diabetic retinopathy (Level of Evidence: A)"
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| "3. Intravitreal injections of antivascular endothelial growth factor are indicated for center-involved diabetic macular edema, which occurs beneath the foveal center and may threaten reading vision (Level of Evidence: A)"
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| "4. The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage (Level of Evidence: A)"
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NEUROPATHY
Screening
| "1. All patients should be assessed for diabetic peripheral neuropathy starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter. (Level of Evidence: B)"
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| "2. Assessment should include a careful history and 10-g monofilament testing and at least one of the following tests: pinprick, temperature, or vibration sensation. (Level of Evidence: B)"
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| "3.Symptoms and signs of autonomic neuropathy should be assessed in patients with microvascular and neuropathic complications. (Level of Evidence: E)"
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Treatment
| "1. Optimize glucose control to prevent or delay the development of neuropathy in patients with type 1 diabetes A and to slow the pro- gression of neuropathy in patients with type 2 diabetes. (Level of Evidence: B)"
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| "2. Assess and treat patients to reduce pain related to diabetic peripheral neuropathy B and symptoms of autonomic neuropathy and to improve quality of life. (Level of Evidence: E)"
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| "1. Perform a comprehensive foot evaluation each year to identify risk factors for ulcers and amputations. (Level of Evidence: B)"
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| "2. Obtain a prior history of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy, and renal dis- ease and assess current symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication). (Level of Evidence: B)"
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| "3. The examination should include inspection of the skin, assessment of foot deformities, neurological assess- ment including 10-g monofilament testing and pinprick or vibration testing or assessment of ankle reflexes, and vascular assessment including pulses in the legs and feet. (Level of Evidence: B)"
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| "4. Patients with a history of ulcers or amputations, foot deformities, insensate feet, and peripheral arterial disease are at substantially increased risk for ulcers and amputations and should have their feet examined at every visit. (Level of Evidence: C)"
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| "5. Patients with symptoms of claudication or decreased or absent pedal pulses should be referred for ankle-brachial index and for further vascular assessment. (Level of Evidence: C)"
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| "6. A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet (e.g., dialysis patients and those with Charcot foot, prior ulcers, or amputation). (Level of Evidence: B)"
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| "7. Refer patients who smoke or who have histories of prior lower- extremity complications, loss of protective sensation, structural abnormalities, or peripheral arte- rial disease to foot care specialists for ongoing preventive care and lifelong surveillance. (Level of Evidence: C)"
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| "8. Provide general foot self-care education to all patients with diabetes.(Level of Evidence: B)"
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References
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