Standards of Medical Care in Diabetesd2017: Summary of Revisions
- It is updated to include a new consensus on the staging of type 1 diabetes and a discussion of a proposed unifying diabetes classification scheme that focuses on b-cell dysfunction and disease stage as indicated by glucose status
- **Due to recent data, delivering a baby weighing 9 lb or more is no longer listed as an independent risk factor for the development of prediabetes and type 2 diabetes.
- **The recommendation to test women with gestational diabetes mellitus for persistent diabetes was changed from 6–12 weeks’ postpartum to 4–12 weeks’ postpartum to allow the test to be scheduled just before the standard 6-week postpartum obstetrical checkup so that the results can be discussed with the patient at that time of the visit or to allow the test to be rescheduled at the visit if the patient did not get the test.
- The Standards of Care now recommends the assessment of sleep pattern and duration as part of the comprehensive medical evaluation based on emerging evidence suggesting a relationship between sleep quality and glycemic control.
- An expanded list of diabetes comorbidities now includes autoimmune diseases, HIV, anxiety disorders, depression, disordered eating behavior, and serious mental illness.
- The recommendation for nutrition therapy in people prescribed flexible insulin therapy was updated to include fat and protein counting in addition to carbohydrate counting for some patients to reflect evidence that these dietary factors influence insulin dosing and blood glucose levels
- Based on new evidence of glycemic benefits, the Standards of Care now recommends that prolonged sitting be interrupted every 30 min with short bouts of physical activity.
- A recommendation was added to highlight the importance of balance and flexibility training in older adults.
- To reflect new evidence showing an association between B12 deficiency and long-term metformin use, a recommendation was added to consider periodic measurement of B12 levels and supplementation as needed.
- Based on recommendations from the International Hypoglycaemia Study Group, serious, clinically significant hypoglycemia is now defined as glucose ,54 mg/dL (3.0 mmol/L), while the glucose alert value is defined as #70 mg/dL (3.9 mmol/L)
- Bariatric surgery to be referred as Metabolic surgery to emphasize its role.
Pharmacologic Approaches to Glycemic Treatment
- new evidence showing an association between B12 deficiency and longterm metformin use, a recommendation was added to consider periodic measurement of B12 levels and supplementation as needed
- Based on the results of two large clinical trials, a recommendation was added to consider empagliflozin or liraglutide in patients with established cardiovascular disease to reduce the risk of mortality
- In patients with long-standing suboptimally controlled type 2 diabetes and established atherosclerotic cardiovascular disease, empagliflozin or liraglutide should be considered as they have been shown to reduce cardiovascular and all-cause mortality when added to standard care. Ongoing studies are investigating the cardiovascular benefits of other agents in these drug classes.
- The algorithm for the use of combination injectable therapy in patients with type 2 diabetes has been changed to reflect studies demonstrating the noninferiority of basal insulin plus glucagonlike peptide 1 receptor agonist versus basal insulin plus rapid-acting insulin versus two daily injections of premixed insulin, as well as studies demonstrating the noninferiority of multiple dose premixed insulin regimens versus basal-bolus therapy.
- A treatment recommendation was updated to clarify that either basal insulin or basal plus bolus correctional insulin may be used in the treatment of noncritically ill patients with diabetes in a hospital setting, but not sliding scale alone.
- Insulin was emphasized as the treatment of choice in pregnancy based on concerns about the concentration of metformin on the fetal side of the placenta and glyburide levels in cord blood.