AACE-ACE - Practice Guidelines For Developing Diabete Mellitus

AACE/ACE Guidelines
AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND

AMERICAN COLLEGE OF ENDOCRINOLOGY
CLINICAL PRACTICE GUIDELINES FOR DEVELOPING
A DIABETES MELLITUS COMPREHENSIVE CARE PLAN 2015
Yehuda Handelsman, MD, FACP, FACE, FNLA1; Zachary T. Bloomgarden, MD, MACE2;
George Grunberger, MD, FACP, FACE3; Guillermo Umpierrez, MD, FACP, FACE4;
Robert S. Zimmerman, MD, FACE5; Timothy S. Bailey, MD, FACP, FACE, ECNU6;
Lawrence Blonde, MD, FACP, FACE7; George A. Bray, MD, MACP, MACE8;
A. Jay Cohen, MD, FACE, FAAP9; Samuel Dagogo-Jack, MD, DM, FRCP, FACE10;
Jaime A. Davidson, MD, FACP, MACE11; Daniel Einhorn, MD, FACP, FACE12;
Om P. Ganda, MD, FACE13; Alan J. Garber, MD, PhD, FACE14; W. Timothy Garvey, MD15;
Robert R. Henry, MD16; Irl B. Hirsch, MD17; Edward S. Horton, MD, FACP, FACE18;
Daniel L. Hurley, MD, FACE19; Paul S. Jellinger, MD, MACE20; Lois Jovanovi, MD, MACE21;
Harold E. Lebovitz, MD, FACE22; Derek LeRoith, MD, PhD, FACE23; Philip Levy, MD, MACE24;
Janet B. McGill, MD, MA, FACE25; Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU26;
Jorge H. Mestman, MD27; Etie S. Moghissi, MD, FACP, FACE28;
Eric A. Orzeck, MD, FACP, FACE29; Rachel Pessah-Pollack, MD, FACE30;
Paul D. Rosenblit, MD, PhD, FACE, FNLA31; Aaron I. Vinik, MD, PhD, FCP, MACP, FACE32;
Kathleen Wyne, MD, PhD, FNLA, FACE33; Farhad Zangeneh, MD, FACP, FACE34

The American Association of Clinical Endocrinologists/American College of Endocrinology Medical Guidelines for
Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for
specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional
judgment was applied.

These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid
changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information
in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations.
Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient
circumstances.
Copyright 2015 AACE.
ENDOCRINE PRACTICE Vol 21 (Suppl 1) April 2015 1
2 AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1)
AACE Task Force

for Developing a Diabetes Comprehensive Care Plan
Writing Committee
Cochairpersons
Yehuda Handelsman, MD, FACP, FACE, FNLA
Zachary T. Bloomgarden, MD, MACE
George Grunberger, MD, FACP, FACE
Guillermo Umpierrez, MD, FACP, FACE
Robert S. Zimmerman, MD, FACE
Task Force Members
Timothy S. Bailey, MD, FACP, FACE, ECNU
Lawrence Blonde, MD, FACP, FACE
George A. Bray, MD, MACP, MACE
A. Jay Cohen, MD, FACE, FAAP
Samuel Dagogo-Jack, MD, DM, FRCP, FACE
Jaime A. Davidson, MD, FACP, MACE
Daniel Einhorn, MD, FACP, FACE
Om P. Ganda, MD, FACE
Alan J. Garber, MD, PhD, FACE
W. Timothy Garvey, MD
Robert R. Henry, MD
Irl B. Hirsch, MD
Edward S. Horton, MD, FACP, FACE
Daniel L. Hurley, MD, FACE
Paul S. Jellinger, MD, MACE
Lois Jovanovi, MD, MACE
Harold E. Lebovitz, MD, FACE
Derek LeRoith, MD, PhD, FACE
Philip Levy, MD, MACE
Janet B. McGill, MD, MA, FACE
Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU
Jorge H. Mestman, MD
Etie S. Moghissi, MD, FACP, FACE
Eric A. Orzeck, MD, FACP, FACE
Paul D. Rosenblit, MD, PhD, FACE, FNLA
Aaron I. Vinik, MD, PhD, FCP, MACP, FACE
Kathleen Wyne, MD, PhD, FNLA, FACE
Farhad Zangeneh, MD, FACP, FACE
Reviewers
Lawrence Blonde, MD, FACP, FACE
Alan J. Garber, MD, PhD, FACE
AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1) 3
Abbreviations:
A1C = hemoglobin A1c; AACE = American Association
of Clinical Endocrinologists; ACCORD = Action
to Control Cardiovascular Risk in Diabetes; ACE =
From the 1Medical Director & Principal Investigator, Metabolic Institute of
America, President, American College of Endocrinology, Tarzana, California;
2Clinical Professor, Mount Sinai School of Medicine, Editor, Journal of Diabetes,
New York, New York; 3Chairman, Grunberger Diabetes Institute, Clinical
Professor, Internal Medicine and Molecular Medicine & Genetics, Wayne
State University School of Medicine, Bloomfield Hills, Michigan; 4Professor
of Medicine, Emory University School of Medicine, Director, Endocrinology
Section, Grady Health System, Atlanta, Georgia; 5Vice Chairman
Endocrinology, Director, Cleveland Clinic Diabetes Center, Cleveland Clinic,
Cleveland, Ohio; 6Clinical Associate Professor, UCSD School of Medicine,
Director, AMCR Institute, Escondido, California; 7Director, Ochsner
Diabetes Clinical Research Unit, Department of Endocrinology, Diabetes
and Metabolism, Ochsner Medical Center, New Orleans, Louisiana; 8Boyd
Professor and Professor of Medicine, Pennington Center, Louisiana State
University, Baton Rouge, Louisiana; 9Medical Director, The Endocrine Clinic,
P.C., Memphis, Tennessee; 10A.C. Mullins Professor & Director, Division of
Endocrinology, Diabetes and Metabolism, University of Tennessee Health
Science Center, Memphis, Tennessee; 11Clinical Professor of Medicine,
Division of Endocrinology, Touchstone Diabetes Center, The University
of Texas, Southwestern Medical Center, Dallas, Texas; 12Immediate Past
President, American College of Endocrinology, Past-President, American
Association of Clinical Endocrinologists, Medical Director, Scripps Whittier
Diabetes Institute, Clinical Professor of Medicine, UCSD, Associate Editor,
Journal of Diabetes, Diabetes and Endocrine Associates, La Jolla, California;
13Senior Physician and Director, Lipid Clinic, Joslin Diabetes Center,
Associate Clinical Professor of Medicine, Harvard Medical School, Boston,
Massachusetts; 14Professor, Departments of Medicine, Biochemistry, and
Molecular Biology, and Molecular and Cellular Biology, Baylor College of
Medicine, Houston, Texas; 15Professor and Chair, Department of Nutrition
Sciences, University of Alabama at Birmingham, Director, UAB Diabetes
Research Center, Mountain Brook, Alabama; 16Professor of Medicine,
UCSD, Chief, Section of Diabetes, Endocrinology & Metabolism, VA San
Diego Healthcare System, San Diego, California; 17Professor of Medicine,
University of Washington School of Medicine, Seattle, Washington; 18Senior
Investigator, Joslin Diabetes Center, Professor of Medicine, Harvard Medical
School, Brookline, Massachusetts; 19Assistant Professor of Medicine, Mayo
Clinic, Rochester, Minnesota; 20Professor of Clinical Medicine, University of
Miami, Miller School of Medicine, Miami, Florida, The Center for Diabetes
& Endocrine Care, Hollywood, Florida; 21Physician Consultant, Sansum
Diabetes Research Institute, Clinical Professor of Medicine, Keck School
of Medicine of USC, Attending Physician, Santa Barbara County Health
Care Services, Adjunct Professor Biomolecular Science and Engineering
and Chemical Engineering, University of California Santa Barbara, Santa
Barbara, California; 22Professor of Medicine, State University of New York
Health Science Center at Brooklyn, Staten Island, New York; 23Director of
Research, Division of Endocrinology, Diabetes and Bone Diseases, Mount
Sinai School of Medicine, New York, New York; 24Clinical Professor
of Medicine, University of Arizona College of Medicine, Banner Good
Samaritan Multispecialty Group, Phoenix, Arizona; 25Professor of Medicine,
Division of Endocrinology, Metabolism & Lipid Research, Washington
University, St. Louis, Missouri; 26Clinical Professor of Medicine, Director,
Metabolic Support, Division of Endocrinology, Diabetes, and Bone Disease,
Icahn School of Medicine at Mount Sinai, New York, New York; 27Professor
of Medicine and Obstetric and Gynecology, Keck School of Medicine of
USC, Los Angeles, California; 28Clinical Associate Professor, University
of California Los Angeles, Marina Del Ray, California; 29Endocrinology
Associates, Houston, Texas; 30Assistant Clinical Professor, Mount Sinai
School of Medicine, New York, New York, ProHealth Care Associates,
Division of Endocrinology, Lake Success, New York; 31Clinical Professor,
Medicine, Division of Endocrinology, Diabetes, Metabolism, University
California Irvine School of Medicine, Irvine, California, Co-Director,
Diabetes Out-Patient Clinic, UCI Medical Center, Orange, California,
Director & Principal Investigator, Diabetes/Lipid Management & Research
Center, Huntington Beach, California; 32Professor of Medicine/Pathology/
Neurobiology, Director of Research & Neuroendocrine Unit, Eastern
Virginia Medical Center, The Strelitz Diabetes Center, Norfolk, Virginia;
33Weill Cornell Medical College, Houston Methodist Hospital, Houston,
Texas; 34Endocrine, Diabetes & Osteoporosis Clinic, Sterling, Virginia.
Address correspondence to American Association of Clinical
Endocrinologists, 245 Riverside Ave, Suite 200, Jacksonville, FL 32202.
E-mail: publications@aace.com. DOI:10.4158/EP15672.GLSUPPL.
To purchase reprints of this article, please visit: www.aace.com/reprints.
Copyright 2015 AACE.
angiotensin-converting enzyme; ADA = American

Diabetes Association; ADVANCE = Action in Diabetes
and Vascular Disease: Preterax and Diamicron MR
Controlled Evaluation; AER = albumin excretion rate;
ApoB = apolipoprotein B; ARB = angiotensin II receptor blocker; ASCVD = atherosclerotic cardiovascular disease; BEL = best evidence level; BMI = body
mass index; CDC = Centers for Disease Control and
Prevention; CDE = certified diabetes educator; CGM =
continuous glucose monitoring; CKD = chronic kidney
disease; CPAP = continuous positive airway pressure;
CPG = clinical practice guideline; CSII = continuous
subcutaneous insulin infusion; CVD = cardiovascular
disease; DCCT = Diabetes Control and Complications;
DKA = diabetic ketoacidosis; DM = diabetes mellitus;
DPP = Diabetes Prevention Program; DPP-4 = dipeptidyl peptidase 4; DSME = diabetes self-management
education; DSPN = distal symmetric polyneuropathy;
EL = evidence level; ESRD = end-stage renal disease;
FDA = U.S. Food and Drug Administration; FPG =
fasting plasma glucose; GDM = gestational diabetes
mellitus; GFR = glomerular filtration rate; GI = gastrointestinal; GLP-1 = glucagon-like peptide 1; HBV
= hepatitis B virus; HDL-C = high-density lipoprotein
cholesterol; HR = hazard ratio; ICU = intensive care
unit; IFG = impaired fasting glucose; IGT = impaired
glucose tolerance; ISF = insulin sensitivity factor;
LDL-C = low-density lipoprotein cholesterol; LDL-P
= low-density lipoprotein particles; Look AHEAD =
Look Action for Health in Diabetes; MDI = multiple
daily injections; MNT = medical nutrition therapy;
NPH = neutral protamine Hagedorn; OGTT = oral glucose tolerance test; OSA = obstructive sleep apnea; PG
= plasma glucose; POC = point-of-care; PPG = postprandial glucose; PTH = parathyroid hormone; Q =
clinical question; R = recommendation; RAAS = reninangiotensin-aldosterone system; RCT = randomized
controlled trial; SFN = small-fiber neuropathy; SGLT2
= sodium glucose cotransporter 2; SMBG = self-monitoring of blood glucose; T1D = type 1 diabetes; T2D
= type 2 diabetes; TZD = thiazolidinedione; UKPDS =
United Kingdom Prospective Diabetes Study; VADT =
Veterans Affairs Diabetes Trial
1. INTRODUCTION
These 2015 clinical practice guidelines (CPGs) for
developing a diabetes mellitus (DM) comprehensive care
plan are an update of the 2011 American Association of
Clinical Endocrinologists (AACE) Medical Guidelines
for Clinical Practice for Developing a Diabetes Mellitus
Comprehensive Care Plan (1 [EL 4; NE]). The mandate
for this CPG is to provide a practical guide for comprehensive care that incorporates an integrated consideration of
micro- and macrovascular risk (including cardiovascular

risk factors such as lipids, hypertension, and coagulation)
rather than an isolated approach focusing merely on glycemic control. In addition to topics covered in the 2011 CPG,
this update offers new and expanded information on vaccinations; cancer risk; and management of obesity, sleep disorders, and depression among persons with DM, as well as
medical management of commercial vehicle operators and
others with occupations that put them at increased risks of
obesity and DM or in which hypoglycemia might endanger
other individuals. In addition, discussions of hypertension
management, nephropathy management, hypoglycemia,
and antihyperglycemic therapy have been substantially
revised and updated. The 2015 treatment goals emphasize individualized targets for weight loss, glucose, lipid,
and hypertension management. In addition, the 2015
Guidelines promote personalized management plans with
a special focus on safety beyond efficacy.
When a routine consultation is made for DM management, these new guidelines advocate taking a comprehensive approach and suggest that the clinician should move
beyond a simple focus on glycemic control. This comprehensive approach is based on the evidence that although
glycemic control parameters (hemoglobin A1c [A1C],
postprandial glucose [PPG] excursions, fasting plasma
glucose [FPG], glycemic variability) have an impact on
the risk of microvascular complications and cardiovascular
disease (CVD), mortality, and quality of life, other factors
also affect clinical outcomes in persons with DM.
The objectives of this CPG are to provide the
following:
An education resource for the development of a
comprehensive care plan for clinical endocrinologists and other clinicians who care for patients
with DM.
An evidence-based resource addressing specific
problems in DM care.
A document that can eventually be electronically
implemented in clinical practices to assist with
decision-making for patients with DM.
To achieve these goals, this CPG includes an executive summary consisting of 67 clinical practice recommendations organized within 24 questions covering the
spectrum of DM management. The recommendations
provide brief, accurate answers to each question, and an
extensively referenced appendix organized according to
the same list of questions provides supporting evidence for
each recommendation. The format is concise and does not
attempt to present an encyclopedic citation of all pertinent
primary references, which would create redundancy and
overlap with other published CPGs and evidence-based
reports related to DM. Therefore, although many highest
evidence level (EL) studiesconsisting of randomized
controlled trials (RCTs) and meta-analyses of these trials
(EL 1)are cited in this CPG, in the interest of conciseness, there is also a deliberate, preferential, and frequent
citation of derivative EL 4 publications that include many
primary evidence citations (EL 1, EL 2, and EL 3). Thus,
this CPG is not intended to serve as a DM textbook but
rather to complement existing texts as well as other DM
CPGs available in the literature including previously published AACE DM CPGs.
2. METHODS
The AACE Board of Directors mandated an update
of the 2011 AACE DM CPG (1 [EL 4; NE]), which
expired in 2014. Selection of the cochairs, primary writers, and reviewers, as well as the logistics for creating this
evidence-based CPG were conducted in strict adherence
with the AACE Protocol for Standardized Production of
Clinical Practice Guidelines2010 and 2014 Updates (2
[EL 4; CPG NE; see Fig. 1; Tables 1-4]; 3 [EL 4; CPG NE;
see Tables 1-4]).
All primary writers are AACE members and credentialed experts in the field of DM care. This CPG has
been reviewed and approved by the primary writers, other
invited experts, the AACE Publications Committee, and
the AACE Board of Directors before submission for peer
review by Endocrine Practice. All primary writers made
disclosures regarding multiplicities of interests and attested
that they are not employed by industry.
Reference citations in the text of this document include
the reference number, numerical descriptor (e.g., EL 1, 2, 3,
or 4), and semantic descriptor (Table 1). Recommendations
are based on the quality of supporting evidence (Table 2),
all of which have also been rated (Table 3). This CPG is
organized into specific and relevant clinical questions
labeled Q.
Recommendations (numerically labeled R1, R2,
etc.) are based on importance and evidence (Grades A,
B, and C) or expert opinion when there is a lack of conclusive clinical evidence (Grade D). The best EL (BEL),
which corresponds to the best conclusive evidence found
in the Appendix to follow, accompanies the recommendation grade in this Executive Summary; definitions of evidence levels are provided in Figure 1 and Table 1 (2 [EL
4; CPG NE; see Fig. 1; Table 1-4]). Comments may be
appended to the recommendation grade and BEL regarding
any relevant subjective factors that may have influenced
the grading process (Table 4). Details regarding each recommendation may be found in the corresponding section
of the Appendix. Thus, the process leading to a final recommendation and grade is not rigid; rather, it incorporates
a complex expert integration of objective and subjective
factors meant to reflect optimal real-life clinical decisionmaking and enhance patient care. Where appropriate, multiple recommendations are provided so that the reader has
management options. This document is only intended to
serve as a guideline. Individual patient circumstances and

presentations differ, and the ultimate clinical management
is based on what is in the best interest of the individual
patient, involving patient input and reasonable clinical
judgment by the treating clinicians.
3. EXECUTIVE SUMMARY
To guide readers, DM comprehensive management recommendations are organized into the following
questions:
Q1. How is diabetes screened and diagnosed?
Q2. How is prediabetes managed?
Q3. What are the glycemic treatment goals of
DM?
Q4. How are glycemic targets achieved for type 2
diabetes (T2D)?
Q5. How should glycemia in type 1 diabetes
(T1D) be managed?
Q6. How is hypoglycemia managed?
Q7. How is hypertension managed in patients
with diabetes?
Q8. How is dyslipidemia managed in patients
with diabetes?
Q9. How is nephropathy managed in patients
with diabetes?
Q10. How is retinopathy managed in patients with
diabetes?
Q11. How is neuropathy diagnosed and managed

in patients with diabetes?
Q12. How is CVD managed in patients with
diabetes?
Q13. How is obesity managed in patients with
diabetes?
Q14. What is the role of sleep medicine in the care
of the patient with diabetes?
Q15. How is diabetes managed in the hospital?
Q16. How is a comprehensive diabetes care plan
established in children and adolescents?
Q17.
How should diabetes in pregnancy be
managed?
Q18. When and how should glucose monitoring be
used?
Q19. When and how should insulin pump therapy
be used?
Q20. What is the imperative for education and
team approach in DM management?
Q21. Which vaccinations should be given to
patients with diabetes?
Q22. How should depression be managed in the
context of diabetes?
Q23. What is the association between diabetes and
cancer?
Q24. Which occupations have specific diabetes
management requirements?
Fig. 1. 2010 American Association of Clinical Endocrinologists (AACE) Clinical Practice

Guideline (CPG) methodology. Current AACE CPGs have a problem-oriented focus that results
in a shortened production time line, middle-range literature searching, emphasis on patient-oriented evidence that matters, greater transparency of intuitive evidence rating and qualifications,
incorporation of subjective factors into evidence-recommendation mapping, cascades of alternative approaches, and an expedited multilevel review mechanism.
Readers are referred to the Appendix (section 4) for

more detail and supporting evidence for each question.
3.Q1. How is Diabetes Screened and Diagnosed?
R1. There is a continuum of risk for poor health
outcomes in the progression from normal glucose tolerance to overt T2D. Screening should be
considered in the presence of risk factors for DM
(Table 5) (Grade C; BEL 3). Individuals at risk
for DM whose glucose values are in the normal
range should be screened every 3 years; clinicians
may consider annual screening for patients with 2
or more risk factors (Grade C; BEL 3).
R2. The following criteria may be used to diagnose DM (Table 6) (Grade B; BEL 3):
FPG concentration (after 8 or more hours of
no caloric intake) 126 mg/dL, or
Plasma glucose concentration 200 mg/dL 2
hours after ingesting a 75-g oral glucose load
in the morning after an overnight fast of at
least 8 hours, or
Symptoms of hyperglycemia (e.g., polyuria, polydipsia, polyphagia) and a random
(casual, nonfasting) plasma glucose concentration 200 mg/dL, or
A1C level 6.5%
Glucose criteria (i.e., FPG or 2-h glucose
after a 75-g oral glucose load) are preferred for
the diagnosis of DM. The same testplasma glucose or A1C measurementshould be repeated
on a different day to confirm the diagnosis of
DM. However, a glucose level 200 mg/dL in the
presence of DM symptoms does not need to be
confirmed (Grade B; BEL 3).
R3. Prediabetes may be identified by the presence
of impaired glucose tolerance (IGT), which is a
plasma glucose value of 140 to 199 mg/dL 2 hours
after ingesting 75 g of glucose, and/or impaired
fasting glucose (IFG), which is a fasting glucose
value of 100 to 125 mg/dL (Table 6) (Grade B;
BEL 2). A1C values between 5.5 and 6.4% inclusive should be a signal to do more specific glucose
testing (Grade D; BEL 4). For prediabetes, A1C
testing should be used only as a screening tool;
FPG measurement or an oral glucose tolerance
test (OGTT) should be used for definitive diagnosis (Grade B; BEL 2). Metabolic syndrome based
on National Cholesterol Education Program IV
Adult Treatment Panel III criteria should be considered a prediabetes equivalent (Grade C; BEL
3).
R4. Pregnant females with DM risk factors
should be screened at the first prenatal visit for
undiagnosed T2D using standard criteria (Grade
D; BEL 4). At 24 to 28 weeks gestation, all pregnant subjects should be screened for gestational
Table 1
2010 American Association of Clinical Endocrinologists Protocol for
Production of Clinical Practice GuidelinesStep I: Evidence Ratinga
Numerical
descriptor
(evidence level)b
1
Meta-analysis of randomized controlled trials (MRCT)
Randomized controlled trials (RCT)
Meta-analysis of nonrandomized prospective or case-controlled trials (MNRCT)
Nonrandomized controlled trial (NRCT)
Prospective cohort study (PCS)
Retrospective case-control study (RCCS)
Cross-sectional study (CSS)
Surveillance study (registries, surveys, epidemiologic study, retrospective chart

review, mathematical modeling of database) (SS)
Consecutive case series (CCS)
Single case reports (SCR)
No evidence (theory, opinion, consensus, review, or preclinical study) (NE)
a Adapted
b
Semantic descriptor (reference methodology)
from (1): Endocr Pract. 2010;16:270-283.

1, strong evidence; 2, intermediate evidence; 3, weak evidence; and 4, no evidence.
DM (GDM) with a 2-hour OGTT using a 75-g

glucose load. GDM may be diagnosed using the
following plasma glucose criteria: FPG >92 mg/
dL, 1-hour post-glucose challenge value 180
mg/dL, or 2-hour value 153 mg/dL (Grade C;
BEL 3).
R5. DM represents a group of heterogeneous
metabolic disorders that develop when insulin secretion is insufficient to maintain normal
plasma glucose levels. T2D is the most common
form of DM, accounting for more than 90% of
cases, and is typically identified in patients who
are overweight or obese and/or have a family history of DM, a history of GDM, or meet the criteria
for metabolic syndrome. Once DM glucose criteria have been satisfied, T2D should be diagnosed
based on patient history, phenotype, and lack of
autoantibodies characteristic of T1D (Grade A;
BEL 1). Most persons with T2D have evidence
of insulin resistance (such as elevated fasting
or postprandial plasma insulin and/or elevated
C-peptide concentrations), high triglycerides,
and/or low high-density lipoprotein cholesterol
[HDL-C]).
R6. T1D is usually characterized by absolute
insulin deficiency and should be confirmed by
the presence of autoantibodies to glutamic acid
decarboxylase, pancreatic islet cells (tyrosine
phosphatase IA-2), zinc transporter (ZnT8), and/
or insulin (Grade A; BEL 1). Some forms of
T1D have no evidence of autoimmunity and have
been termed idiopathic. T1D can also occur in
people who are overweight or obese. Therefore,
documenting the levels of insulin and C-peptide
and the presence or absence of immune markers in addition to the clinical presentation may
help establish the correct diagnosis to distinguish

between T1D and T2D in children or adults and
determine appropriate treatment (Grade B; BEL
2).
R7. Any child or young adult with an atypical
presentation, course, or response to therapy may
be evaluated for monogenic DM (formerly maturity-onset diabetes of the young); diagnostic likelihood is strengthened by a family history over
3 generations, suggesting autosomal dominant
inheritance (Grade C; BEL 3).
3.Q2. How is Prediabetes Managed?

R8. T2D can be prevented or at least delayed

by intervening in persons who have prediabetes (see Table 6 for glucose criteria) (Grade A,
BEL 1). Frequent measurement of FPG and/or an
OGTT may be used to assess the glycemic status of patients with prediabetes (Grade C; BEL
3). The clinician should manage CVD risk factors
(especially elevated blood pressure and/or dyslipidemia) and excessive weight, and monitor these
risks at regular intervals (Grade C; BEL 3).
R9. Persons with prediabetes should modify their
lifestyle, including initial attempts to lose 5 to 10%
of body weight if overweight or obese and participate in moderate physical activity (e.g., walking)
at least 150 minutes per week (Grade B; BEL
3). Physicians should recommend patients participate in organized lifestyle change programs with
follow-up, where available, because behavioral
support will benefit weight-loss efforts (Grade
B; BEL 3).
R10. In addition to lifestyle modification,
medications including metformin, acarbose, or
Table 2
2010 American Association of Clinical Endocrinologists Protocol for Production of
Clinical Practice GuidelinesStep II: Evidence Analysis and Subjective Factorsa
Study design
Data analysis
Interpretation of results
Premise correctness
Intent-to-treat
Generalizability
Allocation concealment (randomization)
Appropriate statistics
Logical
Selection bias
Incompleteness
Appropriate blinding
Validity
Using surrogate end points (especially in

first-in-its-class intervention)
Sample size (beta error)
Null hypothesis vs. Bayesian statistics
a
Reprinted from (1): Endocr Pract. 2010;16:270-283.
Table 3
2010 American Association of Clinical Endocrinologists Protocol for
Production of Clinical Practice GuidelinesStep III:
Grading of Recommendations; How Different Evidence Levels can be
Mapped to the Same Recommendation Gradea,b
Best
evidence
level
Subjective
factor
impact
Two-thirds
consensus
Mapping
Recommendation
grade
None
Yes
Direct
Positive
Yes
Adjust up
None
Yes
Direct
Negative
Yes
Adjust down
Positive
Yes
Adjust up
None
Yes
Direct
Negative
Yes
Adjust down
Positive
Yes
Adjust up
None
Yes
Direct
Negative
Yes
Adjust down
1, 2, 3, 4
NA
No
Adjust down
Starting with the left column, best evidence levels (BELs), subjective factors, and
consensus map to recommendation grades in the right column. When subjective
factors have little or no impact (none), then the BEL is directly mapped to
recommendation grades. When subjective factors have a strong impact, then
recommendation grades may be adjusted up (positive impact) or down (negative
impact). If a two-thirds consensus cannot be reached, then the recommendation grade
is D. NA, not applicable (regardless of the presence or absence of strong subjective
factors, the absence of a two-thirds consensus mandates a recommendation grade D).
b Reprinted from (1): Endocr Pract. 2010;16:270-283.
thiazolidinediones (TZDs) should be considered

for patients who are at moderate-to-high risk for
developing DM, such as those with a first-degree
relative with DM (Grade A; BEL 1).
3.Q3. What are the Glycemic Treatment Goals of DM?
3.Q3.1. Outpatient Glucose Targets for
Nonpregnant Adults
R11. Glucose targets should be individualized
and take into account life expectancy, disease
duration, presence or absence of micro- and
macrovascular complications, CVD risk factors,
comorbid conditions, and risk for hypoglycemia, as well as the patients psychological status (Grade A; BEL 1). In general, the goal of
therapy should be an A1C level 6.5% for most

nonpregnant adults, if it can be achieved safely
(Table 7) (Grade D; BEL 4). To achieve this target A1C level, FPG may need to be <110 mg/dL,
and the 2-hour PPG may need to be <140 mg/dL
(Table 7) (Grade B, BEL 2).
In adults with recent onset of T2D and no
clinically significant CVD, glycemic control
aimed at normal (or near-normal) glycemia
should be considered, with the aim of preventing the development of micro- and macrovascular complications over a lifetime, if it can
be achieved without substantial hypoglycemia
or other unacceptable adverse consequences
(Grade A; BEL 1). Although it is uncertain
that the clinical course of established CVD is
improved by strict glycemic control, the progression of microvascular complications clearly is

delayed. A less stringent glucose goal should be
considered (A1C 7 to 8%) in patients with history of severe hypoglycemia, limited life expectancy, advanced renal disease or macrovascular
complications, extensive comorbid conditions,
or long-standing DM in which the A1C goal has
been difficult to attain despite intensive efforts,
so long as the patient remains free of polydipsia,
polyuria, polyphagia, and other hyperglycemiaassociated symptoms (Grade A; BEL 1).
3.Q3.2. Inpatient Glucose Targets for

Nonpregnant Adults
R12. For most hospitalized persons with hyperglycemia in the intensive care unit (ICU), a glucose range of 140 to 180 mg/dL is recommended,
provided this target can be safely achieved (Table
7) (Grade D; BEL 4). For general medicine and
surgery patients in non-ICU settings, a premeal
glucose target <140 mg/dL and a random blood
glucose <180 mg/dL are recommended (Grade
C; BEL 3).
3.Q3.3. Outpatient Glucose Targets for
Pregnant Subjects
R13. For females with GDM, the following glucose goals should be considered: preprandial glucose concentration 95 mg/dL and either a 1-hour
postmeal glucose value 140 mg/dL or a 2-hour
postmeal glucose value 120 mg/dL (Grade D;
BEL 4). For females with pre-existing T1D or
T2D who become pregnant, glucose should be
controlled to meet the following goals (but only
if they can be safely achieved): premeal, bedtime,
and overnight glucose values between 60 and 99
mg/dL; a peak PPG value between 100 and 129
mg/dL; and an A1C value 6.0% (Grade D; BEL
4).
3.Q4. How are Glycemic Targets Achieved for T2D?
3.Q4.1. Therapeutic Lifestyle Changes
R14. Medical nutrition therapy (MNT) is recommended for all people with prediabetes or DM,
including T1D, T2D, GDM, and other less common forms of DM. MNT must be individualized,
generally via evaluation and teaching by a trained
nutritionist or registered dietitian or a physician
knowledgeable in nutrition (Grade D; BEL 4).
The goals of MNT are to improve overall health
by teaching patients to eat a diet containing a
variety of foods in appropriate amounts to help
manage body weight, glucose, lipids, and blood
pressure (Table 8). Nutritional recommendations

should take into account personal and cultural
preferences, as well as the individuals knowledge
of nutrition, willingness to change eating habits,
and barriers to change. For people on insulin therapy, insulin dosage adjustments should match carbohydrate intake (e.g., with use of carbohydrate
counting).
R15. Patients should engage in at least 150 minutes per week of moderate-intensity exercise such
as brisk walking (15- to 20-minute mile) or its
equivalent (Grade B; BEL 2). Persons with T2D
should also incorporate flexibility and strengthtraining exercises (Grade B; BEL 2). Patients
must be evaluated initially for contraindications
and/or limitations to physical activity, and then
an exercise prescription should be developed for
each patient according to both goals and activity limitations. Physical activity programs should
begin slowly and build up gradually (Grade D;
BEL 4). Patients with T1D should also exercise
regularly; however, individuals requiring insulin
therapy should be educated about the acute and
chronic effects of exercise on blood glucose levels and learn how to adjust insulin dosages and
food intake to maintain good glucose control
before, during, and after exercise to avoid significant hypo- or hyperglycemia (Grade D; BEL 4).
3.Q4.2. Antihyperglycemic Pharmacotherapy for T2D

R16. Pharmacotherapy for T2D should be prescribed based on suitability for the individual
patients characteristics (Grade D; BEL 4). As
shown in Table 9, antihyperglycemic agents vary
in their impact on FPG, PPG, weight, and insulin
Table 4
2010 American Association of
Clinical Endocrinologists Protocol for Production of
Clinical Practice GuidelinesStep IV:
Examples of Qualifiersa
Cost-effectiveness
Risk-benefit analysis
Evidence gaps
Alternative physician preferences (dissenting opinions)
Alternative recommendations (cascades)

Resource availability
Cultural factors
Relevance (patient-oriented evidence that matters)

a
Reprinted from (1): Endocr Pract. 2010;16:270-283.
Table 5
Risk Factors for Prediabetes and T2D: Criteria for Testing for Diabetes in Asymptomatic Adults
Age 45 years without other risk factors
CVD or family history of T2D
Overweight or obesea
Sedentary lifestyle
Member of an at-risk racial or ethnic group: Asian, African American, Hispanic, Native American (Alaska
Natives and American Indians), or Pacific Islander
HDL-C <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)
IGT, IFG, and/or metabolic syndrome
PCOS, acanthosis nigricans, NAFLD
Hypertension (BP >140/90 mm Hg or on therapy for hypertension)
History of gestational diabetes or delivery of a baby weighing more than 4 kg (9 lb)
Antipsychotic therapy for schizophrenia and/or severe bipolar disease
Chronic glucocorticoid exposure
Sleep disorders in the presence of glucose intolerance (A1C >5.7%, IGT, or IFG on previous testing),
including OSA, chronic sleep deprivation, and night-shift occupation
Abbreviations: A1C = hemoglobin A1C; BP = blood pressure; CVD = cardiovascular disease; HDL-C = high-density
lipoprotein cholesterol; IFG = impaired fasting glucose; IGT = impaired glucose tolerance; NAFLD = nonalcoholic
fatty liver disease; OSA = obstructive sleep apnea; PCOS = polycystic ovary syndrome.
a Testing should be considered in all adults who are obese (BMI 30 kg/m2), and those who are overweight (BMI 25
to <30 kg/m2) and have additional risk factors. At-risk BMI may be lower in some ethnic groups, in whom parameters
such as waist circumference and other factors may be used.
secretion or sensitivity, as well as the potential

for hypoglycemia and other adverse effects. The
initial choice of an agent involves comprehensive
patient assessment including a glycemic profile
obtained by self-monitoring of blood glucose
(SMBG) and the patients A1C, weight, and presence of comorbidities. Minimizing the risks of
hypoglycemia and weight gain are priorities.
R17. Details about the effects of and rationale for
available antihyperglycemic agents can be found
in the 2015 AACE Comprehensive Diabetes
Management Algorithm Consensus Statement
(4). The AACE recommends initiating therapy
with metformin, a glucagon-like peptide 1 (GLP1) receptor agonist, a dipeptidyl peptidase 4
(DPP-4) inhibitor, a sodium glucose cotransporter
2 (SGLT2) inhibitor, or an -glucosidase inhibitor for patients with an entry A1C <7.5% (Grade
C; BEL 3). A TZD, sulfonylurea, or glinide may
be considered as alternative therapies but should
be used with caution due to side-effect profiles
(Grade C; BEL 3). For patients with entry A1C
levels >7.5%, the AACE recommends initiating
treatment with metformin (unless contraindicated)
plus a second agent, with preference given to
agents with a low potential for hypoglycemia that

are weight neutral or associated with weight loss
(Grade C; BEL 3). This includes GLP-1 receptor agonists, SGLT2 inhibitors, or DPP-4 inhibitors as the preferred second agents; TZDs and
basal insulin may be considered as alternatives.
Colesevelam, bromocriptine, or an -glucosidase
inhibitor have limited glucose-lowering potential but also carry a low risk of adverse effects
and may be useful for glycemic control in some
situations (Grade C; BEL 3). Sulfonylureas and
glinides are considered the least desirable alternatives due to the risk of hypoglycemia (Grade B;
BEL 2). For patients with an entry A1C >9.0%
who have symptoms of hyperglycemia, insulin
therapy alone or in combination with metformin
or other oral agents is recommended (Grade A;
BEL 1). Pramlintide and the GLP-1 receptor agonists can be used as adjuncts to prandial insulin
therapy to reduce postprandial hyperglycemia,
A1C, and weight (Grade B; BEL 2). The longacting GLP-1 receptor agonists also reduce fasting glucose.
R18. Insulin should be considered for T2D
when noninsulin antihyperglycemic therapy
fails to achieve target glycemic control or when

a patient, whether drug nave or not, has symptomatic hyperglycemia (Grade A; BEL 1).
Therapy with long-acting basal insulin should be
the initial choice in most cases (Grade C; BEL
3). The insulin analogs glargine and detemir are
preferred over intermediate-acting neutral protamine Hagedorn (NPH) because analog insulins
are associated with less hypoglycemia (Grade C;
BEL 3). When control of postprandial hyperglycemia is needed, preference should be given to
rapid-acting insulins (the analogs lispro, aspart,
and glulisine or inhaled insulin) over regular
human insulin because the former have a more
rapid onset and offset of action and are associated with less hypoglycemia (Grade B; BEL 2).
Premixed insulin formulations (fixed combinations of shorter- and longer-acting components)
of human or analog insulin may be considered
for patients in whom adherence to more intensive insulin regimens is problematic; however,
these preparations have reduced dosage flexibility
and may increase the risk of hypoglycemia compared with basal insulin or basal-bolus regimens
(Grade B; BEL 2). Basal-bolus insulin regimens
are flexible and recommended for intensive insulin therapy (Grade B; BEL 3).
R19. Intensification of pharmacotherapy requires
glucose monitoring and medication adjustment at
appropriate intervals (e.g., every 3 months) when
treatment goals are not achieved or maintained
(Grade C; BEL 3). The 2015 AACE algorithm
outlines treatment choices on the basis of the A1C
level (4 [EL 4; NE]).
3.Q5. How Should Glycemia in T1D be Managed?

R20. Insulin must be used to treat T1D (Grade

A; BEL 1). Physiologic insulin regimens, which
provide both basal and prandial insulin, should be
used for most patients with T1D (Grade A; BEL
1). These regimens involve the use of insulin analogs for most patients with T1D (Grade A; BEL
1) and include the following approaches:
Multiple daily injections (MDI), which
usually involve 1 to 2 subcutaneous
injections daily of basal insulin to control glycemia between meals and overnight, and subcutaneous injections of
prandial insulin or inhaled insulin before
each meal to control meal-related glycemia (Grade A; BEL 1)
Continuous subcutaneous insulin infusion (CSII) to provide a more physiologic way to deliver insulin, which may
improve glucose control while reducing
risks of hypoglycemia (Grade A; BEL
1)
3.Q6. How is Hypoglycemia Managed?

R21. Oral administration of rapidly absorbed glucose should be used to treat hypoglycemia (generally defined as any blood glucose <70 mg/dL
with or without symptoms including anxiety, palpitations, tremor, sweating, hunger, paresthesias,
behavioral changes, cognitive dysfunction, seizures, and coma; severe hypoglycemia is defined
as any that requires assistance from another person
Table 6
Glucose Testing and Interpretation
Normal
High Risk for Diabetes
Diabetes
FPG <100 mg/dL
IFG
FPG 100-125 mg/dL
FPG 126 mg/dL
2-h PG <140 mg/dL
IGT
2-h PG 140-199 mg/dL
2-h PG 200 mg/dL

Random PG 200 mg/dL +
symptoms
A1C <5.5%
5.5 to 6.4%
For screening of prediabetesa
6.5%
Secondaryb
Abbreviations: A1C = hemoglobin A1C; FPG = fasting plasma glucose; IFG = impaired fasting glucose; IGT =
impaired glucose tolerance; PG = plasma glucose.
a A1C should be used only for screening prediabetes. The diagnosis of prediabetes, which may manifest as either IFG
or IGT, should be confirmed with glucose testing.
b Glucose criteria are preferred for the diagnosis of DM. In all cases, the diagnosis should be confirmed on a separate
day by repeating glucose or A1C testing. When A1C is used for diagnosis, follow-up glucose testing should be done
when possible to help manage DM.
Table 7
Comprehensive Diabetes Care Treatment Goals
Parameter
Glucose

A1C, %
FPG, mg/dL
2-h PPG, mg/dL
Inpatient hyperglycemia:
glucose, mg/dL
Blood pressure
Systolic, mm Hg
Diastolic, mm Hg
Lipids

LCL-C, mg/dL
Non-HDL-C, mg/dL
Triglycerides, mg/dL
TC/HDL-C ratio
ApoB, mg/dL
LDL particles
Weight

Weight loss
Anticoagulant therapy
Aspirin
Treatment goal
Reference
(evidence level and
study design)
Individualize on the basis of age,

comorbidities, duration of disease;
in general 6.5 for most; closer to
normal for healthy; less stringent for
less healthy
<110
<140
(4 [EL 4; NE])
140-180
(5 [EL 4; consensus NE])
Individualize on the basis of age,

comorbidities, and duration of
disease, with general target of:
~130
~80
(8 [EL 4; NE])
<100, moderate risk

<70, high risk
<130, moderate risk
<100, high risk
<150
<3.5, moderate risk
<3.0, high risk
<90, moderate risk
<80, high risk
<1,200 moderate risk
<1,000 high risk
(4 [EL 4; NE])
Reduce weight by at least 5 to 10%;

avoid weight gain
(4 [EL 4; NE])
For secondary CVD prevention or

primary prevention for patients at
very high riska
(9 [EL 1; MRCT but small

sample sizes and event
rates]; 10 [EL 1; MRCT];
11 [EL 1; MRCT];
12 [EL 2; PCS])
Abbreviations: ApoB = apolipoprotein B; BEL = best evidence level; CVD = cardiovascular disease; DM = diabetes
mellitus; EL = evidence level; FPG = fasting plasma glucose; HDL-C = high-density lipoprotein cholesterol; IFG =
impaired fasting glucose; IGT = impaired glucose tolerance; LDL = low-density lipoprotein; MRCT = meta-analysis
of randomized controlled trials; NE = no evidence (theory, opinion, consensus, review, or preclinical study); PCS =
prospective cohort study; PPG = postprandial glucose; TC = total cholesterol.
a High risk, DM without cardiovascular disease; very high risk, DM plus CVD.
to administer carbohydrates or glucagon or take

other corrective action). If the patient is unable
to swallow or is unresponsive, subcutaneous or
intramuscular glucagon or intravenous glucose
should be given by a trained family member or
medical personnel (Grade A; BEL 1). The usual
adult dose of subcutaneous glucagon is 1 mg (1
unit). For children weighing less than 44 lbs (20

kg), the dose is half the adult dose (0.5 mg). As
soon as the patient is awake and able to swallow,
he or she should receive a rapidly absorbed source
of carbohydrate (e.g., fruit juice) followed by a
snack or meal containing both protein and carbohydrates (e.g., cheese and crackers or a peanut
Table 8
American Association of Clinical Endocrinologists Healthful Eating Recommendations for
Patients With Diabetes Mellitus
Topic
Recommendation
Reference
(evidence level and
study design)
General eating
habits
Eat regular meals and snacks; avoid fasting to lose weight

Consume plant-based diet (high in fiber, low calories/glycemic
index, and high in phytochemicals/antioxidants)
Understand Nutrition Facts Label information
Incorporate beliefs and culture into discussions
Use mild cooking techniques instead of high-heat cooking
Keep physician-patient discussions informal
(71 [EL 3; SS];

72 [EL 4; position NE];
73 [EL 4; position NE];
74 [EL 4; review NE];
75 [EL 3; SS]; 76 [EL 1; RCT];
86 [EL 3; SS])
Carbohydrate
Explain the 3 types of carbohydratessugars, starch, and

fiberand the effects on health for each type
Specify healthful carbohydrates (fresh fruits and vegetables,
legumes, whole grains); target 7-10 servings per day
Lower-glycemic index foods may facilitate glycemic control
(glycemic index score <55 out of 100: multigrain bread,
pumpernickel bread, whole oats, legumes, apple, lentils,
chickpeas, mango, yams, brown rice), but there is insufficient
evidence to support a formal recommendation to educate
patients that sugars have both positive and negative health
effects
(73 [EL 4; position NE];

80 [EL 4; NE review];
89 [EL 4; review NE])
Fat
Specify healthful fats (low mercury/contaminant-containing

nuts, avocado, certain plant oils, fish)
Limit saturated fats (butter, fatty red meats, tropical plant
oils, fast foods) and trans fat; choose fat-free or low-fat dairy
products
(82 [EL 4; review NE];

88 [EL 4; NE review])
Protein
Consume protein in foods with low saturated fats (fish, egg

whites, beans); there is no need to avoid animal protein
Avoid or limit processed meats
(73 [EL 4; position NE];

83 [EL 2; MNRCT];
85 [EL 2; PCS, data may not be
generalizable to patients with
diabetes already])
Micronutrients
Routine supplementation is not necessary; a healthful eating

meal plan can generally provide sufficient micronutrients
Specifically, chromium; vanadium; magnesium; vitamins A, C,
and E; and CoQ10 are not recommended for glycemic control
Vitamin supplements should be recommended to patients at
risk of insufficiency or deficiency
(84 [EL 4; CPG NE])
Abbreviations: BEL = best evidence level; CPG = clinical practice guideline; EL = evidence level; MNRCT = meta-analysis of nonrandomized prospective or case-controlled trials; NE = no evidence (theory, opinion, consensus, review, or preclinical study);
PCS = prospective cohort study; RCT = randomized controlled trial.
Neutral
Possible benefit
Neutral
CHF
CVD
Bone
Neutral
Neutral
Neutral
Moderate
(caution in
PIs about
pancreatitis)
Exenatide not
indicated in
CrCl <30 mL/
min
Bone loss
Neutral
Neutral
Neutral
GU
infection
risk
Loss
Neutral
Neutral
Neutral
Neutral
Neutral
(caution: possibly
increased CHF
hospitalization
risk in CV safety
trial)
Neutral
(caution in
PIs about
pancreatitis)
Dose adjustment
may be necessary
(except
linagliptin)
Neutral
Neutral
Neutral
Moderate
Mild
DPP4I
Gain
Moderate
bone loss
Neutral
Moderate
Neutral
May
worsen
fluid
retention
Neutral
Neutral
Neutral
Moderate
Neutral
Neutral
Neutral
Neutral
Moderate
Neutral
Moderate
Neutral
AGI
Mild
Moderate
TZD
Neutral
Neutral
Neutral
Mild
Neutral
Neutral
Neutral
Neutral
Mild
Mild
Coles
Neutral
Safe
Neutral
Moderate
Neutral
Neutral
Neutral
Neutral
Mild
Neutral
BCR-QR
Neutral
Neutral
Neutral
Increased
hypoglycemia
risk
Gain
SU: moderate to
severe
Glinide: mild to
moderate
Neutral
Moderate
SU: moderate
Glinide: mild
SU/Glinide
Mild
Pram
Neutral
Neutral
Neutral
Neutral
Increased risks of
hypoglycemia and
fluid retention
Gain
Moderate to severe,
especially with
short/rapid-acting
or premixed
Neutral
Neutral
Neutral
Neutral
Moderate
Neutral
Loss
Neutral
Neutral
Moderate to
Moderate to
marked (short/
marked
rapid-acting insulin
or premixed)
Moderate to
marked (basal
insulin or
premixed)
Insulin
Abbreviations: AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; CHF = congestive heart failure; CKD = chronic kidney disease; Coles = colesevelam;
CrCl = creatinine clearance; CV = cardiovascular; DPP4I = dipeptidyl peptidase 4 inhibitors; FPG = fasting plasma glucose; GI = gastrointestinal; GLP1RA = glucagon-like peptide
1 receptor agonists; GU = genitourinary; Met = metformin; NAFLD = nonalcoholic fatty liver disease; PI = prescribing information; PPG = postprandial glucose; SGLT2I = sodiumglucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones.
a Boldface type highlights a benefit or potential benefit; italic type highlights adverse effects.
b Mild: albiglutide and exenatide; moderate: dulaglutide, exenatide extended release, and liraglutide.
Moderate
GI adverse
effects
Loss
Slight loss
Contraindicated
in stage 3B, 4, 5
CKD
Weight
Renal
impairment/ GU
Neutral
Neutral
Hypoglycemia
Mild
Mild
NAFLD benefit
Mild
Moderate to
marked
Mild
PPG lowering
Moderate
SGLT2I
Mild to
moderateb
Moderate
GLP1RA
FPG lowering
Met
Table 9
Effects of Diabetes Drug Actiona
butter sandwich) (Grade C; BEL 3). Patients

with severe hypoglycemia and altered mental status or with persistent hypoglycemia need to be
hospitalized (Grade A; BEL 1). If the patient has
hypoglycemic unawareness and hypoglycemiaassociated autonomic failure, several weeks of
hypoglycemia avoidance may reduce the risk or
prevent recurrence of severe hypoglycemia. In
patients with T2D who become hypoglycemic and
have been treated with an -glucosidase inhibitor
in addition to insulin or an insulin secretagogue,
oral glucose or lactose-containing foods (dairy
products) must be given because -glucosidase
inhibitors inhibit the breakdown and absorption of complex carbohydrates and disaccharides
(Grade C; BEL 3).
3.Q8. How is Dyslipidemia Managed in

Patients with Diabetes?

3.Q7. How is Hypertension Managed in


R22. The blood pressure goal for persons with

DM or prediabetes should be individualized and
should generally be about 130/80 mm Hg (Table
7) (Grade B; BEL 2). A more intensive goal (e.g.,
<120/80 mm Hg) should be considered for some
patients, provided this target can be reached safely
without adverse effects from medication (Grade
C; BEL 3). More relaxed goals may be considered for frail patients with complicated comorbidities or those who have adverse medication effects
(Grade D; BEL 4).
R23. Therapeutic lifestyle modification for hypertension should include dietary interventions that
emphasize reduced salt intake such as DASH
(Dietary Approaches to Stop Hypertension), physical activity, and, as needed, consultation with a
registered dietitian and/or certified diabetes educator (CDE) (Grade A; BEL 1). Pharmacologic
therapy should be used to achieve targets unresponsive to therapeutic lifestyle changes alone
(Grade A; BEL 1). The clinician should select
antihypertensive agents on the basis of their ability to reduce blood pressure and prevent or slow
the progression of nephropathy and retinopathy;
angiotensin-converting enzyme (ACE) inhibitors
or angiotensin II receptor blockers (ARBs) are
preferred in patients with DM (Grade C; BEL
3). Combination therapy should be used when
needed to achieve blood pressure targets, including calcium channel antagonists, diuretics, combined /-adrenergic blockers, and newer-generation -adrenergic blockers in addition to agents
that block the renin-angiotensin system (Grade
A; BEL 1).
R24. All patients with DM should be screened for

dyslipidemia (Grade B; BEL 2). Therapeutic recommendations should include lifestyle changes
and, as needed, consultation with a registered
dietitian and/or CDE (Grade B; BEL 2).
R25. Because macrovascular disease may be evident prior to the diagnosis of DM, lipid levels of
patients with prediabetes should be managed in
the same manner as those of patients with DM
(Grade D; BEL 4).
R26. In persons with DM or prediabetes and no
atherosclerotic CVD (ASCVD) or major cardiovascular risk factors (i.e., moderate CVD risk),
treatment efforts should target a low-density lipoprotein cholesterol (LDL-C) goal of <100 mg/dL
and a non-HDL-C goal of <130 mg/dL (Grade B;
BEL 2). In high-risk patients (those with DM and
established ASCVD or at least 1 additional major
ASCVD risk factor such as hypertension, family
history, low HDL-C, or smoking), a statin should
be started along with therapeutic lifestyle changes
regardless of baseline LDL-C level (Grade A;
BEL 1). In these patients, an LDL-C level <70
mg/dL and a non-HDL-C treatment goal <100
mg/dL should be targeted (Table 7) (Grade B;
BEL 2). If the triglyceride concentration is 200
mg/dL, non-HDL-C may be used to predict
ASCVD risk (Grade C; BEL 3). Secondary treatment goals may be considered, including apolipoprotein B (ApoB) <80 mg/dL and low-density
lipoprotein particles (LDL-P) <1,000 nmol/L in
patients with ASCVD or at least 1 major risk factor, and <90 mg/dL or <1,200 nmol/L in patients
without ASCVD and no additional risk factors,
respectively (Grade D; BEL 4).
R27. Pharmacologic therapy should be used to
achieve lipid targets unresponsive to therapeutic lifestyle changes alone (Grade A; BEL 1).
Statins are the treatment of choice in the absence
of contraindications. Statin dosage should always
be adjusted to achieve LDL-C and non-HDL-C
goals (Table 7) unless limited by adverse effects
or intolerance (Grade A; BEL 1). Combining
the statin with a bile acid sequestrant, niacin,
and/or cholesterol absorption inhibitor should
be considered when the desired target cannot be
achieved with the statin alone; these agents may
be used instead of statins in cases of statin-related
adverse events or intolerance (Grade C; BEL
3). In patients who have LDL-C levels at goal
but triglyceride concentrations 200 mg/dL and
C; BEL 3). Follow-up with eyecare specialists

should typically occur on an annual basis, but
patients with T2D who have had a negative ophthalmologic examination may be screened every
2 years (Grade B; BEL 2). In patients with T1D,
a referral should be made within 5 years of diagnosis (Grade C; BEL 3). Females who are pregnant and have DM should be referred for frequent/
repeated eye examinations during pregnancy and
1 year postpartum (Grade B; BEL 2). Patients
with active retinopathy should have examinations
more than once a year, as should patients receiving
vascular endothelial growth factor therapy (Grade
C; BEL 3). Optimal glucose, blood pressure, and
lipid control should be implemented to slow the
progression of retinopathy (Grade A; BEL 1).
low HDL-C (<35 mg/dL), treatment protocols

including the use of fibrates, niacin, or high-dose
omega-3 fatty acids may be used to achieve the
non-HDL-C goal (Table 7) (Grade B; BEL 2).
High-dose omega-3 fatty acids, fibrates, or niacin may also be used to reduce triglyceride levels
500 mg/dL (Grade C; BEL 3).
3.Q9. How is Nephropathy Managed in

R28. Beginning 5 years after diagnosis in patients

with T1D (if diagnosed before age 30) or at diagnosis in patients with T2D and those with T1D
diagnosed after age 30, annual assessment of
serum creatinine to determine the estimated glomerular filtration rate (eGFR) and urine albumin
excretion rate (AER) should be performed to identify, stage, and monitor progression of diabetic
nephropathy (Grade C; BEL 3). Patients with
nephropathy should be counseled regarding the
need for optimal glycemic control, blood pressure
control, dyslipidemia control, and smoking cessation (Grade B; BEL 2). In addition, they should
have routine monitoring of albuminuria, kidney
function electrolytes, and lipids (Grade B; BEL
2). Associated conditions such as anemia and
bone and mineral disorders should be assessed
as kidney function declines (Grade D; BEL 4).
Referral to a nephrologist is recommended well
before the need for renal replacement therapy
(Grade D; BEL 4).
R29. Renin-angiotensin-aldosterone system
(RAAS) blockade is recommended for patients
with DM who have chronic kidney disease (CKD)
categories G2, G3a, G3b, and if slow progression
is demonstrated, G4 (see Fig. 2 for category definitions) (Grade A; BEL 1). Serum potassium levels should be closely monitored (Grade A; BEL
1). RAAS-blocking drugs are not safe for use
in pregnant subjects. ACE inhibitors and ARBs
should not be used together due to increased risks
of adverse effects, particularly hyperkalemia
(Grade B; BEL 2).
R30. Weight loss with regular exercise is recommended for patients with DM and category G2 to
G4 CKD (Grade D; BEL 4).
3.Q10. How is Retinopathy Managed in

R31. At the time of diagnosis, patients with T2D
should be referred to an experienced ophthalmologist for a dilated eye examination (Grade
3.Q11. How is Neuropathy Diagnosed and

Managed in Patients with Diabetes?

R32. Diabetic neuropathy may be diagnosed clinically but also must be differentiated from other
neurologic conditions. Patients with T1D should
have a complete neurologic evaluation 5 years
after the diagnosis of DM and subsequent annual
evaluations (Grade B; BEL 2). Patients with
T2D should have their first neurologic examination at the time of diagnosis and yearly thereafter
(Grade B; BEL 2).This exam should consist of
a complete foot inspection including assessment
of foot structure and deformity, skin temperature
and integrity, the presence of ulcers, vascular status, presence of pedal pulses, and toe and foot
amputations (Grade B; BEL 2). For a complete
discussion of diabetic foot assessment, refer to
the American Diabetes Association (ADA) Foot
Care Task Force report, which has been endorsed
by the AACE (6). Neurologic testing may include
assessment of sensation using 1- and 10-g monofilaments; vibration perception using a 128-Hz
tuning fork; ankle reflexes; and touch, pinprick,
and warm and cold thermal sensations (Grade B;
BEL 2). Painful neuropathies may have no physical signs, and diagnosis may require skin biopsy
or other surrogate measures of small-fiber neuropathy (SFN) (Grade D; BEL 4). Screening for
cardiovascular autonomic neuropathy should be
performed at diagnosis of T2D or 5 years after the
diagnosis of T1D and then annually (Grade D;
BEL 4). Tests should include time and frequency
domain measures of heart rate variability with
deep inspiration, Valsalva maneuver, and blood
pressure change from a lying to standing position
(Grade D; BEL 4).
Fig. 2. GFR and albuminuria grid illustrating the risk of progression by color intensity. The number in each box suggests the frequency of monitoring (number of times per year). Green indicates stable disease with annual follow-up measurements if CKD is
present; yellow indicates caution and calls for 1 measurement per year; orange requires 2 measurements per year; red calls for
3 measurements per year, and deep red may require close monitoring at a frequency of 4 times or more per year (at least every
1-3 months). These general parameters are based on expert opinion and must take into account underlying comorbid conditions
and disease state, as well as the likelihood of a change in management for any individual patient. CKD = chronic kidney disease;
GFR = glomerular filtration rate. Frequency of recommendations from the KDIGO CKD Workgroup (263 [EL 4; NE]; 266 [EL 4;
NE]). Modified and reprinted with permission from Macmillan Publishers Ltd: Kidney International 2011;80(1):17-28, copyright
2011.
R33. Controlling glucose to individual target levels is recommended to prevent the onset of neuropathy (Grade A; BEL 1). Although nothing has
been shown to reverse neuropathy once it is established, there is speculation that interventions that
reduce oxidative stress, improve glycemic control,
and/or improve dyslipidemia and hypertension
might have a beneficial effect on established diabetic neuropathy.
R34. Tricyclic antidepressants, anticonvulsants,
and serotonin and norepinephrine reuptake inhibitors should be considered for the treatment of painful neuropathy (Grade A; BEL 1).
R35. Large-fiber neuropathies should be managed
with strength, gait, and balance training; pain management; orthotics to treat and prevent foot deformities; tendon lengthening for pes equinus from
Achilles tendon shortening; and/or surgical reconstruction and full-contact casting for foot ulcers, as
needed (Grade B; BEL 2).
R36. SFNs should be managed with foot protection (e.g., padded socks), supportive shoes
with orthotics if necessary, regular foot and shoe
inspection, prevention of heat injury, and use of
emollient creams. For pain management, the medications mentioned in R34 should be considered
(Grade B; BEL 2).
3.Q12. How is CVD Managed in


R37. Because CVD is the primary cause of death

for most persons with DM, a DM comprehensive
care plan should include modifications of CVD
risk factors (Grade B; BEL 2). The cardiovascular risk reduction targets are summarized in Table
7.
R38. The use of low-dosage aspirin (75 to 162 mg
daily) is recommended for secondary prevention
of CVD (Grade A; BEL 1). Some patients may
benefit from higher doses (Grade B; BEL 2). For
primary prevention of CVD, aspirin use may be
considered for those at high cardiovascular risk
(10-year risk >10%) (Grade D; BEL 4).
R39. Measurement of coronary artery calcification
or coronary imaging may help assess whether a
patient is a reasonable candidate for intensification
of glycemic, lipid, and/or blood pressure control
(Grade B; BEL 2). Screening for asymptomatic
coronary artery disease with various stress tests
in patients with T2D has not been clearly demonstrated to improve cardiac outcomes and is therefore not recommended (Grade A; BEL 1).
considered in patients with severe obesity-related

complications including T2D if the BMI is 35
kg/m2 (Grade B; BEL 2). Patients with T2D who
undergo malabsorptive procedures, such as Rouxen-Y gastric bypass or biliopancreatic diversion
with duodenal switch, must have careful postoperative follow-up because of risks of micronutrient deficiencies and hypoglycemia (Grade D;
BEL 4).
3.Q14. What is the Role of Sleep Medicine
in the Care of the Patient with Diabetes?

3.Q13. How is Obesity Managed in


R40. Obesity should be diagnosed according

to body mass index (BMI) (Grade B; BEL 2).
Individuals with a BMI 30 kg/m2 are classified
as obese, and those with a BMI of 25 to <30 kg/m2
are overweight. For Southeast Asians and Asian
Indians, lower BMI cutpoints may be appropriate.
Measurement of waist circumference may be considered for individuals with a BMI between 25 and
35 kg/m2 (Grade D; BEL 4). Those with waist
circumference values >102 cm (40 in) for males
and > 88 cm (35 in) for females are at higher risk
for metabolic disease. In addition to these anthropometric measures, patients should be evaluated
for obesity-related complications, including other
components of metabolic syndrome, sleep apnea,
and osteoarthritis to determine disease severity
and facilitate obesity staging (Grade D; BEL 4).
R41. Lifestyle modifications including behavioral changes, reduced calorie diets, and appropriately prescribed physical activity should be implemented as the cornerstone of obesity management
(Grade A; BEL 1). Pharmacotherapy for weight
loss may be considered when lifestyle modification fails to achieve the targeted goal (Grade A;
BEL 1). Pharmacotherapy may be initiated at the
same time as lifestyle modification in patients with
BMIs of 27 to 29.9 kg/m2 and 1 obesity-related
complication such as T2D (Grade D; BEL 4).
Pharmacotherapy and lifestyle modification may
be initiated together in patients with BMI 30 kg/
m2 regardless of the presence of complications
(Grade D; BEL 4). Bariatric surgery should be
R42. Adults with T2D, especially obese males

older than 50 years, should be screened for
obstructive sleep apnea (OSA), which is common
in this population (Grade D; BEL 4). This condition should be suspected based on a history of
daytime drowsiness and heavy snoring, especially
if a bed partner witnesses apneas. Increasing evidence supports home apnea testing. Referral to a
sleep specialist should be considered in patients
suspected of havingOSA or restless leg syndrome
and when patients are intolerant of continuous
positive airway pressure (CPAP) devices (Grade
A; BEL 1). CPAP and similar oxygen delivery
systems should be used to treat OSA (Grade
A; BEL 1). Weight loss may also significantly
improve OSA.
3.Q15. How is Diabetes Managed in the Hospital?

R43. Insulin can rapidly control hyperglycemia and therefore should be used for the majority of hospitalized patients with hyperglycemia
(Grade A; BEL 1). Intravenous insulin infusion
should be used to treat persistent hyperglycemia
among critically ill patients in the intensive care
unit (ICU) (Grade A; BEL 1). Scheduled subcutaneous insulin therapy with basal, nutritional,
and correctional components should be used for
glycemic management in noncritically ill patients
(Grade A; BEL 1). Insulin dosing should be synchronized with provision of meals or enteral or
parenteral nutrition (Grade A; BEL 1). Exclusive
use of sliding scale insulin should be discouraged (Grade A; BEL 1). Preference should be
given to regular insulin for intravenous administration and insulin analogs for subcutaneous
administration (Grade D; BEL 4).
R44. All patients, independent of a prior diagnosis of DM, should have laboratory blood glucose
testing upon hospital admission (Grade C; BEL
3). Patients with known history of DM should
have their A1C measured in the hospital if this
assessment has not been performed in the preceding 3 months (Grade D; BEL 4). A1C should
also be measured in patients with hyperglycemia
in the hospital who do not have a prior diagnosis
of DM (Grade D; BEL 4). Glucose monitoring
with bedside point-of-care (POC) testing should
be initiated in all patients with known DM and in
nondiabetic patients receiving therapy associated
with high risk of hyperglycemia, such as corticosteroids or enteral or parenteral nutrition (Grade
D; BEL 4). Patients with persistent hyperglycemia require ongoing POC testing with treatment
similar to patients with known history of DM.
R45. A plan for preventing and treating hypoglycemia should be established for each patient, and
hypoglycemic episodes should be documented in
the medical record (Grade C; BEL 3).
R46. Appropriate plans for follow-up and care
should be documented at hospital discharge for
inpatients with a prior history of DM as well
as nondiabetic patients with hyperglycemia or
increased A1C levels (Grade D; BEL 4). DM
discharge planning should start soon after hospitalization, and clear DM management instructions
should be provided at discharge (Grade D; BEL
4).
3.Q17. How Should Diabetes in

Pregnancy be Managed?

3.Q16. How is a Comprehensive Diabetes Care Plan

Established in Children and Adolescents?

R47. The pharmacologic treatment of any form

of DM in children should not, at this stage of our
knowledge, differ in substance from treatment
for adults (Grade D; BEL 4), except in children
younger than about 4 years, when bolus premeal
insulin may be administered after rather than
before a meal due to variable and inconsistent
calorie/carbohydrate intake. In children or adolescents with T1D, MDI or CSII insulin regimens are
preferred (Grade C; BEL 3). Injection frequencies may become problematic in some school
settings. Higher insulin-to-carbohydrate ratios
and basal insulin dosages may be needed during puberty (Grade C; BEL 3). Insulin requirements may be increased 20 to 50% during menstrual periods in pubescent girls (Grade C; BEL
3). In children or adolescents with T2D, diet and
lifestyle modification should be implemented first
(Grade A; BEL 1). Addition of metformin and/
or insulin should be considered when glycemic
targets are not achievable with lifestyle measures
(Grade B; BEL 2). An extensive review of guidelines for the care of children with DM from the
International Society of Pediatric and Adolescent
Diabetes was published in 2009 and is available

on their website (13).
R48. T1D in adolescents should be managed
in close consultation with the patient and their
family members. The ADA; Juvenile Diabetes
Research Foundation (JDRF); and National
Institute of Diabetes, Digestive, and Kidney
Diseases (NIDDK) offer resources to help with
transition planning (14-16).
R49. For females with GDM, glucose should be

managed with the following treatment goals: preprandial glucose concentration 95 mg/dL and
either a 1-hour postmeal glucose 140 mg/dL or a
2-hour postmeal glucose 120 mg/dL (Grade C;
BEL 3).
R50. All females with pre-existing DM (T1D,
T2D, or previous GDM) should have access to
preconception care to ensure adequate nutrition
and glucose control before conception, during
pregnancy, and in the postpartum period (Grade
B; BEL 2). Preference should be given to rapidacting insulin analogs to treat postprandial hyperglycemia in pregnant subjects (Grade D; BEL 4).
Regular insulin is acceptable when analogs are not
available. Basal insulin needs should be met using
rapid-acting insulin via CSII or by using long-acting insulin (e.g., NPH or detemir, which are U.S.
Food and Drug Administration [FDA] pregnancy
category B) (Grade A; BEL 1). Although insulin is the preferred treatment during pregnancy,
metformin and glyburide have been shown to
beeffective alternatives that do not cause adverse
effects in some females (Grade C; BEL 3).
3.Q18. When and How Should Glucose

Monitoring be Used?

R51. A1C should be measured at least twice

yearly in all patients with DM and at least 4 times
yearly in patients not at target (Grade D; BEL 4).
R52. SMBG should be performed by all patients
using insulin (minimum of twice daily and ideally
before any insulin injection) (Grade B; BEL 2).
More frequent SMBG after meals or in the middle of the night may be required for insulin-taking
patients with frequent hypoglycemia, patients not
at A1C targets, or those with hypoglycemic symptoms (Grade C; BEL 3). Patients not requiring
insulin therapy may benefit from SMBG, especially to provide feedback about the effects of
their lifestyle and pharmacologic therapy; testing

frequency must be personalized.
R53. Continuous glucose monitoring (CGM)
should be considered for patients with T1D and
T2D on basal-bolus therapy to improve A1C levels and reduce hypoglycemia (Grade B; BEL 2).
Early reports suggest that even patients not taking
insulin may benefit from CGM (Grade D; BEL
4).
3.Q19. When and How Should Insulin Pump

Therapy be Used?

sleep quantity and quality. Additional topics commonly taught in DSME programs outline principles of glycemia treatment options; blood glucose
monitoring; insulin dosage adjustments; acute
complications of DM; and prevention, recognition, and treatment of hypoglycemia.
3.Q21. Which Vaccinations Should be Given to

R54. Candidates for CSII include patients with

T1D and patients with T2D who are insulin dependent (Grade A; BEL 1). CSII should only be used
in patients who are motivated and knowledgeable
in DM self-care, including insulin adjustment. To
ensure patient safety, prescribing physicians must
have expertise in CSII therapy, and CSII users
must be thoroughly educated and periodically
reevaluated. Sensor-augmented CSII, including
those with a threshold-suspend function, should
be considered for patients who are at risk of hypoglycemia (Grade A; BEL 1).
3.Q20. What is the Imperative for Education and

Team Approach in DM Management?

R55. An organized multidisciplinary team may

best deliver care for patients with DM (Grade D;
BEL 4). Members of such a team can include a
primary care physician, endocrinologist, physician assistant, nurse practitioner, registered nurse,
dietitian, exercise specialist, and mental health
professional. The educational, social, and logistical elements of therapy and variations in successful care delivery associated with age and maturation increase the complexity of caring for children
with DM.
R56. Persons with DM should receive comprehensive diabetes self-management education
(DSME) at the time of DM diagnosis and subsequently as appropriate (Grade D; BEL 4). DSME
improves clinical outcomes and quality of life in
individuals with DM by providing the knowledge
and skills necessary for DM self-care. Therapeutic
lifestyle management must be discussed with all
patients with DM or prediabetes at the time of
diagnosis and throughout their lifetime (Grade
D; BEL 4). This includes MNT (with reduction and modification of caloric and fat intake to
achieve weight loss in those who are overweight
or obese), appropriately prescribed physical activity, avoidance of tobacco products, and adequate
R57. AACE supports the recommendations of

the Centers for Disease Control and Prevention
(CDC) Advisory Committee on Immunization
Practices (ACIP) that all patients with DM be
vaccinated for influenza and pneumococcal infection. An annual influenza vaccine should be provided to those with DM who are 6 months old
(Grade C; BEL 3). Furthermore, a pneumococcal
polysaccharide vaccine should be administered to
patients with DM age 2 years (Grade C; BEL 3).
A single administration of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) should
be administered to adults with DM age 19 to 64
years (Grade C; BEL 3). The 13-valent pneumococcal conjugate vaccine should be administered
in series with the PPSV23 to all adults aged 65
years (Grade C; BEL 3). Revaccination is also
indicated for those with nephrotic syndrome,
chronic renal disease, and other immunocompromised states, such as posttransplantation.
R58. Hepatitis B vaccinations should be administered to adults 20 to 59 years of age as soon after
DM diagnosis as possible (Grade C; BEL 3).
Vaccination of adults 60 years should be considered based on assessment of risk and likelihood
of an adequate immune response (Grade C; BEL
3).
R59. All children and adolescents with DM
should receive routine childhood vaccinations
according to the normal schedule (Grade C; BEL
3).
R60. Tetanus-diphtheria-pertussis (Tdap) vaccine
is typically included with routine childhood vaccinations. However, all adults with DM should
receive a tetanus-diphtheria (Td) booster every 10
years (Grade D; BEL 4).
R61. Patients with DM may need other vaccines
to protect themselves against other illnesses.
Healthcare professionals may consider vaccines
for the following diseases based on individual
needs of the patient: measles/mumps/rubella,
varicella (chicken pox), and polio. In addition,
patients traveling to other countries may require
vaccines for endemic diseases (Grade D; BEL
4).
3.Q22. How Should Depression be Managed in the

Context of Diabetes?

R62. Screening for depression should be performed routinely for adults with DM because
untreated depression can have serious clinical
implications for patients with DM (Grade A;
BEL 1).
R63. Patients with depression should be referred
to mental health professionals who are members
of the DM care team (Grade D; BEL 4).
3.Q23. What is the Association Between

Diabetes and Cancer?

R64. In light of the increased risk of certain cancers in patients with obesity or T2D, healthcare
professionals should educate patients regarding
this risk and encourage a more healthy lifestyle
(Grade D; BEL 4). Weight reduction, regular
exercise, and a healthful diet are recommended
(Grade C; BEL 3). Individuals with obesity and
those with T2D should be screened more often
and more rigorously for common cancers and
those associated with these metabolic disorders
(Grade B; BEL 2).
R65. To date, no definitive relationship has been
established between specific antihyperglycemic
agents and an increased risk of cancer or cancerrelated mortality. Healthcare professionals should
be aware of potential associations but should recommend therapeutic interventions based on the
risk profiles of individual patients (Grade D;
BEL 4).
R66. When a patient with DM has a history of
a particular cancer, the physician may consider
avoiding a medication that was initially considered disadvantageous to that cancer, even though
no proof has been forthcoming (Grade D; BEL
4).
3.Q24. Which Occupations Have Specific Diabetes

Management Requirements?

R67. Commercial drivers are at high risk for

developing T2D. Persons with DM engaged in
various occupations including commercial drivers and pilots, anesthesiologists, and commercial
or recreational divers have special management
requirements. Treatment efforts for such patients
should be focused on agents with reduced likelihood of hypoglycemia (Grade C; BEL 3).
4. APPENDIX: EVIDENCE BASE

In this update, there are 671 citations of which 226
(34%) are EL 1 (strong), 121 (18%) are EL 2 (intermediate), 117 (17%) are EL 3 (weak), and 205 (31%) are EL 4
(no clinical evidence). The majority of recommendations
are EL 1 or 2: 347/671 (52%), which is slightly increased
from 180/375 (48%) in the 2011 AACE CPG (1 [EL 4;
NE]). The evidence base presented here provides relevant
information for the recommendations in the Executive
Summary.
4.Q1. How is Diabetes Screened and Diagnosed?
4.Q1.1. Diagnosis of DM
DM refers to a group of metabolic disorders that result
in hyperglycemia, regardless of the underlying etiology.
DM is diagnosed by using any of 3 established criteria for
elevated blood glucose concentrations (Table 6) (17 [EL 4;
consensus NE]).
An International Expert Committee has recommended
that an A1C level 6.5% also be used as a criterion for
diagnosis of DM (18 [EL 4; consensus NE]). Subsequent
analyses of the fidelity of DM diagnosis using A1C versus
FPG or 2-hour OGTT (Table 6) have brought this practice
into question (19 [EL 3; SS]). Moreover, A1C is known
to be affected by nonglycemic factors such as changes in
red blood cell maturity and survival and impaired renal
function, and it may be unreliable as a measure of glycemic burden in some patients from certain ethnic groups,
including those of African American and Latino heritage
(20 [EL 3; SS]; 21 [EL 4; review NE]; 22 [EL 3; SS]).
On the basis of these limitations, A1C measurement cannot be recommended as a primary method for diagnosing DM. The diagnosis of DM is best confirmed by 1 of
the 3 established direct measures of plasma glucose, with
A1C as a secondary criterion (Table 6). In the absence of
unequivocal hyperglycemia, the same type of test should
be repeated on a different day to confirm the diagnosis of
DM because of glucose level variability (23 [EL 4; review
NE]). In view of physiological changes in pregnancy that
could affect glycated hemoglobin levels, A1C should not
be used for GDM screening or diagnosis (24 [EL 3; CCS]).
4.Q1.2. Classification of DM
DM is classified into T1D, T2D, GDM, monogenic
DM, and other less common conditions such as chronic
pancreatitis, pancreatic resection, or rare insulin resistance
and mitochondrial syndromes. T1D accounts for <10%
of all DM cases and occurs more commonly in children
and young adults but can occur at any age. It is also more
common in persons of European ancestry and is caused
by absolute insulin deficiency that usually results from an

immune-mediated destruction of the pancreatic cells. In a
minority of patients with T1D, evidence for autoimmunity
is lacking, and the etiology of islet destruction is unclear.
Severe insulinopenia in T1D predisposes patients to diabetic ketoacidosis (DKA). However, DKA can also occur
in patients with T2D (25 [El 4; NE]; 26 [EL 3; SS]).
T2D accounts for >90% of all cases of DM; it remains
undiagnosed for years in many affected persons because
they are asymptomatic. Consequently, up to 25% of
patients with T2D have already developed at least 1 microvascular complication by the time of diagnosis (27 [EL
1; RCT]). Insulin resistance and concurrent relative insulin deficiency and glucagon dysregulation underlie T2D
pathophysiology (28 [EL 4; NE]; 29 [EL 2; PCS]). Crosssectional surveys indicate a higher prevalence of diagnosed
DM in African Americans, Hispanic Americans, and other
persons of non-European origin compared with European
Americans (30 [EL 3; SS]).
4.Q2. How is Prediabetes Managed?
Prediabetes is a condition defined by an increased risk
of developing DM and CVD. Prediabetes can be identified
by the presence of IGT (OGTT result of 140 to 199 mg/dL
2 hours after ingesting 75 g of glucose), IFG (FPG value of
100 to 125 mg/dL), or A1C value of 5.5 to 6.4% (Table 6).
The metabolic syndrome, based on National Cholesterol
Education Program IV Adult Treatment Panel III (NCEP
ATP III) criteria, may be considered a prediabetes equivalent. Polycystic ovary syndrome (PCOS) is also a prediabetes condition (31 [EL 4; consensus NE]). Risk factors
suggesting a need for screening are listed in Table 5 (31
[EL 4; consensus NE]).
Prevention of T2D depends upon systematic lifestyle
modifications including caloric intake reduction (e.g.,
500 kcal deficit per day) and regular exercise (30 minutes
aerobic work at least 5 days per week) to lose >7% body
weight (4 [EL 4; NE]). Lifestyle management alone may be
adequate for low-risk states and can reduce DM incidence
by as much as 58% (4 [EL 4; NE]). The weight-loss agents
orlistat (120 mg 3 times daily) (32 [EL 1; RCT]) and phentermine/topiramate extended release (up to 15/92 mg once
daily) (33 [EL 1; RCT]) prevented or delayed new cases
of DM in 48 to 79% of patients with prediabetes taking
these medications for 2 to 4 years in the respective studies.
Weight-loss surgery may normalize glycemia in patients
with prediabetes, prevent the appearance of overt T2D,
and reduce its progression. In the Swedish Obese Subjects
Study, bariatric surgery reduced the incidence of DM by
75% over 10 years (P<.001) (34 [EL 2; PCS]).
For patients in whom lifestyle modification after
3 to 6 months has failed to produce necessary improvement, pharmacologic intervention may be appropriate. In
fact many, if not the majority, of patients will benefit from
starting medications concomitantly with lifestyle intervention, just as in other metabolic diseases. No antihyperglycemic medications are approved by the FDA solely for the
management of prediabetes and/or the prevention of T2D.
Metformin (35 [EL 1; RCT]) and acarbose (36 [EL 1; RCT];
37 [EL 1; RCT]; 38 [EL 4; opinion NE]) might be appropriate for certain patients. TZDs reduced the risk of DM progression by 60 to 72% (39 [EL 1; RCT]; 40 [EL 1; RCT]);
however, because of their potential for long-term adverse
effects, their usage in this population is controversial.
More extensive discussion can be found in the American
College of Endocrinology consensus on the management
of prediabetes (31 [EL 4; consensus NE]). Metformin is an
antihyperglycemic drug that is not approved for obesity;
however, the Diabetes Prevention Program (DPP) demonstrated that it reduces the risk of developing DM in persons with IGT (35 [EL 1; RCT]; 41 [EL 1; RCT, follow-up
study]). In 3 studies, orlistat reduced conversion to DM (32
[EL 1; RCT]; 42 [EL 1; RCT]; 43 [EL 1; MRCT]). One of
these studies reported a reduction from 10.9 to 5.2% (P
= .041) in the conversion rate to DM (42 [EL 1; RCT]).
Orlistat therapy is also associated with decreases in A1C;
in 1 study, A1C decreased by 1.1% and 0.2% in the orlistat and control groups, respectively. Orlistat therapy also
resulted in a mean weight loss of 5% (44 [EL 2; MNRCT]).
Phentermine/topiramate extended release reduced
the annualized incidence rates of T2D by 70.5 and 78.7%
among patients receiving the 7.5/46 mg and 15/92 mg
doses, respectively, over 2 years (P<.05 versus placebo).
These reductions were related to the degree of weight
loss (10.9% and 12.1% in the low- and high-dose groups,
respectively, versus 2.5% in the placebo group; P<.0001)
and were accompanied by significant improvements in cardiometabolic parameters (33 [EL 1; RCT]).
High-dose liraglutide (3 mg) reduced weight by a
mean of 9 kg, and 84% of patients with prediabetes at baseline had normal glucose values after 1 year; after 2 years,
up to 62% of patients taking liraglutide 2.4 or 3 mg (pooled
analysis) maintained normal glucose levels (45 [EL 1;
RCT]; 46 [EL 1; RCT]). This is likely the result of both
the substantial weight loss and the incretin effect of this
agent on blood glucose control (45 [EL 1; RCT]; 46 [EL
1; RCT]). A large-scale study specifically examining the
effect of liraglutide on the incidence of T2D is underway.
4.Q3. What are the Glycemic Treatment Goals of DM?
4.Q.3.1. Outpatient Glucose Targets for
Nonpregnant Adults
There is no dispute that elevated glucose levels are
associated with micro- and macrovascular complications
of DM. Similarly, it has been accepted that strategies aimed
at lowering glucose concentrations can lead to lower rates
of microvascular and perhaps macroangiopathic complications (47 [EL 1; RCT]; 48 [EL 3; SS]; 49 [EL 1; RCT,
posttrial monitoring]; 50 [EL 3; SS]; 51 [EL 1; RCT];

52 [EL 1; RCT, posthoc analysis]). What have remained
under debate are the specific targets for glucose control in
patients with DM.
Healthy persons do not exhibit preprandial plasma
glucose concentrations >99 mg/dL or >120 mg/dL 2 hours
after meals. Indeed, there was a progressively increased
risk of T2D in males with FPG levels >87 mg/dL in 1 study
(53 [EL 3; SS]) and >94 mg/dL in another study based on
long-term follow-up (54 [EL 3; SS]). Similarly, standardized DCCT (Diabetes Control and Complications Trial)aligned A1C levels remained <6.0% in healthy individuals.
Epidemiologic evidence shows a continuous relationship
between A1C and CVD and all-cause mortality, with the
lowest rates at A1C levels <5% (55 [EL 2; PCS]).
Logically, one should aim for normal A1C levels
when treating patients with DM. However, it is unknown
whether treating patients with DMsome with pre-existing diabetic complicationsusing complicated regimens
to force glucose concentrations into the normal range
actually prevents or delays those complications. In the
ACCORD (Action to Control Cardiovascular Risk in
Diabetes) trial, intensive therapy targeting an A1C <6%
significantly reduced the risks and progressions of retinopathy, nephropathy, and neuropathy compared with a standard approach targeting an A1C of 7 to 8% (52 [EL 1; RCT,
posthoc analysis]; 56 [EL 1; RCT]). Significant reductions
in the risk or progression of nephropathy were seen in the
ADVANCE (Action in Diabetes and Vascular Disease:
Preterax and Diamicron MR Controlled Evaluation) study,
which targeted an A1C <6.5% in the intensive therapy
group versus standard approaches (57 [EL 1; RCT]). In
ACCORD, mortality increased with increasing A1C
among intensively treated patients, with the excess mortality only affecting patients whose A1C remained >7%
(58 [EL 1; RCT]). Meanwhile, a U-shaped mortality curve
was observed in the standard therapy group, with increasing death rates at both low (<7%) and high (>8%) A1C
levels (58 [EL 1; RCT]). Similar U-shaped curves were
found in a 7-year observational study of patients with T1D
(59 [EL 2; PCS]) and a 22-year observational study of
>20,000 patients with T2D (60 [EL 2; RCCS]). A corollary of this issue is the safety of those therapies in view
of the demonstrated increase of frequency of severe hypoglycemia during attempts at intensive glycemic control
(57 [EL 1; RCT]; 61 [EL 1; RCT]; 62 [EL 1; RCT]; 63
[EL 1; RCT]). As discussed in Q6. How is hypoglycemia
managed?, much of the mortality in ACCORD may have
been related to hypoglycemia, and the hazard ratio (HR)
for hypoglycemia-associated deaths was actually higher in
the standard treatment than the intensive therapy groups
(64 [EL 3; SS]).
No RCTs have yet established optimal glycemic targets. Professional organizations have relied on results from
existing intervention trials achieving improved A1C levels
and epidemiologic analyses of various studies to arrive at

consensus statements or expert opinions regarding targets.
Thus, some (4 [EL 4; NE]) have recommended a general
target A1C level 6.5%, while others have recommended a
general target of <7% (65 [EL 4; NE]; 66 [EL 4; CPG NE]).
In all cases, the potential risks of intensive glycemic control
may outweigh its benefits, especially in patients with frequent severe hypoglycemia, hypoglycemia unawareness,
or a very long duration of DM, particularly in the presence
of established and advanced atherosclerosis, advanced age,
and terminal illness.
In patients with DM, an A1C level >7% is associated
with increased risk of micro- and macrovascular complications (50 [EL 3; SS]; 51 [EL 1; RCT]; 67 [EL 1; RCT]; 68
[EL 1; RCT]). Strategies aimed at lowering glycemic levels (as evidenced by A1C lowering) have decreased microvascular complications and, in some cases, macrovascular
complications (48 [EL 3; SS]; 49 [EL 1; RCT, posttrial
monitoring]; 50 [EL 3; SS]; 51 [EL 1; RCT]; 52 [EL 1;
RCT, posthoc analysis]; 69 [EL 1; RCT]). As discussed in
Q4. How are glycemic targets achieved? as well as in
the 2015 AACE Algorithm for Diabetes Management (4
[EL 4; NE]), some newer therapies carry a lower risk of
hypoglycemia, which may enable more patients to safely
achieve individualized target A1C levels. To achieve the
target A1C levels, fasting and preprandial glucose levels
should be <110 mg/dL. The evidence in support of a PPG
target is predominantly based on cross-sectional and prospective epidemiologic studies with few RCTs (4 [EL 4;
NE]; 70 [EL 2; PCS]).
4.Q4. How are Glycemic Targets Achieved for T2D?
4.Q4.1. Therapeutic Lifestyle Changes
The components of therapeutic lifestyle changes
include healthful eating, regular physical activity, sufficient sleep, avoidance of tobacco products, limited alcohol
consumption, and stress reduction.
Nutritional medicine in DM comprehensive care consists of 3 components: counseling about general healthful eating, MNT, and specialized nutrition support. The
last category applies to those patients receiving enteral
or parenteral nutrition in which medications provided for
glycemic control must be synchronized with carbohydrate
delivery; however, this topic is beyond the scope of this
CPG. The components of healthful eating for patients with
DM are described in Table 8 (4 [EL 4; NE]; 71 [EL 3; SS];
72 [EL 4; position NE]; 73 [EL 4; position NE]; 74 [EL
4; review NE]; 75 [EL 3; SS]; 76 [EL 1; RCT]; 77 [EL 4;
review NE]; 78 [EL 4; review NE]; 79 [EL 4; review NE];
80 [EL 4; NE review]; 81 [EL 4; review NE]; 82 [EL 4;
review NE]; 83 [EL 2; MNRCT]; 84 [EL 4; CPG NE]; 85
[EL 2; PCS, data may not be generalizable to patients with
diabetes already]; 86 [EL 3; SS]; 87 [EL 4; review NE]; 88
[EL 4; NE review]; 89 [EL 4; review NE]). The physician
or a registered dietitian should discuss these recommendations in plain language with patients at the initial visit after
DM diagnosis and then periodically during follow-up office
visits (4 [EL 4; NE]). Comments should be broad and nontechnical, about foods suitable for the general population
(including those without DM) that promote health versus
foods that may promote disease or disease complications.
Discussions between patients and healthcare professionals should include information on specific foods and meal
planning, grocery shopping, and dining-out strategies.
MNT addresses the metabolic needs of patients with
DM and involves a more detailed discussion, usually in
terms of calories, grams, and other metrics. The goal is
to intensify efforts of healthy eating behaviors aimed at
optimizing glycemic control and reducing the risks of DM
complications. These recommendations should also be discussed and implemented by the physician or a registered
dietitian for all patients with DM.
All patients should be advised how to achieve and
maintain a healthful weight. For overweight individuals with a BMI of 25 to 29.9 kg/m2, this corresponds to
achieving a normal range BMI of 18.5 to 24.9 kg/m2. For
obese individuals with a BMI >30 kg/m2, the initial recommended target is a weight loss of at least 5 to 10% of body
weight. Several randomized clinical trials lasting 1 year (90
[EL 1; RCT, single blinded]; 91 [EL 1; RCT, not blinded,
adherence not controlled for]) or 2 years (92 [EL 1; RCT,
not blinded]; 93 [EL 1; RCT]) have compared diets and
report successful weight loss regardless of macronutrient
content (e.g., low fat, low carbohydrate, etc.). In a randomized comparison of the Atkins, Ornish, Weight Watchers,
and Zone diets, weight change did not differ between diets
(about 5 kg), and adherence to the diet was the single most
important criterion of successful weight loss (90 [EL 1;
RCT, single blinded]). The key to adopting the principles
given in Tables 7 and 8 is to personalize the recommendations on the basis of a patients specific medical conditions,
lifestyle, and behaviors. Patients unable to accomplish this
should be referred to a registered dietitian or weight-loss
program with a proven success rate. In areas underserved
by registered dietitians, physicians should take on more
responsibility during patient encounters for nutritional
counseling and reinforcing healthful eating patterns.
A review and position paper on MNT for both T1D
and T2D was recently published (94 [EL 4; NE]). Key
recommendations address the need for consistency in
day-to-day carbohydrate intake, adjusting insulin doses
to match carbohydrate intake (e.g., use of carbohydrate
counting), limitation of sucrose-containing or high-glycemic index foods, adequate protein intake, heart-healthy
diets, weight management, regular physical activity,
and increased glucose monitoring. Data from the Look
AHEAD (Action for Health in Diabetes) and DPP studies
provide additional evidence that lowering caloric intake is
the main driver for weight loss. The Look AHEAD trial
is the longest RCT to evaluate intensive lifestyle change

on weight loss in patients with T2D (95 [EL 1; RCT, not
blinded]). The maximal weight loss in patients with T2D in
Look AHEAD was greater than among patients with prediabetes in the DPP. The magnitude of weight loss after 1
year in Look AHEAD was related to the frequency of using
meal replacements, amount of physical activity performed,
and attendance at behavioral sessions (96 [EL 1; RCT]).
For a discussion of the Look AHEAD results, see section
4.Q13.4.
There is good evidence that regular physical activity
improves glucose control in persons with T2D (97 [EL
1; RCT, small sample size]; 98 [EL 2; NRCT]; 99 [EL
2; NRCT]; 100 [EL 2; NRCT]). Because physical activity is usually combined with caloric restriction and weight
loss, as in combined lifestyle intervention programs, distinguishing the effects of increased physical activity alone
from those of calorie restriction and weight loss is often difficult. However, studies on exercise alone show improved
glucose control (101 [EL 1; RCT]; 102 [EL 4; commentary
NE]; 103 [EL 1; RCT]). Regular physical exerciseboth
aerobic exercise and strength trainingis important to
improve a variety of CVD risk factors, decrease the risk
of falls and fractures, and improve functional capacity
and sense of well-being (102 [EL 4; commentary NE]).
Physical activity is also a main component in weight loss
and maintenance programs. Activity of at least 150 minutes per week of moderate-intensity exercise such as brisk
walking (e.g., a 15- to 20-minute mile) or its equivalent
(e.g., yoga, walking during golf, water aerobics, physical
play with children, etc.), is now well accepted and part of
the nationally recommended guideline for physical activity. For persons with T2D, recommendations include flexibility and strength training exercises in addition to aerobic
exercise (101 [EL 1; RCT]). The Look AHEAD study had a
goal of 175 minute/week of moderately intense activity in
addition to a focus on increased lifestyle daily activity. The
1-year results revealed a significant association between
minutes of physical activity and weight loss, indicating
that those who were more active lost more weight (96 [EL
1; RCT]). The benefits and risks of increasing physical
activity and the practical aspects of implementing a physical training program in people with T2D are discussed in
detail in a position paper (104 [EL 4; consensus NE]). The
key points are that patients must be evaluated initially for
contraindications and/or limitations to increased physical
activity; an exercise prescription should be developed for
each patient according to both goals and limitations; and
additional physical activity should be started slowly and
built up gradually.
People with T1D generally experience the same benefits of regular physical exercise as T2D patients. However,
patients requiring insulin therapy must also learn about the
acute and chronic effects of exercise on glucose regulation and how to adjust insulin dosages and food intake to
maintain glucose control before, during, and after exercise

to avoid significant hypoglycemia or hyperglycemia (105
[EL 4; NE]).
The final component of therapeutic lifestyle change is
the use of behavior modification strategies in support of
healthy eating and regular activity. However, several studies have shown that attempts to include lifestyle change
counseling as part of routine primary care fail to help
patients achieve or sustain weight loss. In addition, the
initial success of a structured lifestyle program may fade
without continued support (106 [EL 1; RCT, not blinded]),
suggesting that ongoing behavioral strategies in addition to
education on healthy eating and physical activity should be
included in lifestyle intervention programs. Look AHEADs
long-term behavior modification program included regular
individual and periodic group contact modeled on the DPP.
The results demonstrated that extended behavioral support
within an intensive lifestyle intervention program helps
facilitate meaningful weight loss for up to 8 years (95 [EL
1; RCT, not blinded]). The behavioral strategy toolbox in
both the DPP and Look AHEAD studies suggested an array
of options including motivational interviewing, goal setting to improve adherence, refresher courses, campaigns,
and incentives such as prizes.
4.Q4.2. Antihyperglycemic Pharmacotherapy
The goal of glycemic treatment in subjects with T2D
is to achieve clinical and biochemical targets with as few
adverse consequences as possible. This straightforward
statement has important implications for the choice of specific antihyperglycemic agents in T2D, which should be
guided by the patients medical needs and treatment goals,
as well as the agents glucose-reducing potency, tolerability and side-effect profile, ease of administration and convenience, cost effectiveness, and extraglycemic effects. All
currently available oral glucose-lowering agents are more
or less similar in their glucose-lowering potency (107 [EL
1; MRCT]; 108 [EL 3; CSS]). As monotherapy, most oral
antihyperglycemic agents reduce A1C by 0.5 to 2.0%.
Larger decrements are seen in patients with more marked
A1C elevations, likely explaining the apparent greater efficacy of older agents versus newer ones (4 [EL 4; NE]).
However, the various classes of glucose-lowering agents
differ widely in other respects (Table 9).
Complete descriptions of available antihyperglycemic
agents, their mechanisms of action, and rationale for use
in different clinical situations can be found in the 2015
AACE Comprehensive Diabetes Management Algorithm
Consensus Statement (4 [EL 4; NE]) as well the 2012 Joint
ADA/European Association for the Study of Diabetes
(EASD) Algorithm Consensus Statement (109 [EL 4;
NE]). In addition to lowering glucose, the priority in DM
management is to minimize the risks of hypoglycemia and
weight gain. The AACE preferentially recommends agents
that do not increase these risks (Table 10).
Metformin carries a low risk of hypoglycemia, is

weight neutral, produces durable antihyperglycemic
effects, and has robust cardiovascular safety; however, it
should not be used in patients with advanced renal impairment (69 [EL 1; RCT]; 110 [EL 1; RCT]; 111 [EL 4;
NE]; 112 [EL 2; RCCS]). It is equally efficacious across
all weight categories (normal, overweight, and obese) in
T2D (113 [EL 1; MRCT]). Metformin may have anorectic effects, is sometimes associated with weight loss, may
cause gastrointestinal (GI) adverse effects (e.g., dyspepsia,
loose stools, or diarrhea), and may be associated with the
development of vitamin B12 deficiency over time (114 [EL
1; RCT]). Metformin should be continued as background
therapy and used in combination with other agents, including insulin, in patients who do not reach their glycemic
target on monotherapy. When metformin is contraindicated
or not tolerated, acceptable alternatives include GLP-1
receptor agonists, SGLT2 inhibitors, DPP-4 inhibitors,
and -glucosidase inhibitors. TZDs, sulfonylureas, and
glinides may also be used, although caution should be
exercised owing to the potential for weight gain, hypoglycemia, or other risks.
Sulfonylureas and glinides increase insulin secretion
in a glucose level-independent fashion. Ideal candidates
for treatment with sulfonylureas are patients with T2D
whose duration of DM is <5 years and who do not have
end-organ complications (e.g., CKD), and are willing to
follow a healthy diet and exercise plan and perform SMBG
to reduce the likelihood of hypoglycemia. For unknown
reasons, not all patients with T2D respond to sulfonylureas
(primary failure), and antihyperglycemic effectiveness
declines after several years of treatment in many patients
(secondary failure) (115 [EL 1; RCT]). The main side
effect of the sulfonylureas is hypoglycemia, which can be
more prolonged than that produced by insulin, particularly
when longer-acting formulations are used in the elderly
(116 [EL 4; NE]). Renal insufficiency also increases the
risk of sulfonylurea-associated hypoglycemia.
TZDs have been shown to improve insulin sensitivity and to preserve or improve -cell secretory function in
patients with T2D. In addition to their glycemic effects,
these agents also improve a wide range of cardiovascular
risk markers (117 [EL 1; RCT]; 118 [EL 1; MRCT]) and
may help prevent central nervous system insulin resistancerelated cognitive dysfunction (119 [EL 2; PCS]). Clinical
studies and meta-analyses of RCTs reported that treatment
with pioglitazone results in a statistically significant reduction in the composite outcome of nonfatal acute myocardial infarction, stroke, and all-cause mortality (120 [EL 1;
MRCT]). TZDs are also useful in patients with nonalcoholic steatohepatitis (121 [EL 4; review NE]); however,
they lead to weight gain comparable to that with sulfonylurea and insulin therapy (122 [EL 2; MNRCT]). TZDs
may also cause fluid retention (particularly in patients
with cardiac or renal disease), which may contribute
to TZD-associated weight gain and peripheral edema.

Because of this, TZDs are contraindicated in patients with
New York Heart Association class 3 and 4 congestive heart
failure. TZDs can also reduce bone mineralization and are
associated with nonosteoporotic bone fractures (123 [EL 1;
RCT, posthoc analysis]; 124 [EL 2; PCS]). The TZD rosiglitazone has been withdrawn from use in Europe and was
severely restricted in the United States because of concerns
over a possible increase in CVD risk (125 [EL 4; review
NE]). The FDA recently lifted this restriction (126 [EL 4;
NE]). According to the FDA, pioglitazone, but not rosiglitazone, may be associated with increased rates of bladder
cancer, although there is not enough evidence to support
a clear association (127 [EL 4; NE]). A recent cumulative
exposure analysis involvingdata from1.01 million persons from multiple countries over 5.9 million person-years
found no association between exposure to pioglitazone and
bladder cancer (128 [EL 3; SS]).
The GLP-1 receptor agonists and DPP-4 inhibitors
increase insulin secretion in a glycemic level-dependent
manner. In addition to glucose lowering, the GLP-1 receptor agonists may slow gastric emptying, promote early satiety, and reduce food intake, which may result in weight
loss. Currently approved GLP-1 receptor agonists include
albiglutide, dulaglutide, exenatide, and liraglutide, which
are administered by injection on a twice daily, daily, or
weekly basis. These agents are most useful as add-on
therapies for patients with inadequately controlled DM

during oral monotherapy (129 [EL 1; RCT]; 130 [EL 1;
RCT follow-up study]; 131 [EL 1; RCT]; 132 [EL 1; RCT];
133 [EL 1; RCT]; 134 [EL 4; animal study NE]; 135 [EL
1; RCT]; 136 [EL 1; RCT]; 137 [EL 1; RCT]). Several
clinical trials have compared the effects of adding a GLP-1
receptor agonist (exenatide twice daily or liraglutide) to
insulin (glargine insulin or mixed insulin) in patients with
inadequately controlled T2D on oral agents (138 [EL 1;
RCT]; 139 [EL 1; RCT]; 140 [EL 1; MRCT]). All of the
studies show equivalent or slightly better A1C lowering
by GLP-1 receptor agonists with the advantages of a 2- to
3-kg weight loss and little or no additional hypoglycemia.
The main adverse effects with GLP-1 receptor agonists
are nausea, vomiting, and diarrhea (141 [EL 1; MNCT]),
which usually diminish over time. Approximately 5 to
10% of patients cannot tolerate these drugs due to GI
effects. In rodents, GLP-1 receptor agonists may increase
the frequency of benign and malignant C-cell neoplasms;
however, in humans, neither acute pancreatitis nor medullary thyroid carcinoma has been convincingly shown to
be caused by incretin-based therapies (142 [EL 4; NE]).
Nevertheless, GLP-1 receptor agonists should be used cautiously in patients with a history of pancreatitis and discontinued if acute pancreatitis develops during use. All GLP-1
receptor agonists except twice-daily exenatide are contraindicated in patients with a personal or family history of
Table 10
Pharmacologic Agents for T2D Treatmenta
Monotherapy
Dual therapy
Triple therapy
Metformin (or other

first-line agent) plus
First- and second-line

agent plus
Metformin
GLP1RA
GLP1RA
GLP1RA
SGLT2I
SGLT2I
SGLT2I
DPP4I
TZDb
DPP4I
TZDb
Basal insulinb
AGI
Basal insulinb
DPP4I
TZDb
Colesevelam
Colesevelam
SU/glinideb
BCR-QR
BCR-QR
AGI
AGI
SU/glinideb
SU/glinideb
Abbreviations: A1C = hemoglobin A1C; AGI = -glucosidase inhibitors;

BCR-QR = bromocriptine quick release; DPP4I = dipeptidyl peptidase 4
inhibitors; GLP1RA = glucagon-like peptide 1 receptor agonists;
SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas;
TZD = thiazolidinediones.
a Intensify therapy whenever A1C exceeds individualized target. Boldface
denotes little or no risk of hypoglycemia or weight gain, few adverse events,
and/or the possibility of benefits beyond glucose lowering.
b Use with caution.
medullary thyroid carcinoma and in patients with multiple

endocrine neoplasia syndrome type 2. The FDA has stated
that patients taking a GLP-1 receptor agonist do not need to
be monitored for medullary thyroid carcinoma (e.g., with
calcitonin levels).
DPP-4 inhibitors do not cause weight gain; they can
be administered in patients with CKD at full dosage when
not cleared by the kidneys (linagliptin) or with appropriate
dose adjustment for agents that are renally cleared (sitagliptin, saxagliptin, alogliptin); they lack significant GI
adverse effects (143 [EL 4; opinion NE]); and they have
been associated with reduction in cardiovascular events
in analyses of registration trials (144 [EL 1; MRCT]),
although neither benefit nor harm was seen in cardiovascular outcome studies conducted in subjects with advanced
CVD in placebo-controlled, randomized studies with alogliptin or saxagliptin (145 [EL 1; RCT]; 146 [EL 1; RCT]).
The trial comparing saxagliptin with placebo showed an
increased likelihood of hospitalization for congestive
heart failure and an increase in hypoglycemia (146 [EL 1;
RCT]); this should lead to caution in the use of this agent
in persons with a history of heart failure who also have
existing CVD. With regard to hypoglycemia, it should be
noted that approximately 40% of the patients receiving
saxagliptin in the trial also received a sulfonylurea, a combination that increases the likelihood of hypoglycemia.
The main adverse effects noted with DPP-4 inhibitors are
a small increase in upper respiratory tract viral infections
(rates of nasopharyngitis were 6.4% with a DPP-4 inhibitor
versus 6.1% with comparators; risk ratio, 1.2; 95% confidence interval [CI] 1.0 to 1.4) and a rare hypersensitivity
reaction (141 [EL 1; MNCT]).
The SGLT2 inhibitors are the newest oral agents
approved for the treatment of T2D. The glucosuric effect
of these agents leads to weight loss in most patients. Most
patients also experience decreases in systolic blood pressure. Elderly patients on loop diuretics need to be monitored for postural hypotension. Because they exert their
glycemic effects in the kidney, these agents have limited
efficacy in patients with CKD. Also, by increasing glycosuria, SGLT2 inhibitors may increase the risk of urinary infection and fungal genital tract infection. Small
increases in LDL-C levels (4 to 8 mg/dL) occurred with
canagliflozin, dapagliflozin, and empagliflozin in pivotal
trials. Dehydration due to increased diuresis could lead to
hypotension and adverse cardiovascular effects, although
no cardiac safety signals have been reported (147 [EL 4;
NE]). Bone fracture has been described in postmarketing
safety reporting. As with all new agents, aggressive postmarketing surveillance for SGLT2 inhibitor adverse effects
is ongoing.
Colesevelam, -glucosidase inhibitors, and bromocriptine primarily affect PPG levels and are worth consideration in selected patients. Colesevelam carries a low
risk of hypoglycemia and also reduces LDL-C, for which

it was originally developed. Its main adverse effect is constipation, but it is not systemically absorbed and therefore
is not likely to have systemic adverse effects (148 [EL 4;
NE]).
-Glucosidase inhibitors also have a low risk for
hypoglycemia, although patients may not tolerate the GI
side effects (e.g., bloating, flatulence, diarrhea). Clinical
trials have shown some cardiovascular benefit in patients
with IGT or DM (36 [EL 1; RCT]; 37 [EL 1; RCT]).
The dopamine receptor agonist bromocriptine does
not cause hypoglycemia. It can cause nausea and orthostasis and should not be used in patients taking antipsychotic
drugs. Bromocriptine may be associated with reduced cardiovascular event rates (149 [EL 1; RCT]).
Because many patients do not achieve adequate
glycemic control with monotherapy, combining antihyperglycemic agents is often appropriate (4 [EL 4; NE]).
Metformin is quite effective when administered in combination with the other agents, as long as one avoids its use
in patients with CKD (creatinine 1.4 mg/dL in females
or 1.5 mg/dL in males) (4 [EL 4; NE]) or GI intolerance.
Sulfonylureas, in contrast, are problematic when used in
combinations because they can cause hypoglycemia and
may reduce, eliminate, or minimize the weight-loss benefit
of drugs such as metformin, GLP-1 receptor agonists, and
SGLT2 inhibitors (122 [EL 2; MNRCT]).
4.Q4.2.1. Insulin Use in T2D
Insulin is usually initiated in T2D when combination
therapy with other agents fails to maintain the glycemic
goal, or when a patient, whether drug nave or on a treatment regimen, presents with an A1C level >9.0% and
symptomatic hyperglycemia (4 [EL 4; NE]). The traditional postponement of insulin therapy after prolonged failure of lifestyle and oral agents to achieve glycemic control
has been revised in the last decade to incorporate primarily
basal insulin therapy much sooner, often in combination
with oral agents or GLP-1 receptor agonists (4 [EL 4; NE];
109 [EL 4; NE]).
Insulin therapy may be initiated as a basal, basalbolus, prandial, or premixed regimen, although for most
patients, starting with a basal insulin analog added to the
existing antihyperglycemic regimen is preferred (Table 11)
(4 [EL 4; NE]). The combination of insulin with any antihyperglycemic agent raises the potential for hypoglycemia.
Patients should be closely monitored, and those on sulfonylureas or glinides may require dosage reductions or discontinuation of the oral agent. TZDs can be associated with
weight gain, edema, and increased risk of congestive heart
failure in combination with insulin. Basal insulin analogs
are preferred over NPH insulin because of a reduced risk of
hypoglycemia (150 [EL 1; RCT]; 151 [EL 1; MRCT]; 152
Table 11
Recommended Steps for the Addition of Insulin to Antihyperglycemic Therapy (4 [EL 4; NE])
Glucose Value
Total Daily Dose
Step 1. Start basal (long-acting insulin)

A1C <8%
0.1-0.2 units/kg
A1C >8%
0.2-0.3 units/kg
Notes/Caveats
Consider discontinuing SU therapy
Basal analogs preferred over NPH
Step 2. Titrate insulin every 2-3 days to reach glycemic goalsa

Fixed regimen
Increase by 2 units/day
Adjustable regimen

FBG >180 mg/dL
Add 4 units
FBG 140-180 mg/dL
Add 2 units
FBG 110-139 mg/dL
Add 1 unit
Step 3. Monitor for hypoglycemia

BG <70 mg/dL
Reduce by 10 to 20%
BG <40 mg/dL
Reduce by 20 to 40%
Abbreviations: A1C = hemoglobin A1C; BG = blood glucose; FBG = fasting blood glucose; NPH = neutral protamine
Hagedorn; SU = sulfonylureas.
a For most patients with T2D taking insulin, glucose goals are A1C <7% and fasting and premeal blood glucose
<110 mg/dL in the absence of hypoglycemia. A1C and FBG targets may be adjusted based on patients age,
duration of diabetes, presence of comorbidities, diabetic complications, and hypoglycemia risk.
[EL 1; MRCT]; 153 [EL 1; RCT]). The insulin regimen

to be prescribed and the exact treatment goals should be
discussed with the patient.
Insulin-treated patients should be instructed in SMBG.
Most insulin-treated patients with T2D should conduct
SMBG 2 times daily, but the frequency and timing should
be dictated by the particular needs and goals of the patient,
as well as hypoglycemia risk (see Q18. When and how
should glucose monitoring be used?).
Premixed insulins are popular with patients, but they
provide less dosing flexibility and have been associated
with a higher frequency of hypoglycemia compared to
basal and basal-bolus regimens (154 [EL 1; RCT]; 155
[EL 3; SS]; 156 [EL 1; RCT]). Nevertheless, there are
some patients for whom a simpler regimen is a reasonable
compromise.
When mealtime glucose control is needed or when
glycemic goals are not met on a basal insulin regimen plus
oral agents or a GLP-1 receptor agonist, insulin therapy
intensification to a basal-bolus regimen (using a rapid-acting insulin analog or inhaled insulin) should be considered
(Table 12).
Use of the amylin analog pramlintide in conjunction
with bolus insulin improves both glycemia and weight in
patients with T2D (157 [EL 1; RCT, small sample size]; 158
[EL 1; RCT, not blinded]). The incretins (GLP-1 receptor
agonists and DDP-4 inhibitors) have properties similar to
those of pramlintide and also increase endogenous insulin
secretion. The combination of basal insulin and incretin

therapy decreases basal glucose and PPG and may minimize weight gain and the risk of hypoglycemia compared
with basal-bolus insulin regimens. Pharmacokinetic and
pharmacodynamic studies of combination GLP-1 receptor
agonists and basal insulin analogs have shown an additive
effect on blood glucose decreases (138 [EL 1; RCT]; 159
[EL 1; RCT]; 160 [EL 4; NE]; 161 [EL 1; RCT]; 162 [EL 1;
RCT, not blinded, not placebo controlled]). The combined
use of DPP-4 inhibitors or SGLT2 inhibitors with insulin
is also effective in improving glycemic control with a relatively low risk of hypoglycemia (163 [EL 1; RCT]; 164
[EL 1; RCT]).
Hypoglycemia and weight gain are the most common
adverse effects of insulin therapy (4 [EL 4; NE]; 165 [EL
4; NE]). Rates and the clinical impact of hypoglycemia are
frequently underestimated (166 [EL 4; NE]), but about 7
to 15% of insulin-treated patients with T2D experience at
least 1 episode of hypoglycemia per year (167 [EL 1; RCT,
not blinded]), and 1 to 2% have severe hypoglycemia (165
[EL 4; NE]; 166 [EL 4; NE]). The frequency of hypoglycemia increases with intensive insulin targets, use of sulfonylureas, decreased caloric intake, delayed meals, exercise,
alcohol consumption, CKD, T2D duration, and cognitive
impairment (166 [EL 4; NE]). Large randomized trials conducted in subjects with established T2D have revealed that
subjects with a history of 1 or more severe hypoglycemic
events had an approximately two- to fourfold higher rate of
mortality for reasons that remain unknown (64 [EL 3; SS];

168 [EL 1; RCT]). It has been proposed that hypoglycemia
may be a marker for persons at higher risk of death rather
than being its proximate cause (166 [EL 4; NE]); nevertheless, avoidance of hypoglycemia by appropriately reducing
insulin dosages seems prudent.
Patients receiving insulin gain about 1 to 3 kg more
weight than they do with other treatment agents. Patients
with proliferative retinopathy and an A1C >10% are at
highest risk of worsening retinopathy (169 [EL 4; NE]).
More detail on insulin therapy initiation, titration, and
intensification for T2D can be found in the 2015 AACE
Comprehensive Diabetes Management Algorithm (4 [EL
4; NE]).
4.Q5. How Should Glycemia in T1D be Managed?

Insulin therapy is necessary for life in all patients with
T1D (EL 1; all-or-nothing). Physiologic insulin regimens, using both basal and prandial insulin, provided by
either MDI or CSII, have not been formally tested in RCTs
against nonphysiologic insulin regimens (once or twice
daily insulin). Rather, physiologic insulin regimens have
been formally studied as 1 component of a comprehensive
treatment strategy for patients with T1D.
Numerous RCTs have compared basal insulin analogs
with NPH insulin in addition to rapid-acting analogs with
regular human insulin. With insulin analogs, no additional
improvements in A1C have been shown, but there is a
Table 12
Recommended Steps for the Intensification of Insulin Therapy When
Prandial Control is Needed (4 [EL 4; NE])
Therapeutic option
Insulin dose
Notes/caveats
Step 1. Add prandial therapy

GLP-1 receptor agonist, SGLT2
inhibitor, or DPP-4 inhibitor
Prandial insulin
TDD 0.3-0.5 units/kg

(50% basal; 50% prandial)
If glucose goals remain unmet,

add prandial insulin
Basal + prandial insulin analogs
preferred over NPH + regular
insulin or premixed insulin
Step 2. Titrate insulin every 2-3 days to reach glycemic goalsa

Fixed regimen
Increase TDD by 2 units/day
Adjustable regimen

FBG >180 mg/dL
Increase TDD by 4 units
FBG 140-180 mg/dL
Increase TDD by 2 units
FBG 110-139 mg/dL
Increase TDD by 1 unit
2-h PPG or next premeal glucose

>180 mg/dL
Increase prandial dose for the

next meal by 10%
Premixed insulin

FBG/premeal BG >180 mg/dL
Increase TDD by 10%
Step 3. Monitor for hypoglycemia

Fasting hypoglycemia
Reduce basal insulin dose
Nighttime hypoglycemia
Reduce basal insulin or

reduce short/rapid-acting
insulin taken before supper or
evening snack
Between meal hypoglycemia
Reduce previous premeal

short/rapid-acting insulin
Abbreviations: BG = blood glucose; DPP-4 = dipeptidyl peptidase 4 inhibitors; FBG = fasting blood glucose;
GLP-1 = glucagon-like peptide 1 receptor agonists; NPH = neutral protamine Hagedorn; PPG = postprandial glucose;
SGLT2 = sodium glucose cotransporter 2; TDD = total daily dose.
a For most patients with T2D taking insulin, glucose goals are A1C <7% and fasting and premeal blood glucose
<110 mg/dL in the absence of hypoglycemia. A1C and FBG targets may be adjusted based on patients age, duration
of diabetes, presence of comorbidities, diabetic complications, and hypoglycemia risk.
consistent reduction of moderate and severe hypoglycemia

(170 [EL 4; review NE]). In comparisons of MDI and CSII
for T1D, there have been small but consistent improvements in A1C, as well as substantial reductions in severe
hypoglycemia (171 [EL 1; MRCT]; 172 [EL 1; MRCT]).
4.Q5.1. Basic Principles of Insulin Therapy in T1D
The starting dose of insulin is usually based on weight,
with doses ranging from 0.4 to 0.5 units/kg/day of total
insulin with higher amounts required for patients who are
obese (increasingly common in T1D) or have a sedentary
lifestyle, as well as during puberty.
In general, basal insulin requirements are usually 40
to 50% of the total daily insulin doses. No data support the
superiority of 2 injections of a basal insulin analog over 1
injection of basal insulin analog in patients with T1D.
The dose of prandial insulin is usually determined by
estimating the carbohydrate content of the meal. Insulinto-carbohydrate (I:C) ratios usually range from 1:20 for the
very insulin sensitive to 1:5 for the insulin-resistant patient.
Similarly, correction dose insulin for premeal or betweenmeal hyperglycemia is based on the insulin sensitivity factor (ISF), which is based on the overall insulin sensitivity
of the patient, loosely estimated by the individuals total
daily insulin dose. Although various formulas have been
used to estimate the appropriate ISF, this parameter should
only be viewed as an estimation due to numerous factors
that can alter blood glucose. The most commonly used formula is:
1,800/total daily dose of insulin = Number of mg/dL
of glucose that will be reduced by 1 unit of insulin
The other key factor that needs to be appreciated is
insulin action time. For most subcutaneous injections, this
ranges from 4 to 6 hours. There are no data to quantify an
individual patients insulin action time and in fact it can
change from day to day.
With the knowledge of the I:C ratio, ISF, and insulin action time, patients on MDI or CSII can calculate the
appropriate correction dose insulin. This is significantly
simpler with CSII, as most pumps include bolus calculators
to perform the calculations by pressing a few buttons. For
those using MDI, there are a variety of smart phone apps
available, in addition to several blood glucose meters that
can assist patients with these calculations. Most patients
using MDI, however, will need to estimate the insulin on
board from the last injection of prandial insulin based on
standard curves that can be provided to them (170 [EL 4;
review NE]).
4.Q5.2. Adjunctive Medications for T1D
The amylin analog pramlintide, the only other medication approved for the treatment of T1D, is administered
with prandial insulin. A1C reductions are consistently
modest, and mild weight loss is common. Nausea is a common adverse effect. There is a potential risk of severe hypoglycemia if patients do not appropriately reduce the prandial insulin dosage (173 [EL 1; RCT]; 174 [EL 1; RCT];
175 [EL 1; RCT]; 176 [EL 1; MRCT]). Tachyphylaxis is
often seen after several years of therapy.
While there is growing interest and anecdotal reports
of successful use of both GLP-1 receptor agonists and
SGLT2 inhibitors in T1D, to date appropriate trials have
not been published, and formal recommendations cannot
be provided. In addition, recommendations for the use of
metformin in T1D cannot be made due to lack of indication
and concerns of lactic acidosis in a population predisposed
to ketoacidosis. Nevertheless, the use of metformin in T1D
has been of great interest, and new data should be available
in the future (177 [EL 1; MRCT]).
4.Q6. How is Hypoglycemia Managed?
4.Q6.1. Definition
The classical definition of hypoglycemia in patients
with DM is a low blood glucose level accompanied by
symptoms of hypoglycemia (e.g., palpitations, hunger;
see section 4.Q6.2) that are relieved by the ingestion of
glucose (i.e., the Whipple triad) (178 [EL 4; review NE]).
However, hypoglycemia may be asymptomatic, and any
blood glucose <70 mg/dL is generally considered hypoglycemia (179 [EL 4; NE]). In addition, hypoglycemia symptoms can occur in the normal glucose range in a patient
with very high glucose levels that drop quickly. SMBG can
be helpful but is not necessarily diagnostic because of glucose meter inaccuracy.
Severe hypoglycemia is defined as any low blood glucose event that requires assistance from another person to
administer carbohydrates or glucagon or take other corrective action (179 [EL 4; NE]).
4.Q6.2. Symptoms
Hypoglycemia manifests as neurogenic and/or neuroglycopenic symptoms that range in severity from mild to
life threatening and include anxiety, palpitations, tremor,
sweating, hunger, paresthesias, behavioral changes, cognitive dysfunction, seizures, and coma. Certain hypoglycemia-related responses (psychomotor function) are altered
in the elderly compared with younger patients. Although
severe hypoglycemia generally results in recognizable
symptoms, mild-to-moderate hypoglycemia may remain
asymptomatic and unreported in patients with T2D or with
hypoglycemia unawareness (179 [EL 4; NE]).
4.Q6.3. Etiology
In patients with DM, iatrogenic hypoglycemia
stems from an imbalance among insulinogenic therapy,
food intake, physical activity, organ function (gluconeogenesis), and counterregulation with glucagon and/or
epinephrine (hypoglycemia-associated autonomic failure).

Hyperinsulinemia, increased alcohol intake, starvation,
and organ failure may be aggravating factors (166 [EL 4;
NE]; 180 [EL 4; NE]). Noniatrogenic hypoglycemia (i.e.,
insulinoma) is beyond the scope of these guidelines.
4.Q6.4. Risks
The primary cause of hypoglycemia is intensification
of therapy to achieve a lower A1C target, as demonstrated
by intensive therapy trials. Over 3.5 years in the ACCORD
study, severe hypoglycemia occurred at an annualized rate
of 3.1% of patients in the intensive therapy group (mean
endpoint A1C 6.4%; target <6.0%) versus 1.0% per year in
the standard therapy group (mean endpoint A1C 7.5%) (62
[EL 1; RCT]). During the ADVANCE study, in which the
goal A1C of 6.5% was met in the intensive group, 0.7% of
intensively treated patients experienced severe hypoglycemia on an annual basis compared with 0.4% of patients per
year in the standard care group (57 [EL 1; RCT]). Finally,
in the UKPDS (United Kingdom Prospective Diabetes
Study), wherein intensive treatment led to a mean endpoint A1C of 7.0%, hypoglycemia occurred in 1.8% of
insulin-treated patients per year in the intensive group versus 0.7% of conventionally treated patients per year (69
[EL 1; RCT]). The risk of hypoglycemia is greater in older
patients and those with longer DM duration, kidney failure,
or lesser insulin reserve. Dementia is another important
risk factor for hypoglycemia, and recurrent hypoglycemia
appears to increase the risk of dementia (181 [EL 3; SS];
182 [EL 2; RCCS]; 183 [EL 2; PCS]). The failure to recognize symptoms of hypoglycemia can increase the risk
of subsequent hypoglycemia by causing autonomic failure,
leading to a cycle of recurrent hypoglycemia and hypoglycemia unawareness (180 [EL 4; NE]).
4.Q6.5. Sequelae
Recent studies have suggested an association of
hypoglycemia with adverse cardiovascular events. In
ADVANCE, severe hypoglycemia was associated with
significant risk increases for cardiovascular events including death (168 [EL 1; RCT]). In ACCORD, hypoglycemia was considered a suspect behind the increased mortality observed in the intensive-treatment arm. However,
glucose levels at time of death were unknown, and the
hypothesis remains unproven (58 [EL 1; RCT]; 64 [EL 3;
SS]). Moreover, the HR for hypoglycemia-related mortality was even higher in the standard therapy arm of that
study (adjusted HR in intensive treatment arm: 1.41, 95%
CI, 1.03 to 1.93; in standard therapy arm: 2.30, 95% CI,
1.46 to 3.65) (64 [EL 3; SS]). A recent meta-analysis of
prospective and retrospective clinical trials demonstrated
that severe hypoglycemia doubled the risk of cardiovascular events (184 [EL 2; MNRCT]), while an observational trial showed that, over a period of 5 years, mortality
was 3.4 times higher among patients who reported severe
hypoglycemia at baseline (185 [EL 2; PCS]). The proposed

mechanism for these effects posits that hypoglycemia
reduces baroreceptor sensitivity and increases sympathoadrenal system activity, which can trigger a fatal ventricular arrhythmia in the setting of reduced baroreflex sensitivity (186 [EL 4; NE]).
Other short- and long-term consequences of severe
hypoglycemia include neurologic conditions ranging from
temporary cognitive impairment to dementia as well as
major vascular events such as stroke, myocardial infarction, acute cardiac failure, ventricular arrhythmias, and
sudden death (166 [EL 4; NE]; 180 [EL 4; NE]; 187 [EL 4;
NE]). The complications of hypoglycemia are also associated with short-term disability and higher healthcare costs
(188 [EL 4; NE]).
4.Q6.6. Management
Hypoglycemia is the primary limiting factor in the
treatment of both T1D and T2D. It remains a significant
barrier in terms of treatment adherence and achievement of
glycemic goals (166 [EL 4; NE]).
Long-term management of hypoglycemia depends on
appropriate adjustment of therapy to prevent hypoglycemia or reduce its frequency and severity in patients prone
to hypoglycemia (e.g., the elderly and patients with T1D).
In T2D, hypoglycemia typically occurs in association with
use of exogenous insulin, sulfonylureas (especially glyburide) (189 [EL 1; MRCT]), and glinides; symptoms may
be mild, moderate, or severe. The risk of hypoglycemia
may be further increased by the addition of other antihyperglycemic agents to sulfonylureas or insulin. Therefore,
in adults with T2D, treatment strategies should emphasize
classes of pharmaceutical agents that are not associated
with severe hypoglycemia, many of which are available
(Table 9). Also, the role of hypoglycemia must be considered in determining ideal A1C goals for each patient. These
issues are reviewed in the AACE algorithm for T2D (4 [EL
4; NE]).
SMBG is an important tactic to help patients document hypoglycemia, although it is essential that the glucose meter meet accuracy standards. CGM may be useful
in patients with recurrent asymptomatic hypoglycemia
(hypoglycemia unawareness) (179 [EL 4; NE]).
Patients who have marked swings in glucose levels
are particularly susceptible to hypoglycemia unawareness.
This condition can be reversed by a period of therapy that
dampens glycemic excursions and hypoglycemia avoidance (190 [EL 2; NRCT]; 191 [EL 3; SCR]).
4.Q7. How is Hypertension Managed in
The majority of persons with T2D either have uncontrolled hypertension or are on treatment for elevated blood
pressure (192 [EL 3; SS]). Hypertension is not only more
prevalent in persons with T2D than in the general population, it also predicts progression to DM. Once diagnosed
with hypertension, an individual is 2.5 times more likely
to be diagnosed with DM within the next 5 years (193
[EL 2; PCS]; 194 [EL 4; review NE]). The combination
of hypertension and DM magnifies the risk of DM-related
complications. The UKPDS demonstrated that hypertension treatment decreased both micro- and macrovascular complications of DM (195 [EL 1; RCT]). This study
showed that each 10 mm Hg decrease in systolic blood
pressure (achieved with either an ACE inhibitor [captopril] or an -adrenergic blocker [atenolol]) was associated
with a 15% reduction in rates of DM-related mortality, an
11% reduction in myocardial infarction, and a 13% reduction in the microvascular complications of retinopathy or
nephropathy (196 [EL 2; PCS]).
Subsequent trials that have included large numbers
of persons with DM, including the HOT (Hypertension
Optimal Treatment) trial (197 [EL 1; RCT]), the HOPE
(Heart Outcomes Prevention Evaluation) study (198 [EL
1; RCT]), the LIFE (Losartan Intervention for Endpoint
Reduction in Hypertension) study (199 [EL 1; RCT]),
and ALLHAT (Antihypertensive and Lipid-Lowering
Treatment to Prevent Heart Attack Trial) (200 [EL 1;
RCT]), have demonstrated that blood pressure control
improves cardiovascular outcomes when aggressive blood
pressure targets are achieved. Numerous other studies have
also demonstrated decreased nephropathy and retinopathy progression. Based on these data, the Seventh Joint
National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7), AACE,
and ADA previously recommended that blood pressure in
DM be controlled to <130/80 mm Hg (201 [EL 4; NE]; 202
[EL 4; CPG NE]; 203 [EL 4; NE]; 204 [EL 4; NE]).
However, the target for blood pressure lowering
remains somewhat controversial as clinical trial data to support the level of 130/80 mm Hg are sparse. Epidemiologic
data suggest no evidence of a threshold for adverse outcomes, with a normal blood pressure level <115/75 mm
Hg (205 [EL 4; review NE]). Clinical trial data show that
intensifying therapy with blood pressure-lowering medications slows the progression of nephropathy and retinopathy (195 [EL 1; RCT]; 196 [EL 2; PCS]; 206 [EL 1; RCT,
questionnaires and other variables may have confounded]).
Neither the ACCORD blood pressure trial nor subanalyses
of other large blood pressure trials have shown that targeting a systolic blood pressure <120 mm Hg (compared with
<140 mm Hg) has any impact on the standard composite
outcome of fatal and nonfatal major cardiovascular events
in persons with DM, although stroke was significantly
reduced (HR 0.59; 95% CI, 0.39 to 0.89; P = .01) (207 [EL
1; RCT]). Thus, data from prospective RCTs do not support
a positive effect of blood pressure targets below 130/80
mm Hg on cardiovascular outcomes. Consequently, various recently published guidelines from different societies
have generally recommended a blood pressure target for

persons with DM of <140/80 to 90 mm Hg, with an option
to individualize to the lower target of <130/80 mm Hg (8
[EL 4; NE]; 208 [EL 4; NE]; 209 [EL 4; NE]; 210 [EL 4;
NE]; 211 [EL 4; NE]; 212 [EL 4; NE]).
Once the diagnosis of hypertension is established, the
data are clear that blood pressure lowering prevents both
micro- and macrovascular complications associated with
DM. Analysis of the UKPDS data suggests that blood pressure lowering should be the first priority in managing a
patient presenting with newly diagnosed hypertension and
DM. While glucose and lipid management remain important, blood pressure lowering will have the greatest and
most immediate impact on morbidity and mortality (195
[EL 1; RCT]; 206 [EL 1; RCT, questionnaires and other
variables may have confounded]).
Accurate measurement of blood pressure remains fundamental to the diagnosis and effective management of
hypertension (8 [EL 4; NE]). The equipment, which can
be aneroid, mercury, or electronic, should be inspected
and validated on a regular maintenance schedule. Initial
training and regularly scheduled retraining in the standardized technique provides consistency in measurements. The
patient must be properly prepared and positioned; blood
pressure should be measured after being seated quietly
for at least 5 minutes in a chair (rather than on an exam
table), with feet on the floor and arm supported at heart
level. Caffeine, exercise, and smoking should be avoided
for at least 30 minutes prior to measurement. Measurement
of blood pressure in the standing position is indicated periodically, especially in those at risk for postural hypotension. An appropriately sized cuff (cuff bladder encircling
at least 80% of the arm) should be used to ensure accuracy.
At least 2, and preferably 3, measurements should be made
and the average recorded.
While 24-hour ambulatory blood pressure monitoring
(ABPM) is not included as part of the diagnostic criteria
for hypertension, it has become an important tool for guiding patient management. Patients whose 24-hour ABPM
mean blood pressure exceeds 135/85 mm Hg are nearly
twice as likely to have a cardiovascular event as those
with values that remain <135/85 mm Hg, irrespective of
the level of the office blood pressure (213 [EL 4; review
NE]). Routine use of ABPM, at least annually, should be
considered for the evaluation of white coat hypertension,
masked hypertension, and nighttime nondipping status, all
of which are associated with increased long-term morbidity and mortality.
Blood pressure targets are based upon the combination of data from clinical trials and epidemiology studies
and should be individualized for patients with consideration of their anticipated lifespan and risk factors for heart
disease and stroke (e.g., presence of metabolic syndrome,
smoking, and evidence of end organ damage). In the presence of multiple risk factors, consideration can be given to
an intensive goal of <120/80 mm Hg, provided it can be

attained safely, with a less intense goal of <130/80 mm Hg
in patients with complicated comorbidities and/or medication side effects. Frequent reassessment is needed to ensure
that the blood pressure goal is maintained without unacceptable adverse effects. If side effects develop, consideration should be given to reducing dosage and/or changing
the class of medication. If such changes do not alleviate
symptoms, consideration should be given to relaxing the
target to the higher level of <140/80 to 90 mm Hg, which
will still provide cardiovascular protection.
The selection of medications can be guided by diseaseand ethnic-specific considerations. Clinical trials with
diuretics, ACE inhibitors, ARBs, -adrenergic blockers,
and calcium antagonists have a demonstrated benefit in the
treatment of hypertension in both T1D and T2D (Table 13)
(8 [EL 4; NE]; 197 [EL 1; RCT]; 198 [EL 1; RCT]; 199 [EL
1; RCT]; 214 [EL 1; RCT, posthoc analysis]). Whether any
class is superior to another is no longer considered when
choosing therapy because most patients with DM will need
at least 2 to 4 drugs to achieve target blood pressure. The
choice of pharmacologic agents is guided by additional
considerations such as the presence of albuminuria, CVD,
heart failure, or postmyocardial infarction status; possible
metabolic side effects; number of pills per day; and cost.
Early in the disease process, the primary concerns will be
slowing of nephropathy and retinopathy while minimizing
impact on triglycerides (Table 13). As heart disease develops, consideration of cardiovascular benefits factor into the
choice of agents for blood pressure lowering; given that
diastolic heart disease develops early in T2D, the use of
ARBs could be considered earlier, before the diagnosis of
systolic heart failure. However, the combination of multiple RAAS blockers (i.e., ACE inhibitor, ARB, and/or renin
inhibitor) should generally be avoided (215 [EL 1; RCT];
216 [EL 4; NE]).
The UKPDS study group performed a 10-year posttrial
monitoring observational study that demonstrated a loss of
benefit within 2 years if tight blood pressure control was
not maintained (206 [EL 1; RCT, questionnaires and other
variables may have confounded]). These data reinforce
the imperative to initiate blood pressure-lowering therapy
with continued reinforcement to maintain compliance with
therapy. The introduction of fixed-dose combination tablets combining 2 or 3 agents in 1 pill has facilitated patient
compliance and adherence with multidrug regimens and
should be encouraged as part of initial therapy. The use
of multiple fixed-dose combination tablets can provide a
4-drug regimen with just 2 tablets, thus allowing a patient
to reach their blood pressure goal while optimizing compliance with therapy. ABPM should be utilized to guide blood
pressure management because it allows assessment of the
patients blood pressure variability, thus facilitating medication adjustments to develop an appropriate individualized treatment regimen and avoid overtreatment.
4.Q8. How is Dyslipidemia Managed in

4.Q8.1. Lipid Targets
Treatment targets for dyslipidemia in DM are based
on the presence of ASCVD risk factors including hypertension, a family history of ASCVD, low HDL-C, and
smoking, as well as serum levels of LDL-C, other lipids,
lipoproteins, or lipoprotein components (Table 7). T2D
carries a high lifetime risk for developing ASCVD, so risk
should be stratified as moderate (patients <40 years of age,
no major risk factors) or high (1 major risk factors). A
potential third category of very high risk (patients with
T2D and established ASCVD) could also be considered.
Risk stratification in this manner can guide management
strategies. In patients at high or very high risk for ASCVD,
the goals for LDL-C, non-HDL-C, and ApoB should be
<70 mg/dL, <100 mg/dL, and <80 mg/dL, respectively. In
patients at moderate risk, the respective goals should be
<100 mg/dL, <130 mg/dL, and <90 mg/dL (4 [EL 4; NE];
7 [EL 4; CPG NE]; 217 [EL 3; SS]). Other targets include
a triglyceride concentration <150 mg/dL in all patients,
and LDL-P <1,200 nmol/L in patients at moderate risk and
<1,000 nmol/L in those at high risk (4 [EL 4; NE]; 7 [EL
4; CPG NE]).
4.Q8.2. Managing Dyslipidemia
A thorough review of the management of dyslipidemia
can be found in the 2012 AACE Guidelines for Management
of Dyslipidemia and Prevention of Atherosclerosis (218
[EL 4; NE]), and updated targets are discussed in the 2015
AACE Comprehensive Diabetes Management Consensus
Statement (4 [EL 4; NE]). In prediabetes and DM, multiple disturbances in lipoprotein metabolism result from
the combined effects of insulin deficiency, insulin resistance, and hyperglycemia. T2D dyslipidemia is characterized by increased levels of triglyceride-rich lipoproteins
(very low-density lipoprotein, intermediate-density lipoprotein, and remnant particles), low levels of HDL-C, and
increased levels of small, dense LDL-P (219 [EL 4; review
NE]). Hypertriglyceridemia is thus indirectly linked with
changes in HDL-C and LDL-C composition that are conducive to accelerated atherogenesis (220 [EL 4; review
NE]). Patients who have T1D with persistent proteinuria
are at particularly increased risk of premature atherosclerosis (221 [EL 4; NE]). However, the rising prevalence of
overweight and obesity may contribute to increased rates
of the lipid and lipoprotein pattern related to insulin resistance among prediabetic individuals and those with T2D
(222 [EL 1; RCT]).
4.Q8.3. Dyslipidemia Screening and Follow-Up
(7 [EL 4; CPG NE])
Screen all adult patients with yearly fasting lipid
profile: total cholesterol, triglycerides, HDL-C, and
LDL-C.
If not at goal, lipid profiling should be repeated more

frequently after initiation of treatment. ApoB determination may also be useful to confirm goal attainment
but is not recommended for routine screening (4 [EL
4; NE]; 218 [EL 4; NE]).
LDL-C and calculated non-HDL-C (total cholesterol
HDL-C) are the primary targets of therapy, with
respective goals set according to risk levels (Table 7).
If LDL-C is at goal but non-HDL-C is above goal, consider additional LDL-C or triglyceride-lowering therapies (preferably first with maximally tolerated statin
therapy). Once both LDL-C and non-HDL-C targets
have been achieved, consider evaluation of secondary
targets, either ApoB or LDL-P, and treat accordingly
(218 [EL 4; NE]) (4 [EL 4; NE]).
Additional biomarkers, including high sensitivity
C-reactive protein (hs-CRP), lipoprotein(a), and lipoprotein-associated phospholipase A2 (LpPLA2), are
independent risk factors shown to increase ASCVD
risk. Measuring these biomarkers may enhance understanding of an individual patients risk for consideration of more aggressive therapy (218 [EL 4; NE]).
4.Q8.4. Dyslipidemia Therapeutic Recommendations

All patients should receive information about physical activity recommendations, a meal plan designed to
improve glucose and lipids, and cardiovascular risk reduction strategies. Consultation with a CDE is desirable (7 [EL
4; CPG NE]; 223 [EL 1; RCT]).

CARDS (Collaborative Atorvastatin Diabetes Study),
an RCT involving patients with T2D plus hypertension,
smoking, retinopathy, and/or microalbuminuria, demonstrated the benefits of statin therapy for primary prevention of CVD in patients with DM (224 [EL 1; RCT]).
To date, no RCT dedicated solely to patients with DM
has examined CVD secondary prevention. However,
several trials with large DM subpopulations, including
the GREACE (Greek Atorvastatin and Coronary-HeartDisease Evaluation), TNT (Treating to New Targets), and
PROVE-IT (Pravastatin or Atorvastatin Evaluation and
Infection Therapy) trials, have shown significant reductions in mortality and CVD events (225 [EL 1; RCT];
226 [EL 1; RCT]; 227 [EL 1; RCT, retrospective study]).
Therefore, in high-risk patients with DM who have had a
prior ASCVD event or those who have DM plus at least 1
additional major ASCVD risk factor (hypertension, family history of ASCVD, low HDL-C, or smoking), a statin
should be started along with therapeutic lifestyle changes
regardless of baseline LDL-C level (7 [EL 4; CPG NE];
228 [EL 1; MRCT]; 229 [EL 1; MRCT]). Lipids should be
rechecked within 12 weeks. If the LDL-C or non-HDL-C
concentration remains >70 mg/dL or >100 mg/dL, respectively, the statin dosage should be titrated with the goal of
lowering LDL-C to <70 mg/dL and non-HDL-C to <100
mg/dL (Table 7). If these targets cannot be achieved with
maximally tolerated statin therapy, the goal should be to
reduce LDL-C by >50%; more potent statins can reduce
LDL-C up to 60% (7 [EL 4; CPG NE]; 218 [EL 4; NE]).
Table 13
Suggested Priority of Initiating Blood Pressure-Lowering Agents
Therapy
Reference
(evidence level and study design)
Evidence based
RAAS blockers (ACE inhibitor or ARB)
(198 [EL 1; RCT]; 199 [EL 1; RCT])
Thiazide diuretic
(194 [EL 4; review NE])
-Adrenergic blocker
(199 [EL 1; RCT])
Individualized therapy
Calcium channel blockers
(214 [EL 1; RCT, posthoc analysis])
Aldosterone receptor blockers
(202 [EL 4; CPG NE])
Direct renin inhibitor

Selective 1-adrenergic blockers
Central 2 agonists
Direct vasodilators
Abbreviations: ACE = angiotensin-converting enzyme; ARB = angiotensin II receptor blocker;
RAAS = renin-angiotensin-aldosterone system.
Measurement of ApoB may be useful in some cases to

confirm an ApoB goal of <80 mg/dL (or LDL-P <1,000
nmol/L), even if LDL-C is 70 mg/dL (218 [EL 4; NE]).
The combination of a statin with another lipid-lowering
agent may be required to achieve these targets.
The moderate risk category describes persons with
DM without known ASCVD or any of the other major
cardiovascular risk factors (hypertension, family history,
low HDL-C, smoking). In such patients, treatment should
begin with therapeutic lifestyle changes for an initial 6- to
8-week trial. Goals for the primary targetsLDL-C and
non-HDL-Care <100 mg/dL and <130 mg/dL, respectively (212 [EL 4; NE]; 223 [EL 1; RCT]; 224 [EL 1; RCT];
230 [EL 1; RCT]). The secondary targets ApoB (<90 mg/
dL) or LDL-P (<1,200 nmol/L) may also be considered.
When goals of therapy are not achievable, for whatever
reason, a 30 to 50% reduction in LDL-C is desirable. For
patients older than 40 years without diagnosed ASCVD but
who have 1 additional major ASCVD risk factor, statin
therapy may be considered even if the LDL-C concentration is <100 mg/dL (212 [EL 4; NE]; 223 [EL 1; RCT]; 224
[EL 1; RCT]; 230 [EL 1; RCT]). In patients younger than
40 years, initiation of statin therapy for primary prevention
of CVD in both males and females needs to be individualized, based on other risk factors and comorbidities. The use
of various 10-year or life-time risk calculators is an option
to decide the intensity of treatment, but currently available
risk calculators lack sufficient accuracy and are limited by
discrepancies between predicted and observed event rates
(231 [EL 4; NE]; 232 [EL 4; NE]). In patients with statin
intolerance or unacceptable adverse events, a bile acid
sequestrant (233 [EL 1; RCT]), niacin (234 [EL 1; RCT];
235 [EL 4; review NE]; 236 [EL 1; RCT]), or cholesterol
absorption inhibitor (237 [EL 1; RCT]; 238 [EL 1; RCT])
should be considered alone or in combination. No study
has yet been designed to investigate the cardiovascular
outcomes benefit of adding bile acid sequestrants, niacin,
or cholesterol absorption inhibitors to statins in patients
whose atherogenic markers (LDL-C, non-HDL-C, ApoB,
and LDL-P) are not already at target levels.
In patients with end-stage renal disease (ESRD) or
advanced heart failure, or in those on hemodialysis, no
clear evidence supports an ASCVD benefit from LDLC-lowering therapy (239 [EL 4; NE]; 240 [EL 4; NE]).
Patients with eGFR <60 mL/min/1.73 m2 who are not
dialysis-dependent are at high risk for ASCVD events and
should be managed using the LDL-C, non-HDL-C, and
ApoB goals defined here. Such patients should be monitored closely to determine whether statin dose adjustment
is necessary depending on comorbidities, drug interactions, and renal status (239 [EL 4; NE]; 240 [EL 4; NE]).
In patients with LDL-C at goal but a fasting triglyceride concentration 150 mg/dL or low HDL-C (35 mg/
dL), the following actions should be implemented:
Optimize glycemic control and emphasize weight

loss (if indicated) (7 [EL 4; CPG NE]; 223 [EL 1;
RCT])
Modify, if possible, any medications that may
contribute to hypertriglyceridemia
In patients with fasting triglyceride concentrations of 200 to 499 mg/dL, titrate statin therapy
to maximum tolerated dose to achieve goals for
LDL-C and non-HDL-C as well as the secondary
target (ApoB or LDL-P) (7 [EL 4; CPG NE]; 217
[EL 3; SS]; 241 [EL 2; PCS]); nonstatin therapies
in combination with statins are often required in
these settings
In the setting of persistently elevated fasting triglycerides (>200 mg/dL) against the background
of maximally tolerated LDL-C-lowering therapies, triglyceride-reducing therapies such as a
fibrate, high-dose omega-3 fatty acid, or niacin
may be utilized to further reduce non-HDL-C
(218 [EL 4; NE]; 242 [EL 4; consensus]; 243 [EL
4; review NE]; 244 [EL 3; SS]; 245 [EL 1; RCT];
246 [EL 3; SS])
If the fasting triglyceride concentration is 500
mg/dL (i.e., severe hypertriglyceridemia), begin
treatment with a very low-fat diet and reduced
intake of simple carbohydrates and initiate a
fibrate, high-dose omega-3-fatty acid, and/or niacin. All 3 of these triglyceride-lowering therapies
may be required in combination in patients with
severe hypertriglyceridemia (247 [EL 4; review
NE]). No RCT has yet been designed to investigate the additive benefit of reducing severe
hypertriglyceridemia to prevent pancreatitis.
Observational data and retrospective analyses,
however, do support triglyceride-lowering therapy for prophylaxis against or treatment of acute
pancreatitis (248 [EL 4; NE]; 249 [EL 3; SS]).
Rule out other secondary causes and reassess
lipid status when the triglyceride concentration is
<500 mg/dL (235 [EL 4; review NE]; 250 [EL 4;
NE]). Additional statin therapy and possibly other
agents are usually required to achieve the primary
LDL-C and non-HDL-C goals (235 [EL 4; review
NE]), as well as secondary goals for ApoB or
LDL-P, for the purpose of cardiovascular event
prevention (248 [EL 4; NE]; 249 [EL 3; SS]). No
RCT has yet been designed to investigate the benefit of reducing severe (triglycerides >500 mg/dL)
or moderate (>200 mg/dL) hypertriglyceridemia
to prevent CVD.

Modification of triglycerides with the proliferatoractivated receptor- agonist fenofibrate failed to reduce
ASCVD events in 2 separate trials in patients with T2D:
FIELD (Fenofibrate Intervention and Event Lowering in

Diabetes) (251 [EL 1; RCT]) and ACCORD-Lipid (245
[EL 1; RCT]). The mean baseline triglyceride levels were
153 mg/dL in FIELD (251 [EL 1; RCT]) and 162 mg/dL
in ACCORD-Lipid (245 [EL 1; RCT]). Posthoc and prespecified subgroup analyses and meta-analyses of 5 major
fibrate trialsHHS (Helsinki Heart Study), VA-HIT
(Veterans Affairs HDL Intervention trial), BIP (Bezafibrate
Infarction Project), FIELD, and ACCORD-Lipidhave
shown a cardiovascular benefit in patients with moderate
dyslipidemia (triglycerides >200 mg/dL and HDL-C <40
mg/dL, either isolated or together) but not in patients without dyslipidemia (218 [EL 4; NE]; 252 [EL 4; NE]; 253
[EL 1; MRCT]; 254 [EL 1; MRCT]; 255 [EL 4; NE]).

Two separate RCTs tested the HDL-C-raising hypothesis in patients with coronary artery disease optimally
treated with statins with or without ezetimibe. In AIMHIGH (Atherothrombosis Intervention in Metabolic
Syndrome with Low HDL/High Triglycerides: Impact on
Global Health Outcomes), the atherogenic markers LDLC, non-HDL-C, and ApoB were 74, 108, and 81 mg/dL,
respectively, prior to randomization (256 [EL 1; RCT]).
Before randomization in HPS2-THRIVE (Heart Protection
Study 2Treatment of HDL to Reduce the Incidence of
Vascular Events), LDL-C, non-HDL-C, and ApoB were
63, 84, and 68 mg/dL, respectively, and triglyceride and
HDL-C levels were 120 mg/dL and 44 mg/dL, respectively
(257 [EL 1; RCT]). In each of these trials, the addition of
niacin resulted in small improvements in lipids, but these
changes were not accompanied by any significant reduction
in ASCVD events (256 [EL 1; RCT]; 257 [EL 1; RCT]).
Thus niacin cannot be recommended as adjunctive therapy
if LDL-C, non-HDL-C, and ApoB goals are already met.
However, in other settings, where the goals of these atherogenic markers have not been met, niacin remains a viable
treatment option.
4.Q8.5. Lipid Management in Prediabetes
The principles and goals of lipid management in
prediabetes are the same as those for DM described
previously (Table 7). No randomized intervention trials dedicated to patients with prediabetes use ASCVD
events as outcome measures. Diet, exercise, and weight
loss or maintenance should be emphasized for all prediabetes patients.

Moderate-potency or high-potency statins, possibly
combined with cholesterol absorption inhibitors or bile
acid sequestrants, are effective for achieving LDL-C,
non-HDL-C, and ApoB or LDL-P goals in prediabetes
(7 [EL 4; CPG NE]). Low HDL-C is also common in
prediabetes. Low HDL-C and high triglycerides are both
associated with increased levels of LDL-P. Niacin is
effective in raising HDL-C, but it also increases insulin
resistance and may accelerate the appearance of overt
DM. Fibrates may be considered, but the use of gemfibrozil is discouraged owing to its interaction with statin
clearance and the risk for severe rhabdomyolysis.

Meta-analyses of statin RCTs indicate that statin use
is associated with significant increases in the risk of progression to T2D among patients with prediabetes: a 9%
increase with moderate statin dosing and 12% increase
with intensive statin dosing (258 [EL 1; MRCT]; 259
[EL 1; MRCT]). Patients with prediabetes should be
warned of the potential added risk of conversion to DM
with statin use. The net comparison of benefit versus
risk is >4 ASCVD events prevented for 1 conversion
from prediabetes to DM (260 [EL 4; NE]). A thorough
risk-benefit analysis, taking into account the patients
individual risk of converting to DM versus prevention
of ASCVD, should be discussed with the patient.
4.Q9. How is Nephropathy Managed in

Diabetic nephropathy accounts for 40 to 50% of all
cases of ESRD in the U.S. and occurs in about 40% of
patients with DM, increasing with age (261 [EL 3; SS]).
Diabetic nephropathy is represented histologically by the
presence of basement membrane thickening, mesangial
expansion, podocyte loss, and nodular or diffuse glomerulosclerosis (262 [EL 4; NE]). The pathologic changes,
which modestly correlate with the degree of kidney injury
as measured by blood and urine tests, are typically present before functional tests are positive (262 [EL 4; NE]).
Consequently, prevention of microvascular complications
such as nephropathy should be started upon diagnosis of
DM and be intensified in those with evidence of kidney
damage. Guidelines for the diagnosis and management
of CKD in patients with DM have recently been updated
by the Kidney Disease: Improving Global Outcomes
(KDIGO) working group (263 [EL 4; NE]) and the Kidney
Disease Outcomes Quality Initiative (KDOQI) Committee
(264 [EL 4; NE]). The AACE concurs with both guidelines
in general.
The KDIGO guidelines recommend phasing out the
term microalbuminuria and replacing it with the term albuminuria. Testing for the presence of albuminuria can be
done using a spot urine sample or a timed collection. AER
levels >30 mg/g creatinine or 30 mg/day indicate kidney
damage and are also a marker of cardiovascular risk (263
[EL 4; NE]; 264 [EL 4; NE]). Urinary albumin may be seen
in the setting of urinary tract or systemic infection, after
exercise, or in the presence of hematuria, so confirmation is
necessary to establish the diagnosis of diabetic nephropathy. An AER of >300 mg/g creatinine or >300 mg/day indicates greater damage and greater risk for progression of
renal insufficiency, anemia, CVD, and infections. Sudden
onset or rapidly increasing AER should prompt additional
tests to rule out other kidney diseases. Table 14 lists correlations between AER, urine dipstick, and tests of total
protein excretion.
GFR should be estimated from a creatinine-based
calculation such as the Modification in Renal Disease
(MDRD) or Chronic Kidney Disease Epidemiology (CKDEPI) equations. The CKD-EPI equation is more accurate
for calculation of eGFR above 60 mL/min/1.73 m2, and
this equation is currently preferred (263 [EL 4; NE]).
However, most laboratories report a calculated eGFR using
the MDRD when eGFR is <60 mL/min/1.73 m2. Figure 2
depicts the new classification system for CKD in patients
with DM that incorporates both eGFR and albuminuria in
the risk assessment. Note that in Figure 2, stage 3 CKD has
been divided into 2 categories, G3a for eGFR 45 to 60 mL/
min/1.73 m2 and G3b for eGFR 30 to 45 mL/min/1.73 m2.
The terminology used to describe CKD provides a composite picture by integrating the cause, eGFR, and AER.
For example, a patient with DM, an eGFR of 40 mL/
min/1.73 m2, and an AER of 250 mg/g creatinine would be
categorized as diabetes/G3b/A2. The heat grid shown
in Figure 2 indicates the new terminology, the level of risk

for cardiovascular events and progression of kidney disease by color intensity, and the recommended frequency
for monitoring renal parameters (263 [EL 4; NE]; 265 [EL
2; MNRST]; 266 [EL 4; NE]). Progression of CKD is classified as rapid if the decline in eGFR is 5 mL/min per
1.73 m2 per year or if the patient has a dramatic increase
in AER.
Prevention of the development of diabetic nephropathy includes optimal control of plasma glucose (A1C goal
<6.5% unless limited by hypoglycemia), blood pressure
control with RAAS inhibition as first-line therapy, treatment of hyperlipidemia, and smoking cessation (264
[EL 4; NE]). Intensive glucose control (A1C levels <7%
in T2D and <7.5% in T1D) in several early intervention
studies reduced the risk of incident albuminuria (A2) and
progression of AER to proteinuria (47 [EL 1; RCT]; 51
[EL 1; RCT]; 57 [EL 1; RCT]; 68 [EL 1; RCT]; 69 [EL 1;
RCT]). Intensive glucose control has not been shown to
diminish the progression of diabetic nephropathy or cardiovascular mortality in patients with advanced CKD, but
Table 14
Relationship Among Categories For Albuminuria and Proteinuria (263 [EL 4; NE])a,b
Categories
Measure
Normal to mildly
increased (A1)
Moderately
increased (A2)
Severely
increased (A3)
AER (mg/24 hours)
<30
30-300
>300
PER (mg/24 hours)
<150
150-500
>500
ACR
(mg/mmol)
<3
3-30
>30
(mg/g)
<30
30-300
>300
PCR
(mg/mmol)
<15
15-50
>50
(mg/g)
<150
150-500
>500
Negative to trace
Trace to +
+ or greater
Protein reagent strip
Abbreviations: ACR = albumin-to-creatinine ratio; AER = albumin excretion rate; PCR = protein-tocreatinine ratio; PER = protein excretion rate.
a Reprinted with permission from Macmillan Publishers Ltd: Kidney International Supplement.
2013;3(1):1-150, copyright 2013.
b Albuminuria and proteinuria can be measured using excretion rates in timed urine collections, ratio
of concentrations to creatinine concentration in spot urine samples, and using reagent strips in spot
urine samples. Relationships among measurement methods within a category are not exact. For
example, the relationships between AER and ACR and between PER and PCR are based on the
assumption that average creatinine excretion rate is approximately 1.0 g/d or 10 mmol/day. The
conversions are rounded for pragmatic reasons. (For an exact conversion from mg/g of creatinine
to mg/mmol of creatinine, multiply by 0.113.) Creatinine excretion varies with age, sex, race and
diet; therefore the relationship among these categories is approximate only. ACR <10 mg/g (<1 mg/
mmol) is considered normal; ACR 10-30 mg/g (1-3 mg/mmol) is considered high normal. ACR
>2,200 mg/g (>220 mg/mmol) is considered nephrotic range. The relationship between urine
reagent strip results and other measures depends on urine concentration.
these patients have an increased risk of hypoglycemia, so

glycemic targets and therapies may need to be modified as
diabetic nephropathy progresses.

The KDIGO guidelines recommend that patients without albuminuria be treated to a blood pressure <140/90 mm
Hg, but <130/80 mm Hg in the presence of albuminuria
(267 [EL 4; NE]). Although care must be taken to avoid
orthostasis and drug side effects, AACE recommends individualized blood pressure targets, with a goal of about
130/80 mm Hg for most patients (see Q7. How is hypertension managed in patients with diabetes?).

Smoking cessation and lipid lowering are also important interventions for prevention of cardiorenal complications of DM, which are increased at every level of CKD
(265 [EL 2; MNRST]). Therapy with statins reduces the
relative risk of major vascular events in patients with DM
by 17% for every 39 mg/dL decrease in LDL-C (228 [EL
1; MRCT]). Patients with DM and CKD up to stage 4,
including posttransplant patients, benefit from lipid lowering with statins. However, the beneficial effect of statins is
lost in patients who require dialysis (228 [EL 1; MRCT];
268 [EL 1; RCT]; 269 [EL 1; MRCT]; 270 [EL 1; RCT];
271 [EL 1; MRCT]).

Slowing the progression of kidney dysfunction is critical for patient survival and quality of life. Therapies shown
to positively affect AER and declining eGFR include ACE
inhibitors and ARBs. Consequently, T1D and T2D patients
with albuminuria should be treated with an ACE inhibitor
or ARB at the highest tolerated dose (198 [EL 1; RCT]; 272
[EL 1; RCT]). Data are lacking on the effectiveness of ACE
inhibitor and ARBs in patients with DM and reduced eGFR
who do not have albuminuria. However, AACE recommends RAAS blockade in all patients with DM who have
CKD categories G2, G3a, G3b, and if slow progression is
demonstrated, category G4. The RAAS-blocking drugs
may potentiate hyperkalemia and may cause harm when
used with nonsteroidal anti-inflammatory drugs (NSAIDs)
or in patients with renovascular hypertension or dehydration. They are not safe for use in pregnancy. Combination
therapy with an ACE inhibitor and ARB or with a renin
inhibitor added to 1 of the other RAAS-blockading agents
does not prolong survival or prevent progression of CKD
(216 [EL 4; NE]; 273 [EL 1; RCT]; 274 [EL 1; RCT]). In
patients with advanced CKD (G3b and higher), combination therapy increases the risk of hyperkalemia and acute
kidney injury and is therefore not recommended (216 [EL
4; NE]; 274 [EL 1; RCT]; 275 [EL 4; review NE]). Data on
the use of aldosterone antagonists with ACE inhibitors or
ARB classes is limited, but the same cautions apply.

If the GFR continues to decline despite excellent glycemic and blood pressure control, protein restriction may
be of some benefit. KDIGO recommends limiting protein
intake to 0.8 g/kg per day (approximately 10% of daily calories) in patients with progressive diabetic nephropathy or
eGFR <30 mL/min/1.73 m2. Additional dietary restrictions
may be required to control potassium and phosphorus

levels. Salt intake should be limited to 2 g per day in all
patients with DM who require antihypertensive medications. Obesity is a risk factor for hypertension and incident
CKD, so weight loss along with exercise is recommended
for patients with DM without evidence of kidney disease as
well as patients with category G2 to G4 CKD. Unintended
weight loss is associated with poorer outcomes in dialysis
patients.
Patients with CKD are at risk for drug toxicity and
acute kidney injury. Antihyperglycemic therapies should
be modified to reduce excessive drug exposure and hypoglycemia (276 [EL 3; CSS]). Many other drugs should
be avoided or used with caution in patients with CKD.
Patients should be informed of their CKD diagnosis and
should avoid dehydration and imaging that requires gadolinium, high phosphate-containing bowel preparations, or
high doses of iodinated contrast dyes.
Patients with diabetic nephropathy should undergo
annual or more frequent assessment of electrolytes to assess
potassium and acid-base status; blood counts to assess anemia status; and calcium, phosphorus, vitamin D, and parathyroid hormone (PTH) measurements to assess mineral
metabolism (263 [EL 4; NE]). Hyperkalemia is managed
by dietary restriction and adjustment of antihypertensive
medications. For those with a bicarbonate level <22 mEq/L,
the addition of oral sodium bicarbonate is recommended
to correct the acidosis. Anemia, defined as hemoglobin
(Hb) <13 g/dL in males and <12 g/dL in females, should
be further investigated with iron, transferring saturation
(TSAT), ferritin, vitamin B12, and folate levels (277 [EL 4;
NE]). Deficiencies should be replaced, and a TSAT target
of 30% achieved, regardless of ferritin level (277 [EL 4;
NE]). Iron given intravenously may produce better results
than oral replacement. AACE recommends adequate calcium intake and achievement of 25(OH)D3 levels of >30
ng/dL in all patients. Supplementing vitamin D2 or D3 may
reduce PTH without causing harm (277 [EL 4; NE]; 278
[EL 3; SS]). Active vitamin D preparations may be necessary to keep the PTH level from increasing as kidney function declines. Hyperphosphatemia should be corrected into
the normal range with dietary modification and judicious
use of phosphate binders.
Referral to a nephrologist is appropriate when the
presentation is atypical, progression of albuminuria or
decline in eGFR is rapid, or when secondary manifestations of CKD require expert advice. Referral of patients
with stage 4 CKD to a nephrologist allows time for sufficient planning to accommodate individual patient needs
(279 [EL 4; opinion NE]). Renal transplantation is the
preferred replacement therapy for patients with DM and
ESRD because long-term outcomes are superior to those
achieved with dialysis. For patients with T1D, the possibility of combined kidney-pancreas transplantation allows for
considerably better outcomes (280 [EL 2; PCS]).
4.Q10. How is Retinopathy Managed in


Diabetic retinopathy is the leading cause of blindness
in adults. The lesions of diabetic retinopathy include background or nonproliferative retinopathy, macular edema,
preproliferative retinopathy, and proliferative retinopathy.
Approximately 50% of patients with T1D develop background retinopathy after 7 years, and most have some form
of retinopathy after 20 years (281 [EL 4; review NE]).
Diabetic retinopathy is present in 25 to 45% of patients
with T2D, and between 2 and 8% of patients with T2D
have proliferative retinopathy and/or macular edema (282
[EL 3; SS]). Diabetic retinopathy is present in approximately 20, 40, and 70% of patients with T2D after <10,
10 to 20, and >20 years of the disease, respectively, with
prevalence rates of proliferative retinopathy and/or macular edema around 2, 10, and 25% at the respective durations (283 [EL 2; MNRCT]). Higher levels of glucose and
blood pressure, as well as the presence of nerve and renal
diabetic complications, are associated with greater likelihood of developing retinopathy (284 [EL 3; SS]).

The goal is to detect clinically significant retinopathy before vision is threatened. Funduscopy performed
by internists or endocrinologists is often suboptimal;
therefore, referral to an experienced ophthalmologist for
an annual dilated eye examination is recommended (285
[EL 2; MNRCT]). The complete ophthalmologic examination can also detect other common conditions such as
cataracts, glaucoma, and macular degeneration. The use of
nonmydriatic fundus cameras equipped with digital transmission technology enables large-scale, POC screening for
retinopathy (286 [EL 3; SS]). Patients with abnormal retinal photographs are then triaged to full examination by an
ophthalmologist. This 2-step approach can be an efficient
strategy for retinopathy screening at the population level,
particularly in remote areas (287 [EL 3; SS]). However, the
system is still under development and does not replace the
current recommendation for an annual dilated eye examination by an ophthalmologist from the time of diagnosis
because of the lag between onset and diagnosis of T2D
(288 [EL 3; CSS]). Given the relatively low prevalence
of proliferative retinopathy and/or macular edema in T2D
during the first decade after diagnosis, however, the suggestion is now being made that T2D patients who have had
a negative ophthalmologic examination may safely have
the screening interval increased to 2 years (289 [EL 4; NE];
290 [EL 2; RCCS]). As retinopathy develops over a period
of 5 or more years from initial hyperglycemia, screening
should be initiated within 5 years of diagnosis in patients
with T1D (291 [EL 3; SS]). Pregnancy is a risk factor for
progression of retinopathy, and ophthalmologic examinations should be performed repeatedly during pregnancy
and for 1 year postpartum (292 [EL 2; PCS, longitudinal
follow-up study]). Patients with active lesions may be
followed up more frequently, while those who have had

repeatedly normal eye findings can be seen less frequently.

Optimization of glucose and blood pressure are proven
strategies for primary prevention of diabetic retinopathy
(68 [EL 1; RCT]; 195 [EL 1; RCT]; 196 [EL 2; PCS]; 293
[EL 2; PCS]). Good control of glycemia and blood pressure
are also effective in slowing the progression of pre-existing
background retinopathy.
There is, in addition, evidence that certain pharmacologic treatment approaches may have specific benefit in
diabetic retinopathy, including ACE inhibitors, ARBs (294
[EL 1; RCT]; 295 [EL 1; RCT]), and fibrate lipid-lowering
agents (56 [EL 1; RCT]; 296 [EL 1; RCT, substudy]; 297
[EL 2; RCCS]). Research into other novel pharmacologic
agents with potential benefits may lead to additional medical treatments (298 [EL 1; RCT, small sample size]).
Panretinal scatter laser photocoagulation is the treatment of choice for high-risk proliferative retinopathy (299
[EL 4; review NE]). For macular edema, the combination of
focal laser photocoagulation with intravitreal antivascular
endothelial growth factor modalities appears to offer optimal benefit (300 [EL 1; MRCT]). Vitrectomy is reserved
for patients with persistent vitreous hemorrhage or significant vitreous scarring and debris (299 [EL 4; review NE]).
4.Q11. How is Neuropathy Diagnosed and
Managed in Patients with Diabetes?
Diabetic neuropathy affects about half of all patients
with DM, contributing to substantial morbidity and mortality and resulting in a huge economic burden for DM care
(301 [EL 4; NE]; 302 [EL 3; SS]). It is the most common
form of neuropathy in developed countries and is responsible for 50 to 75% of nontraumatic amputations (302 [EL
3; SS]; 303 [EL 4; NE]). It is a major cause of falls in older
patients that lead to lacerations, fractures, and traumatic
brain injuries (304 [EL 4; NE]). Diabetic neuropathy is a
set of clinical syndromes that affect distinct regions of the
nervous system, singly or in combination. It may be silent
and go undetected while exercising its ravages, or it may
present with clinical symptoms and signs that, although
nonspecific and insidious with slow progression, also
mimic those seen in many other diseases. Diabetic neuropathy is, therefore, diagnosed by exclusion. Unfortunately
neither endocrinologists nor nonendocrinologists have
been trained to recognize the condition, and even when
diabetic neuropathy is symptomatic, less than one-third of
physicians recognize the cause or discuss this with their
patients (305 [EL 1; RCT]).
Diabetic neuropathy encompasses multiple different disorders involving proximal, distal, somatic, and
autonomic nerves. It may be acute and self-limiting or
a chronic, indolent condition. It may be focal such as a
mononeuritis involving single nerves or entrapment neuropathies (e.g., carpal tunnel syndrome, ulnar entrapment,
and peroneal entrapment, among others). Proximal lumbosacral, thoracic, and cervical radiculoplexus neuropathies
involving the proximal limb girdle are, for the most part,
inflammatory demyelinating conditions requiring immunotherapy and, if caught early, are reversible (306 [EL 4;
NE]; 307 [EL 4; review NE]; 308 [EL 4; position NE];
309 [EL 4; NE]). The distal neuropathies are characteristically symmetric, glove and stocking distribution, lengthdependent sensorimotor polyneuropathies that develop
on a background of long-standing chronic hyperglycemia
superimposed upon CVD risk factors (310 [EL 3; CSS];
311 [EL 2; PCS]; 312 [EL 2; PCS]). They may be acute or
chronic. The acute variety usually occurs within 8 weeks
of initiating intensification of glycemic control with insulin
or oral agents that results in a too-rapid lowering of blood
glucose by >30% or A1C by >2% (313 [EL 2; PCS]; 314
[EL 4; review NE]). There may also be atypical variants
of diabetic neuropathy such as SFNs, which present predominantly with pain and autonomic features (306 [EL 4;
NE]; 315 [EL 2; CSS]). Risk factors include metabolic syndrome (316 [EL 3; CSS]), IFG, and IGT (317 [EL 2; PCS];
318 [EL 3; retrospective chart review SS]). The scope of
diabetic neuropathy is reviewed elsewhere (304 [EL 4;
NE]; 319 [EL 4; review NE]; 320 [EL 4; NE]; 321 [EL 4;
NE]; 322 [EL 4; NE]; 323 [EL 4; NE]; 324 [EL 4; NE]; 325
[EL 1; MRCT]; 326 [EL 4; NE]).
Prevalence rates of neuropathy in DM are between 5
and 100%, depending on diagnostic criteria used (327 [EL
3; CSS]; 328 [EL 3; CSS]). Because of the lack of agreement on the definition and diagnostic assessment of neuropathy, several consensus conferences were convened to
overcome the current problems. The most recent of these
has redefined the minimal criteria for the diagnosis of typical distal symmetric polyneuropathy (DSPN) (305 [EL 1;
RCT]):
1. Possible DSPN. The presence of symptoms or
signs of DSPN, which may include the following:
Symptoms: decreased sensation, positive
neuropathic sensory symptoms (e.g., asleep
numbness, prickling or stabbing, burning, or
aching pain) predominantly in the toes, feet,
or legs
Signs: symmetric decrease of distal sensation
or unequivocally decreased or absent ankle
reflexes
2. Probable DSPN. The presence of a combination
of symptoms and signs of neuropathy including
any 2 or more of the following: neuropathic symptoms, decreased distal sensation, or unequivocally
decreased or absent ankle reflexes
3. Confirmed DSPN. The presence of an abnormality of nerve conduction plus a symptom or symptoms, or a sign or signs, of neuropathy. If nerve
conduction is normal, a validated measure of SFN
(with class 1 evidence) may be used. To assess for
the severity of DSPN, several approaches have

been recommended (329 [EL 4; NE]).
4. Subclinical DSPN. Abnormal nerve conduction
or a validated measure of SFN (with class 1 evidence) without signs or symptoms of neuropathy. Definitions 1, 2, or 3 can be used for clinical
practice, and definitions 3 or 4 can be used for
research studies.
5. SFN should be graded as follows (330 [EL 4;
NE]):
a. Possible: the presence of length-dependent symptoms and/or clinical signs of
small-fiber damage
b. Probable: the presence of length-dependent symptoms, clinical signs of smallfiber damage, and normal sural nerve
conduction
c. Definite: the presence of length-dependent symptoms, clinical signs of smallfiber damage, normal sural nerve conduction, and altered intraepidermal
nerve-fiber density at the ankle and/or
abnormal thermal thresholds at the foot

Several reviews discuss useful approaches to the treatment of the common forms of diabetic neuropathy, as well
as algorithms for pain management, diagnosis, and treatment of the manifestations of autonomic neuropathy (331
[EL 4; review NE]; 332 [EL 4; review NE]). Treatment
guidelines published by the American Academy of
Neurology, Toronto Expert Panel, and European Federation
of Neurological Societies suggest that pregabalin, gabapentin, venlafaxine, duloxetine, tricyclic antidepressants,
and opioids are the drugs with the best evidence to support
their use for painful neuropathy (329 [EL 4; NE]; 333 [EL
4; NE CPG]; 334 [EL 1; NE CPG]). However, no treatments have been approved for the prevention or reversal
of diabetic neuropathy. Even tight glycemic control at
best limits the progression of neuropathy in patients with
T1D, as shown in the DCCT and EDIC (Epidemiology of
Diabetes Interventions and Complications) studies, and
does not affect neuropathy in patients with T2D, as seen in
the ACCORD, UKPDS, and ADVANCE studies (335 [EL
4; NE]).

Large-fiber neuropathies may involve sensory and/
or motor nerves, and most affected patients present with a
glove and stocking distribution of sensory loss (336 [EL 4;
review NE]). Once large-fiber diabetic neuropathy has been
diagnosed, therapy should be initiated to reduce symptoms
and prevent further progression. It is vitally important
to institute measures to prevent foot ulcers that lead to
amputations. In general these are daily inspection, protective socks, appropriate footwear, and avoidance of injury.
Cardinal interventions to prevent falls and fractures are to
improve strength and balance in patients with large-fiber
neuropathy (337 [EL 2; PCS]; 338 [EL 1; RCT]; 339 [EL

1; RCT]). Patients with DM who have large-fiber neuropathies are uncoordinated and ataxic and are 17 times more
likely to fall than their counterparts without neuropathy
(340 [EL 2; RCCS]). Low-impact activities that emphasize
muscular strength and coordination and challenge the vestibular system such as a Bosu ball; use of rubber bands to
strengthen lower limb muscles; and Pilates, yoga, and Tai
Chi to strengthen the body core, may also be particularly
helpful (341 [EL 2; PCS, small sample size]; 342 [EL 2;
PCS, small sample size]).

Small-nerve fiber dysfunction usually occurs early and
is often present without objective signs or electrophysiologic evidence of nerve damage (343 [EL 3; SS]).
Skin punch biopsy, a minimally invasive procedure,
allows morphometric quantification of intraepidermal
nerve fibers. The European Federation of the Neurological
Societies and the Peripheral Nerve Society endorse
intraepidermal nerve fiber quantification to confirm the
clinical diagnosis of SFN with a strong (Level A) recommendation (344 [EL 4; consensus NE]). Intraepidermal
nerve fiber density inversely correlates with both cold and
heat detection thresholds (345 [EL 3; CSS]). Intraepidermal
nerve fiber density is significantly reduced in symptomatic
patients with normal findings from nerve conduction studies and those with metabolic syndrome, IGT, and IFG,
suggesting early damage to small nerve fibers (346 [EL 3;
CSS]; 347 [EL 3; CSS]). Intraepidermal nerve fiber density
is also reduced in painful neuropathy compared with that
observed in painless neuropathy (348 [EL 3; SS]). Diet and
exercise intervention in IGT leads to increased intraepidermal nerve fiber density (349 [EL 2; PCS]). These data suggest that intraepidermal nerve fiber loss is an early feature
of the metabolic syndrome, prediabetes, and established
DM, and the loss progresses with increasing neuropathic
severity. There may be nerve regeneration with treatment.

Noninvasive tests of small nerve fiber function have
recently been recognized. Corneal confocal microscopy
may be used to detect small nerve fiber loss in the cornea.
This technique correlates with neuropathy severity and can
be used to monitor responses to transplantation and other
procedures (347 [EL 3; CSS]). Contact heat-evoked potentials use nociceptive heat as a stimulus, and the response is
recorded through electroencephalographic readings. This
technique can be used to detect SFN in the absence of other
indices (350 [EL 2; NRCT]). Sudomotor function assesses
the sweat response by analyzing sweat production or sweat
chloride concentrations and detects early neurophysiologic
abnormalities in peripheral autonomic function (351 [EL 2;
PCS]).
Strategies for management of SFN include simple
measures that can protect the foot deficient in functional
C fibers from developing ulceration, and therefore, from
gangrene and amputation. Wearing padded socks can promote ulcer healing and/or reduce the likelihood of ulcer
development (352 [EL 2; PCS]). Patients should inspect

the plantar surface of their feet with a mirror on a daily
basis and test bathwater with a part of the body that is not
insensate before submerging a numb foot. Patients should
also be cautioned against falling asleep in front of the fireplace with their insensate feet close to the fire. Emollient
creams can moisturize dry skin and prevent cracking and
infection.

A definition of peripheral neuropathic pain in DM,
adapted from one recently proposed by the International
Association for the Study of Pain (308 [EL 4; position
NE]), is pain arising as a direct consequence of abnormalities in the peripheral somatosensory system in people with
diabetes. It has been estimated that between 3 and 25% of
persons with DM might experience neuropathic pain (353
[EL 4; review NE]). In practice, the diagnosis of neuropathic pain in DM is a clinical one, relying on the patients
description of pain: the symptoms are distal, symmetric,
and associated with nocturnal exacerbations, and they are
commonly described as prickling, deep aching, sharp, electric-shock like, and burning with hyperalgesia (354 [EL 4;
review]). There is frequently allodynia on examination
(353 [EL 4; review NE]; 354 [EL 4; review]). Symptoms
are usually associated with clinical signs of peripheral neuropathy, although occasionally in acute neuropathic pain,
symptoms may occur in the absence of signs. A number
of simple numeric rating scales can be used to assess the
frequency and severity of painful symptoms (353 [EL 4;
review NE]), and other causes of neuropathic pain must
be excluded. Outcome measures to assess response to
therapy should include patient-reported improvements
in the measures and numeric rating scales (355 [EL 4;
review NE]), including the Neuropathic Pain Symptoms
Inventory, the Brief Pain Inventory, and the Neuropathic
Pain Questionnaire. Quality of life improvement should
also be assessed, preferably using a validated neuropathyspecific scale such as NeuroQol or the Norfolk Quality of
Life Scale (356 [EL 3; SS]).

Physicians must be able to differentiate painful diabetic
neuropathy from other unrelated or coexisting conditions.
The most common of these are claudication, Mortons neuroma, Charcot neuroarthropathy, fasciitis, osteoarthritis,
and radiculopathy. The algorithm provided (Fig. 3) distinguishes between the different conditions that can produce
pain and provides recommendations for their management
(314 [EL 4; review NE]; 357 [EL 4; NE]). The FDA has
approved only the serotonin and norepinephrine reuptake
inhibitor duloxetine, the anticonvulsant pregabalin, and
the opioid tapentadol for neuropathic pain, but level 1
evidence also exists to support the use of tricyclic antidepressants (e.g., amitriptyline) and the anticonvulsant gabapentin (358 [EL 1; MRCT]; 359 [EL 1; MRCT]). Recent
studies have shown improvement of pain with an 21
calcium antagonist (360 [EL 1; RCT, posthoc analysis])
and tapentadol, a weak opioid agonist with norepinephrine
Fig. 3. Treatment algorithm for neuropathic pain after exclusion of nondiabetic etiology and stabilization of glycemic control (314 [EL 4;
review NE]; 357 [EL 4; NE]). Reprinted from the Journal of Clinical Endocrinology and Metabolism, Vol. 95, A. Vinik, "The approach to
the management of the patient with neuropathic pain," pp. 4802-4816. Copyright 2010, with permission from Elsevier.
reuptake inhibition, which thereby combines 2 pain relief

mechanisms (361 [EL 1; RCT]). Topical treatment using a
5% lidocaine plaster applied to the most painful area (362
[EL 1; RCT]) is effective in some studies.

Recent studies have highlighted metformin-associated
B12 deficiency, which can lead to neuropathy-like symptoms. These symptoms can be reversed by supplementation with methylcobalamin, the biologically active form of
vitamin B12 (363 [EL 1; RCT]; 364 [EL 4; NE]; 365 [EL 3;
CSS]; 366 [EL 4; NE]). New thresholds for B12 levels have
now been established (364 [EL 4; NE]; 365 [EL 3; CSS]).

Cardiovascular autonomic neuropathy is significantly
associated with overall mortality (367 [EL 4; review NE];
368 [EL 2; MNRCT]) and in some studies, but not all, with
morbidity including silent myocardial ischemia, coronary
artery disease, stroke, diabetic neuropathy progression, and
perioperative morbidity. Some pathogenetic mechanisms
may link cardiovascular autonomic neuropathy to cardiovascular dysfunction and diabetic complications (367 [EL
4; review NE]). Cardiovascular autonomic neuropathy
assessment may be used for cardiovascular risk stratification in patients with and without established CVD, as a
marker for patients requiring more intensive monitoring
during the perioperative period and other physiological
stresses, and as an indicator for more or less intensive

pharmacotherapeutic and lifestyle management of comorbid conditions. Cardiovascular autonomic neuropathy may
be useful for prediction of cardiovascular risk, and a combination of cardiovascular autonomic neuropathy (369 [EL
3; SS]) and symptoms of peripheral neuropathy increase
the odds ratio to 4.55 for CVD and mortality (314 [EL 4;
review NE]). Indeed, this is the strongest predictor of CVD
risk, far greater than blood pressure, lipoprotein profile,
and even adenosine scans (370 [EL 4; NE]). The reported
prevalence of diabetic autonomic neuropathy varies widely
(7.7 to 90%) depending on the cohort studied and the methods used for diagnosis (371 [EL 4; review NE]; 372 [EL
4; review NE]). All the manifestations of autonomic nerve
dysfunction, along with suggested testing, the symptom
complex, and possible therapies, are listed in Table 15 (310
[EL 3; CSS]). A more complete discussion can be found in
recent reviews (369 [EL 3; SS]; 373 [EL 4; NE]).

Cardiovascular reflex tests are the criterion standard
in clinical autonomic testing (374 [EL 4; position NE]).
The most widely used tests assessing cardiac parasympathetic function are based on the time-domain heart rate
response to deep breathing, a Valsalva maneuver, and postural change. Valsalva maneuvers must not be performed
Table 15
Clinical Features, Diagnosis, and Treatment of Diabetic Autonomic Neuropathy (310 [EL 3; CSS])
Symptoms
Cardiac
Resting tachycardia, exercise
intolerance
Exercise bradycardia
Exercise intolerance
Postural hypotension, dizziness,
weakness, fatigue, syncope
Gastrointestinal
Gastroparesis, erratic glucose
control
Tests
Treatments
HRV, MUGA thallium scan,

MIBG scan
HRV, MUGA thallium scan,
MIBG scan, dopamine levels
and scans
HRV, supine and
standing blood pressure,
catecholamines
Graded supervised exercise, ACE inhibitors,

-adrenergic blockers
Graded supervised exercise, dopaminergic agonists
Gastric emptying study,

barium study
Frequent small meals and prokinetic agents

(metoclopramide, domperidone; erythromycin;
lubiprostone; linaclotide; oral gastric analgesics;
the combination of atropine, hyoscyamine,
phenobarbital, and scopolamine; Maalox; and
viscous xylocaine)
Antibiotics, antiemetics, bulking agents, tricyclic
antidepressants, pyloric botulinum toxin, gastric
pacing
High-fiber diet, bulking agents, osmotic laxatives,
lubricating agents
Soluble dietary fiber, gluten and lactose restriction,
anticholinergic agents, cholestyramine, antibiotics,
somatostatin, pancreatic enzyme supplements
Abdominal pain, early satiety,

nausea, vomiting, bloating,
belching
Constipation
Endoscopy, manometry,
electrogastrogram
Diarrhea (often nocturnal

alternating with constipation)
None
Sexual dysfunction
Erectile dysfunction
Vaginal dryness
Bladder dysfunction
Frequency, urgency, nocturia,
urinary retention, incontinence
Sudomotor dysfunction
Anhidrosis, heat intolerance, dry
skin, hyperhidrosis
Endoscopy
Mechanical measures, clonidine, midodrine,

octreotide, erythropoietin
H&P, HRV, penile-brachial

pressure index, nocturnal
penile tumes
None
Sex therapy, psychological counseling,

5-phosphodiesterase inhibitors, prostaglandin E1
injections, devices, or prostheses
Vaginal lubricants
Cystometrogram,
postvoiding
sonography
Bethanechol, intermittent catheterization
Quantitative sudomotor
axon reflex, sweat test,
sudorimetry, skin blood flow
Pupillomotor and visceral dysfunction
Vision blurring, impaired light
Pupillometry, HRV
adaptation to ambient light,
Argyll-Robertson pupil
Impaired visceral sensation:
Physical assessment, medical
silent myocardial infarction,
history
hypoglycemia unawareness
Emollients and skin lubricants, scopolamine,

glycopyrrolate, botulinum toxin, vasodilators,
arginine supplementation
Care with driving at night
Recognition of unusual presentation of myocardial
infarction, control of risk factors, control of plasma
glucose levels
Abbreviations: ACE = angiotensin-converting enzyme; H&P = history and physical; HRV = heart rate variability; MIBG = metaiodobenzylguanidine; MUGA = multiunit gated blood pool.
in patients with proliferative retinopathy. Cardiovascular

sympathetic function is assessed by measuring the blood
pressure response to orthostatic change and a Valsalva
maneuver. The combination of cardiovascular autonomic
tests with sudomotor function tests may allow a more
accurate diagnosis of diabetic autonomic neuropathy (375
[EL 4; NE]). Frequency domain measurements of the total
spectral power, the standard deviation of normal R-R intervals, and the root means squared of the standard deviation
of R-R intervals have recently been shown to be the most
sensitive indicator of autonomic imbalance. These changes
also precede the rise in circulating levels of inflammatory
cytokines such as interleukin 6 (IL-6) and tumor necrosis
factor (TNF-), as well as a fall in the high molecular
weight adiponectin/leptin ratios in newly diagnosed DM
(376 [EL 2; PCS]; 377 [EL 4; NE]).
Patients with DM and features of cardiac autonomic
dysfunction such as unexplained tachycardia, bradycardia, orthostatic hypotension, and poor exercise tolerance
or those with other symptoms of autonomic dysfunction
should be evaluated for the presence of cardiovascular
autonomic neuropathy. Screening for cardiovascular autonomic neuropathy should be performed at diagnosis of
T2D and 5 years after the diagnosis of T1D.

Retrospective and prospective studies have suggested
a relationship between hyperglycemia and the development and severity of diabetic neuropathy, as well as significant effects of intensive insulin treatment on prevention
of neuropathy (378 [EL 4; review NE]). Treating oxidative
stress may improve peripheral and autonomic neuropathy
in adults with T2D (379 [EL 1; RCT]; 380 [EL 1; RCT];
381 [EL 1; RCT]; 382 [EL 1; RCT]). A systematic review
of -lipoic acid in the treatment of diabetic neuropathic
pain found that this drug may help relieve pain and improve
neuropathy, possibly through its potent antioxidant properties to reduce glutathione concentrations (383 [EL 4;
NE]). The SYDNEY (Symptomatic Diabetic Neuropathy),
ALADIN (Alpha-Lipoic Acid in Diabetic Neuropathy), and
SYDNEY 2 trials showed benefit in painful neuropathy,
and the NATHAN (Neurological Assessment of Thioctic
Acid in Diabetic Neuropathy) 1 trial showed improvement
in neuropathy scores and delayed progression (384 [EL 1;
RCT]; 385 [EL 1; RCT]).
TZDs, which reduce hyperglycemia through reductions in insulin resistance, may also reduce chronic inflammation and potentially affect pathways leading to peripheral neuropathy (386 [EL 4; review NE]; 387 [EL 1; RCT];
388 [EL 3; SS]). Fibrates and statins may protect against
peripheral nerve function decline in adults with T2D (389
[EL 2; PCS]; 390 [EL 2; PCS]). Older adults taking statins
show a greater benefit than younger adults because of their
higher attributable risk of CVD (391 [EL 4; review NE]). A
modest association between statin use and peripheral neuropathy was found in a review of the 1999-2004 National
Health and Nutrition Examination Survey (NHANES)
data, but the authors cautioned not to overinterpret the

findings, which may be explained by many uncontrolled,
confounding factors, so no causal inference can be made
(392 [EL 3; SS]).
Small studies in patients with DM have shown that
aerobic exercise improved quantitative test results for
peripheral nerve function and cardiac autonomic neuropathy (393 [EL 2; PCS]). Among participants and/or those
with peripheral neuropathy and DM, balance training is
effective in improving balance outcomes and probably
reduces risk of falls (394 [EL 3; SS]; 395 [EL 2; NRCT
single-blinded]).
4.Q12. How is CVD Managed in
CVD is increased two- to threefold in patients with
DM. The best data have come from studies that ascertained
cardiovascular mortality as a function of FPG, 2-hour PPG,
or A1C in nondiabetic and diabetic populations (55 [EL
2; PCS]; 396 [EL 2; RCCS]; 397 [EL 3; SS]; 398 [EL 2;
PCS]). In a meta-analysis involving 447,064 patients, the
rate of fatal coronary heart disease in patients with DM
was reported to be 5.4% versus 1.6% in nondiabetic subjects. Diabetic females had a significantly higher relative
fatal cardiovascular risk than males (3.50 versus 2.06) (399
[EL 2; MNRCT]). The original 7-year East-West Study in
a Finnish population showed that the incidence of myocardial infarction in patients with DM and no preceding
myocardial infarction at baseline was equivalent to that of
persons without DM who had had a previous myocardial
infarction at baseline. The incidence of myocardial infarction in the diabetic population was almost sixfold greater
than the incidence in nondiabetic persons with no previous
myocardial infarction at baseline (400 [EL 3; SS]). A subsequent 18-year follow-up of the same cohort confirmed
that the patients with DM without evidence of any ischemic heart disease at baseline had as great or a greater risk
for CVD-related death and total CVD as persons without
DM who had had previous ischemic heart disease at baseline (401 [EL 3; SS]). A nationwide study of 3.3 million
residents in Denmark with a 5-year follow-up showed
similar results (402 [EL 3; SS]).

It is difficult to quantitatively define the factors
responsible for DM being a CVD risk factor because insulin resistance, hypertension, lipid abnormalities, endothelial dysfunction, inflammation, and procoagulant factors
are all present in patients with T1D and T2D, as well as
in those with less severe forms of hyperglycemia. Early
epidemiologic studies indicated that the age-adjusted cardiovascular event rate for patients with DM was twofold
greater than that of the nondiabetic individual at each identical level of systolic blood pressure from 105 to 195 mm
Hg (403 [EL 4; review NE]). The 12-year follow-up of
MRFIT (Multiple Risk Factor Intervention Trial) showed
that at every level of total cholesterol, the rate of CVDrelated death was threefold higher for patients with DM
versus the rate in patients without DM (404 [EL 2; PCS]).
Patients with DM not only have an increase in risk factors for CVD, but the risk factors cause more disease in
a hyperglycemic environment. Autonomic neuropathy is a
risk factor for CVD and a strong predictor for CVD events
(369 [EL 3; SS]; 405 [EL 1; RCT]).
Comprehensive risk reduction programs have
decreased the incidence of acute myocardial infarction
in patients with DM by 67.8% from 1990 to 2010 (406
[EL 3; SS]). The recent American College of Cardiology
(ACC)/American Heart Association (AHA) Task Force on
Practice Guidelines recommends the use of a newly developed risk prediction algorithm based on atherosclerotic
events to determine the 10-year risk of patients developing a cardiovascular event (407 [EL 4; NE]). However,
Ridker and Cook presented analyses from several large
studies suggesting that the new risk prediction algorithm
significantly overpredicts event rates (232 [EL 4; NE]).
The AACE recommends starting a statin in patients with
DM and at least 1 major additional ASCVD risk factor
regardless of LDL-C level if they are >40 years of age;
primary prevention strategies for younger patients should
be individualized (see Q8. How is dyslipidemia managed
in patients with diabetes?).
4.Q12.1. Glycemic Control
Hyperglycemia increases CVD both by its direct
effects and indirectly via effects on other cardiovascular
risk factors. Abnormal glucose regulation is common in
patients referred to a cardiologist for coronary artery disease and is associated with poor outcomes (408 [EL 3;
SS]; 409 [EL 2; PCS]; 410 [EL 3; SS]). Intensive glycemic
control reduces micro- and macrovascular complications
in patients with DM. The 2 large clinical trials of glycemic
control in patients with DM of only a few years duration
(DCCT and UKPDS) both showed marked decreases in
microvascular complications with intensive glycemic control versus standard glucose control: DCCT, 60 to 70% (68
[EL 1; RCT]); UKPDS, 25% reduction (50 [EL 3; SS]).
While neither showed a decrease in myocardial infarction
during the trial, both showed reductions in macrovascular
events in the intensively treated cohort in long-term extension studies (49 [EL 1; RCT, posttrial monitoring]; 411 [EL
1; RCT]).

The beneficial effects of intensive glycemic control
in reducing vascular complications appear to be inversely
related to the extent of vascular disease at the time it is
initiated. The ACCORD (62 [EL 1; RCT]), ADVANCE (57
[EL 1; RCT]), and VADT (Veterans Affairs Diabetes Trial)
(61 [EL 1; RCT]) trials investigated the effect of intensive
glycemic control versus standard glycemic control on the
development of new cardiovascular events in patients with
mean durations of diagnosed T2D of 8.5 to 11 years either
with baseline previous cardiovascular events (35 to 45% of

patients) or high cardiovascular risk. The duration of the
trials was 3.5 to 7.0 years. All 3 trials failed to show a significant benefit of intensive glycemic control in reducing
new cardiovascular events.
Subanalyses of the ACCORD study indicated that
patients without a previous cardiovascular event or those
who entered the study with an A1C level 8% had a significant benefit from intensive glycemic control (62 [EL 1;
RCT]). A subanalysis from the VADT trial indicated that
patients who entered the trial with a duration of DM <15
years had a decrease in cardiovascular events with intensive glycemic control (412 [EL 2; PCS]).
A randomized controlled substudy in the VADT trial
investigated the utility of measuring coronary artery calcification in predicting subsequent clinical cardiovascular
events (413 [EL 1; RCT, posthoc analysis with other methodological limitations]). At the end of the 6-year study,
the extent of baseline coronary artery calcification was
found to correlate very well with the development of clinical cardiovascular events. Patients who entered the study
with high coronary artery calcification scores (>100) had
no reduction in clinical cardiovascular events with intensive glycemic control, while those who entered with low
scores (<100) had a 90% reduction in clinical events with
the intensive glycemic control regimen.
Glycemic control can have a long-term effect on the
rate and severity of future vascular complications (49 [EL
1; RCT, posttrial monitoring]; 411 [EL 1; RCT]). In contrast, there is no such legacy effect of blood pressure control on cardiovascular risk (206 [EL 1; RCT, questionnaires
and other variables may have confounded]).
4.Q12.2. Antiplatelet Therapy

The use of aspirin for primary prevention has become
controversial owing to recent data showing little to no benefit in certain patient populations (9 [EL 1; MRCT but small
sample sizes and event rates]). In patients with proven
CVD, aspirin (75 to 162 mg daily) is generally indicated
(9 [EL 1; MRCT but small sample sizes and event rates]).
Adjuvant therapies such as adenosine diphosphate receptor antagonists may also be helpful, especially if peripheral
vascular disease is present.
Data from the many clinical trials and observational
studies on the use of low-dosage aspirin in the primary prevention of CVD in patients with DM continue to be controversial (405 [EL 1; RCT]). Several recent meta-analyses
show no statistically significant benefit on either total cardiovascular outcomes or individual events such as death,
myocardial infarction, or stroke (10 [EL 1; MRCT]). An
observational study in patients with T2D reported that lowdosage aspirin was associated with a paradoxical increase
in CVD risk in primary prevention, and the risk of GI
bleeding was rather high (414 [EL 1; RCT]). Observational
studies such as The Fremantle Diabetes Study reported
beneficial reductions in all-cause and CVD-related mortality with regular low-dosage aspirin use, particularly in
males older than 65 years (12 [EL 2; PCS]). These conflicting findings may reflect the results of studies showing
that patients with DM have an increased resistance to the
effects of aspirin (415 [EL 1; MRCT]). This aspirin resistance has been linked in part to an effect of hyperglycemia
(416 [EL 2; PCS]). Most studies (11 [EL 1; MRCT]; 12
[EL 2; PCS]; 415 [EL 1; MRCT]), but not all (416 [EL 2;
PCS]), support the use of low-dosage aspirin in the secondary prevention of CVD in patients with DM. Once-daily
low-dose aspirin may be associated with incomplete inhibition of cyclooxygenase 1 (COX-1) activity and thromboxane A2 (TXA2)-dependent platelet function in patients
with DM (417 [EL 2; PCS]). Some data support the use of
twice-daily low-dose aspirin in patients with DM and CVD
(418 [EL 1; RCT]).
4.Q12.3. Asymptomatic Coronary Artery Disease

Although screening for asymptomatic coronary artery
disease in patients with T2D does not improve cardiac
outcomes, the measurement of coronary artery calcification may be useful in assessing whether some patients with
long-standing DM are reasonable candidates for intensification of glycemic control and or lipid lowering. The
impression in the past was that diagnosing asymptomatic
CVD in patients with DM would result in improved care
and better long-term clinical outcomes; however, findings
from well-conducted clinical trials have not supported this
idea (405 [EL 1; RCT]).

The use of coronary calcification scores might help
to identify those patients who will receive the most benefit from intensive glycemic control (413 [EL 1; RCT,
posthoc analysis with other methodological limitations]).
A large prospective study is necessary to validate such an
approach. Meanwhile, in those patients with long-standing
DM, coronary artery calcification scores could separate
those who already have extensive disease from those with
significantly less severe disease.
4.Q13. How is Obesity Managed in


The natural history of obesity reflects a small positive
energy balance over a prolonged period of time, which
produces excess fat storage and adipose tissue mass. BMI
(weight in kilograms divided by height in meters squared)
is used to differentiate normal weight (18.5 to 24.9 kg/
m2); overweight (25 to 29.9 kg/m2); and obesity classes
I (30 to 34.9 kg/m2), II (35 to 39.9 kg/m2), and III (40
kg/m2) (419 [EL 4; NE]). Clinical correlation is required
since BMI may not reflect adipose tissue mass in muscular athletes, sarcopenic obesity, paraplegia, frailty, and
other conditions. Also, lower BMI criteria for obesity have
been recommended for some ethnicities (e.g., 23 kg/m2
is considered overweight in southeast Asians) (420 [EL 4;

NE]).

While insulin resistance can exist independent of obesity, excess weight gain, particularly with accumulation of
fat in ectopic compartments such as visceral adipose tissue,
can exacerbate insulin resistance and increase risk for the
development of metabolic syndrome, nonalcoholic fatty
liver disease (NAFLD), hypertension, prediabetes, and
T2D. Whether individuals are insulin sensitive or resistant,
increased adiposity can also lead to biomechanical complications of obesity including osteoarthritis, OSA, gastroesophageal reflux disease (GERD), urinary stress incontinence, and disability. Thus, primary prevention is needed
to prevent obesity, and secondary treatment and prevention
is required to stabilize or decrease body weight and prevent
the emergence of complications in patients who are overweight or obese without complications. When excess adiposity adversely impacts health by causing obesity-related
complications, more aggressive interventions are needed to
induce and sustain weight loss and treat the complications
(421 [EL 4; NE]).
4.Q13.1. Lifestyle Modification for Weight Loss
Lifestyle change is a cornerstone for weight management in the patient with or without DM, and includes 3
components: caloric restriction, increased energy expenditure through increased physical activity, and behavior
changes related to lifestyle. All diets are superior to no diet,
and differences between individual diets with different
macronutrient composition are minimal (93 [EL 1; RCT];
422 [EL 1; MRCT]). Therefore, healthy meal plans such
as the Mediterranean, low carbohydrate, low fat (with an
emphasis on high-water content, low-energy-dense foods),
low glycemic index, DASH Diet (which emphasizes fruits,
vegetables, and low-fat dairy products), and vegetarian
diets have been advocated to take into account personal
and cultural preferences that accommodate nutrition guidelines (423 [EL 4; NE]). Caloric reduction is critical for
weight loss regardless of the meal plan. For longer-term
compliance, a moderate calorie deficit of ~500 kcal below
energy expenditure is commonly advocated, although
many patients are successfully initiated on very low calorie
diets (~800 kcal/day) including the use of meal replacements (bars and shakes) that add structure to the diet (96
[EL 1; RCT]).
Increased physical activity is important for maintaining weight loss. For cardiometabolic conditioning, a recommendation consistent with guidelines proposed by the
ADA, AHA, and American College of Sports Medicine
(ACSM) would include 30 minutes of moderate intensity
exercise 5 days per week for a total of 150 minutes/week,
or 20 to 25 minutes of intense exercise 3 days per week for
a total of 60 to 75 minutes/week combined with resistance
training involving each major muscle group 2 to 3 days
per week (104 [EL 4; consensus NE]; 424 [EL 4; NE]).
However, it is important to individualize the prescription

for physical activity. Reduction in sedentary behavior can
be helpful.
The third component of lifestyle focuses on behavior
modification (423 [EL 4; NE]). The components of a lifestyle program include education and behavior modification including self-monitoring of food intake and physical
activity, learning to cope with negative thoughts by means
other than eating, portion control, and consuming meals
at regular times and in places where one can focus on the
act of eating. A mental health professional is commonly
needed to address issues such as disordered eating and
depression, which, if not treated proactively, can jeopardize the effectiveness of lifestyle therapy.
4.Q13.2. Obesity Pharmacotherapy

The first step in evaluating medications for the overweight patient is to determine whether the patient is taking
drugs that produce weight gain, including some antihyperglycemic agents (Table 9), antidepressants, and antiseizure
medications (425 [EL 4; NE]; 426 [EL 4; NE]; 427 [EL 1;
RCT]). If such agents are identified and there are acceptable weight-neutral or weight loss-inducing alternatives,
the healthcare professional should consider changing the
medication (425 [EL 4; NE]).
Several drugs are approved by the FDA for weight
reduction in patients with and without DM (426 [EL 4;
NE]; 428 [EL 4; NE]). These include several sympathomimetic amines (phentermine, benzphetamine, and phendimetrazine), which are approved for short-term use (12
weeks). Five medicines are approved for long-term use
and, therefore, are more useful in the treatment of obesity
as a chronic if not lifelong disease. These include orlistat
(32 [EL 1; RCT]; 429 [EL 1; MRCT]), lorcaserin (430 [EL
1; RCT]; 431 [EL 1; RCT]; 432 [EL 1; RCT]), phentermine/topiramate extended release (33 [EL 1; RCT]; 433
[EL 1; RCT]; 434 [EL 1; RCT]; 435 [EL 1; RCT]; 436 [EL
1; RCT]), naltrexone/bupropion extended release (437 [EL
1; RCT]; 438 [EL 1; RCT]; 439 [EL 1; RCT]; 440 [EL 1;
RCT]), and a high-dose formulation of liraglutide (45 [EL
1; RCT]; 46 [EL 1; RCT]; 441 [EL 1; RCT]).

All weight-loss medications are approved for patients
with BMI 27 to 29.9 kg/m2 with at least 1 obesity-related
complication and BMI 30 kg/m2 regardless of complications. These drugs vary with respect to efficacy as defined
by weight loss in RCTs and differ regarding adverse effect
profile, cautions, and warnings. In addition, lorcaserin and
phentermine/topiramate extended release are classified
by the U.S. Drug Enforcement Administration as having the potential for abuse and are schedule IV controlled
substances (442 [EL 4; NE]). However, these differences
enable individualized treatment. On any treatment program there are patients who do very well and for whom the
medication should be continued; for others, the treatment
may be ineffective, and the patient may lose little weight or
even gain weight. The FDA has advised drug discontinuation if <5% of body weight is lost after 12 weeks on the
maximal dose of the medication. At that point, an alternative weight-loss medication may be prescribed.
All weight-loss medications serve as an adjunct to
lifestyle modification therapy. Except for orlistat, these
medications act to decrease appetite and enhance compliance with a reduced-calorie meal plan. Therefore, maximal
benefit is achieved in conjunction with lifestyle therapy,
and all clinical trials demonstrated greater weight loss
when the medication was added to lifestyle modification
than that achieved with lifestyle modification plus placebo.
The patient should be familiarized with the drugs and their
potential side effects and should receive effective lifestyle
support for weight loss during pharmacologic therapy (443
[EL 1; MRCT]; 444 [EL 1; MRCT]).
4.Q13.3. Bariatric Surgery
Bariatric surgery is an effective approach for attaining significant and durable weight loss in severely obese
patients with and without DM. Because metabolic as well
as weight-related comorbidities are often improved or
resolved through weight loss due in part to neuroendocrine
mechanisms, the term metabolic surgery is often used
instead of bariatric surgery. In general, metabolic operations alter the GI tract by reducing stomach capacity (gastric restrictive operations); rerouting nutrient flow, leading
to some degree of malabsorption (bypass procedures);
or combining both concepts. Metabolic procedures have
evolved since the jejunoileal bypass was abandoned in the
1970s. Commonly performed procedures along with frequency of use include Roux-en-Y gastric bypass (RYGB,
49%), sleeve gastrectomy (SG, 30%), adjustable gastric
banding (AGB, 19%), and biliopancreatic diversion (BPD,
2%). A meta-analysis of 136 mostly short-term studies in
more than 22,000 patients showed an overall loss of 61.2%
of excess body weight, with effects differing by procedure. In those with gastric banding, the loss of excess body
weight was 47.5%. It was 61.6% after gastric bypass and
68.2% with gastroplasty. The highest success rate of 70.1%
reduction in excess body weight was seen with BPD (445
[EL 2; MNRCT]). In patients with severe obesity and T2D,
bariatric surgery has been shown to provide significantly
improved outcomes at 12 months for weight loss, number
of DM medications used, and glycemic control (e.g., A1C
and fasting glucose levels) compared to patients receiving
intensive lifestyle therapy (446 [EL 1; RCT, not blinded];
447 [EL 1; RCT, not blinded]).
These procedures carry a mortality risk (which is
low when performed in centers of excellence), as well
as morbidity due to surgical and nutritional complications. The patients require life-long medical follow-up and
must adhere to ongoing lifestyle modification for optimal
outcomes. However, the development of laparoscopic
approaches to all these metabolic operations in the mid
1990s has significantly reduced perioperative morbidity

and mortality.
The indications for weight-loss surgery have evolved
since the seminal National Institutes of Health (NIH)
guidelines from 1991 (448 [EL 4; NE]). In the 2011 guidelines for bariatric surgery specifically in patients with
T2D, the International Diabetes Federation (IDF) recommended considering surgery for individuals with T2D who
are obese (BMI >30 kg/m2) and had not achieved the IDF
treatment targets with an optimal medical regimen, especially if other cardiovascular risk factors were present (449
[EL 4; NE]). In 2013, joint clinical practice guidelines
from the AACE, Obesity Society (TOS), and American
Society for Metabolic & Bariatric Surgery (ASMBS) recommended consideration of surgical weight loss for all
patients with BMI >40 kg/m2 (unless surgery would pose
significant risk) and for patients with BMI >35 kg/m2 who
have at least 1 major obesity-related comorbidity (450 [EL
4; NE]).
4.Q13.4. Effects of Weight Loss in T2D
Weight loss has long been known to enhance insulin
sensitivity and improve glycemia in patients with T2D
(451 [EL 4; NE]). It is highly effective whether achieved
through lifestyle modification (452 [EL 1; RCT]; 453 [EL
2; PCS]; 454 [EL 1; MRCT]; 455 [EL 1; RCT]), pharmacotherapy (431 [EL 1; RCT]; 436 [EL 1; RCT]; 438 [EL
1; RCT]; 456 [EL 1; RCT]), or bariatric surgery (34 [EL
2; PCS]; 446 [EL 1; RCT, not blinded]; 447 [EL 1; RCT,
not blinded]; 457 [EL 2; PCS]). These studies have consistently shown that weight loss lowers A1C while decreasing
the need for conventional DM medications and producing
significant decreases in blood pressure and improvements
in lipids and lipoproteins.

The long-term benefits of weight reduction in T2D
were underscored by the Look AHEAD study, which randomized patients with T2D to either intensive lifestyle
intervention consisting of a moderate calorie reduction
diet, regular exercise, and behavioral interventions or the
standard DM support and education program (452 [EL 1;
RCT]; 458 [EL 1; RCT]). Mean weight loss from baseline was greater in the intensive subgroup (~9% after 1
year and 4.7% after 4 years) than in the standard subgroup
(1.1% weight loss at 4 years) and was associated with more
marked reductions in A1C. In fact, progressive declines in
FPG, A1C, systolic and diastolic blood pressure, and triglycerides, together with progressive increments in HDLC, were observed as the amount of weight loss increased
from 5 to >15%. The Look AHEAD study was terminated
early because the subgroups did not differ in terms of a
complex cardiovascular outcome measure (459 [EL 1;
RCT]).

Until 2012, the only obesity medication approved for
chronic use in the U.S. was orlistat, which has been shown
to be effective in T2D (456 [EL 1; RCT]; 460 [EL 1; RCT];
461 [EL 1; RCT]). The weight loss produced by orlistat led

to A1C reductions of 0.75% units after 1 year of therapy
(baseline value 8.9%) in patients with T2D who were overweight or obese; sulfonylurea dosages also decreased in 1
study (461 [EL 1; RCT]). The other long-term weight-loss
medications approved by the FDA have also been shown
to be safe and effective in treating patients with T2D who
are overweight or obese. In the 52-week study of lorcaserin
10 mg twice daily plus lifestyle modification in patients
with T2D (BLOOM-DM [Behavioral Modification and
Lorcaserin for Obesity and Overweight Management in
Diabetes Mellitus] trial) A1C decreased by 0.9% (baseline 8.1%, P<.001 versus placebo), together with a 4.5%
weight loss and reduced need for antihyperglycemic
medications (431 [EL 1; RCT]). Phentermine/topiramate
extended release significantly reduced A1C values below
that observed in patients randomized to lifestyle plus placebo in a cohort of patients with mild-to-moderate, shorterduration T2D and also in patients with severe, long-standing T2D on multiple medications (433 [EL 1; RCT]; 435
[EL 1; RCT]; 436 [EL 1; RCT]). In both cohorts, patients
randomized to phentermine/topiramate extended release
experienced a decreased need for antihyperglycemic medications and improvements in cardiovascular risk factors.
Naltrexone/bupropion extended release (COR [Contrave
Obesity Research]Diabetes study) produced greater
weight loss (5.0% versus 1.8% from baseline), A1C reduction (0.6% versus 0.1% units), and improvements in triglycerides and HDL-C compared with lifestyle alone (438
[EL 1; RCT]). The high dose (3 mg) formulation of liraglutide significantly reduced weight in persons without diabetes who were obese (45 [EL 1; RCT]; 46 [EL 1; RCT]; 441
[EL 1; RCT]), while lower dosages of this agent have significantly reduced both weight and A1C in glucose-control
studies involving patients with T2D (4 [EL 4; NE]).

Bariatric surgery procedures in patients with T2D have
produced marked reductions in both A1C and DM medications and can result in DM remission (normal A1C values
without antihyperglycemic agents) in some patients. In the
Swedish Obese Subjects Study, bariatric surgery produced
DM remission rates of 72% and 30% after 2 and 15 years,
respectively, and was associated with a reduction in microvascular DM complications (457 [EL 2; PCS]; 462 [EL 2;
PCS]). In addition, follow-up over 20 years demonstrated
that both cardiovascular disease events and mortality were
reduced in patients treated by surgery (457 [EL 2; PCS]).
In the STAMPEDE (Surgical Therapy and Medications
Potentially Eradicate Diabetes Efficiently) trial, glycemic
control in subjects with T2D following bariatric surgery
was improved compared with that in medically treated
patients (447 [EL 1; RCT, not blinded]). These data should
be interpreted cautiously because glycemic control in the
medically treated patients will vary depending on the intensity of therapy. In addition, there was no weight-loss arm
using intensive lifestyle/behavior therapy plus weight-loss
medications. Thus, the data support bariatric surgery as an

effective therapeutic approach in T2D patients with BMI
35 with uncontrolled DM and obesity refractory to lifestyle and pharmacotherapy.
4.Q14. What is the Role of Sleep Medicine in the
Care of the Patient with Diabetes?

Daytime drowsiness is the most obvious symptom of a
sleep disorder and has been shown to be associated with an
increased risk of accidents, increased errors in judgment,
and diminished performance (463 [EL 3; SS]). Sleep deprivation also increases major risk factors for heart disease
as it aggravates insulin resistance, hypertension, hyperglycemia, dyslipidemia, and inflammatory cytokines. Restless
leg syndrome is increasingly being recognized as a medical cause of sleep disturbance, and medication can be quite
successful in relieving it (464 [EL 3; CSS]). When OSA or
restless leg syndrome is suspected, the usual course is to
refer to a sleep specialist who may choose to do an overnight study in a sleep laboratory, although most sleep disturbances can be diagnosed with overnight oximetry testing at home after a careful history and physical (465 [EL
4; NE]; 466 [EL 1; RCT, not blinded]). OSA is especially
common in adults with DM, occurring in approximately 2
of 3 males with DM older than 65 years (467 [EL 4; review
NE]).
OSA is the most common type of sleep apnea and is
caused by physical obstruction of the airway during sleep.
OSA refers to numerous episodes during sleep where the
individual stops breathing and is then awakened by the
need for oxygen. Usually the individual is unaware of the
awakenings, which may happen hundreds of times per
night and are accompanied by very loud snoring and grunts
and snorts when breathing resumes. OSA is more common
in males, the elderly, and individuals with obesity (468 [EL
3; CSS]; 469 [EL 3; CSS]). Treatment of OSA in patients
with DM can lower FPG, PPG, and A1C levels as much
as or more than oral agents (470 [EL 3; CSS]; 471 [EL
3; SS]). Successful OSA treatment may lead to improvements in cardiovascular outcomes (472 [EL 2; PCS]; 473
[EL 1; RCT, single-blind]; 474 [EL 1; RCT, single-blind]),
although data have not shown a consistent benefit in terms
of metabolic control (470 [EL 3; CSS]; 471 [EL 3; SS];
475 [EL 1; RCT, small sample size]; 476 [EL 1; RCT,
small sample size]; 477 [EL 2; PCS]). Patients with newly
diagnosed OSA should persevere through the initial, often
frustrating phase of CPAP when finding the right equipment can be a challenge. When CPAP is successful, it can
dramatically improve quality of life (478 [EL 2; CPS]).
Because of recent improvements in the technology, this
treatment should be re-evaluated for patients in whom
CPAP failed in the past. For certain subgroups with OSA,
surgery to widen the airway or devices that reposition the
jaw may be appropriate.
4.Q15. How is Diabetes Managed in the Hospital?

DM represents the seventh leading cause of death
(479 [EL 3; SS]) and is the second-leading comorbid condition among hospital discharges in the United States (480
[EL 3; SS]). The association between inpatient hyperglycemia and increased risk for complications and mortality
is well established (481 [EL 3: SS]; 482 [EL 2; PCS]).
Hyperglycemia is associated with prolonged hospital stay,
increased incidence of infections, greater disability after
hospital discharge, and death (483 [EL 2; RCCS]; 484 [EL
2; PCS]).
Substantial evidence indicates that correction of
hyperglycemia with insulin administration reduces hospital complications and mortality in the critically ill, as well
as in general medicine and surgery patients (485 [EL 1;
RCT]; 486 [EL 2; MNRCT]). Several RCTs including the
real-world NICE-SUGAR (Normoglycemia in Intensive
Care Evaluation and Survival Using Glucose Algorithm
Regulation) study (487 [EL 1, RCT]; 488 [EL 1; RCT,
protocol violations]; 489 [EL 1 RCT, not blinded]) and
meta-analyses (486 [EL 2; MNRCT]; 490 [EL 1, MRCT];
491 [EL 1, MRCT]) have reported higher rates of severe
hypoglycemia and increased morbidity and mortality with
intensive insulin therapy (glycemic targets of 80 to 110
mg/dL) compared to more relaxed glycemic targets. The
AACE/ADA consensus statement on inpatient glycemic
control outlines the argument in favor of more relaxed glycemic targets in the ICU, as high as 140 to 180 mg/dL (5
[EL 4; consensus NE]). Although strong evidence is lacking, somewhat lower glucose targets may be appropriate in
selected patients, such as surgical populations in units that
have shown low rates of hypoglycemia. However, glucose
targets <110 mg/dL are not recommended. In addition,
minimizing glycemic variability, independent of glucose
levels, could result in lower rates of complications and cardiovascular mortality in critically ill patients (492 [EL 2;
PCS]; 493 [EL 3: SS]; 494 [EL 2; RCCS]), and in reduced
hospital stays and mortality in non-ICU settings (495 [EL
2; RCCS]).
4.Q15.1. Treatment of Hyperglycemia in
Hospitalized Patients
Patients with DM have a threefold greater chance of
hospitalization compared to those without DM (496 [EL
3; SS]; 497 [EL 3; SS]), and it is estimated that 20% of
all adults discharged have DM, with 30% requiring 2 or
more hospitalizations in any given year (496 [EL 3; SS]).
It is well established that hyperglycemia in patients with or
without a prior diagnosis of DM increases both mortality
and disease-specific morbidity in hospitalized patients (5
[EL 4; consensus NE]; 481 [EL 3: SS]; 483 [EL 2; RCCS];
498 [EL 2; PCS]), and that goal-directed insulin therapy
can improve outcomes (485 [EL 1; RCT]; 499 [EL 1,
RCT]; 500 [EL 2; PCS]). This topic has been extensively
reviewed in the AACE/ADA Consensus Statement on

Inpatient Hyperglycemia (5 [EL 4; consensus NE]), 2014
ADA Standards of Medical Care in DM (212 [EL 4; NE]),
and 2012 Endocrine Society Clinical Practice Guideline
for the Management of Hyperglycemia in Hospitalized
Patients in the Noncritical Care Setting (501 [EL 4; NE]).

The management of hyperglycemia in the hospital setting presents multiple challenges including variable nutritional status and altered levels of consciousness, as well as
resource limitations for monitoring glycemia during these
changes. Given the paramount importance of patient safety,
reasonable glucose targets in the hospital setting should be
set at modestly higher levels than targets for outpatients
with DM. For most critically ill patients in the ICU, a glucose concentration range of 140 to 180 mg/dL is recommended, provided these targets can be safely achieved. For
patients in non-ICU settings, a premeal glucose target of
<140 mg/dL and a random blood glucose of <180 mg/dL is
recommended; however, glycemic targets should be modified according to clinical status. For patients who are able
to achieve and maintain glycemic control without hypoglycemia, a lower target range may be reasonable. For patients
with terminal illness and/or with limited life expectancy or
at high risk for hypoglycemia, a higher target range (<180
mg/dL) may be reasonable.
Insulin therapy is the preferred method of glycemic
control in most hospitalized patients. In ICUs, intravenous
infusion of insulin is the preferred route of administration. In the critical care setting, a variety of continuous
insulin infusion protocols have been shown to be effective
in achieving glycemic control with a low rate of hypoglycemic events and also to improve hospital outcomes (499
[EL 1, RCT]; 500 [EL 2; PCS]; 502 [EL 3; SS]; 503 [EL
3; SS]). Recently, computer-based algorithms aiming to
direct nursing staff adjustment of insulin infusion rate have
become commercially available (504 [EL 3; SS]; 505 [EL
3; SS]). No major clinical outcome differences have been
reported in the frequency of hypoglycemic events, length
of ICU or hospital stay, or mortality among different intravenous insulin algorithms. Thus, most insulin algorithms
appear to be appropriate alternatives for managing hyperglycemia in critically ill patients, and the choice depends
on physicians preferences and cost considerations.
Most patients with T2D and all patients with T1D in
the ICU receiving intravenous insulin infusion will require
transition to a subcutaneous regimen (5 [EL 4; consensus
NE]). Patients suitable for this transition ideally have a
stable infusion rate and blood glucose levels in the target
range. Several studies recommend starting at a daily insulin
dose ~80% of the intravenous insulin used in the preceding
12 to 24 hours and splitting it into basal and bolus insulin
(5 [EL 4; consensus NE]). Nondiabetic patients with stress
or newly diagnosed hyperglycemia who have required an
insulin rate 1 to 2 units/hour at the time of transition may
not require a scheduled subcutaneous insulin regimen (506

[EL 4; NE]). Many of these patients can be treated with
correction insulin to determine if they will require scheduled subcutaneous insulin.
Outside of the critical care setting, scheduled subcutaneous insulin regimens with a combination of basal,
nutritional, and correctional components is recommended.
Prolonged use of sliding scale insulin as the sole method of
glucose control is strongly discouraged. RCTs have shown
that treatment with a basal prandial regimen using insulin
analogs is preferred to sliding scale regular insulin alone.
This approach results in improved glycemic control and
lower rates of hospital complications in general medical
and surgical patients with T2D (485 [EL 1; RCT]; 507
[EL 1; RCT]; 508 [EL 1; RCT]). Patients with T1D should
be treated with basal-prandial insulin regimens to avoid
severe hyperglycemia and DKA. In insulin-nave patients
with T2D, a starting total daily insulin dose between 0.3
and 0.5 units/kg/day has been shown to be effective and
safe in general medicine and surgery patients. Patients with
T2D receiving insulin therapy before admission are at risk
for severe hyperglycemia in the hospital if insulin therapy
is discontinued. Assessment of the need for modification
of the home insulin regimen is important as requirements
vary according to clinical stressors and altered caloric
intake (5 [EL 4; consensus NE]; 509 [EL 4; NE]). Lower
starting total daily insulin doses of 0.20 to 0.25 units/kg are
recommended in patients with impaired kidney function
(510 [EL 1; RCT, not blinded, small sample size]; 511 [EL
2; RCCS]), in the elderly, and in those with poor caloric
intake (511 [EL 2; RCCS]; 512 [EL 3; SS]). In addition,
for those receiving insulin prior to admission, reducing
the total daily insulin dose by 20 to 25% is recommended
to avoid hypoglycemia in hospitalized patients with poor
caloric intake (512 [EL 3; SS]).

Each of the major classes of noninsulin antihyperglycemic agents has substantial limitations for inpatient use,
so they are generally not recommended (5 [EL 4; consensus NE]; 501 [EL 4; NE]). These agents provide limited
flexibility or opportunity for rapid titration in a setting
where acute changes in patient status often demand such
action. A recent randomized pilot study reported that the
use of the DPP-4 inhibitor sitagliptin plus correction doses
with rapid-acting insulin resulted in similar daily glucose
control compared to patients treated with basal-bolus insulin or basal insulin plus sitagliptin (513 [EL 1; RCT, not
blinded]). Patients with an admission glucose >180 mg/dL
treated with DPP-4 inhibitors, however, had worse glucose
control compared with patients treated with basal-bolus
insulin therapy. Despite the shortcomings of oral antihyperglycemic therapy in the hospital setting, transition to
oral agents 1 or 2 days before discharge is often necessary
for patients whose glycemia was well controlled on oral
agents before admission.
4.Q15.2. Glucose Monitoring in the Hospital

Bedside capillary POC testing is the preferred method
for guiding ongoing glycemic management of hospitalized
patients (5 [EL 4; consensus NE]; 501 [EL 4; NE]). POC
testing is usually performed 4 times a day: before meals
and at bedtime for patients who are eating. For nil per os
patients or those receiving continuous enteral nutrition,
POC testing is recommended every 4 to 6 hours. More frequent glucose monitoring is indicated in patients treated
with continuous intravenous insulin infusion or after a
medication change that could alter glycemic control, such
as corticosteroid use, abrupt discontinuation of enteral or
parenteral nutrition, or frequent episodes of hypoglycemia.
4.Q15.3. Medical Nutrition Therapy

MNT is an essential component of inpatient glycemic
management in patients with DM and hyperglycemia. The
goals of inpatient MNT for patients with DM are to help
optimize glycemic control, provide adequate calories to
meet metabolic demands, address individual needs based
on personal food preferences, and provide a discharge plan
for follow-up care. Most hospitalized patients require 25 to
35 calories/kg/day; critically ill patients require between 15
and 25 calories/kg/day (514 [EL 4; NE]; 515 [EL 4; NE]).
This translates to a diet containing approximately 1,800 to
2,000 calories/day or ~200 g carbohydrate per day divided
between meals. Care must be taken not to overfeed hospitalized patients because this can exacerbate hyperglycemia.
No single meal planning system is ideal for hospitalized
patients; however, hospitals should provide a consistent
carbohydrate DM meal-planning system (514 [EL 4; NE]).
The carbohydrate components of breakfast, lunch, dinner,
and snacks may vary, but the day-to-day carbohydrate content of specific meals and snacks should be kept constant.
Patients requiring clear or full liquid diets should receive
~200 g carbohydrate per day in equally divided amounts at
meal and snack times. Patients on liquid diets, in particular
during the perioperative period, do not meet these nutritional needs. Increasing evidence indicates that food intake
should be initiated as quickly as possible with progression
from clear liquids to full liquids to solid foods as rapidly
as tolerated in surgical patients (516 [EL 4; NE]). Early
enteral feeding is safe and well tolerated and is associated
with reduced wound morbidity, improved wound healing,
fewer septic complications, diminished weight loss, and
improved protein kinetics (516 [EL 4; NE]).
4.Q15.4. hypoglycemia and Hospital Outcomes
Several meta-analyses of RCTs have reported a 6- or
7.7-fold risk ratio for occurrence of hypoglycemia with
intensive insulin therapy versus conventional glycemic
control in critically ill patients (490 [EL 1, MRCT]; 517
[EL 1; MRCT]), with some studies showing a risk ratio
>10 (490 [EL 1, MRCT]). Inpatient hypoglycemia has been
associated with higher rates of hospital complications, longer hospital stays, higher healthcare resource utilization,
and increased hospital mortality, creating a J-shaped relationship between glucose levels and death rates (518 [EL
3; CSS]; 519 [EL 3; SS]). A glucose <50 mg/dL has been
found to be associated with 22.2% mortality compared to
2.3% in patients without hypoglycemia (520 [EL 2; PCS]).
Hypoglycemia is associated with adverse cardiovascular
outcomes, such as prolonged QT intervals, ischemic electrocardiogram changes, angina, arrhythmias, and death
(521 [EL 2; PCS]).
Despite these epidemiologic associations between
hypoglycemia and poor clinical outcomes, data demonstrating that insulin-induced hypoglycemia is the direct cause
of harm in hospitalized patients are sparse. It is the severity
of hypoglycemia, not the insulin therapy, that is associated
with an increased risk of mortality in the critically ill (519
[EL 3; SS]). Hypoglycemia resulting from severe systemic
illness (spontaneous hypoglycemia), rather than insulininduced hypoglycemia, is associated with increased risk of
inpatient mortality and complications (522 [EL 3; SS]; 523
[EL 2; RCCS]; 524 [EL 2; PCS]).
4.Q15.5. Recommendations After Hospital Discharge
Patients with stress, or hospital-related, hyperglycemia, defined as any blood glucose concentration >140
mg/dL without evidence of previous DM, should undergo
hemoglobin A1C testing during the hospital stay (501 [EL
4; NE]). Measurement of A1C provides the opportunity to
differentiate patients with stress hyperglycemia from those
with DM who were previously undiagnosed, as well as to
identify patients with known DM who would benefit from
intensification of their glycemic management. In the presence of hyperglycemia, an A1C >6.5% suggests the diagnosis of DM. Because about half of patients admitted with
stress-related hyperglycemia have confirmed DM at 1 year
(525 [EL 2; PCS]), they should be closely monitored after
discharge.
Few studies have focused on the optimal management of hyperglycemia after hospital discharge. Although
insulin is used for most patients with DM in the hospital, many patients do not require insulin after discharge.
Clinical guidelines (5 [EL 4; consensus NE]; 501 [EL
4; NE]) recommend tailoring the discharge treatment
regimen for patients with DM based on the admission
A1C value. Patients with acceptable DM control could be
discharged on their prehospitalization treatment regimen
(oral agents and/or insulin therapy) if there are no contraindications. Patients with preadmission suboptimal control
should have intensification of therapy at discharge, either
by additional or increased dosage of oral agents, addition
of basal insulin, or a more complex insulin regimen as
warranted by their admission glucose control (526 [EL 2;
PCS]).
4.Q16. How is a Comprehensive Diabetes Care Plan

Established in Children and Adolescents?

Advances in molecular and genetic science have uncovered multiple causes of DM in the neonatal period through
the first year of life. It is beyond the scope of this paper to
elucidate each genetic cause of neonatal DM. Clinically,
these vary from permanent neonatal DM to transient forms,
which remit only to recur later in childhood (transient neonatal DM). Although all forms of neonatal DM result from
compromised insulin secretion, there is variation in presentation ranging from early and acute onset of DKA to
mild, asymptomatic hyperglycemia resulting from heterozygous glucokinase mutations. Important advances have
been made in understanding the molecular mechanisms
of those forms produced by mutations in the KCNJ1 gene
encoding the potassium channel protein Kir6.2 in cells
(527 [EL 3; SS]) and in the ABCC8 gene encoding the sulfonylurea receptor protein SUR1 (528 [EL 3; SS]). Other
causes have also been defined, including mutations in the
insulin gene (529 [EL 3; SS]). Recognizing these disorders and distinguishing them from T1D is important. Most
cases result from new mutations, but they are heritable, and
several forms respond to sulfonylureas, negating the need
for insulin therapy and improving glycemic control (530
[EL 2; PCS]). Excellent reviews on this topic are available
(531 [EL 4; review NE]; 532 [EL 4; guidelines NE]).
Monogenic DM, initially called MODY (533 [EL 4;
review NE]) because of its description as maturity-onset
diabetes occurring in young adults, is currently being
described with greater frequency in children and adolescents, as well as in adults. These genetic forms of DM
result from compromised insulin secretion, in 1 case by
mutations in the gene encoding the enzyme glucokinase
(GK), and in the other cases by mutations in genes encoding transcription factors important for pancreas formation
and later for insulin secretion (534 [EL 3; SS]). They are
uncommon, and most cases in surveyed populations are the
result of mutations in GK or in the gene encoding hepatic
nuclear factor 1a (HNF1A) (535 [EL 3; SS]). Diagnosing
these cases is important for many reasons. Although new
mutations do occur, these conditions are usually inherited
as autosomal dominant traits. Diagnosis in 1 family member frequently leads to discovery of pedigrees in which
many family members are being inappropriately treated as
having T1D or T2D (536 [EL 4; review NE]), or GDM
(537 [EL 3; SS]). Making the correct diagnosis is important for genetic counseling and instituting proper therapy.
Many affected patients respond to insulin secretagogues,
do not require insulin or insulin sensitizers, or require no
therapy (in the case of glucokinase deficiency).

Cystic fibrosis-related diabetes (CFRD) is a combination of insulin resistance plus insulin deficiency disorder.
Oral agents such as TZDs or DPP-4 inhibitors can usually
control glucose levels in these patients for several years,
but the insulin deficiency will eventually require insulin

therapy, which may involve intensive regimens such as
basal-bolus insulin or even insulin pumps. The main goal
is prevention of glucosuria, weight loss, and asthenia rather
than tight glucose control. Steroid use in patients with
CFRD may radically affect glucose levels. The patient,
family, and endocrinologist should remain in close communication so insulin dosages can be adjusted as needed.
T1D is the most common form of DM occurring in
children and adolescents, and its incidence is increasing in
most populations throughout the world. The same types of
insulin and administration regimens used in older patients
are also used in children. Most physicians treating DM in
children use MDI regimens, and when appropriate, CSII
(538 [EL 3; SS]). Some use morning NPH insulin when
it is difficult for the child to receive or administer a midday injection. CSII is also being used more often in infants
and toddlers who eat frequently; the use of pumps can help
parents improve the care of very young patients (539 [EL
2; PCS]). In adolescents, the main problems with glycemic
control often involve social and behavioral complications
(540 [EL 3; SS]). The increased insulin resistance associated with puberty, especially when coupled with obesity,
sometimes requires large insulin doses and high insulin-tocarbohydrate ratios.
Although T2D has been reported in preschool children, one must be cautious making this diagnosis in preadolescent children, taking care to exclude T1D by assessing immune markers and monogenic DM through a careful
family history and genetic testing. Guidelines for differentiating T1D from T2D in children have been published
(532 [EL 4; guidelines NE]), but several reports have demonstrated that these are imperfect and that phenotypic overlap between these disorders in children is common. T2D
remains a diagnosis of exclusion in adolescents. Lifestyle
modification (healthy diet and increased physical activity)
is always the first treatment choice, but the effectiveness
in children has not been extensively studied. Treatment of
T2D in children does not differ appreciably from its treatment in adults. Metformin has been studied (541 [EL 1;
RCT]) and remains the only oral medication formally indicated by the FDA for use in children with T2D, although
rosiglitazone and glimepiride report pediatric studies in
their labels. Insulin is effective and used widely alone or in
combination with metformin.

The TODAY (Treatment Options for Type 2 Diabetes
in Adolescents and Youth) trial demonstrated that current
therapy for children or adolescents with T2D is inadequate;
monotherapy with metformin was associated with durable
glycemic control in only half of children and adolescents
with T2D, and its effectiveness lasted <18 months (542
[EL 1; RCT]). Multiple ongoing trials are examining the
use of newer medications in adolescents with T2D, including DPP-4 inhibitors, GLP-1 receptor agonists, and SGLT2
inhibitors. These agents may improve glucose levels
without weight gain (or with weight loss) and/or hypoglycemia. However, although these classes are approved
for adults, none are currently FDA approved for people
younger than 18 years of age. Nevertheless, many pediatric endocrinologists use these agents in combination in
younger patients to avoid the use of insulin and TZDs due
to risks of weight gain and hypoglycemia.
SMBG frequency in pediatric patients with T1D has
been shown to be predictive of A1C levels and complications (543 [EL 3; SS]). However, CGM benefits pediatric
patients only when used on a virtually daily basis. When
CGM was used 6 days per week, decreases in both A1C
and the frequency and severity of hypoglycemia have been
reported (544 [EL 2; PCS]; 545 [EL 1; MRCT]).
Incorporation of an exercise and nutrition plan are
critical for managing either T1D or T2D in children and
adolescents. Ideally, a nutritionist should consult with the
entire family. The care of children and adolescents with
DM involves not only parents and the healthcare team,
but also grandparents, older siblings, teachers, coaches,
and any other adults in regular contact with the child. It
is important for these caregivers to maintain regular contact with each other and the healthcare team. Texting and
emailing of glucose values can be helpful.
The management approach to treating the adolescent
with T1D is like playing jazz: it requires improvisation and
persistence. The healthcare professional should discuss
the following with adolescents who have DM: drug and
alcohol avoidance and abuse prevention, cigarette smoking prevention and cessation, sexual activity, pregnancy
prevention and consequences, and automobile responsibilities and hypoglycemia prevention and management
while driving. Transitioning to DM care for adults requires
a well thought out plan with patients and their families.
The ADA, JDRF, and NIDDK offer resources to help with
transition planning (14 [EL 4; NE]; 15 [EL 4; NE]; 16 [EL
4; NE]).
An extensive review of CPGs for the care of DM in
children from the International Society of Pediatric and
Adolescent Diabetes was published in 2009 and is available on their website (13 [EL 4; CPG NE]).
4.Q17. How should Diabetes in

Pregnancy be Managed?
Abnormal glucose tolerance develops at higher rates
and at younger ages among offspring of females with DM.
Maternal DM is one of the strongest risk factors for the
development of T2D among Pima Indian children (546
[EL 2; PCS]; 547 [EL 3; CCS]; 548 [EL 3; SS]). By the
time these offspring reach childbearing age, they are very
likely to be obese and have DM, thereby perpetuating a
vicious cycle (548 [EL 3; SS]). That this is not simply a
genetic predisposition is inferred from the finding of lower
rates of DM in offspring of females who were born before
their mothers developed DM (549 [EL 3; SS]); this is true

among sibling pairs whose birth dates straddle the onset of
their mothers DM (546 [EL 2; PCS]). Thus, all females
with DM in the childbearing years should have preconception care and guidance to target an A1C level of <6.5%
(212 [EL 4; NE]; 550 [EL 2; PCS]). Frequent POC A1C
monitoring allows the clinician to assess the most recent
average glucose by comparing the current A1C POC test
with the previous weeks POC A1C. The rate of change
and direction of the change reflects the trend of recent glucose levels. Although the steady state is not achieved until
6 to 8 weeks later, a rising A1C reflects recent hyperglycemia and allows the clinician an opportunity to discuss the
observation and work with the patient for solutions.
The HAPO (Hyperglycemia and Adverse Pregnancy
Outcomes) study confirmed findings in the Pima Indians
(546 [EL 2; PCS]) that, even among offspring of females
without GDM as it is currently defined (551 [EL 2; PCS];
552 [EL 4; consensus NE]; 553 [EL 4; review NE]; 554
[EL 3; PCS]; 555 [EL 3; SS]), there is a linear association
between maternal glucose concentration during pregnancy
and newborn weight, rates of large-for-gestational-age,
and cesarean delivery. DM during pregnancy and even
maternal obesity itself (552 [EL 4; consensus NE]) set the
stage for a vicious cycle with offspring of mothers with
DM during pregnancy being more likely to become obese
and to develop DM at younger ages (554 [EL 3; PCS]).
Maternal DM and obesity, although major risk factors for
the metabolic health of the offspring, are not the only factors at play in the early stages of childhood that can have
lasting adverse effects on offspring. Both low and high
birth weight are associated with higher rates of DM (555
[EL 3; SS]). Abnormal birth weight directly affects the offspring and leads to higher rates of GDM eventually in the
offspring, thereby compounding the vicious cycle. Early
diagnosis and treatment of DM, careful preconception care
and guidance for females with DM or at risk for GDM, and
meticulous control of glucose abnormalities throughout
pregnancy are currently our best hope to break this cycle
(556 [EL 4; review NE]). Thus, subjects with DM risk factors (Table 5) should be screened at the first prenatal visit
for undiagnosed T2D using standard criteria (Table 6),
and all pregnant subjects without a prior diagnosis of DM
should be screened for GDM with a 2-hour OGTT using
a 75-g glucose load at 24 to 28 weeks gestation. Glucose
criteria diagnostic for GDM are an FPG >92 mg/dL, 1-hour
post-glucose challenge value 180 mg/dL, or 2-hour value
153 mg/dL (557 [EL 4; CPG]).

In T1D, optimal care may necessitate CGM and CSII.
The rapid-acting insulin analogs for pump therapy that
have been studied in pregnancy include lispro and aspart
(558 [EL 2; NRCT]; 559 [EL 3; retrospective study SS];
560 [EL 3; retrospective study SS]; 561 [EL 1; RCT]). The
data that detemir is safe in pregnancy are convincing, and
this agent is now considered pregnancy category B (562
[EL 3; SCR]; 563 [EL 3; retrospective study SS]; 564

[EL 1; RCT, not blinded]; 565 [EL 1; RCT, not blinded]).
Glargine is widely used; however, there are still no conclusive reports on its safety, and it remains pregnancy
category C. Although insulin is the preferred treatment
approach, metformin and glyburide have been shown to
beeffective alternatives without adverse effects in some
females. Metformin crosses the placenta and is classified
as category B for pregnancy; sulfonylureas do not cross the
placenta. Regardless, the optimal therapy for subjects with
GDM or T2D who are not able to maintain normoglycemia
with a proper meal plan is insulin (212 [EL 4; NE]).
4.Q18. When and How Should Glucose
Monitoring be Used?

Current glucose monitoring strategies can be classified
into 2 categories: patient self-monitoring, which would
allow patients to change behavior (diet and/or exercise)
or medication dose (most often insulin), and long-term
assessment, which allows both the patient and the clinician to evaluate overall glucose control and risk for complications over weeks or months. Although some form of
glucose self-monitoring has long been available, current
forms of self-monitoring include SMBG and CGM, while
long-term assessment is most often by A1C.

A1C is defined as the stable adduct of glucose at the
N-terminal amino group of the chain of hemoglobin.
Glycated hemoglobin is quantified most commonly with
methods that distinguish it from nonglycated hemoglobin
on the basis of either charge (cation-exchange chromatography, electrophoresis, isoelectric focusing) or structural
characteristics (affinity chromatography, immunoassays).
A1C and mean glucose are directly related over the lifespan of the red blood cell (100 to 120 days), but 50% of
A1C is determined by glycemia during the 1 month preceding measurement. Currently, 99% of laboratories in the
United States use a standardized and certified assay traced
to the DCCT. More recently, using CGM, each level of
A1C was measured as estimated average glucose. There
are numerous patient populations in which A1C may not
reflect average glucose. These reasons can include changes
in erythrocyte survival time (e.g., hemolysis, splenomegaly, or use of epoetin alfa), alterations in the hemoglobin
molecule (hemoglobinopathies), iron status, or recent
blood transfusion (23 [EL 4; review NE]). Renal failure
also results in a different A1C level than would be seen in
those with normal kidney function (566 [EL 2; PCS]).

Current glucose meters perform rapid tests with small
blood volumes and are easily operated by laypersons with
DM in the outpatient setting. They are equipped with a variety of features, ranging from storing results of glucose tests
performed to simple pattern analysis to Bluetooth connectivity to smartphones. The ISO (Institutional Organization
for Standardization) specifies requirements for in vitro
glucose monitoring systems that measure capillary blood

glucose, for specific design verification procedures, and for
the validation of self-measurement performance by laypersons with DM. The 2013 ISO 15197 standard for glucose
meter accuracy is stricter than the 2003 version. The new
standard requires that 95% of values fall within 15% for
glucose levels >100 mg/dL and within 15% for glucoses
<100 mg/dL. The 2003 version allowed 20% difference
for glucose >75 mg/dL. Each of the meter chemistries has
its own set of potential interfering substances; however,
newer technology is helping to reduce these.
In T1D, SMBG has not been studied on its own, but
rather as one component of a comprehensive treatment
strategy (68 [EL 1; RCT]). SMBG frequency (in a retrospective analysis) has been shown to be predictive of A1C
levels (543 [EL 3; SS]; 567 [EL 3; SS]; 568 [EL 2; RCCS];
569 [EL 3; CSS]).
Patient adherence to monitoring and treatment is the
greatest predictor of glycemic control. When used appropriately, CGM can lead to decreased A1C and reduced
hypoglycemic exposure (570 [EL 1; RCT]; 571 [EL 1;
RCT]). CGM currently uses interstitial fluid glucose as
an alternative to plasma glucose. Both currently approved
systems use glucose oxidase embedded on the sensor. With
current technology, there is usually a lag time of up to 7
minutes between the plasma and interstitial glucose and
the receiver display. Despite improvements, accuracy of
the current generation of CGM devices is not yet deemed
sufficient by the FDA to approve them to replace standard
glucose meters for insulin-dosing decisions. Additional
research is needed before recommendations can be made
regarding CGM use in patients with T2D.
4.Q19. When and How Should Insulin Pump
Therapy be Used?

Insulin pumps have been used for more than 30 years
(572 [EL 4; review NE]). By definition, they provide constant, continuous infusion of short-acting insulin driven by
mechanical force and delivered via a soft cannula under
the skin. In the United States, it is estimated that 20 to 30%
of patients with T1D and <1% of insulin-treated patients
with T2D use CSII (573 [EL 3; SS]). The FDA estimates
that the number of U.S. patients with T1D using CSII was
~375,000 in 2007, up from approximately 130,000 in 2002
(574 [EL 4; review NE]).

Recent advances in insulin pumps include dose calculators (wizards), which are standard on all current models; the ability to program different basal insulin rates to
match activities; color touch screens; universal serial bus
(USB)-rechargeable batteries; prefilled insulin cartridges;
and disposability. In addition, pumps now offer multiple
infusion set types, various catheter tubing lengths, and
tubeless pumps with an integrated infusion set and reservoir. Clinical trials are underway to validate methods that
accelerate insulin action, including the addition of hyaluronidase to the tubing, heating of the injection site, intradermal insulin injection, and new formulations of rapidacting insulin (575 [EL 4; NE]; 576 [EL 4; NE]; 577 [EL
4; NE]; 578 [EL 2; PCS]). CGM sensor-augmented pumps
with a threshold suspend function represent the first step
toward an automatic or semiautomatic closed-loop insulin delivery device. Such pumps suspend insulin delivery
for 2 hours (or until the suspension is manually overridden) when the CGM sensor glucose level declines below a
specified threshold (579 [EL 3; CCS]; 580 [EL 1; RCT, not
blinded]).

Prompted by these advances in pump technology, the
AACE recently updated its Consensus Statement on CSII
(581 [EL 4; NE]), which includes a thorough review of
the state of the art. Numerous other position statements
and guidelines are available from the ADA (582 [EL
4; review NE]); the American Association of Diabetes
Educators (583 [EL 4; CPG NE]); the American Academy
of Pediatrics (584 [EL 4; position NE]); and the European
Society for Paediatric Endocrinology, the Lawson Wilkins
Pediatric Endocrine Society, and the International Society
for Pediatric and Adolescent Diabetes, which published
a joint consensus statement regarding the use of insulin
pumps in children (585 [EL 4; consensus NE]).
Table 16 presents a summary of important clinical
research findings on CSII efficacy and safety in patients
with T1D, including the results of key meta-analyses covering clinical research on insulin pump therapy published
after 2003 (172 [EL 1; MRCT]; 586 [EL 1; MRCT]; 587
[EL 1; MRCT]; 588 [EL 1; MRCT]; 589 [EL 1; MRCT]).
Table 17 summarizes evidence from RCTs of CSII in
T2D (590 [EL 1; RCT, not blinded]; 591 [EL 1; RCT, not
blinded, small sample size]; 592 [EL 1; RCT, not blinded];
593 [EL 1; RCT, small sample size, not blinded]; 594 [EL
3; CCS]; 595 [EL 3; CCS]; 596 [EL 1; RCT, not blinded];
597 [EL 1; RCT, small sample size, not blinded]).
Based on this evidence and other currently available
data, CSII appears to be justified for basal-bolus insulin
therapy in appropriately selected patients with T1D who
have inadequate control with MDI. The ideal CSII candidate is a patient with T1D or absolutely insulin-deficient
T2D (as confirmed with C-peptide measurement) who currently takes insulin multiple times per day, assesses blood
glucose levels multiple times daily, is motivated to achieve
tighter glycemic control, and is willing and intellectually and physically able to undergo the rigors of insulin
pump therapy initiation and maintenance. Eligible patients
should be capable of frequent SMBG (at least initially)
and/or CGM device use. Furthermore, candidates must be
able to master carbohydrate counting, insulin correction,
and adjustment formulas and be prepared to troubleshoot
problems related to pump operation and plasma glucose
levels. Lastly, patients should be emotionally mature, with
a stable life situation, and be willing to maintain frequent
contact with members of their healthcare team, in particular their pump-supervising physician and CDE.
Concerns have been raised about the costs incurred
by CSII. However, recent evidence indicates that CSII is
a cost-effective treatment option, both in general and compared with MDI for children and adults with T1D. Table
18 summarizes the key assumptions and findings of recent
representative cost-effectiveness analyses comparing CSII
with MDI in specific patient populations (598 [EL 3; SS];
599 [EL 3; SS]; 600 [EL 3; SS]; 601 [EL 3; retrospective
review SS]; 602 [EL 3; SS]; 603 [EL 1; RCT, posthoc analysis]; 604 [EL 3; SS]).
4.Q20. What is the Imperative for Education and
Team Approach in DM Management?

A team must be involved in DM care. Working with
different healthcare professionals allows the patient to
learn in-depth information about a variety of topics related
to their stated, and usually unstated, health concerns. It
also ensures that the patients needs are cared for and
addressed. Use of other healthcare professionals skills
and specialties ensures the patient has the best care and
understanding of their condition. Often, problems may be
apparent to one healthcare professional but go unnoticed
by another. For example, recognizing a patients illiteracy or vision problems in a group class may be difficult,
but these problems may be obvious during a one-on-one
encounter.
Diabetes Healthsense from the National Diabetes
Education Program, a joint venture of the NIH and CDC,
is an important resource for all diabetes care teams (605
[EL 4; NE]). This website offers over 150 resources
developed by behavior change experts to help patients
better adhere to clinician recommendations about diabetes management.
4.Q20.1. Certified Diabetes Educators

A CDE is generally a nurse or registered dietitian but
could be another healthcare professional. CDEs teach in a
variety of inpatient and outpatient settings. They cover all
topics related to DM management from insulin administration to foot care. They often have more time than physicians to devote to each patient, which allows them to focus
on specific needs. Often patients report they receive more
practical knowledge from their CDE than they do from
their physician. Having a CDE credential indicates the
passing of the certification examination and special ability
in this area.
4.Q20.2. Registered Dietitians

A healthful diet is necessary for everyone to maintain
good health. However, persons with DM especially need
to follow their prescribed meal plan and physical activity program as an integral part of their therapy. Registered
Abbreviations: A1C, hemoglobin A1C; CSII, continuous subcutaneous insulin infusion; EL, evidence level; MDI, multiple daily injections; MRCT, meta-analysis of randomized
controlled trials; RCT, randomized controlled trial; T1D, type 1 diabetes mellitus; T2D, type 2 diabetes mellitus.
A1C was significantly lower with CSII vs. MDI; A1C reduction was
only evident for studies with mean patient age >10 years
Severe hypoglycemia occurred at a comparable rate with CSII and
MDI therapy
177 studies identified; final review

Comparison of glycemic control and
hypoglycemic incidence with short-acting, consisted of 11 RCTs published
between 2000 and 2008
analog-based CSII (n = 444) vs. MDI
(n = 439) therapy of 12 weeks duration
in patients with T2D
(172 [EL 1; MRCT])
Risk of severe hypoglycemia was decreased with CSII vs. MDI;

greatest reduction observed in patients with DM of longest duration
and in those with highest baseline rates of severe hypoglycemia with
MDI therapy
A1C was lower for CSII than for MDI, with greatest improvement
seen in patients with highest initial A1C values on MDI
Examination of CSII and MDI effects on

glycemic control and incidence of severe
hypoglycemia in patients with T1D
(n = 1,414); focused on studies with 36
months of CSII therapy and >10 episodes
of severe hypoglycemia per 100 patientyears with MDI therapy
(589 [EL 1; MRCT])

consisted of 22 RCTs and before/
after studies published between
1996 and 2006
Comparison of effects of CSII and MDI

on glycemic control and hypoglycemia in
adults and children with T1D (n = 669) or
T2D (n = 239)
(588 [EL 1; MRCT])
A1C reduction greater and insulin requirements lower with CSII

than MDI in adults and adolescents with T1D; risk of hypoglycemia
comparable among adult patients (data unavailable for adolescent
patients); no conclusive CSII benefits seen for patients with T2D

consisted of 22 RCTs (17 T1D, 2
T2D, 3 pediatric) published through
March 2007
In patients with T1D, A1C was mildly decreased with CSII vs. MDI;
CSII effect on hypoglycemia unclear
CSII and MDI outcomes were similar among patients with T2D
Notes:
CSII efficacy in patients with hypoglycemia unawareness or recurrent
severe hypoglycemia inconclusive because of lack of data
Comparison of effects of CSII vs. MDI

on glycemic control, hypoglycemic risk,
insulin requirements, and adverse events
in adults with T1D (n = 908), children
with T1D (n = 74), and patients with T2D
(n = 234)
(587 [EL 1; MRCT])
Clinical findings
Compared with MDI, CSII therapy was associated with significant
improvements in glycemic control on the basis of decreases in A1C
and mean blood glucose levels
Analysis of CSII complications before 1993 revealed decreased risk
of hypoglycemic events with insulin pump therapy, but a potential
increased risk of diabetic ketoacidosis
Notes:
Changes in insulin requirements and body weight not included in
analysis because of insufficient data
CSII did not appear to be associated with increased risk of poor
psychosocial outcomes, although effects on patient perspectives
and psychosocial functioning were difficult to assess because of
inconsistencies in study design and methodology
2,483 studies identified; 61

met initial criteria; final review
consisted of 52 studies (37 paired,
4 randomized crossover, and 11
parallel) published between 1979
and 2001
Number/types of studies
included in meta-analysis

consisted of 15 RCTs published
between 2002 and March 2008
Investigation of metabolic and

psychosocial impact of CSII therapy
vs. other treatment modalities (e.g.,
MDI, conventional therapy) in children,
adolescents, and adults (n = 1,547)
Meta-analysis objectives
(586 [EL 1; MRCT])
Reference
(evidence level
and study design)
Table 16
Meta-Analyses of Studies of CSII Published Since 2003
10
17
107
40
132
20
331
(594 [EL 3; CCS])
(593 [EL 1; RCT, small

sample size, not blinded])
(592 [EL 1; RCT, not

blinded])

blinded, small sample size])

blinded])
(597 [EL 1; RCT, small

sample size, not blinded])

blinded])
RCT
RCT
Parallel
Crossover
Parallel
Crossover
Observational
Observational
Design
6 months
4 months
24 weeks
2 periods of 18
weeks
1 year
2 periods of 12
weeks
3 successive
nights
30 weeks
Follow-up
1.1 (1.2)
9.2
(HbA1)
CSII: 13.2c
MDI: 12.8
0.4 (1.1)
10.6
(HbA1)
7.5 (1.2)
+0.4 (1.3)b
0.8 (1.5)b
7.6 (1.2)
6.4 (0.8)
8.6 (1.6)
NA
NA
MDI
6.6 (0.8)
7.7 (0.8)
FPG:
99.1 (28.8) mg/dL
5.0 (0.9)
CSII
CSII: 8.2 (1.4)

MDI: 8.0 (1.1)
CSII-MDI: 10.1 (1.6)

MDI-CSII 10.2 (1.4)
CSII: 8.4 (1.1)

MDI: 8.1 (1.2)
9 (1.6)
FPG:
209 (52.3) mg/dL
7.9 (1.9)
Baseline
A1C (%) (SD)a
<.0001
<.05
NS
.007
.19
<.03
<.0001
<.001
P value
Abbreviations: A1C = hemoglobin A1C; CSII = continuous subcutaneous insulin infusion; FPG = fasting plasma glucose; MDI = multiple daily injections; NS = not significant;
RCT = randomized controlled trial; T2D = type 2 diabetes mellitus.
a Change in glycemic control reported as A1C unless otherwise noted.
b A1C values for CSII and MDI are presented by Wainstein et al as a direct treatment effect in the completers cohort.
c Reported in study as median mmol hydroxymethylfurfural (HMF) per mol hemoglobin (Hb) and converted to median percentage HbA based on the following formula, which
1
was determined via comparison with a column chromatography method over the range of 4 to 13%: HbA1 (%) = 0.21 (A1C in mmol HMF/mol Hb) - 0.35 (597 [EL 1; RCT,
small sample size, not blinded]).
15
Number
randomized
(595 [EL 3; CCS])
Reference
Table 17
RCTs Comparing CSII and MDI for Patients With T2D
To evaluate the long-term (60-year) costeffectiveness of CSII compared with MDI in

adult patients with T1D
Canadian payer perspective
Computer simulation model (CORE Diabetes
Model)
Assessment report to examine the clinical and

cost-effectiveness of using CSII to treat DM
(T1D and during pregnancy)
NICE, United Kingdom
Systematic review and economic evaluation
(74 studies included)
To project the long-term (60-year) costs and

outcomes of CSII compared with MDI in
patients with T1D
United Kingdom; third party NHS perspective
Model)
To estimate the long-term cost-effectiveness of

SAPT compared to MDI in T1D
To project the long-term clinical and economic

outcomes of CSII treatment compared to MDI
in T1D in Denmark
Meta-analysis of CSII treatment from over 50
studies
(598 [EL 3; SS])
(600 [EL 3; SS])
(602 [EL 3; SS])
(603 [EL 1; RCT,

posthoc analysis])
(604 [EL 3; SS])
CSII: Can$27,265
MDI: Can$23,797
NA
CSII: 80,511
MDI: 61,104
(variance = 25,648/QALY
gained with CSII)
QALY gains for CSII

vs. MDI were 0.655
NA
QALY gains for CSII

vs. MDI were 0.76
CSII was associated

with improved
quality-adjusted life
expectancy compared
to MDI (QALY not
calculated)
Lifetime costs were higher

for CSII than for MDI with
ICERs in terms of cost per
QALY within the range
considered good value for
money
ICER =
(c1-c2)/q1 q2 = $229,582
Lifetime cost:
SAPT: $253,493
MDI: $167,170
CSII: $16,992
MDI: $27,195
QALY gains for CSII

vs. MDI were 0.262
QALY gains for SAPT

vs. MDI were 0.376
Cost per QALY (ICER)
QALYs gained
CSII led to improved long-term clinical outcomes

due to improved glycemic control vs. MDI
Economic impact of CSII vs. MDI would likely
represent good value for cost
Despite superior clinical benefits of SAPT

compared to MDI, SAPT did not appear to be
economically attractive in the U.S. for adults
with T1D in its current state of development
Further clinical development to reduce disposable
costs of the system could improve this
Improvements in glycemic control with CSII vs.

MDI led to a reduced incidence of DM-related
complications
For patients with T1D, CSII represents good
value on the basis on current UK standards
CSII is cost-effective for T1D in both children

and adults
No evidence that CSII is better than MDI in
pregnancy
Improved glycemic control from CSII led

to reduced incidence of DM complications
including PDR, ESRD, PVD
The NNT for PDR was 9 (i.e., only 9 patients
need to be treated with CSII to avoid 1 case
of PDR)
Additional key findings
Abbreviations: CORE = Center for Outcomes Research; CSII = continuous subcutaneous insulin infusion; EL = evidence level; ESRD = end-stage renal disease; ICER =
incremental cost-effectiveness; MDI = multiple daily injections; NA = not applicable; NHS = National Health Services (United Kingdom); NICE = National Institute for Health
and Clinical Excellence; NNT = number needed to treat; PDR = proliferative diabetic retinopathy; PVD = peripheral vascular disease; QALY = quality-adjusted life year;
SAPT = sensor-augmented pump therapy; T1D = type 1 diabetes mellitus; T2D = type 2 diabetes mellitus.
To estimate long-term (60-year) costeffectiveness of CSII compared with MDI in

adults and children with T1D
U.S. third-party payer perspective
Model)
Study objective, perspective, data source
(599 [EL 3; SS])
Reference
Table 18
Summary Data from Cost-effectiveness Analyses Comparing Continuous Subcutaneous Insulin Infusion with Multiple Daily Injections in Adults and Children with T1D
dietitians can develop a healthful eating plan and can also

provide related DM education. They can document problems such as disordered meal patterns, timing of meals,
eating disorders, lack of money for food, or other physiologic and psychosocial problems. These issues may not
be identified during physician office visits.
4.Q20.3. Nurses and Medical Assistants

Registered nurses, as well as licensed practical nurses
(LPNs) and medical assistants (MAs), can provide an
assessment before the physician sees the patient, which
allows for a better focus on any identified problems.
Teaching medication administration is another important
area that can be delegated to a nurse or MA. Physician time
can be saved when the nurse fields phone calls related to
medication administration, assessment of medication tolerability, and other DM-related management issues.
4.Q20.4. Nurse Practitioners and Physician Assistants
A patient may see these nonphysician clinicians in
conjunction with the physician. These healthcare professionals can set up treatment plans and set goals that other
team members will implement in the patients care, allowing the physician to focus on specific treatment issues.
These clinicians may also be able to assume some treatment decisions, thus freeing the physician to concentrate
on other healthcare issues.
4.Q20.5. Primary Care Physicians
Each patient should have a primary care physician
who addresses other aspects of care beyond DM alone.
Typically, specialists have longer wait times for appointments, so that patients might not be seen on a timely basis
for medical issues that need more immediate evaluation.
Other specialists such as a cardiologist, nephrologist, ophthalmologist, psychologist, and podiatrist might be warranted as part of the DM healthcare team. It is important
for patients to see the appropriate specialist as part of their
care.
4.Q21. Which Vaccinations Should be Given to

Bacterial and viral infections cause significant morbidity and mortality in patients with DM (606 [EL 4; NE]). A
recent Canadian cohort study of adults with DM <65 years
of age showed that DM increased the risk of influenzaassociated hospitalizations by 6% (risk ratio 1.06, 95% CI
1.02 to 1.10; absolute risk difference 6 per 1,000 adults per
year) even though the rates of influenza and pneumonia
were similar between diabetic and nondiabetic populations
(P=.11) (607 [EL 3; SS]). Both community-acquired and
nosocomial infections with pneumococcal bacteria may
also be higher among patients with DM, who may also be at
greater risk of death from these diseases (608 [EL 3; CSS];
609 [EL 2; PCS]; 610 [EL 2; PCS]). However, vaccines can

safely and effectively reduce serious complications from
influenza. A case-control study demonstrated that vaccines
reduced DM-related hospital admissions by as much as
79% during flu epidemics (611 [EL 2; RCCS]). In addition,
no evidence suggests that people with DM have inadequate
serologic or clinical responses to these vaccinations. The
CDC ACIP recommends a yearly influenza vaccine for all
individuals with DM, although live attenuated influenza
vaccine should be used with caution because its safety in
patients with DM has not been established. Inactivated
influenza vaccine may be considered for patients with
DM (612 [EL 4; NE]). The CDC ACIP also recommends
single administration of the 23-valent pneumococcal vaccine (PPSV23) for adults with diabetes aged 19 to 64 years
(613 [EL 4; NE]). Furthermore, the 13-valent pneumococcal conjugate vaccine (PCV13) should be administered in
series with the PPSV23 to all adults 65 years (614 [EL 4;
NE]).
4.Q21.1. Hepatitis B Vaccine

Over the past 2 decades, the CDC has received 29 case
reports of hepatitis B virus (HBV) infection in hospitals
and long-term care facilities; of these, 25 were in patients
with DM who were receiving blood glucose monitoring
from healthcare personnel who were providing care for
more than 1 patient. HBV remains stable and highly transmissible for long periods of time on surfaces such as lancing devices, blood glucose meters, and insulin pens. The
reservoirs of these devices can retain sufficient blood to
transmit the virus and thus should never be shared between
patients (615 [EL 4; NE]).
Other CDC analyses suggest that acute HBV infections occur in approximately twice as many adults with
DM as those without when persons with HBV-related risk
behaviors are excluded. Acute infections are also more
likely to progress to chronic hepatitis B. Seroprevalence
of antibody to the HBV core antigen, which suggests past
or current infection, is 60% higher among adults with DM
than those without. DM may also increase HBV-associated
mortality (615 [EL 4; NE]).

As a result of these findings, the CDC ACIP now
recommends that all adults with DM aged 19 to 59 years
be vaccinated against HBV as soon as possible after DM
diagnosis, and HBV vaccination should be considered for
individuals age 60 years after assessment of risk and the
likelihood of an adequate immune response. The differential age recommendations are based on economic models
that yielded age-stratified calculations. The incremental
cost per quality-adjusted life-year (QALY) saved was
$75,100 for adults up to 59 years, but costs per QALY
saved increased substantially with greater age after this
point because of other causes of mortality, as well as
declining immune responses to the vaccine in older adults
(615 [EL 4; NE]).
4.Q22. How Should Depression be Managed

in the Context of Diabetes?
Routine screening for depression in adults with DM
is recommended. Untreated comorbid depression can have
serious clinical implications for patients with DM because
depression contributes to poor self-care, less treatmentrelated adherence, and poor glycemic control (616 [EL 1;
meta-analysis]). In addition, depression may be a risk factor for developing DM (617 [EL 2; MNRCT]). Depression
and DM also are associated with a significantly increased
all-cause and CVD-related mortality rate (618 [EL 2;
PCS]). Chronic use of antidepressant medication is associated with a modestly increased relative risk of T2D (619
[EL 3; SS]). This may reflect the association of DM with
depression rather than suggest an adverse effect of these
agents (620 [EL 2; PCS]). The impact of the newer agents
for treating depression is yet to be established, especially if
they contribute to weight gain (621 [EL 2; NRCT]).

Collaboration with mental health professionals skilled
in treating patients with DM can improve glycemic control
and psychological well-being (622 [EL 1; RCT, singleblinded]). Patients with depression or DM-related distress
should be referred to mental health professionals who are
integrated into the DM care team (212 [EL 4; NE]).
4.Q23. What is the Association Between
Diabetes and Cancer?
Epidemiologic evidence suggests increased risks of
cancer and cancer mortality in patients with obesity and
DM (623 [EL 3; SS]; 624 [EL 2; PCS]; 625 [EL 2; PCS]).
Whether antihyperglycemic therapy increases cancer risk
remains unknown due to limited and conflicting data,
although the latest analyses do not support increased cancer risk for any given treatment. Readers should consult the
AACE/ACE Consensus Statement on Diabetes and Cancer
for a complete discussion (626 [EL 4; NE]).

Increased BMI (>25 kg/m2) is associated with an
increased risk of a wide variety of cancers. The strongest
associations appear to be for endometrial, gall bladder,
esophageal (adenocarcinoma), renal, thyroid, ovarian,
breast, and colorectal cancer, with weaker but still statistically significant associations for leukemia, malignant and
multiple melanoma, pancreatic cancer, and non-Hodgkin
lymphoma (627 [EL 2; MNRCT]; 628 [EL 2; MNRCT];
629 [EL 2; MNRCT]; 630 [EL 2; MNRCT]; 631 [EL 2;
MNRCT]). Increased BMI may, however, be protective for
lung, esophageal (squamous) (628 [EL 2; MNRCT]), and
prostate cancer (632 [EL 3; SS]) in males, although more
aggressive prostate cancers seem to be more common in
males who are overweight or obese (633 [EL 4; NE]). In
females, increased BMI may be protective for premenopausal breast and lung cancer (628 [EL 2; MNRCT]). As
noted in the 2013 AACE/ACE Consensus Statement on
Diabetes and Cancer, a higher BMI is also closely associated with increased levels of endogenous insulin, insulinlike growth factors, inflammatory cytokines, and other
factors that can have downstream procancer growth effects
(626 [EL 4; NE]). These and other potential mechanisms
have been recently reviewed (634 [EL 4; NE]).

DM also significantly increases the risk of various
common cancers, including endometrial, breast, hepatic,
bladder, pancreatic, and colorectal cancers. As with
increased BMI, the risk of prostate cancer appears to be
decreased among males with DM (635 [EL 2; MNRCT];
636 [EL 2; MNRCT]; 637 [EL 2; MNRCT]; 638 [EL 2;
MNRCT]; 639 [EL 2; MNRCT]; 640 [EL 2; MNRCT]).
In addition to the other obesity-related mechanisms
noted above, hyperinsulinemia appears strongly connected
to the development of cancer in patients with DM. Animal
models suggest that increased activation of insulin and
insulin growth factor 1 (IGF-1) receptor leads to increased
tumor volume (641 [EL 4; NE]; 642 [EL 4; NE]; 643 [EL
4; NE]). Whether hyperglycemia contributes to cancer
development is less clear. Energy for tumor cell growth
and proliferation comes from glucose but also from amino
acids such as glutamine (644 [EL 4; NE]). In fact, cancer
cells can thrive using nonglycemic energy sources due to
genetic mutations in tumor cells, as well changes to intracellular signaling stimulated by activation of growth factor
receptors (644 [EL 4; NE]; 645 [EL 4; NE]; 646 [EL 4;
NE]).

The evidence for the effects of specific antihyperglycemic agents on cancer risk is limited and confounded by
factors such as the indications for specific drugs, effects on
other cancer risk factors such as body weight and hyperinsulinemia, and the complex progressive nature of hyperglycemia and pharmacotherapy in T2D. Metformin may
have a neutral effect or modestly decrease cancer incidence
and mortality, particularly colorectal, hepatocellular, and
lung cancer (647 [EL 2; PCS]; 648 [EL 2; MNRCT]; 649
[EL 1; MRCT]; 650 [EL 2; MNRCT]). The effect of metformin on cancer outcomes is currently being explored in
prospective trials. Pioglitazone may be associated with a
very small, nonsignificant risk of bladder cancer, although
recent evidence from a large population study suggests
there is no significant association (127 [EL 4; NE]; 128
[EL 3; SS]). TZD therapy in general is not associated with
other cancers.

The risk of cancer with incretin therapies has garnered
much attention since the publication of a meta-analysis
finding an increased incidence of pancreatic disease in
individuals taking these medications (651 [EL 3; SS]).
However, a thorough review of available data conducted
by the FDA and the European Medicines Agency (EMA)
has not uncovered evidence to support a causal association (652 [EL 4; NE]). In particular, results from a pooled
analysis of sitagliptin data (653 [EL 1; MRCT]), as well
as from the SAVOR (Saxagliptin Assessment of Vascular
Outcomes Recorded) (146 [EL 1; RCT]) and EXAMINE

(Examination of Cardiovascular Outcomes with Alogliptin
versus Standard of Care) trials (145 [EL 1; RCT]) did not
show any increased incidence of pancreatic disease among
patients taking these agents. Results from 2 retrospective cohort studies indicate no risk of pancreatitis with
exenatide (654 [EL 3; SS]; 655 [EL 3; SS]), while 1 study
reported an increased risk for past users but not for recent
or current users (656 [EL 2; PCS]). An increase in thyroid
carcinoma occurred in preclinical trials of liraglutide; in
liraglutide clinical trials, 1.3 cases of thyroid cancer per
1,000 patient-years occurred in patients taking liraglutide
versus 1.0 cases per 1,000 patient-years in those receiving
placebo (657 [EL 4; NE]).
Contrary to preliminary evidence suggesting that
exogenous insulin may be associated with an increased
cancer risk, recent studies have not substantiated this risk,
including the large-scale ORIGIN (Outcome Reduction
with an Initial Glargine Intervention) trial, which involved
>6,000 patients receiving glargine over a median trial duration of 6 years. In ORIGIN, use of insulin glargine was not
associated with an increased risk of any cancer (HR, 1.0;
95% CI, 0.88 to 1.13) or cancer death (HR, 0.94; 95% CI,
0.77 to 1.15) (658 [EL 1; RCT]).
Among the SGLT2 inhibitors, more cases of bladder
cancer occurred among dapagliflozin-treated than controltreated patients in clinical trials, and the product labeling
indicates that this agent should not be used in patients with
active bladder cancer and should be used with caution in
patients with a history of bladder cancer (659 [EL 4; NE]).
An increased incidence of bladder cancer was not observed
in clinical trials with canagliflozin (660 [EL 4; NE]).
4.Q24. Which Occupations Have Specific
Diabetes Management Requirements?

The licensing and certification of various occupations,
including commercial drivers and pilots, anesthesiologists,
and commercial or recreational divers, is restricted for persons with insulin-treated DM because of the potential risk
hypoglycemia may pose to the patient and others.
4.Q24.1. Risk of Accidents

An area of great concern has been whether DM might
lead operators of commercial vehicles (e.g., bus, truck,
taxi, ferry, or airplane) to lose control and have an accident, putting themselves or others at risk of injury. Eye
disease associated with DM, including the various forms
of retinopathy and cataract, is of course a potential cause
of impaired driving ability, and there is general consensus that ascertainment of the visual acuity of commercial
motor vehicle drivers or airline pilots is a reasonable measure for measuring such risk. Similarly, coronary artery
disease, CVD, musculoskeletal conditions, and diabetic
neuropathy might in various ways impair safe driving or
piloting ability. The U.S. Federal Motor Carrier Safety

Administration and Federal Aviation Administration both
require medical certification for operating commercial
motor vehicles (used in interstate commerce) and airplanes;
these are based on a medical examination including vision,
audiometric, and cardiac assessments, as well as standard
history and physical examination. Both organizations cite
the use of insulin for glycemic control as a criterion for disqualification. Although an insulin-waiver program exists
for drivers, this is a complex undertaking, leading many to
refuse the treatment even if medically needed. It should be
noted that individual states might have separate regulations
governing commercial drivers licenses (661 [EL 4; NE]).
For commercial pilots, insulin treatment is an absolute disqualification (662 [EL 4; NE]).
4.Q24.2. Hypoglycemia and Antihyperglycemic
Treatments
Hypoglycemia may impair judgment and motor ability, which could increase the likelihood of an accident during operation of a motor vehicle or airplane. The Federal
Motor Carrier Safety Administration Evidence Report on
Diabetes and Commercial Motor Vehicle Driver Safety
addressed a set of key questions relevant to this topic (663
[EL 4; NE]):
1. Are individuals with DM at increased risk for a
motor vehicle crash compared with individuals
who do not have DM?
2. Is hypoglycemia an important risk factor for a
motor vehicle crash among individuals with DM?
3. What risk factors are associated with an increased
incidence of severe hypoglycemia, and what is the
incidence of severe hypoglycemia with different
treatments and treatment modalities (e.g., use of
insulin and injectable noninsulin drugs such as
GLP-1 receptor agonists)?
4. How effective is hypoglycemia awareness training
in preventing the consequences of hypoglycemia?
The authors of the report performed a set of meta-analyses of existing publications to address these 4 questions.
They showed evidence that, taken as a whole, individuals
with DM do not have a significantly increased risk of motor
vehicle accidents compared with drivers without DM.
However, a separate analysis of studies conducted within
the U.S. showed a 25% increase in risk of accidents, while
studies conducted outside the U.S. showed no increased
risk. This was particularly true when non-U.S. and U.S.
cohorts of insulin-treated persons were compared. The
analysis of the 2 available U.S. studies showed a 2.75-fold
greater risk of motor vehicle accident when insulin-treated
persons were compared with individuals without DM (P =
.001), while studies from outside the U.S. demonstrated no
significant difference in accident risk. In contrast, a metaanalysis restricted to U.S. studies of persons with DM not
using pharmacologic treatment or using oral antihyperglycemic agents did not show a significant increase in risk of
accidents. In the individual studies included in the analysis,
sulfonylurea use did not significantly increase the risk of
accident (664 [EL 2; RCCS]; 665 [EL 2; RCCS]; 666 [EL
2; RCCS]).

The applicability of these studies to the current population of persons with DM in the U.S. is limited because recommended treatment goals and approaches have changed
dramatically since the follow-up periods of most of the cited
studies. First, the studies of insulin users involved mostly
patients with T1D, but the use of a basal insulin analog as
the sole administered insulin for T2D is associated with
considerably lower hypoglycemia rates than older insulin
preparations or the use of basal-bolus treatment (667 [EL
1; RCT, not blinded]). Second, sulfonylurea treatment is
associated with a greater likelihood of hypoglycemia than
all other noninsulin antihyperglycemic agents (metformin,
TZDs, -glucosidase inhibitors, DPP-4 inhibitors, and
GLP-1 receptor agonists) and carries a nearly a twofold
greater likelihood of hypoglycemia than basal insulin (668
[EL 1; MRCT]). Unfortunately, reliable large population
studies of motor vehicle accidents involving patients with
T2D treated with current approaches are not available
(studies of oral antihyperglycemic agents included in the
meta-analysis examined data from the late 1980s to early
1990s). Finally, and perhaps most importantly, the role of
SMBG in preventing episodes of hypoglycemia was not
well addressed in the available studies.
4.Q24.3. Commercial Drivers and Lifestyle
Over the past 2 decades, the prevalence of obesity
among commercial motor vehicle operators has risen even
faster than in the general population. Commercial drivers may be away from home for long periods of time with
infrequent stops, usually driving for long periods. At times
they have limited control over their work environment,
and little time for exercise. Meals tend be irregular, and
dining choices are often limited. A population-based survey of 1,265 U.S. long-haul truck drivers, 76% of whom
were physically inactive, showed that 69% were obese
compared to 31% in the age-matched U.S. adult working
population, and 51% versus 19% were smokers (669 [EL
3; SS]). Obesity, hypertension, and DM in turn increase the
risk of OSA among drivers (670 [EL 2; RCCS]), which is
not only a risk factor for accidents but also may contribute to worsening of glycemia and other cardiovascular risk
factors. Although the details differ, commercial car drivers
represent another large group with similar health concerns
(671 [EL 3; SS]).
Because commercial vehicle operators (particularly
drivers) exhibit a variety of lifestyle issues that put them
at high risks of DM and associated comorbidities, this
group would particularly benefit from improved healthcare
access with a focus on measures to reduce obesity.
ACKNOWLEDGMENT
We acknowledge the medical writing assistance of
Amanda M. Justice, who was instrumental in the publication of this guideline.
Members of the AACE Task Force for Developing a
Diabetes Comprehensive Care Plan and/or authors include
Yehuda Handelsman, MD, FACP, FACE, FNLA*; Zachary
T. Bloomgarden, MD, MACE*; George Grunberger,
MD, FACP, FACE*; Guillermo Umpierrez, MD, FACP,
FACE*; Robert S. Zimmerman, MD, FACE*; Timothy
S. Bailey, MD, FACP, FACE, ECNU; Lawrence Blonde,
MD, FACP, FACE; George A. Bray, MD, MACP, MACE;
A. Jay Cohen, MD, FACE, FAAP; Samuel DagogoJack, MD, DM, FRCP, FACE; Jaime A. Davidson, MD,
FACP, MACE; Daniel Einhorn, MD, FACP, FACE; Om
P. Ganda, MD, FACE; Alan J. Garber, MD, PhD, FACE;
W. Timothy Garvey, MD; Robert R. Henry, MD; Irl B.
Hirsch, MD; Edward S. Horton, MD, FACP, FACE; Daniel
L. Hurley, MD, FACE; Paul S. Jellinger, MD, MACE;
Lois Jovanovi, MD, MACE; Harold E. Lebovitz, MD,
FACE; Derek LeRoith, MD, PhD, FACE; Philip Levy,
MD, MACE; Janet B. McGill, MD, MA, FACE; Jeffrey
I. Mechanick, MD, FACP, FACE, FACN, ECNU; Jorge H.
Mestman, MD; Etie S. Moghissi, MD, FACP, FACE; Eric
A. Orzeck, MD, FACP, FACE; Rachel Pessah-Pollack,
MD, FACE; Paul D. Rosenblit, MD, PhD, FACE, FNLA;
Aaron I. Vinik, MD, PhD, FCP, MACP, FACE; Kathleen
Wyne, MD, PhD, FNLA, FACE; and Farhad Zangeneh,
MD, FACP, FACE.
Reviewers are Alan J. Garber, MD, PhD, FACE;
Lawrence Blonde MD, FACP, FACE; and Jeffrey I.
Mechanick, MD, FACP, FACE, FACN, ECNU.
*Cochairpersons
DISCLOSURE
Cochairpersons

Dr. Yehuda Handelsman reports that he has received
consultant/speaker fees and research grant support from
Boehringer Ingelheim GmbH, GlaxoSmithKline plc, and
Novo Nordisk A/S; consultant fees and research grant
support from Amgen Inc, Gilead, Merck & Co, Inc, and
sanofi-aventis U.S. LLC; research grant support from
Intarcia Therapeutics, Inc, Lexicon Pharmaceuticals, Inc,
and Takeda Pharmaceutical Company Limited; consultant fees from Halozyme, Inc; and consultant/speaker fees
from Amarin Corporation, Amylin Pharmaceuticals, LLC,
Janssen Pharmaceuticals, Inc, and Vivus, Inc.

Dr. Zachary Bloomgarden reports that he has received
speaker honoraria from Merck & Co, Inc and Santarus,
Inc; consultant honoraria from Bristol-Myers Squibb
Company/AstraZeneca and Boehringer Ingelheim GmbH;
speaker/consultant honoraria from Johnson & Johnson
Services, Inc and Novo Nordisk A/S; stockholder earnings
from Abbott Laboratories, Covidien, F. Hoffman-La Roche

Ltd, Hospira Inc, Pfizer Inc, St. Jude Medical, Inc, and
Zoetis; and stockholder earnings and consultant honoraria
from Novartis AG.
Dr. George Grunberger reports that he has received
speaker honoraria and research support for his role as investigator from Bristol-Myers Squibb Company, Eli Lilly and
Company, and Novo Nordisk A/S; speaker honoraria from
Amarin Corporation, Janssen Pharmaceuticals, Inc, Merck
& Co, Inc, sanofi-aventis U.S. LLC, Santarus, Inc, Takeda
Pharmaceutical Company Limited, and Valeritas, Inc.

Dr. Guillermo Umpierrez reports that he has received
consultant honoraria and research grant support from
Boehringer Ingelheim GmbH, Merck & Co, Inc, Novo
Nordisk A/S, sanofi-aventis U.S. LLC, and Regeneron.

Dr. Robert S. Zimmerman reports that he has received
speaker honoraria from Janssen Pharmaceuticals, Inc,
Johnson & Johnson Services, Inc, Merck & Co, Inc, and
Santarus, Inc; and research grant support from Novo
Nordisk A/S.
Authors and/or Task Force Members
Dr. Timothy Bailey reports that he has received
speaker/consultant honoraria and research support from
Novo Nordisk A/S; consultant honoraria and research
support from Bayer AG, BD, Medtronic, Inc, and
sanofi-aventis U.S. LLC; and research support from
Abbott Laboratories, ACON Laboratories, Inc, Alere,
Animas Corporation, Cebix Incorporated, Bristol-Myers
Squibb Company, Dexcom, Inc, Eli Lilly and Company,
GlaxoSmithKline plc, Halozyme, Inc, Insulet Corporation,
LifeScan, Inc, MannKind Corporation, Merck & Co, Inc,
Orexigen Therapeutics, Inc, and Tandem Diabetes Care.
Dr. Lawrence Blonde reports that he has received
speaker/consultant honoraria and research grant support to Ochsner Medical Center for his role as investigator from Novo Nordisk A/S and sanofi-aventis U.S. LLC;
research grant support to Ochsner Medical Center for his
role as investigator from Eli Lilly and Company; speaker
honoraria from Amylin Pharmaceuticals, LLC; speaker/
consultant honoraria from AstraZeneca, Bristol-Myers
Squibb Company, Janssen Pharmaceuticals, Inc, and
Merck & Co, Inc; and consultant honoraria from Eisai Inc,
GlaxoSmithKline plc, and Quest Diagnostics Incorporated.

Dr. George Bray reports that he has received speaker
honoraria from Herbalife International of America, Inc and
advisor honoraria from Medifast, Inc.

Dr. Alan J. Cohen reports that he has received speaker
honoraria from AstraZeneca, sanofi-aventis U.S. LLC, and
Takeda Pharmaceutical Company Limited; and speaker
honoraria and research funding from Boehringer Ingelheim
GmbH/Eli Lilly and Company, Merck & Co, Inc, and Novo
Nordisk A/S.

Dr. Samuel Dagogo-Jack reports that he has received
fees for his role as diabetes expert legal consultant from
Sidley Austin LLP and Adams and Reese LLP; consultant

honoraria from Janssen Pharmaceuticals, Inc, Merck & Co,
Inc, and Santarus, Inc; consultant honoraria and research
support for his role as principal investigator from Novo
Nordisk A/S; and research support for his role as principal
investigator from AstraZeneca and Boehringer Ingelheim
GmbH.
Dr. Jaime Davidson reports that he has received
consultant honoraria from Aspire Bariatrics and
GlaxoSmithKline plc; advisory board honoraria from
Amgen Inc and Eli Lilly and Company; advisory board/
speaker honoraria from AstraZeneca/Bristol-Myers Squibb
Company and Novo Nordisk A/S; and advisory board/
speaker bureau honoraria from Janssen Pharmaceuticals,
Inc.

Dr. Daniel Einhorn reports that he has received consultant honoraria from Bristol-Myers Squibb Company/
AstraZeneca; consultant honoraria and research grant support from Eli Lilly and Company and Novo Nordisk A/S;
consultant honoraria and shareholdings from Freedom
Meditech, Inc, GlySens Incorporated, and Halozyme, Inc;
consultant/speaker honoraria and research grant support
from Janssen Pharmaceuticals, Inc; and research grant support from AstraZeneca, MannKind Corporation, sanofiaventis U.S. LLC, and Takeda Pharmaceutical Company
Limited.
Dr. Om Ganda reports that he has received advisory
board honoraria from Amgen Inc. and sanofi-aventis U.S.
LLC and research grant support from Amarin Corporation.

Dr. Alan J. Garber reports that he has received advisory board/consultant/speakers bureau honoraria from
Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo
Nordisk A/S, and Vivus, Inc; consultant/speakers bureau
honoraria from Salix Pharmaceuticals, Inc./Santarus, Inc;
advisory board/consultant honoraria from Bayer AG;
advisory board honoraria from Halozyme Therapeutics,
Inc and GlaxoSmithKline plc; speakers bureau honoraria
from Eisai Inc; and consultant honoraria from Lexicon
Pharmaceuticals, Inc and Viking Therapeutics.

Dr. W. Timothy Garvey reports that he has received
research support from Amylin Pharmaceuticals, Inc, Merck
& Co, Inc, sanofi-aventis U.S. LLC, and Weight Watchers
International, Inc; research support and advisory board
honoraria from Eisai Inc; and advisory board honoraria
from Alkermes plc, AstraZeneca, Bristol-Myers Squibb
Company, Daiichi Sankyo Company, Limited, Janssen
Pharmaceuticals, Inc, LipoScience, Inc, Novo Nordisk
A/S, Takeda Pharmaceutical Company Limited, and Vivus,
Inc.
Dr. Robert R. Henry reports that he has received
research grant support from Hitachi Ltd. and sanofi-aventis
U.S. LLC; consultant/advisory board honoraria from Alere,
ClinMet, Eisai Inc, and Isis Pharmaceuticals, Inc; speaker
honoraria from Amgen Inc, Daiichi Sankyo Company,
Limited, Elcelyx Therapeutics, Inc, Merck & Co., Inc, and
Vivus, Inc; consultant/advisory board/speaker honoraria

from Boehringer Ingelheim GmbH, F. Hoffman-La Roche
Ltd/Genentech Inc, Gilead, Intarcia Therapeutics, Inc,
Johnson & Johnson Services, Inc/Janssen Pharmaceuticals,
Inc, and Novo Nordisk A/S; and consultant/advisory board/
speaker honoraria and research grant support from Eli Lilly
and Company.

Dr. Irl B. Hirsch reports that he has received research
grant support for his role as principal investigator from
Halozyme, Inc and sanofi-aventis U.S. LLC; and consultant honoraria from Abbott Laboratories, BD, and F.
Hoffman-La Roche Ltd.

Dr. Edward Horton reports that he has received advisory board honoraria from Amarin Corporation, Amylin
Pharmaceuticals, LLC, GI Dynamics, Gilead, Janssen
Pharmaceuticals, Inc, Merck & Co, Inc, sanofi-aventis
U.S. LLC, Takeda Pharmaceutical Company Limited, and
Theracos, Inc.

Dr. Daniel L. Hurley reports that that he does not have
any relevant financial relationships with any commercial
interests.
Dr. Paul S. Jellinger reports that he has received
speaker honoraria from Amarin Corporation, Boehringer
Ingelheim GmbH, Bristol-Myers Squibb Company/
AstraZeneca, Janssen Pharmaceuticals, Inc, and Novo
Nordisk A/S.

Dr. Lois Jovanovi reports that she does not have
interests.
Dr. Harold E. Lebovitz reports that he has received
scientific advisory board honoraria from Biocon, Intarcia
Therapeutics, Inc, MetaCure, and Poxel SA; consultant
honoraria from AstraZeneca, Janssen Pharmaceuticals,
Inc, and sanofi-aventis U.S. LLC; and stock dividends
from AbbVie, Inc and Merck & Co, Inc.
Dr. Derek LeRoith reports that he has received consultant honoraria from Bristol-Myers Squibb Company/
AstraZeneca, Janssen Pharmaceuticals, Inc, Merck & Co,
Inc, Novo Nordisk A/S, and sanofi-aventis U.S. LLC.
Dr. Philip Levy reports that he has received speaker
honoraria from Boehringer Ingelheim GmbH, Daiichi
Sankyo Company, Limited, Janssen Pharmaceuticals, Inc,
and Novo Nordisk A/S.
Dr. Janet B. McGill reports that she has received
speakers bureau/consultant honoraria from Janssen
Pharmaceuticals, Inc and Merck & Co, Inc; consultant
honoraria and research grant support to Washington
University School of Medicine from MannKind
Corporation, Novo Nordisk A/S, and sanofi-aventis U.S.
LLC; consultant honoraria from Abbott Laboratories,
AstraZeneca, Boehringer Ingelheim GmbH, Eli Lilly and
Company, and McNEIL-PPC, Inc; and research grant
support to Washington University School of Medicine
from Andromeda Biotech Ltd, Intarcia Therapeutics,
Inc, Novartis AG, and Takeda Pharmaceutical Company

Limited.

Dr. Jeffrey I. Mechanick reports that he has received
honoraria for lectures and program development by Abbott
Nutrition.
Dr. Jorge H. Mestman reports that he does not have
interests.
Dr. Etie S. Moghissi reports that she has received
speaker fees from Boehringer Ingelheim GmbH, Janssen
Pharmaceuticals, Inc, Takeda Pharmaceutical Company
Limited; speaker/consultant fees from Novo Nordisk A/S;
and consultant fees from Amylin Pharmaceuticals, LLC,
AstraZeneca, and sanofi-aventis U.S. LLC.

Dr. Eric Orzeck reports that he does not have any relevant financial relationships with any commercial interests.
Dr. Rachel Pessah-Pollack reports that she does not
have any relevant financial relationships with any commercial interests.
Dr. Paul D. Rosenblit reports that he has received
speaker/advisory board honoraria from Amarin
Corporation; speaker honoraria from Boehringer
Ingelheim GmbH, Bristol-Myers Squibb Company, and
Janssen Pharmaceuticals, Inc; advisory board honoraria
and research grant support for his role as principal investigator from Dexcom, Inc; research grant support for his
role as principal investigator from Amgen Inc, Daiichi
Sankyo Company, Limited, Eli Lilly and Company,
GlaxoSmithKline plc, MannKind Corporation, Novartis
AG, Orexigen Therapeutics, Inc, Pfizer Inc, and sanofiaventis U.S. LLC; and speaker honoraria and research
grant support for his role as principal investigator from
AstraZeneca, Eisai Inc., Merck & Co, Inc, Novo Nordisk
A/S, and Takeda Pharmaceutical Company Limited.

Dr. Aaron I. Vinik reports that he has received consultant fees from Isis Pharmaceuticals, Inc, Merck & Co, Inc,
and Pamlab, Inc; consultant fees and research grant support
for his role as principal investigator from Pfizer Inc; and
research grant support for his role as principal investigator
from Impeto Medical, Intarcia Therapeutics, Inc, Tercica,
Inc, and ViroMed Laboratories Inc.

Dr. Kathleen Wyne reports that she has received
speaker honoraria from AbbVie, Inc, Novo Nordisk A/S,
and Salix Pharmaceuticals, Inc.
Dr. Farhad Zangeneh reports that he has received
consultant/speakers bureau honoraria from Abbott
Laboratories, AbbVie, Inc, Amarin Corporation,
AstraZeneca, Auxilium, Boehringer Ingelheim GmbH,
Bristol-Myers Squibb Company, Daiichi Sankyo
Company, Limited, Eisai Inc, Eli Lilly and Company,
Forest Laboratories, Inc, GlaxoSmithKline plc,
Janssen Pharmaceuticals, Inc, Novo Nordisk A/S, Salix
Pharmaceuticals, Inc, Takeda Pharmaceutical Company
Limited, and Vivus, Inc.
Medical Writer

Ms. Amanda M. Justice reports that she has received
consulting fees for writing/editorial support from AsahiKasei Corporation and sanofi-aventis U.S. LLC.
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AACE-ACE - Practice Guidelines For Developing Diabete Mellitus

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AACE/ACE Guidelines

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND

ENDOCRINE PRACTICE Vol 21 (Suppl 1) April 2015 1

2 AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1)

AACE Task Force

AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1) 3

angiotensin-converting enzyme; ADA = American

4 AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1)

micro- and macrovascular risk (including cardiovascular

AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1) 5

serve as a guideline. Individual patient circumstances and

Q11. How is neuropathy diagnosed and managed

Fig. 1. 2010 American Association of Clinical Endocrinologists (AACE) Clinical Practice

6 AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1)

Readers are referred to the Appendix (section 4) for

Meta-analysis of randomized controlled trials (MRCT)

Randomized controlled trials (RCT)

Meta-analysis of nonrandomized prospective or case-controlled trials (MNRCT)

Nonrandomized controlled trial (NRCT)

Prospective cohort study (PCS)

Retrospective case-control study (RCCS)

Cross-sectional study (CSS)

Surveillance study (registries, surveys, epidemiologic study, retrospective chart

Consecutive case series (CCS)

Single case reports (SCR)

No evidence (theory, opinion, consensus, review, or preclinical study) (NE)

Semantic descriptor (reference methodology)

from (1): Endocr Pract. 2010;16:270-283.

AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1) 7

DM (GDM) with a 2-hour OGTT using a 75-g

help establish the correct diagnosis to distinguish

3.Q2. How is Prediabetes Managed?

R8. T2D can be prevented or at least delayed

Allocation concealment (randomization)

Using surrogate end points (especially in

Reprinted from (1): Endocr Pract. 2010;16:270-283.

8 AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1)

thiazolidinediones (TZDs) should be considered

therapy should be an A1C level 6.5% for most

AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1) 9

improved by strict glycemic control, the progression of microvascular complications clearly is

3.Q3.2. Inpatient Glucose Targets for

pressure (Table 8). Nutritional recommendations

3.Q4.2. Antihyperglycemic Pharmacotherapy for T2D

Relevance (patient-oriented evidence that matters)

Reprinted from (1): Endocr Pract. 2010;16:270-283.

10 AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1)

secretion or sensitivity, as well as the potential

agents with a low potential for hypoglycemia that

AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1) 11

fails to achieve target glycemic control or when

3.Q5. How Should Glycemia in T1D be Managed?

R20. Insulin must be used to treat T1D (Grade

3.Q6. How is Hypoglycemia Managed?

High Risk for Diabetes

FPG <100 mg/dL

FPG 126 mg/dL

2-h PG <140 mg/dL

2-h PG 200 mg/dL