Adult Diabetes Care.
These guidelines were adapted from various 1999 American Diabetes
Association position statements and committee reports.
MAJOR RECOMMENDATIONS:
I. Diagnosis of Diabetes Mellitus
Criteria for Testing for Diabetes in Asymptomatic, Undiagnosed Individuals
Testing for diabetes should be considered for all individuals age 45 and
older and, if normal, should be repeated at 3-year intervals. Testing should
be considered at a younger age, or be carried out more frequently, in
individuals who:
* Are
obese (refer to Body Mass Index [BMI] weight table in the original guideline
document)
* Have a
first-degree relative with diabetes
* Are
members of a high-risk ethnic population (African American, Hispanic, Native
American, Asian)
* Have
delivered a baby weighing more than 9 pounds or were diagnosed with
gestational diabetes mellitus
* Are
hypertensive (blood pressure greater than or equal to 140/90)
* Have a
high density lipoprotein cholesterol level less than or equal to 35 mg/dl
(men) or less than or equal to 45 mg/dl (women), and/or a triglyceride level
equal to or greater than 250 mg/dl
* Had
impaired glucose tolerance or impaired fasting glucose on previous testing
The fasting plasma glucose is the preferred diagnostic test due to its ease
of administration, convenience, acceptability to patients, and lower cost.
Diagnostic Criteria for Diabetes
A fasting plasma glucose value greater than or equal to 126 mg/dl (confirmed
by testing on two different occasions) is diagnostic for diabetes. The new
diagnostic cutpoint (fasting plasma glucose greater than or equal to 126
mg/dl) is based on the observation that this degree of hyperglycemia usually
reflects a serious metabolic abnormality that has been shown to be
associated with serious complications. The revised criteria are for
diagnosis and are not treatment criteria or goals. The HbA1c is not
recommended for diagnosis at this time.
Criteria for the Diagnosis of Diabetes
Fasting Plasma Glucose1 (preferred)
Casual Plasma Glucose2
Oral Glucose Tolerance Test3
Diabetes Mellitus
Fasting Plasma Glucose > 126 mg/dl (7.0 mmol/l)
Casual Plasma Glucose 200 mg/dl (11.1 mmol/l)4
Two-hour Plasma Glucose > 200 mg/dl
Impaired Glucose Homeostasis
Impaired Fasting Glucose
Fasting Plasma Glucose > 110 and <126 mg/dl
Impaired Glucose Tolerance
Two-hour Plasma Glucose > 140 and <200 mg/dl
Normal
Fasting Plasma Glucose <110 mg/dl
Two-hour Plasma Glucose <140 mg/dl
1The fasting plasma glucose is the preferred test for diagnosis, but any one
of the three listed is acceptable. Fasting is defined as no caloric intake
for at least 8 hours.
2Casual is defined as any time of day without regard to time since last
meal. Symptoms are the classic ones of polyuria, polydipsia, and unexplained
weight loss.
3Oral glucose tolerance test should be performed using a glucose load
containing the equivalent of 75 g anhydrous glucose dissolved in water. The
oral glucose tolerance test is not recommended for routine clinical use.
4If casual plasma glucose >160 mg/dl, patient requires diagnostic evaluation
for diabetes.
II. Classification of Diabetes
Type 1
Type 1 diabetes most often results from a cellular mediated autoimmune
destruction of the beta cells of the pancreas. Patients with this form of
diabetes are dependent upon insulin for survival and are at risk for
ketoacidosis. Type 1 commonly occurs in childhood and adolescence but may
occur at any age.
Type 2
Individuals with type 2 diabetes have insulin resistance and relative,
rather than absolute, insulin deficiency. Primary treatment centers on
weight loss, improved nutrition and increased age-appropriate physical
activity. Oral agents may become necessary if the initial treatment is
unsuccessful. These patients do not need insulin to survive but may require
insulin over time for optimal management, especially if oral agents become
ineffective. Type 2 diabetes commonly goes undiagnosed for years because it
is often asymptomatic in its early stages. Individuals with undiagnosed type
2 diabetes are at increased risk for developing macro- and microvascular
complications.
Impaired Fasting Glucose and Impaired Glucose Tolerance
A new stage of impaired glucose homeostasis called impaired fasting glucose
has been defined as a fasting plasma glucose of > 110 mg/dl but <126 mg/dl.
The stage called impaired glucose tolerance is defined as an oral glucose
tolerance test value of >140 mg/dl but <200 mg/dl. Although not clinical
entities in their own right (in the absence of pregnancy), they are risk
factors for future diabetes and cardiovascular disease.
Gestational Diabetes Mellitus
Gestational diabetes mellitus is defined as any degree of glucose
intolerance with onset or first recognition during pregnancy. The definition
applies regardless of whether insulin or only dietary modification is used
for treatment. Gestational diabetes mellitus complicates approximately 4% of
all pregnancies in the U.S.; however, the prevalence is higher among some
minority groups. Six weeks or more after the pregnancy ends, a woman with
gestational diabetes mellitus should be tested to rule out type 1 or 2
diabetes or impaired fasting glucose/impaired glucose tolerance. Women with
gestational diabetes mellitus have a higher risk for type 2 diabetes later
in life.
Goals for Glycemic Control
Normal
Goal
Action Suggested
Fasting/Before Meals
<110 mg/dl
80 to 120 mg/dl
<80 or >140 mg/dl
Before Bedtime
<120 mg/dl
100 to 140 mg/dl
<100 or >160 mg/dl
Hemoglobin A1C
<6%
<7%
>8%
III. Massachusetts Guidelines for Adult
Diabetes Care
History and Physical
Frequency
Description
Blood Pressure and Weight
Every 3-6 months
If blood pressure >130/85 initiate measures to lower
Dilated Eye Exam
Annual1
Refer to ophthalmologist or optometrist
Foot Exam
Every 3 to 6 months
Visual exam without shoes and socks every routine diabetes visit
Comprehensive Lower Extremity Sensory Exam2
Initial/Annual
Teach protective foot behavior if sensation diminished. Refer to podiatrist
if indicated. See Foot Inspection and Monofilament Use Guidelines below
Dental Exam
Every 6 months
Refer to dentist
Smoking Status
Ongoing
Check every visit/Encourage smoking cessation. See Smoking Intervention
Model below
IV.
Labs
Frequency
Description
HbA1c
Every 3-6 months3
Ideal goal <7.0% or <1% above lab norm. Action suggested at >8.0%, make
changes in regimen
Fasting/Random Blood Glucose
As indicated
Compare lab results with glucose self-monitoring
Fasting Lipid Profile
Annual4
See Cardiovascular Risk Reduction Guidelines below
Urinalysis
Annual5
If protein negative or trace, test for microalbumin
If >1+ proteinurea, test 24-hour urine protein and creatinine clearance and
initiate treatment as indicated. See "Screening for Albuminuria in Diabetic
Nephropathy Guideline" section below
Urine Microalbumin/Creatinine
Annual
Test if protein negative or trace on urinalysis
If abnormal, recheck x2 in a 3-month period then treat if 2 out of 3
collections show elevated levels
Serum Creatinine
Initial/As Indicated
Electrocardiogram (EKG)
Initial
If patient is >40 years old or Diabetes Mellitus >10 years
Thyroid Assessment
Initial/As Indicated
Thyroid Palpation, Thyroid Function Test(s) if indicated
V.
Recommended Immunizations
Frequency
Description
Flu Vaccine
Every fall
Pneumovax
Recommended
Revaccination x1 if >65 years old and first vaccine >5 years ago and patient
age <65 at the time of first vaccine
VI.
Self-Management
Frequency
Description
Review Self-Management Skills
Initial/Ongoing
Review Treatment Plan
Initial/Ongoing
Check self-monitoring log book, diet, exercise, and meds
Review Education Plan
Initial/Ongoing
Refer for Diabetes Self-Management Training if indicated
Review Nutrition Plan
Initial/Ongoing
Refer for Medical Nutrition Therapy if indicated
Review Physical Activity Plan
Initial/Ongoing
Assess/Prescribe based on patient's health status
VII.
Counseling
Frequency
Description
Tobacco Use
Annual/Ongoing
Assess readiness/Counsel cessation/Refer
Psychosocial Adjustment
Annual/Ongoing
Suggest diabetes support group/Counsel/Refer
Sexuality/Impotence
Annual/Ongoing
Discuss diagnostic evaluation and therapeutic options
Preconception/Pregnancy
Initial/Ongoing
Need for tight glucose control 3-6 months preconception. Consider early
referral to obstetrician/gynecologist (OB/GYN)
VIII. 1Type 1: Initial exam after 5 years
disease duration.
2Every 3-6 months if patient has high-risk foot conditions.
Use Semmes-Weinstein monofilament or tuning fork.
32 times a year for stable glycemic control. Four times a year if change in
therapy or if not meeting glycemic goals.
4If values fall in lower risk levels, assessment may be repeated every 2
years.
5Type 1: Initial exam to begin with puberty and after 5 years disease
duration.
IX. Note: A flow sheet for Diabetes Care
is included in the original guideline.
X. Diabetes Medications
A. Oral Medications (see original guideline document for dosages)
First Generation Sulfonylureas
* Tolbutamide (Orinase)
* Chloropropamide (Diabenese)
* Tolazamide (Tolinase)
* Acetohexamide (Dymelor)
Second Generation Sulfonylureas
* Glipizide (Glucotrol, Glucotrol XL)
* Glyburide (Micronase, Diabeta)
* Glyburide (Micronized)(Glynase)
* Glimepiride (Amaryl)*
Metaglinides
* Repaglinide (Prandin)
Biguanides
* Metformin (Glucophage)
Alpha Glucosidase Inhibitors
* Acarbose (Precose)
* Miglitol (Glyset)
Thiazolidinediones
* Rosiglitazone (Avandia)**
* Pioglitazone (Actos)
*Amaryl is the only Sulfonylurea approved for the Bedtime Insulin, Daytime
Sulfonylurea (BIDS) regimen.
**Approved also for concomitant use with metformin. May be administered
without regard to food. May cause anovulatory premenopausal women to resume
ovulation. Precaution: Use with caution in the presence of hepatic disease.
Do not use in patients who have discontinued troglitazone therapy due to
hepatic disease. Monitor baseline liver function when initiating therapy,
and every 2 months for one year, then periodically as clinically indicated.
B. Insulin
* Very Short Acting (Lispro)
* Short Acting (Regular)
* Intermediate Acting (NDH/Lente)
* Long Acting (Ultralente)
XI. Cardiovascular Risk Reduction
Guidelines
Summary of Cholesterol Lowering Therapy
While many organizations (National Heart, Lung and Blood Institute [NHLBI]
National Cholesterol Education Program [NCEP], American Heart Association
[AHA] and others) have developed guidelines for screening and treatment of
hypercholesterolemia, controversy exists over specific screening
recommendations. There is, however, agreement that reduction of elevated
cholesterol levels, along with attention to all modifiable cardiac risk
factors, will decrease the incidence of cardiovascular disease. Aggressive
therapy of diabetic dyslipidemia will probably reduce the risk of coronary
heart disease in patients with diabetes.
Category of Risk Based on Lipoprotein Levels in Adults
Risk
Low-Density Lipoprotein (LDL) Cholesterol
High-Density Lipoprotein (HDL) Cholesterol
Triglyceride
High
> 130 mg/dl
M <35 mg/dl
F <45 mg/dl
> 400 mg/dl
Borderline
100-129 mg/dl
35-45 mg/dl
200-399 mg/dl
Low
<100 mg/dl
>45 mg/dl
<200 mg/dl
Treatment Decisions Based on Low-Density Lipoprotein (LDL) Cholesterol Level
in Adults with Diabetes
Contributing Risk Factors
Medical Nutrition Therapy
Drug Therapy
Initiation Level
Low-Density Lipoprotein Goal
Initiation Level
Low-Density Lipoprotein Goal
With Coronary Heart Disease, Peripheral Vascular Disease, or Coronary
Vascular Disease
>100 mg/dl
<100 mg/dl
>100 mg/dl
<100 mg/dl
Without Coronary Heart Disease, Peripheral Vascular Disease, and Coronary
Vascular Disease
>100 mg/dl
<100 mg/dl
>130 mg/dl
<100 mg/dl
Caveats:
0. Medical Nutrition Therapy should be attempted for 3 to 6 months
before starting pharmacological therapy.
1. Since diabetic men and women are considered to have equal coronary
heart disease risk, age and sex are not considered risk factors.
2. For diabetic patients with multiple coronary heart disease risk
factors, some authorities recommend initiation of drug therapy when
low-density lipoprotein (LDL) levels are between 100 and 130 mg/dl.
Aspirin Therapy in Diabetes
Both men and women with diabetes have a two to fourfold increased risk of
dying from the complications of cardiovascular disease. Evidence suggests
that low-dose aspirin therapy should be prescribed as a secondary prevention
strategy and, if no contraindications exist, should also be used as a
primary prevention strategy in men and women with diabetes who are at high
risk for cardiovascular events. Use of aspirin has not been studied in
individuals under the age of 30.
Recommendations
3. Use of aspirin therapy in patients with evidence of large vessel
disease.
4. Use aspirin therapy as a primary prevention strategy in high-risk
individuals with any of the following:
* A family history of coronary heart disease
* Cigarette smoking
* Hypertension
* Overweight (body mass index >25)
* Albuminuria (micro or macro)
* Lipids
* Cholesterol >200 mg/dl
* Low-Density Lipoprotein cholesterol >130 mg/dl
* High-Density Lipoprotein cholesterol <40 mg/dl
* Triglycerides >250 mg/dl
5. Use enteric coated aspirin in doses of 81-325 mg per day.
6. People with aspirin allergy, bleeding tendency, anticoagulant
therapy, recent gastrointestinal bleeding, and clinically active hepatic
disease are not candidates for aspirin therapy.
XII. Smoking Intervention Model
ASK About Smoking at Every Visit
Document in Chart
ADVISE All Smokers to Quit
Advice should be clear, strong, and personalized
ASSIST Smokers in Quitting
Assess motivation to make a quit attempt
Ready to Quit Now
. Identify reasons for wanting to quit
a. Develop a quit plan
* Set quit date within 2 weeks
* Review previous quit attempts
* Identify smoking triggers and challenges
* Brainstorm strategies
* Inform family, friends, and co-workers
b. Provide self-help materials and referrals
c. Encourage nicotine replacement therapy: patch, gum, nasal spray,
inhaler or Non-NRT (buproplon-SR), unless contraindicated
d. Give advice on successful quitting
* Total abstinence
* Avoid alcohol
* Plan for dealing with smokers in the house
Not Ready to Quit Now
e. Use the 4Rs to enhance motivation
* Relevance: Provide patient-specific information
* Risks: Ask patient to identify negative consequences
* Rewards: Ask patient to identify benefits
f. Repetition: Repeat every visit
ARRANGE follow-up
If Quit (Relapse Prevention)
g. Congratulate, encourage maintenance
h. Review benefits from cessation
i. Review successes during quit period
j. Review problems encountered, offer possible solutions
k. Anticipate problems or threats to maintenance, such as weight gain,
depression, or prolonged withdrawal
Timing
l. Contact soon after the quit date, preferably within the first
week, further follow-up as needed.
If Quit Attempt Unsuccessful
m. Ask for recommitment to total abstinence
n. Remind patient to use lapse as a learning experience
o. Review circumstance that caused lapse
p. Develop new plan with patient
Timing
q. Contact soon after new quit date, preferably during the first week,
further contacts needed based on new quit plan.
XIII. Diabetic Nephropathy Guidelines
The earliest clinical evidence of nephropathy is the appearance of low but
abnormal levels (<30 mg/day or 20 micrograms/min) of albumin in the urine,
referred to as microalbuminuria. Microalbuminuria, a harbinger of renal
failure and cardiovascular complications in diabetes, is an albumin
concentration in the urine that is greater than normal, but is not
detectable with common urine dipstick assays for protein.
Screening for Albuminuria
Routine urinalysis should be performed yearly in adults. If positive for
protein, a quantitative measure is helpful in developing a treatment plan.
If the urinalysis is negative for protein, a test for the presence of
microalbumin is necessary.
Three methods to screen for microalbuminuria are shown below:
0. Measurement of the albumin to creatinine ratio in a random spot
collection
1. 24 hour collection with creatinine, allowing the simultaneous
measurement of creatinine clearance
2. Timed (4-hour or overnight) collection
The first method is often preferred in an office-based setting and generally
provides accurate information. There is a marked day-to-day variability in
albumin excretion, so at least 2 of 3 samples done in a 3 to 6 month period
should show elevated levels before designating a patient as having
microalbuminuria. If normal, repeat yearly.
Definitions of Abnormalities in Albumin Excretion
Category
Spot Collection (micrograms/mg creatinine)
24 Hour Collection (mg/24 hours)
Timed Collection (micrograms/min)
Normal
<30
<30
<20
Microalbuminuria
30-300
30-300
20-200
Clinical Albuminuria
>300
>300
>200
Screening for microalbumin with dipsticks or reagent tablets may also be
done if assays are not readily available. Reagents and tablets show a 95%
sensitivity when preformed by trained personnel. All positive tests by
reagent strips or tablets should be confirmed by more specific methods.
Several factors may influence the albumin excretion rate. Screening should
be postponed in the following situations: short-term hyperglycemia,
exercise, marked hypertension, urinary tract infections, acute febrile
illness, or heart failure. Angiotensin converting enzyme (ACE) inhibitors or
nonsteroidal anti-inflammatory drugs (NSAIDs) may also influence results.
Hypertension Control
Both systolic and diastolic hypertension markedly accelerate the progression
of diabetic nephropathy. Control of hypertension has been demonstrated
conclusively to reduce the rate and progression of nephropathy and to reduce
the complications of cerebrovascular disease and cardiovascular disease.
Lifestyle modifications such as weight loss, reduction of salt and alcohol,
and exercise should be a major aspect of initial treatment unless
hypertension is at a more severe stage (systolic >180 mmHg, diastolic >110
mmHg). Medications should be added if lifestyle changes are unsuccessful in
controlling hypertension.
In patients with underlying nephropathy, treatment with angiotensin
converting enzyme inhibitors should also be part of initial therapy.
Angiotensin converting enzyme inhibitors are recommended for all type 1
patients with microalbuminuria, even if normotensive. The use of angiotensin
converting enzyme inhibitors in normotensive type 2 diabetic patients is
less well substantiated. For type 2 patients with hypertension or
progressive albuminuria, angiotensin converting enzyme inhibitors are
recommended. When angiotensin converting enzyme inhibitors are
contraindicated, other antihypertensive agents should be used. Angiotensin
II receptor blockers are being studied in human with regard to renal
protective effects.
In non-pregnant diabetic patients >18 years of age, the primary goal for
therapy is to decrease blood pressure and to maintain it at <130 mm Hg
systolic and <85 mm Hg diastolic. For patients with isolated systolic
hypertension of >180 mm Hg, the initial goal is to decrease the systolic
blood pressure to <160 mm Hg, and to lower the systolic pressure by 20 mm Hg
for those with systolic pressures between 160-179 mm Hg. If these initial
goals are met and well tolerated, further lowering may be indicated.
XIV. Foot Inspection and Monofilament Use
Guidelines
. A visual foot examination is recommended at every visit.
A. A more in-depth inspection should be performed at least annually to
identify high-risk foot conditions.
B. An in-depth exam should include an assessment of:
* Protective Sensation
* Vascular Status
* Skin Integrity
* Foot Structure/Biomechanics
Risk Identification
Amputation is most commonly the eventual result of previous minor trauma
causing foot injury. The two most common causes of minor foot trauma are
ill-fitting new shoes and improper cutting of toenails. The risk of ulcers
or amputations is increased in people who have had diabetes >10 years, are
male, have poor glucose control, smoke, or have cardiovascular, retinal, or
renal complications. Four foot-related conditions are associated with
amputation:
3. Peripheral neuropathy
4. Peripheral vascular disease (PVD)
5. History of ulcers or amputation in the other limb
6. Altered biomechanics
* Evidence of increased pressure (callus, erythema)
* Limited joint mobility, bony deformity, or nail pathology
Assessing Protective Sensation
(Use either the Semmes-Weinstein monofilament or a tuning fork.)
* Have the patient look away or close his or her eyes.
* Hold the filament perpendicular to the skin.
* Avoiding any ulcers, calluses or sores, touch the monofilament to
the skin until it bends. Hold in place for approximately 1.5 seconds, then
gently remove it.
* Randomly test the sites shown on the foot diagram provided in the
original guideline document.
* Elicit a response from the patient at each site. Lack of sensation
at any site may indicate diabetic neuropathy.
* The monofilament may be cleaned with 1:10 sodium hypochlorite
solution if contaminated with blood or body fluids.
Risk Category
Low Risk
High-Risk
All of the following:
One or more of the following:
* Intact protective sensation
* Pedal pulses present
* No severe deformity
* No prior foot ulcer
* No amputation
* Loss of protective sensation
* Absent pedal pulses
* Severe foot deformity
* History of foot ulcer
* Prior amputation
Management Guidelines
Low Risk
High-Risk
* Visual foot exam every routine diabetes
visit
* Annual comprehensive lower extremity
sensory exam
* Assess/recommend appropriate footwear
* Provide patient education for preventive
self-care
* Conduct comprehensive lower extremity exam
every 3-6 months
* Demonstrate preventive self-care of the
feet
* Refer to specialists and diabetes educator
as indicated
* Assess/prescribe appropriate footwear
* Certify Medicare patients for therapeutic
shoe benefits
* Note "High Risk Feet" on medical record
XV. Medical Nutrition Therapy
Purpose: To assist patients in acquiring and maintaining the knowledge,
skills, and behaviors to successfully meet the challenges of daily diabetes
self-management. Without adequate nutrition advice or an individualized meal
plan, patients may have difficulty achieving optimal blood glucose control.
Goals
* Achieve and maintain near normal blood glucose levels by balancing
food intake with medication and physical activity
* Achieve optimal serum lipid levels
* Provide adequate calories for attaining and maintaining reasonable
weight
* Prevent and treat the acute and long-term complications of
diabetes
* Improve overall health through optimum nutrition
Basic Education
For newly diagnosed patients or patients not recently educated about their
diabetes. Basic survival skills should include:
* Relationship of food and meals to blood glucose levels,
medication, and activity
* Basic food/meal plan guidelines
* Consistent times each day for meals and snacks
* Recognition, prevention, and treatment of hypoglycemia
* Sick day management
* Self-monitoring of blood glucose
Essential Education for Ongoing Nutrition Self-Management
For patients recently diagnosed with diabetes who have been taught basic
survival skills or those who have not received current nutrition education.
Others who may benefit from nutrition self-management education include
patients having difficulties with diabetes management or those experiencing
changes in lifestyle, medication, weight, or childbearing status. Follow-up
sessions should focus on increasing the patient's knowledge, skills, and
flexibility as he or she gains experience living with diabetes.
* Sources of nutrients and their effect on blood glucose and lipid
levels
* Label reading and grocery shopping guidelines
* Dining out
* Modifying fat intake
* Use of sugar-containing foods, dietetic foods, and sweeteners
* Alcohol guidelines
* Using blood glucose self-monitoring for glucose pattern control
* Adjusting meal times
* Adjusting food for exercise
* Special occasions, holidays
* Travel, schedule changes
* Vitamin and mineral supplementation
XVI. Self Management Training
Purpose: To provide patients with the management skills necessary to achieve
optimal control of their diabetes. To assist people with diabetes to become
effective self-directed decision makers for their own diabetes care, health
and well being. Without comprehension of the relationship between home blood
glucose readings, meal planning and physical activity, patients with
diabetes will be hindered in their ability to achieve optimal blood glucose
control, and be at higher risk for long term complications.
Goals
* Comprehend the relationship between meals, exercise, medication
and blood glucose monitoring routines
* Correctly identify, treat and prevent the acute complications of
diabetes: hyper- and hypoglycemia
* Prevent or delay the chronic complications of diabetes
* Enhance patient participation in the physician's diabetes
treatment plan and improve patient confidence in self-management skills
* Decrease health care costs by reducing the need for expensive
hospital stays and the treatment of complications
Basic education should be provided regarding:
Overview
* Nature of diabetes in terms of chronicity and metabolism
* Differences between type 1 and type 2 diabetes
* Balance of meals, physical activity and medication, if prescribed
Exercise
* Impact of exercise on blood glucose, lipid levels, hypertension,
and body weight
Acute complications
* Hypoglycemia recognition, causes, treatment, and prevention
* Hyperglycemia recognition, causes, treatment, and prevention
Oral medication management
* Action, side effects, timing of dose(s), interactions
Insulin management
* Action, dosage, onset/peak/duration, pre-loading, mixing,
injecting, site selection, storage, syringe disposal
* Use of Glucagon, if appropriate
Self-monitoring
* Blood glucose meter selection and orientation
* Time(s) to check blood sugar/rationale
* Recording results, reporting to physician
* Disposal of lancets and contaminated materials
* Performance of urinary ketone testing, if appropriate
Continuing education should include:
Overview
* Benefits of optimal diabetes control and factors that influence it
* Effects of insulin resistance, deficiency, and excess
* Treatment of insulin resistance through weight loss, activity, and
medication
Exercise
* Exercise planning appropriate to age, ability, interest, and
willingness
* Complication avoidance during exercise
Oral medication management
* Action times and maximum dose
* Influences of other medications on blood glucose and possible
interactions with oral diabetes medications
Insulin management
* Methods of storing and adjusting insulin during travel
* Syringe reuse: techniques, benefits, and risks
Self-monitoring
* Use of self-monitoring of blood glucose to adjust the treatment
plan based on approved guidelines
* Establish glycated hemoglobin targets
Complication prevention and recognition
* Self foot care, early detection of problems, importance of timely
access to care
* Early recognition of eye disease and need for complete eye exam
annually
* Impact of lipids, importance of monitoring annually or every two
years if values fall within accepted risk levels
* Importance of blood pressure control, need for regular monitoring
* Identify the symptoms, treatment, and major factors of preventing
kidney disease, peripheral vascular disease, cardiovascular disease,
periodontal disease, and neuropathy
Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.
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