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 Glucose^1 (preferred)	Casual Plasma Glucose^2	Oral Glucose Tolerance Test^3
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	Annual^1	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 Exam^2	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 months^3	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	Annual^4	See Cardiovascular Risk Reduction Guidelines below
Urinalysis	Annual^5	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.