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New information in this revision:
- Screening for diabetes. Although little evidence is available on screening for diabetes, screening should be considered every 3 years beginning at age 45 or annually at any age if BMI ≥ 25 kg/m2, history of hypertension, gestational diabetes, or other risk factors.
- A1c for diagnosis. An option for diagnosing diabetes is hemaglobin A1c: 6.5% or greater is diagnostic, 5.7% -6.4% is considered pre-diabetes. (See Table 1 for diagnostic tests and values.)
- New medications for glycemic control. Several new drugs (and drug cautions) have been released, particularly for second line therapy after metformin.
- BP target. A reasonable clinical target is 135/80 mmHg. Mortality increases when patients with diabetes have a diastolic blood pressure below 70 mmHg. More aggressive control may be warranted in patients with renal disease. The HEDIS measure for BP in diabetes is <140/90 mmHg. The clinical target of 135/80 mmHg helps assure patients are under the measurement maximum and recognizes the potential clinical benefit of somewhat lower levels.
- Prescribe "statin for all" patients with diabetes including those patients over > 40 years old with LDL < 100 mg/dl. Check baseline LFTS and if normal, no further monitoring is required. If baseline LFTs are mildly abnormal (over upper limit of normal but < 5 X upper limit of normal): monitor LFTs during first 6 months of statin treatment for stability. Abnormal baseline liver biochemistries can frequently improve with statin therapy.
- Hepatitis B vaccination. Vaccinate patients with diabetes ages 19-59 years as soon as feasbile after diabetes is diagnosed. Risk is increased primarily due to sharing inadequately cleaned blood glucose monitors (e.g., in healthcare settings, households, worksite clinics, schools and camps). Consider vaccinating those aged ≥ 60 based on likelihood of acquiring HBV infection.
- Measures of clinical care quality. National and regional third-party payors measure 13 aspects of care for patients with diabetes related to payment based on quality of care. See "Measures of Performance."
The University of Michigan Medical School designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Original Release Date: October 2012
Termination Date: June 2022
Continued availability of CME credit for this activity depends on a thorough review of its content every three years. This activity was last reviewed for currency and accuracy in June 2019, and availability of CME credit continued.
Connie J Standiford, MD; General Internal Medicine
Sandeep Vijan, MD; General Internal Medicine
Hae Mi Choe, PharmD; College of Pharmacy
R Van Harrison, PhD; Medical Education
Caroline R Richardson, MD; Family Medicine
Jennifer A Wyckoff, MD; Metabolism, Endocrinology & Diabetes
Martha M Funnell, MS, RN, CDE; Diabetes Research and Training Center
William H Herman, MD; Metabolism, Endocrine & Diabetes
Financial Disclosure Information:
Martha M. Funnell, MS, RN, CDE
Advisory Boards; Boehringer Ingelheim, Bristol-Myers Squibb/ AstraZeneca, Halozyme Thera-peutics, Eli Lilly, Animas/ Lifescan, Hygeia Inc, Intuity Medical
William H. Herman, MD, MPH
Consultant: Cebix, Genentech, McKinsey & Co., Sanofi-Adventis, VeraLight
There are no other relevant financial relationships to disclose for this CME activity.
UMHS Guidelines Oversight Team:
Karl T. Rew, MD
R. Van Harrison, PhD
Literature Search Services:
Taubman Medical Library