Managing diabetes in primary care: 2016 recommendations from ADA

The ADA has published the 2016 Standards of Medical Care in Diabetes.
The ADA has published the 2016 Standards of Medical Care in Diabetes.

The American Diabetes Association (ADA) has released a summary of its 2016 recommendations that focus on managing patients with diabetes in primary care, as published March 1 in the Annals of Internal Medicine.

A synopsis of the 2016 Standards of Medical Care in Diabetes highlights 8 key areas for primary care providers: diagnosis, glycemic targets, medical management, hypoglycemia, cardiovascular risk factor management, microvascular disease screening and management, and inpatient diabetes management.

To create the 2016 Standards, the ADA Professional Practice Committee (PPC) searched on MEDLINE to find and grade new evidence from January 1, 2015, through December 7, 2015. Recommendations are assigned an A, B, or C rating based on evidence quality. Some expert opinions are given an E rating to indicate that there is no evidence from clinical trials, clinical trials may be impractical, or existing evidence is conflicting.

Recommendations for diagnosis

The 2016 ADA Standards diagnostic criteria for prediabetes and diabetes are outlined in Table 1.

Table 1. Criteria for the diagnosis of prediabetes and diabetes1

Variable Prediabetes Diabetes
HbA1c level 5.7% to 6.4% ≥6.5%
Fasting plasma glucose level (mmol/L) 5.6 to 6.9 7.0
Fasting plasma glucose level (mg/dL) 100 to 125 ≥126
Oral glucose tolerance test results* (mmol/L) 7.8 to 11.0 11.1**
Oral glucose tolerance test results* (mg/dL) 140 to 199 ≥200**
Random plasma glucose level (mmol/L) - 11.1
Random plasma glucose level (mg/dL) - ≥200***
* 2-h plasma glucose level after a 75-g oral glucose tolerance test
** In the absence of unequivocal hyperglycemia, results should be confirmed by repeated testing.
*** Only diagnostic in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis.

Distinguishing whether a patient has type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) is important, as their diagnosis affects management. T1DM is characterized by the presence of 1 or more autoimmune markers.

Pregnant women with no history of diabetes should be screened for gestational diabetes between 24 and 28 weeks. This can be done through the “1-step” method of a 75-g oral glucose tolerance test or the “2-step” method of a 50-g (non-fasting) test followed by a 100-g oral glucose tolerance test for women who screen positive (A rating).

Recommendations for glycemic targets

Patients should use self-monitoring of blood glucose (SMBG) and HbA1c levels to assess glycemic control. The timing and frequency of SMBG should be tailored based on patients' individual treatment, needs, and goals.

Patients should undergo HbA1c testing at least twice a year if they are meeting treatment goals and have stable glycemic control (E rating). If a patient changes treatment plans or does not meet his or her glycemic goals, HbA1c testing should be done quarterly (E rating). For most adults who are not pregnant, HbA1c levels should be <7% to help reduce microvascular complications and macrovascular disease (A rating). Some patients may benefit from HbA1c goals that are more or less stringent.

Hypoglycemia

If patients are at risk for severe hypoglycemia, providers should prescribe them glucagon and ensure that the patient's close contacts are taught how to administer it (E rating). Severe or frequent hypoglycemia indicates that a patient's treatment regimen should be modified.

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