Diabetes clinical practice recommendations focus attention on individualization of care

The American Diabetes Association has released an annual update to its “Standards of Medical Care in Diabetes.” Many of the 2014 changes concern recommendations for increasing the level of individualized care. 

Standards of Medical Care is an evidence-based position statement containing clinical practice recommendations for diagnosing and treating adults and children with all forms of diabetes. The 2014 version was published in a supplement to the January 2014 issue of Diabetes Care and is available online at bit.ly/19nagu2.

Among its updates/revisions, the document provides clarification on the appropriateness of A1C testing as one of three methods for diagnosing diabetes and suggests a three-month trial (rather than three to six months) of noninsulin monotherapy for hyperglycemia in type 2 diabetes.

The standards of care also recommends encouraging patients with diabetes to work with a nutritionist or dietitian to identify an eating pattern that best fits their needs.

Other recommendations include sodium intake of less than 2,300 milligrams for adults with diabetes and notes that further lowering of sodium intake in patients with diabetes and hypertension should be individualized. Prevention of neuropathy through tight and stable glycemic control, along with improvement in neuropathic symptoms through prevention of extreme blood glucose fluctuations also are important. Standards of care encourages physicians to explore a variety of options when prescribing medication to treat neuropathy and to carefully monitor responses to optimize the benefit for each patient.

The position statement also:

• recommends eye exams every two years for patients who have type 1 or type 2 diabetes and no evidence of retinopathy. (A three-year interval is considered acceptable for patients with type 2 disease that is well controlled and who appear to have minimal risk for diabetic retinopathy.)

• discourages the use of sliding scale insulin dosing in inpatient settings  and recommends a physiologic insulin regimen that provides better coverage.

• suggests cautious use of the new continuous glucose monitoring device with sensor-augmented insulin pump therapy in patients with frequent nocturnal hypoglycemia and/or hypoglycemia unawareness.