2011年ADA糖尿病诊疗指南(-完整-全英文版)

1、STANDARDS OF MEDICAL CAREIN DIABETES2011Table of ContentsSectionSlide No.ADA Evidence Grading System ofClinical Recommendations3I. Classification and Diagnosis of Diabetes4-11II. Testing for Diabetes in Asymptomatic Patients12-15III.Detection and Diagnosis of Gestational Diabetes Mellitus (GDM)16-19

2、IV. Prevention/Delay of Type 2 Diabetes20-21V. Diabetes Care22-50VI. Prevention and Management of Diabetes Complications51-101VII.Diabetes Care in Specific Populations102-119VIII. Diabetes Care in Specific Settings120-126IX. Strategies for Improving Diabetes Care127-130ADA Evidence Grading System fo

3、r Clinical RecommendationsLevel of EvidenceDescriptionAClear or supportive evidence from adequately powered well-conducted, generalizable, randomized controlled trialsCompelling nonexperimental evidenceBSupportive evidence from well-conducted cohort studies or case-control studyCSupportive evidence

4、from poorly controlled or uncontrolled studiesConflicting evidence with the weight of evidence supporting the recommendationEExpert consensus or clinical experienceADA. Diabetes Care 2011;34(suppl 1):S12. Table 1.I. CLASSIFICATION AND DIAGNOSIS OF DIABETESClassification of DiabetesType 1 diabetes-ce

5、ll destructionType 2 diabetesProgressive insulin secretory defectOther specific types of diabetesGenetic defects in -cell function, insulin actionDiseases of the exocrine pancreasDrug- or chemical-inducedGestational diabetes mellitusADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1

6、):S12.Criteria for the Diagnosis of DiabetesA1C 6.5%ORFasting plasma glucose (FPG)126 mg/dl (7.0 mmol/l)ORTwo-hour plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTTORA random plasma glucose 200 mg/dl (11.1 mmol/l)ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.C

7、riteria for the Diagnosis of DiabetesA1C 6.5%The test should be performed in a laboratory using an NGSP-certified method standardized to the DCCT assay*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.ADA. I. Classification and Diagnosis. Diabetes Care 2011;3

8、4(suppl 1):S13. Table 2.Criteria for the Diagnosis of DiabetesFasting plasma glucose (FPG)126 mg/dl (7.0 mmol/l)Fasting: no caloric intake forat least 8 h*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.ADA. I. Classification and Diagnosis. Diabetes Care 201

9、1;34(suppl 1):S13. Table 2.Criteria for the Diagnosis of DiabetesTwo-hour plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTTThe test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water*n the

10、 absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.Criteria for the Diagnosis of DiabetesIn a patient with classic symptoms of hyperglycemia or hyperglycemic crisis,a random plasma gluc

11、ose 200 mg/dl (11.1 mmol/l)ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.Prediabetes: IFG, IGT, Increased A1CCategories of increased risk for diabetes (Prediabetes)*FPG 100-125 mg/dl (5.6-6.9 mmol/l): IFGor2-h plasma glucose in the 75-g OGTT140-199 mg/dl (7.8-11.0

12、 mmol/l): IGTorA1C 5.7-6.4%*For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range.ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 3.II. TESTING FOR DIABETES IN ASYMPTOMAT

13、IC PATIENTSRecommendations: Testing for Diabetes in Asymptomatic PatientsConsider testing overweight/obese adults with one or more additional risk factorsIn those without risk factors, begin testing at age 45 years (B)If tests are normalRepeat testing at least at 3-year intervals (E)Use A1C, FPG, or

14、 2-h 75-g OGTT (B)In those with increased risk for future diabetesIdentify and, if appropriate, treat other CVD risk factors (B)ADA. II. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S13-S14.Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (1)Physical inactivity

15、First-degree relative with diabetesHigh-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)Women who delivered a baby weighing 9 lb or were diagnosed with GDMHypertension (140/90 mmHg or on therapy for hypertension)HDL cholesterol level250 mg/dl (2

16、.82 mmol/l)Women with polycystic ovarian syndrome (PCOS)A1C 5.7%, IGT, or IFG on previous testingOther clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)History of CVD*At-risk BMI may be lower in some ethnic groups.1. Testing should be considered in a

17、ll adults who are overweight (BMI 25 kg/m2*) and have additional risk factors: ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.2. In the absence of criteria (risk factors on previous slide), testing for diabetes should begin at age 45 years3. If results are normal,

18、 testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk statusADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (2)

19、III. DETECTION AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUSRecommendations:Detection and Diagnosis of GDM (1)Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria (B)In pregnant women not previously known to have diabetes,

20、 screen for GDM at 24-28 weeks gestation, using a 75-g OGTT and the diagnostic cutpoints in Table 6 (B)ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2011;34(suppl 1):S15.Screening for and Diagnosis of GDMPerform a 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24-2

21、8 weeks of gestation in women not previously diagnosed with overt diabetesPerform OGTT in the morning after an overnight fast of at least 8 hGDM diagnosis: when any of the following plasma glucose values are exceededFasting 92 mg/dl (5.1 mmol/l)1 h 180 mg/dl (10.0 mmol/l)2 h 153 mg/dl (8.5 mmol/l)AD

22、A. III. Detection and Diagnosis of GDM. Diabetes Care 2011;34(suppl 1):S15. Table 6.Recommendations:Detection and Diagnosis of GDM (2)Screen women with GDM for persistent diabetes 6-12 weeks postpartum (E)Women with a history of GDM should have lifelong screening for the development of diabetes or p

23、rediabetes at least every three years (E)ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2011;34(suppl 1):S15.IV. PREVENTION/DELAY OF TYPE 2 DIABETESRecommendations:Prevention/Delay of Type 2 DiabetesRefer patients with IGT (A), IFG (E), or A1C 5.7-6.4% (E) to support programWeight loss 7% o

24、f body weightAt least 150 min/week moderate activityFollow-up counseling important (B);third-party payors should cover (E)Consider metformin if multiple risk factors, especially if hyperglycemia (e.g., A1C6%) progresses despite lifestyle interventions (B)In those with prediabetes, monitor for develo

25、pment of diabetes annually (E) ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2011;34(suppl 1):S16.V. DIABETES CAREA complete medical evaluation should be performed toClassify the diabetesDetect presence of diabetes complicationsReview previous treatment, glycemic control in patients wi

26、th established diabetesAssist in formulating a management planProvide a basis for continuing carePerform laboratory tests necessary to evaluate each patients medical conditionDiabetes Care: Initial EvaluationADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S16.Components of the Comprehensive Di

27、abetes Evaluation (1)Medical historyAge and characteristics of onset of diabetes(e.g., DKA, asymptomatic laboratory finding)Eating patterns, physical activity habits, nutritional status, and weight history; growth and development in children and adolescentsDiabetes education historyReview of previou

28、s treatment regimens and response to therapy (A1C records)ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S17. Table 8.Components of the Comprehensive Diabetes Evaluation (2)ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S17. Table 8.Current treatment of diabetes, including medications,

29、 meal plan, physical activity patterns, and results of glucose monitoring and patients use of data (1)DKA frequency, severity, and causeHypoglycemic episodesHypoglycemia awarenessAny severe hypoglycemia: frequency and causeComponents of the Comprehensive Diabetes Evaluation (3)ADA. V. Diabetes Care.

30、 Diabetes Care 2011;34(suppl 1):S17. Table 8.Current treatment of diabetes, including medications, meal plan, physical activity patterns, and results of glucose monitoring and patients use of data (2)History of diabetes-related complicationsMicrovascular: retinopathy, nephropathy, neuropathySensory

31、neuropathy, including history of foot lesionsAutonomic neuropathy, including sexual dysfunction and gastroparesisMacrovascular: CHD, cerebrovascular disease, PADOther: psychosocial problems*, dental disease*See appropriate referrals for these categories.Components of the Comprehensive Diabetes Evalu

32、ation (4)ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S17. Table 8.Physical examination (1)Height, weight, BMIBlood pressure determination, including orthostatic measurements when indicatedFundoscopic examination*Thyroid palpationSkin examination (for acanthosis nigricans and insulin inject

33、ion sites)*See appropriate referrals for these categories.Components of the Comprehensive Diabetes Evaluation (5)ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S17. Table 8.*See appropriate referrals for these categories.Physical examination (2)Comprehensive foot examinationInspectionPalpatio

34、n of dorsalis pedis and posterior tibial pulsesPresence/absence of patellar and Achilles reflexesDetermination of proprioception, vibration, and monofilament sensationLaboratory evaluationA1C, if results not available within past 23 monthsIf not performed/available within past yearFasting lipid prof

35、ile, including total, LDL- and HDL-cholesterol and triglyceridesLiver function testsTest for urine albumin excretion with spot urine albumin/creatinine ratioSerum creatinine and calculated GFRTSH in type 1 diabetes, dyslipidemia, or women50 years of ageADA. V. Diabetes Care. Diabetes Care 2011;34(su

36、ppl 1):S17. Table 8.Components of the Comprehensive Diabetes Evaluation (6)ReferralsAnnual dilated eye examFamily planning for women of reproductive ageRegistered dietitian for MNTDiabetes self-management educationDental examinationMental health professional, if neededADA. V. Diabetes Care. Diabetes

37、 Care 2011;34(suppl 1):S17. Table 8.Components of the Comprehensive Diabetes Evaluation (7)Recommendations: Glucose MonitoringSelf-monitoring of blood glucose should be carried out 3+ times daily for patients using multiple insulin injections or insulin pump therapy (A)For patients using less freque

38、nt insulin injections, noninsulin therapy, or medical nutrition therapy aloneSMBG may be useful as a guide to success of therapy (E)However, several recent trials have called into question clinical utility, cost-effectiveness, of routine SMBG in noninsulin-treated patientsADA. V. Diabetes Care. Diab

39、etes Care 2011;34(suppl 1):S17.Recommendations: A1CPerform A1C test at least twice yearly in patients meeting treatment goals (and have stable glycemic control) (E)Perform A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals (E)Use of point-of-care testing f

40、or A1C allows for timely decisions on therapy changes, when needed (E)ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S18.Correlation of A1C with Estimated Average Glucose (eAG)Mean plasma glucoseA1C (%)mg/dlmmol/l61267.071548.6818310.2921211.81024013.41126914.91229816.5ADA. V. Diabetes Care.

41、Diabetes Care 2011;34(suppl 1):S18. Table 9.These estimates are based on ADAG data of 2,700 glucose measurements over 3 months per A1C measurement in 507 adults with type 1, type 2, and no diabetes. The correlation between A1C and average glucose was 0.92. A calculator for converting A1C results int

42、o estimated average glucose (eAG), in either mg/dl or mmol/l, is available at /GlucoseCalculator.aspx.Recommendations:Glycemic Goals in Adults (1)ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S19.Lowering A1C to below or around 7%Shown to reduce microvascular and neuropathic complications of

43、 diabetesIf implemented soon after diagnosis of diabetes, associated with long-term reduction in macrovascular diseaseTherefore, a reasonable A1C goal for many non-pregnant adults is 7% (B)Recommendations:Glycemic Goals in Adults (2)ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S19.Additiona

44、l analysis from several randomized trials suggest a small but incremental benefit in microvascular outcomes with A1C values closer to normalProviders might reasonably suggest more stringent A1C goals for selected individual patients, if this can be achieved without significant hypoglycemia or other

45、adverse effects of treatmentSuch patients might include those with short duration of diabetes, long life expectancy, and no significant cardiovascular disease (B)Recommendations:Glycemic Goals in Adults (3)ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S19.Conversely, less stringent A1C goals

46、 may be appropriate for patients withHistory of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions Those with longstanding diabetes in whom the general goal is difficult to attain despite diabetes self-management educati

47、on, appropriate glucose monitoring, and effective doses of multiple glucose lowering agents including insulin (C)Intensive Glycemic Control and Cardiovascular Outcomes: ACCORDGerstein HC, et al, for the Action to Control Cardiovascular Risk in Diabetes Study Group.N Engl J Med 2008;358:2545-2559.200

48、8 New England Journal of Medicine. Used with permission.Primary Outcome: Nonfatal MI, nonfatal stroke, CVD death HR=0.90 (0.78-1.04)Intensive Glycemic Control and Cardiovascular Outcomes: ADVANCE2008 New England Journal of Medicine. Used with permission.Primary Outcome: Microvascular plus macrovascu

49、lar (nonfatal MI, nonfatal stroke, CVD death)Patel A, et al,. for the ADVANCE Collaborative Group. N Engl J Med 2008;358:2560-2572.HR=0.90 (0.82-0.98)Intensive Glycemic Control and Cardiovascular Outcomes: VADTDuckworth W, et al., for the VADT Investigators. N Engl J Med 2009;360:129-139.Primary Out

50、come: Nonfatal MI, nonfatal stroke, CVD death, hospitalization for heart failure, revascularizationHR=0.88 (0.74-1.05)2009 New England Journal of Medicine. Used with permission.Glycemic Recommendations for Non-Pregnant Adults with Diabetes (1)A1C7.0%*Preprandial capillary plasma glucose70130 mg/dl*

51、(3.97.2 mol/l)Peak postprandial capillary plasma glucose180 mg/dl* (35 kg/m2 and type 2 diabetes (B)After surgery, life-long lifestyle support and medical monitoring is necessary (E)Insufficient evidence to recommend surgery in patients with BMI 64 years previously immunized at 5 years agoOther indi

52、cations for repeat vaccination: nephrotic syndrome, chronic renal disease, immunocompromised states (C)ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S27.VI. PREVENTION AND MANAGEMENT OFDIABETES COMPLICATIONSCVD is a major cause of morbidity, mortality for those with diabetesCommon conditions

53、 coexisting with type 2 diabetes (e.g., hypertension, dyslipidemia) are clear risk factors for CVDDiabetes itself confers independent riskBenefits observed when individual cardiovascular risk factors are controlled to prevent/slow CVD in people with diabetesCardiovascular Disease (CVD) in Individual

54、s with DiabetesADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.Recommendations: Hypertension/Blood Pressure ControlScreening and diagnosisMeasure blood pressure at every routine diabetes visitIf patients have systolic blood pressure130 mmHg or diastolic blood pre

55、ssure 80 mmHgConfirm blood pressure on a separate dayRepeat systolic blood pressure 130 mmHg or diastolic blood pressure 80 confirms a diagnosis of hypertension (C)ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.Recommendations: Hypertension/Blood Pressure Contro

56、lGoalsA goal systolic blood pressure 130 mmHg is appropriate for most patients with diabetes (C)Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate (B)Patients with diabetes should be treated to a diastolic blood pressure 80 mm

57、Hg (B)ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.Recommendations: Hypertension/Blood Pressure ControlTreatment (1)Patients with a systolic blood pressure 130139 mmHg or a diastolic blood pressure 8089 mmHgMay be given lifestyle therapy alone for a maximum of

58、 3 monthsIf targets are not achieved, patients should be treated with the addition of pharmacological agents (E)ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.Recommendations: Hypertension/Blood Pressure ControlTreatment (2)Patients with more severe hypertension

59、 (systolic blood pressure 140 mmHg or diastolic blood pressure 90 mmHg) at diagnosis or follow-upShould receive pharmacologic therapy in addition to lifestyle therapy (A)ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.Recommendations: Hypertension/Blood Pressure

60、ControlTreatment (3)Lifestyle therapy for hypertensionWeight loss if overweightDASH-style dietary pattern including reducing sodium, increasing potassium intakeModeration of alcohol intakeIncreased physical activity (B)ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):