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Vanderbilt Health Affiliated NetworkCare Path GuideType 2 DiabetesTable of ContentsI. IntroductionX? TREATMENT MEASURES AND GOALSXII. PrediabetesX? DIAGNOSING PREDIABETES AND TYPE 2 DIABETESXIII. Type 2 Diabetes Diagnosis and Lifestyle ManagementXIV. Type 2 Diabetes Mellitus Medical ManagementX? ANTIHYPERGLYCEMIC THERAPY GUIDELINESX? DEPRESCRIBING: VALUES, GOALS, APPROACHESX? INSULIN DOSINGX? MEDICATION FOLLOWING CARE TRANSITIONXV. Patient EducationXVI. ReferencesX[I.] INTRODUCTIONDiabetes: A Heavy Burden on Public HealthNationally, almost 23 million people have been diagnosed with diabetes, a chronic and complex condition that typically affects numerous aspects of patient health. The Centers for Disease Control and Prevention (CDC) estimated approximately 30.2 million people, or about 9.4% of the U.S. population, had diabetes in 2015. The CDC projects up to one-third of adults in the U.S. could have this condition by the year 2050.In the southeastern United States, diabetes rates are higher, with estimations varying from 11–14% of state populations. In most southern states, more than one-third of residents are estimated to have prediabetes. Combined with high poverty levels and lower rates of access to health insurance and healthcare in general in the southern U.S., management of chronic conditions, such as type 2 diabetes, becomes a distinct challenge for patients who live in these regions and their care teams.Diabetes is also a costly problem nationally, accounting for $237 billion in medical costs and $90 billion across the U.S. in diminished productivity in 2017. In the Southeast, medical cost burden per state is estimated between $2.4 billion and $7.7 billion., The high costs are caused by a variety of circumstances: The numbers of people with diabetes and costs of care per person are rising, while among individual patient expenses, prices of antihyperglycemic medications are rising steeply and inpatient hospital stays are increasing.If uncontrolled, diabetes can result in amputations, blindness, cardiovascular disease,2(pS139) kidney disease,2(pS154) neuropathy and stroke. Early diagnosis and proper management of type 2 diabetes can help delay, moderate or prevent these complications. Similarly, detection and optimal management of prediabetes can delay or prevent the condition from progressing to type 2 diabetes. Therefore, a focus on type 2 diabetes and prediabetes can benefit individuals, communities and healthcare systems.Emergency Room Use and ReadmissionsPeople with diabetes account for a disproportionate fraction of those who come to the emergency department and are admitted to the hospital following an emergency visit. These visits are sometimes due to conditions arising from uncontrolled or poorly managed diabetes, such as diabetic ketoacidosis and hyperglycemia and more often for comorbid conditions, such as cardiovascular disease. Effective type 2 diabetes management has the potential to prevent costly emergency admissions and repeat visits to the emergency department.,Historically, there has been little study about the effect of diabetes on hospital readmissions, but the disease is a comorbidity to many medical conditions that lead to readmission. Studies have shown that patients with diabetes have a higher risk for 30-day readmission. Patients admitted with a primary diagnosis of diabetes have higher readmission rates than those without diabetes, a 2017 study of more than 7,000 hospital admissions found.[Table I-1]Treatment Measures and GoalsMeasureFrequencyGoalHemoglobin A1cEvery six months< 7.0% or patient-specific goal (See table IV-1.)Blood pressureEach office visitTypically < 130/80 mmHg for patients with diabetes; patient-specific goals may applyFoot examAnnuallyHealthy skin, absence of deformities, full sensation, healthy vascular assessmentStatin medicationFasting lipid panel annuallyADA Guidelines: Prescribe for non-pregnant patients > age 40 OR < age 40 who have 10-year ASCVD risk > 20% +/- other cardiac risk factors.---------------------------------------------2019 AHA/ACC Guidelines: Prescribe moderate-intensity statin for all patients with diabetes and high intensity statin for patients who have had T2DM for > 10 years, albuminuria ≥ 30 mcg albumin/mg creatinine, eGFR < 60 mL/min/1.73 m2, retinopathy, neuropathy, ABI< 0.9Urine albumin/creatinine ratioAnnually< 30 mg albumin/g of creatinineSerum creatinineAnnuallyNormalRetinal/dilated eye examAnnually or biannuallyNormalOffice visitAt least every three months for patients not meeting A1c goal; every six months for patients meeting goalNote: Visits may be distributed between primary care clinician and specialistThe Case for a Care Path GuideRecent studies have demonstrated that inadequate, unnecessary, uncoordinated and inefficient care are responsible for waste in the healthcare system that may account for 35–50% of the nearly $3 trillion the United States spends annually on healthcare. Care path guides become tools for education, reporting, measurement and continuous improvement. Reduction of unnecessary variability is their primary goal. Care paths are designed to standardize care to reduce variability and assure a consistent level of quality for patients across time, venue and provider, combining workflow-friendly, evidence-based practice principles. Health Status Measures and Patient-Reported Outcome MeasuresHealth status measures (HSMs) in general and patient-reported outcome measures (PROMs) in particular are becoming important standard components of patient care. These measures are validated tools which provide insight into patient relevant issues, improve patient/clinician communication and guide individual management. They provide a method to objectify outcomes and quality in a manner that can be shared with patients. These measures require patient participation and have been shown to improve patient engagement in their own healthcare. These outcome measures are an important component of value-based care and are beginning to be important in health policy and reimbursement. [SIDEBAR I-1]PROM ToolsGeneral and BehavioralThe following PROMs help clinicians evaluate general and behavioral health status that could affect outcomes and guide treatment:PAID-5: A five-question screening tool designed to assess emotional distress about diabetes. The five questions are designed to indicate feelings of fear, depression, anxiety about the future, resilience and coping. A score of eight or more indicates emotional distress and calls for further assessment. The PAID-5 is thought to be highly sensitive to identifying problem areas.ARMS-7: A seven-question screening tool designed to assess medication adherence behaviors. There is also an ARMS-D specific to patients with diabetes. The ARMS instrument is reliable and has the added benefit of identifying reasons for adherence problems.Patient Health Questionnaire-2 (PHQ-2): A two-question depression screening tool that can provide information about the patient’s mental health status.37 If the patient has a positive PHQ-2 score of three or higher, they could be further screened with the PHQ-9 screening tool (see next bulleted point).Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10: A 10-question screening tool designed to assess physical, mental and social health, including pain, fatigue and quality of life.About This Care Path GuideThis care pathway was developed by Vanderbilt Health Affiliated Network to guide primary, mid-level and ancillary care clinicians and specialists in an evidence-based approach to diagnosis and treatment of prediabetes and type 2 diabetes in adults. We intend this guide to be useful to caregivers in an array of settings: the emergency department, the urgent care or walk-in clinic, the primary care clinician’s office, and the specialist’s office. This resource is based on national and international guidelines, as well as the expert opinions of members of our network.This care path guide focuses on the diagnosis and treatment of prediabetes and type 2 diabetes in adults. In some cases, the type of diabetes may not be clear based on clinical presentation alone. The prediabetes section of this guide contains a brief discussion of considerations for identifying other types of diabetes (e.g., type 1 diabetes in young adults, gestational diabetes and latent autoimmune diabetes [LADA]) but does not detail specific treatment of these conditions.Clinical JudgmentBy following this care path guide when assessing, diagnosing and treating patients who have prediabetes and type 2 diabetes, clinicians and specialists may reduce variability and individualize treatments with the objective of obtaining positive health outcomes for adults with these conditions. In achieving those positive health outcomes, clinicians will also improve patient satisfaction and reduce unnecessary spending and utilization. The care path guide is intended to be broadly applicable, but it is not meant to substitute forclinical judgment. Clinicians and specialists should tailor processes and approaches to alignwith patient needs, abilities and goals for care.[Sidebar: Contributor’s List]Vanderbilt Health Affiliated Network ContributorsMichelle Griffith, MD, Assistant Professor, Vanderbilt University Medical Center Diabetes/EndocrinologyTiffanie Marksbury, DNP, ANP, CDE, Assistant in Medicine, NP Amb, Vanderbilt University Medical Center Diabetes/EndocrinologyLauren Shaw, RN, BSN, CDE, Patient Care Coordinator, Disease Management TeamChristopher Terry, PharmD, CDE, Clinical Pharmacist, Vanderbilt Health Affiliated Network Medication ManagementHoward Baum, MD, Assoc Professor, Vanderbilt University Medical Center Diabetes/EndoRosette Chakkalakal, MD, MHS, Asst Professor, Vanderbilt University Medical Center Internal MedJessica Herron PA, CDE, Jackson Clinic, Vanderbilt Health Affiliated NetworkBrad Vander Veen, MD, Premier Medical Group, Vanderbilt Health Affiliated NetworkMike Modic, MD, Sr. Vice President, Vanderbilt Health Affiliated NetworkEsther Smith, Admin Director, Vanderbilt Health Affiliated Network Strategic OpsMegan Pacella, Content Manager, Vanderbilt Health Affiliated Network B2B MarketingKaren Stone, Director, Vanderbilt Health Affiliated Network B2B MarketingMatthew Resnick, Assoc Professor, Vanderbilt University Medical Center UrologyMegan Pruce, Vice President, Strategic Mktg, Vanderbilt Health Affiliated NetworkClaude Pirtle, MD, Clinical Fellow, Vanderbilt University Medical Center Biomedical InformaticsJustin Bachmann, MD, MPH, Asst. Professor, Vanderbilt University Medical Center CardiovascularAndrew O. Smith, Sr. Project Mgr, Population Health, Vanderbilt Health Affiliated NetworkRussell Brothers, Principal Analytics Cslt, Enterprise Analytics, Vanderbilt Health Affiliated NetworkTiffany Sarell, PharmD., AAHIVP, Program Director, PBM Services, Vanderbilt Health Rx SolutionJenn Taylor, Account Manager, True NorthJenn Webster, Writer, True NorthLisa Rodgers-Dark, Content Director/Managing Editor, True North[II.] PREDIABETESDiagnosisIn prediabetes, blood glucose levels are elevated but not enough to qualify as type 2 diabetes. Prediabetes is defined by a fasting plasma glucose level of 100 mg/dL to 125 mg/dL, two-hour plasma glucose during a 75 g oral glucose tolerance test of 140 mg/dL to 199 mg/dL, or A1c of 5.7–6.4%.Prediabetes is associated with other medical conditions, including obesity, dyslipidemia and hypertension. People with A1c levels in the prediabetes range have a substantially elevated risk of developing type 2 diabetes, with the risk rising at higher blood glucose levels.The American Diabetes Association (ADA) recommends that asymptomatic adults with risk factors should be considered for prediabetes and type 2 diabetes screenings. Screening for prediabetes may be repeated every one to three years, with frequency determined by the degree of risk. [Algorithm II-1]Diagnosing Prediabetes and Type 2 DiabetesPatient meets criteria for screeningAND/OR Patient has symptoms of high blood sugarTHEN*Test via plasma glucose (fasting plasma glucose or two-hour oral glucose tolerance test) or plasma A1cNormal resultsPlasma A1c less than 5.7% ORFPG less than 100 mg/dL OR2-hour OGTT less than 140 mg/dLAbnormal results below diagnostic threshold for type 2 diabetesPlasma A1c 5.7%–6.4% ORFPG 100–125 mg/dL OR2-hour OGTT 140–199 mg/dLAbnormal results meeting criteria for type 2 diabetes diagnosisPlasma A1c equal to or greater than 6.5% ORFPG equal to or greater than 126 mg/dL OR2-hour OGTT equal to or greater than 200 mg/dLTHEN If abnormal results, repeat the same or alternative test with new blood sample to confirmPatient does not meet diagnostic criteria for prediabetes Patient meets diagnostic criteria for prediabetes on repeat testPatient meets diagnostic criteria for diabetes on repeat testTHENEducate on nutrition and exerciseRepeat testing every three years as long as patient meets screening criteriaTHENdiagnosis of prediabetesTHENDiagnosis of diabetesTHENBegin lifestyle interventions in nutrition and retest A1c at 6 monthsConsider metformin (see text)THENConsider antibody tests for suspected LADA or type 1 diabetes (see sidebar II-1)Begin lifestyle interventions in nutrition and exerciseBegin medical interventions per algorithm IV-1*NOTE: Point-of-care testing should not be used for either plasma A1C or glucose tolerance test in diagnosis phase.[Sidebar II-1]Type 1 Diabetes and LADASome adult patients with type 1 diabetes or latent autoimmune diabetes in adults (LADA) may present with symptoms or be flagged in testing for prediabetes and type 2 diabetes. Adult patients with type 1 diabetes may not present with classic symptoms of childhood diabetes.Adults suspected to have prediabetes or type 2 diabetes according to algorithm II-1 but who are of normal weight or underweight should be further tested for type 1 diabetes or LADA.If there is a suspicion of type 1 diabetes or LADA, the clinician should check the patient’s plasma glucose, C-peptide levels, and/or the presence of glutamic acid decarboxylase (GAD) antibodies or anti-islet antibodies. At minimum, the patient should be started on insulin and referred to an endocrinologist urgently if testing for type 1 diabetes or LADA is positive.Type 2 Diabetes… Usually appears slowly… Occurs more frequently in adults than in children… Commonly features insulin obesity and clinical signs of insulin resistance, such as acanthosis nigricans… Typically runs in families; a first-degree relative may also have type 2 diabetes… Might be effectively managed with oral medication long-termType 1 Diabetes… Usually appears rapidly… Features presence of GAD antibodies, islet cell antibodies or other autoimmune markers1(pS16) … Less frequently has a family history… Requires insulin from the onset…Does not improve with oral agentsLADA… Usually appears slowly… Occurs in adults age 30 or older… Features presence of GAD antibodies about 90% of the time… Often occurs in younger patients who may be overweight but not obese… Often occurs in people with a family history of autoimmune disease… May initially respond to oral therapies but eventually requires insulinPrediabetes Management OverviewPeople with prediabetes should be tested each year for diabetes, and more importantly, they should be offered a full range of diabetes prevention tools, including lifestyle and medical management. An intensive behavioral/lifestyle program, such as the National Diabetes Prevention Program, may reduce the incidence of type 2 diabetes by 58% over three years in people with prediabetes. Another effective program is the National Institute of Diabetes and Digestive and Kidney Diseases Your Game Plan to Prevent Prediabetes. Additional resources can be found in section V. Lifestyle management to prevent the onset of diabetes can also improve related conditions, including dyslipidemia, hypertension and inflammation.Lifestyle ManagementLifestyle management encompasses strategies for becoming physically active, adopting a healthy eating plan and, if necessary, losing weight. Patients should also be encouraged to develop executive functioning skills, including:Goal-settingPlanning for menus and exercise timesTracking progressCollaborating with their healthcare teamsAsking questions and proactively obtaining supportWeight Loss for Diabetes PreventionPeople at risk of developing type 2 diabetes who are overweight or obese benefit from participation in structured behavioral weight-loss therapy, including a reduced-calorie meal plan and regular physical activity.Overweight patients should be counseled to lose at minimum 7% of body weight, based on findings from the National Diabetes Prevention Program. Calorie restriction for gradual weight loss of no more than 1–2 pounds per week is believed most sustainable. Patients who need to lose weight should ideally be referred to a registered dietitian nutritionist (RDN) for individualized counseling and meal planning. Until they can meet with an RDN, patients may be counseled to reduce caloric intake by 500–1,000 calories per day, depending on their body weight.Because weight loss can be challenging, patients who need to lose weight should also be offered a range of therapeutic options for weight loss, including pharmacotherapy and referral for weight-loss surgery, if appropriate.Nutrition and exercise recommendations are applicable for people with type 2 diabetes as well as prediabetes.Smoking CessationSmoking is a major risk factor for development of type 2 diabetes, and individuals with prediabetes who smoke should be referred to a smoking cessation program. Stopping smoking may be associated with a short-term increased risk of developing diabetes, so care team members should coordinate closely to help patients work through the dual challenge of eliminating tobacco use and reducing caloric and carbohydrate intake.Individualization and Behavioral AssistanceLosing weight and starting or increasing exercise can also be challenging for patients, even with the goal of avoiding type 2 diabetes. Numerous competencies and socioeconomic factors impact diet and activity levels. Patients may prefer to eat healthy diets that fit well with their religious or cultural backgrounds, or to exercise in ways that suit their environment, budget and personal preference. Education and support for self-management of prediabetes can help people individualize and maintain healthy eating and behavior patterns and, in so doing, delay or prevent the development of type 2 diabetes.Support for lifestyle changes may be provided by an RDN, a diabetes educator, an exercise coach or other care team member.Medical ManagementMetformin therapy to prevent type 2 diabetes should be considered when:Combined impaired fasting glucose and impaired glucose or tolerance are presentA1c is greater than 6.1% and does not decline with six months of lifestyle changePatient has a BMI ≥ 35 kg/mPatient is younger than age 60Has a history of gestational diabetes mellitusPatient preference should be considered when prescribing metformin for prediabetes.[III.] TYPE 2 DIABETES IDENTIFICATION AND LIFESTYLE MANAGEMENTScreening and DiagnosisThe ADA, the American Academy of Family Physicians and numerous other associations recommend population screening for type 2 diabetes., Early identification of type 2 diabetes can delay or prevent diabetes complications and improve diabetes-related comorbidities. For detailed information on screening and diagnosis of type 2 diabetes, see algorithm II-1. Lifestyle ManagementLifestyle management for patients with type 2 diabetes is a complex process, involving medical nutrition therapy (MNT), physical activity and smoking cessation, as well as the psychosocial supports and wellness education that enable sustained behavioral change. Healthy eating, regular exercise and weight loss can help people with type 2 diabetes keep their blood glucose at lower levels, avoid comorbidities and delay the need to escalate medication regimens. Routine visits with clinicians or other members of the healthcare team between visits can help ensure patients are achieving their goals and help them get back on track when they need extra assistance.NutritionEvery patient diagnosed with type 2 diabetes should be referred for MNT upon diagnosis. Each patient should collaborate with clinicians and other members of the healthcare team to create an eating plan that he or she will be able to maintain long-term. In-depth nutrition planning to support specific health and/or medical goals, MNT is administered in a disease-specific fashion and is most effective when overseen by a registered dietitian nutritionist. MNT aims at improving body weight; helping patients meet blood pressure, cholesterol and glycemic goals; and delaying or preventing diabetes complications or comorbidities. (See table III-1.) MNT is fully covered by Medicare for patients diagnosed with type 2 diabetes.There are many structured, low-calorie meal plans that can help patients meet medical-nutritional goals. Among these, the Mediterranean eating plan is particularly effective; however, a variety of factors—ranging from other health complications to the patient’s tastes, culture and circumstances—all impact what meal plan will be most effective and sustainable. With any meal plan, emphasis should be placed on eating minimally processed, nutrient-dense foods such as vegetables, fruits, nuts and whole grains, as well as selecting lean protein sources including fish, beans and other pulses.419100101600419100101600[Blurb]People with diabetes, like the general population, should limit alcohol consumption to a maximum of one drink per day for women, two for men. Excessive alcohol intake may lead to hyperglycemia. Drinking alcohol in excess may also lead to hypoglycemia due to impaired gluconeogenesis.4191001270041910012700[Table III-1]Elements of Medical Nutrition TherapyELEMENTOBJECTIVESMETHODSMeal planningPatients should learn elements of meal planning, taking into consideration macronutrient balance and overall caloric intake. Visual models such as MyPlate can be useful heuristics. Model diets include the DASH diet and Mediterranean eating plan; however, patients should be empowered to individualize choices. MacronutrientsThe ADA does not recommend a single distribution of carbohydrates, fats and proteins. The goal is macronutrient balance.Encourage balance rather than focusing on specific “good” or “bad” nutrients or foods. Provide a wide range of specific, healthy examples. CarbohydratesIncrease high-fiber carbohydrates; minimize white flour, processed carbohydrates and sugars. Patient-specific objectives relate to glycemic control and avoiding hypoglycemia. Carbohydrates should be divided fairly evenly among meals, with a maximal goal of around 45–60g per meal.Teach carbohydrate monitoring, encouraging a reasonable amount of carbohydrates per meal—visually, this equates to about the amount that fits on one-fourth of a smaller-size plate; patients on insulin may need to monitor closely to determine insulin dosing and/or eat consistently to reduce risk of hyperglycemia or hypoglycemia. FatsMaintain a relatively low-fat diet (less than 25% total intake) while selecting healthy fats to lower cardiovascular risk.Emphasize foods low in trans or saturated fats, high in monounsaturated and polyunsaturated fats. ProteinsResearch is inconclusive on optimal protein intake, although it is possible that higher intake may help patients feel increased satiety.Do not use high protein carbohydrates to treat hypoglycemia.Achievable weight lossAim for gradual, persistent weight loss. Calculate calorie deficit or aim for no less than 1,200 kcal/day for women, 1,500 for men.Regular, frequent, ongoing behavioral support is necessary. Use visual portion guides for patients who have trouble counting calories.ExerciseCombined with nutrition education, exercise can help those with prediabetes and type 2 diabetes lose weight, maintain weight loss, and postpone or avoid diabetes complications. People with suspected health conditions, such as cardiovascular or kidney disease, should receive medical clearance before initiating an exercise program or increasing the intensity of their current regimen.In encouraging patients to begin or intensify their exercise routine, clinicians and specialists should consider the person’s:Current activity level (amount, duration, type)Health status, including possible cardiovascular, metabolic or kidney diseaseGoals for amount, duration and type of physical activityEncourage:Activity Personalization. Patients who take medications with a risk of hypoglycemia may experience activity-induced hypoglycemia. Conversely, catecholamine release during exercise can cause worsening of blood sugars if patients begin exercise while significantly hyperglycemic. Personalized plans for testing blood sugar and adjusting medication or carbohydrate intake around exercise may be needed.Aerobic exercise. The ADA recommends adults with type 2 diabetes engage in at least 150 minutes of moderate-intensity exercise each week, an amount that may be increased in duration or intensity as patient exercise capacity increases. Exercise sessions should be spread out so that no more than one day passes without exercise. Many options do not require equipment or training. For instance, walking at a quick pace, jogging, swimming or water walking, lawn sports, and heavy gardening can all raise heart rate to the moderate-intensity range.Strength training. In addition to aerobic exercise, those with type 2 diabetes should be encouraged to engage in strength or resistance training two to three times a week, allowing at least one rest day between sessions. Strength training can take place in a gym under the supervision of a personal trainer, but basic exercises relying on body weight—such as squats, sit-ups, and push-ups—can be performed at home after minimal instruction.Flexibility and balance. Flexibility and balance training is also important. Older adults, in particular, should perform exercises to improve their balance two to three times weekly. Flexibility and balance exercises, such as yoga or tai chi, are often taught in community settings.Discourage:Sedentary behavior. Regardless of exercise frequency or intensity, people should avoid sitting for prolonged intervals during the day. Those with type 2 diabetes have been shown to improve glucose control when they interrupt periods of sitting every 30 minutes to walk or engage in other light activities.4191001270041910012700[Sidebar III-1]Exercise and Peripheral NeuropathyPatients with peripheral neuropathy may hesitate to exercise due to poor balance and concerns about falling. However, motor deficits and sensory symptoms associated with peripheral neuropathy may be improved by balance training, and exercise may reduce neuropathy-related numbness and pain. Endurance exercises are also effective at delaying effects of peripheral neuropathy. Physical and occupational therapy can help patients at risk of falling develop strength, balance, sensory motor perception and situational awareness so that they can exercise safely. Patients with peripheral neuropathy should wear appropriate footgear at all times and inspect their feet daily: Those with open foot sores or injuries should select non-weight-bearing exercises and consult their clinician about appropriate exercises to avoid negatively impacting the wound or injury.4191001270041910012700Psychosocial SupportLifestyle management for persons with diabetes should include conversations about the resources and support available to them, their goals and expectations for their disease, and their emotional well-being. Quality of life and ability to manage their disease should be assessed for each patient, while patients older than 65 should also be screened for depression and cognitive impairment that may affect their disease management. Vanderbilt Health Affiliated Network recommends the Problem Areas in Diabetes-5 (PAID-5) tool to screen for diabetes-related distress.Clinicians and the diabetes care team should maintain regular, supportive contact with patients and work collaboratively with behavioral health specialists to optimize patient ability to manage diabetes for a good quality of life. In some cases, patients should be referred to a mental health provider for further support. Indications for referral include:Self-care concerns that persist after patient education, including:Cognitive impairmentInadequate support for young, elderly or disabled patientsMental illnessDiagnosis of depression or anxietyDisordered eating, including eating disorder or manipulating medications to provoke weight lossMultiple episodes of diabetic ketoacidosis, hospitalizations, etc.Other significant distressThe Patient VisitNo one model of a patient visit can take all circumstances into account. A patient with type 2 diabetes may need extensive instruction and several referrals in the initial visit after diagnosis, while he or she may need more routine care in a maintenance visit in which all goals are being met. Patients with type 2 diabetes may present for care due to their condition in a variety of settings:Initial visit (new patient or new diagnosis)Maintenance visitUrgent care visit (to urgent care center or symptom-based visit to regular doctor)Emergency room visitConception or pregnancy counselingTelemedicine or e-consult, where services are availableTo reduce unnecessary visits to the emergency room, we recommend teaching patients self-management and sick day skills, including when to contact their care providers for help and when more urgent levels of care are warranted. Provide patients with the My Emergency Plan of Care patient brochure. [IV.] TYPE 2 DIABETES MELLITUS MEDICAL MANAGEMENTGuiding PhilosophyVanderbilt Health Affiliated Network aims to help people with type 2 diabetes attain the best possible blood glucose control given their health and abilities, while relying on the smallest number of effective prescriptions to achieve personalized glycemic control goals. While prescribing directives can be given in the form of a chart or algorithm, each patient’s disease trajectory and personal story—including response to treatment, abilities, environment and preferences—help inform treatment decisions.Individualized Goal Setting and MonitoringIndividualized goal setting for glycemic control should take into account each patient’s preference, health status and ability to undertake treatment responsibilities and expenses. The ADA recommends an A1c goal of less than 7% is reasonable for many non-pregnant adults. Goals may be modified for numerous individual circumstances (see table IV-1). A1c should be monitored by in-office tests at least twice a year for patients meeting this goal and quarterly for patients not meeting the goal. [Table IV-1] CircumstanceConsider more stringent goal (< 6.5%)Consider less stringent goal (< 8%)DurationShort disease durationLong disease durationAbility to control diseaseEffective disease controlInability to control disease even with regular glucose monitoring and medical interventions including insulinPatient preferenceHighly motivated and capablePrefers lower burden of therapySocial supports and access to resourcesReadily availableLimited or absentComplications and comorbiditiesNo complications or comorbiditiesComorbid conditions, vascular complicationsLife expectancyLong life expectancyShort life expectancyAdverse reaction to medications, hypoglycemiaMinimal risk of hypoglycemia or other problems with medicationHigh risk of hypoglycemia, adverse reactions or contraindications to medicationsPrescribing GuidelinesThe primary goal of medication for type 2 diabetes is helping patients achieve glycemic control when lifestyle modifications alone do not achieve the desired change. Secondary goals include reducing cardiovascular risk, enhancing weight loss if needed, avoiding weight gain, avoiding polypharmacy and cost savings. Metformin is prescribed first, with choice of second and third line agents to be determined by patient comorbidities, needs and goals (see algorithm IV-1 as an attachment for additional guidance). Deprescribing of ineffective medications is also an important part of medication management.Antihyperglycemics OverviewThe following table (IV-2) lists medication class as well as generic and brand names of the antihyperglycemic agents mentioned in algorithm IV-1.[Table IV-2]ClassMedications NamesGeneric / BrandTypical DosageA1cReduc-tionCostPositivesNegativesBiguanidesMetformin / Glucophage 500 mg by mouth twice daily/once daily to start – 1,000 mg by mouth twice daily (max)1–1.5%$/$$? Maximum effect in 3–4 weeks? Does not cause hypoglycemia? Weight neutral? Lower cost option? May cause diarrhea or nausea? May cause B12 deficiency? Acidosis risk; should not be taken when dehydration is present, during acute illness or while IV contrast is in useContraindicated for:? Unstable CHF? CKD (eGRF < 30)? Chronic liver disease? AlcoholismMetformin ER / Glucophage XR500–2,000 mg by mouth once daily with p.m. mealGLP-1 receptor agonistsExenatide / Byetta5 mcg subcutaneously twice daily, injected at least 1 hour before a.m. meal and 1 hour before p.m. meal. After 1 month, if needed, can increase to 10 mcg twice daily1–1.5%$$$$? Reduces postprandial hyperglycemia? May reduce weight? Does not cause hypoglycemia? May cause nausea, diarrhea, dizzinessContraindicated for: ? Pancreatitis? History of medullary thyroid cancer (personal or family)? Acute pancreatitis Exenatide ER / Bydureon 2 mg subcutaneously once every 7th dayLiraglutide / Victoza1.2 mg or 1.8 mg subcutaneously once dailyDulaglutide / Trulicity.75 mg or 1.5 mg subcutaneously once every 7th daySemaglutide / Ozempic 0.25 mg subcutaneously once weekly; increase to 0.5 mg subcutaneously starting with week 5. If after at least 4 weeks additional glycemiccontrol is needed, increase to 1 mg subcutaneously once weekly Lixisenatide / Adlyxin10 mcg subcutaneously once daily 60 minutes or less before a.m. meal for 14 days; Starting with day 15, increase to 20 mcg subcutaneously once daily 60 minutes or less prior to a.m. mealSGLT2 inhibitorsCanagliflozin / Invokana 100 mg or 300 mg by mouth once daily1–1.5%$$$? Positive CV effects? May support weight loss? Low hypoglycemia rates? Does not rely on insulin secretion or action for function? Requires normal kidney function? Possibility of UTI, female genital infections? Increased bladder cancer risk (dapagliflozin)? Increased amputation risk (canagliflozin)? Prescribe with caution to geriatric population? Renal function requirementsContraindicated for:? Severe renal impairment? End-stage renal diseaseDapagliflozin / Farxiga5 mg or 10 mg by mouth once dailyEmpagliflozin / Jardiance10 mg or 25 mg by mouth once dailyErtugliflozin / Steglatro5 mg by mouth once daily to start; up to 15 mg by mouth once daily if needed DPP-IV inhibitorsSitagliptin phosphate / Januvia100 mg by mouth once daily (as monotherapy OR combo therapy with metformin or glitazones0.5%$$$? Does not cause hypoglycemia? Effective in 1–2 weeks? Can take with or without eating? Weight neutral? Very mild glucose lowering? Renal dose adjustment for most agents ? Possible increase of heart failure hospitalizations? Possible risk of acute pancreatitis? Higher cost treatment optionSaxagliptin / Onglyza2.5 mg or 5 mg by mouth once dailyLinagliptin / Tradjenta5 mg by mouth once dailyAlogliptin / Nesina6.25–25 mg by mouth once dailySulfonyl-reas (SU)Glipizide LX / Glucotrol LX5 mg–20 mg per day (max) by mouth once or twice daily1–1.5%$? History of effectiveness? Maximum effect in 5–7 days? Tolerated well? Lower cost option? Increased risk of hypoglycemia ? Limited duration of effectiveness? Weight gain? Hypoglycemia? Potentially negative cardiac outcomes (glyburide)Glimepiride / Amaryl1 mg–8 mg (max) per day by mouth once or twice dailyGlyburide / Diabeta2.5–5 mg by mouth once daily w/a.m. mealThiazolid-inedionePioglitazone / Actos1%$$? Does not cause hypoglycemia? OK for metformin-intolerant patients? Fracture risk? Edema? weight gain* Maximum effect in 6–12 weeksContraindicated for: ? Fluid retention related to heart failure? Macular edemaDeprescribing: Values, Goals, ApproachesDeprescribing is an important component of avoiding polypharmacy. It includes discontinuing medications, finding alternative medications when side effects arise, and tapering medications. Deprescribing should be undertaken with an eye toward patient safety. In addition to avoiding polypharmacy, deprescribing may be undertaken:To address recurrent hypoglycemiaWhen patients have impaired renal functionWhen older patients have lost physical or cognitive ability to maintain a complex medication regimenWhen patients have limited life expectancyIn response to troublesome or harmful side effectsOther possible reasons for deprescribing include patient preferences in balancing glycemic control with treatment burden and cost.Deprescribing and PrescribingAs new hyperglycemic agents are added to combat glycemic load, it is appropriate to deprescribe other agents that are ineffective or redundant, or have adverse interactions with new agents. The preceding algorithm (IV-1) includes points at which medications should be discontinued as new options are introduced.Deprescribing and Older PatientsDeprescribing should always be considered for older patients, with the hyperglycemic agent time lapse between when the medication is administered to when it begins working weighed against possible liabilities, especially hypoglycemia.Dose Reduction and MonitoringDeprescribing should be undertaken gradually, incorporating in-office monitoring and home blood sugar testing. After a medication is reduced or discontinued, monitor patients daily for one to two weeks for:Evidence of hyperglycemia, including increased thirst, urination or tiredness; or measured hyperglycemia on home testingEvidence of hypoglycemiaEvidence that adverse effects of reduced or discontinued medication are being ameliorated(Changes in A1c will be delayed relative to other signs.)If patients display ongoing hypoglycemia, consider further reducing dose or deprescribing another medication. If patients demonstrate hyperglycemia, consider restoring the previous dose or trying another medication.Insulin DosingStarting InsulinIf the patient’s A1c target is not met within approximately three months of triple therapy, patient should be moved to basal insulin. Metformin therapy should be maintained. Consider deprescribing secondary and tertiary oral agents, or non-insulin injectables, unless there is clear evidence of efficacy. In following algorithm IV-2, the clinician should also consider renal function and risk of hypoglycemia.[Table IV-3 (with graphs)]Insulin Initiation Onset and Action (Use in Combination With Other Drugs) InsulinBrand NameInsulinTypeTiming Before MealsDuration (Hours)How SuppliedExpiration Once OpenedInsulin aspartFiaspUltra rapid-acting 2.5–5 min3–5 hrsVials28 daysPensInsulin lisproHumalogRapid-acting5–15 min3–6 hrsVialsPensInsulin aspartNovologRapid-acting5–15 min3–6 hrsVialsPensInsulin glulisineApidraRapid-acting5–15 min3–6 hrsVialsPensInsulin regularNovolin RHumulin RShort-acting30 min6–10 hrsVials OnlyNovolin R 42 daysHumulin R 31 daysInsulin aspart protamine & insulin aspartNovolog 70/30Combination< 15 min10–18 hrsVials28 daysPens14 daysInsulin lispro protamine & insulin lisproHumalog 75/25Humalog 50/50Combination< 15 min10–18 hrsVials28 daysPens10 daysInsulin NPHNovolin NHumulin NIntermediate -acting8-18 hrsVialsNovolin42 daysHumulin 14 daysPens (Humulin Only)14 daysInsulin detemirLevemirLong-actingNA14–24 hrsVials42 daysPensInsulin glargineLantus, Basaglar(100 units/mL)Long-acting22–24 hrsVials28 daysPensInsulin glargineToujeo(300 units/mL)Ultra long-acting> 24 hours (up to 36 hours)Pens only42 daysInsulin degludecTresiba (100 units/mL OR 200 units/mLUltra long-acting> 24 hours (up to 42 hours)Pens only56 daysInsulin Initiation and Titration Recommendations[Algorithm IV-2]Initiating Basal Insulin in Type 2 DiabetesA1c < 8%: start 0.1-0.2 units/kg A1c > 8%: start 0.2-0.3 units/kg Consider renal function and hypoglycemia risk Basal insulin Dose Titration Average fasting blood glucose for last 7 mornings Usual patient Fragile Patient > 180 mg/dl Add 6 units or 20%, whichever is greater Add 4 units or 10% 141-180 Add 4 units or 10%, whichever is greater Add 2 units 121-140 Add 2 units or 10%, whichever is greater No change 80-120 No change Decrease dose by 4 units or 10% Any hypoglycemia Dose reduction Dose reduction Fasting glucose 60-70 mg/dL Reduce by 10% Reduce by 15% Fasting glucose < 60 Reduce by 20% Reduce by 25% When targets still prove difficult to meet, introduce prandial insulin according to algorithm IV-3. Consider starting at the largest meal of the day. Start with 3–5 units per meal, depending on basal insulin dose: Also, consider basal dose reduction if basal dose is more than 0.5 units/kg and hyperglycemia is mild. Continue to take hypoglycemia and renal risk into consideration.[Algorithm IV-3]Initiating Prandial Insulin in Type 2 DiabetesConsider starting with largest meal of day vs all meals based on patient needsConsider starting 3-5 units per meal or more, depending on basal insulin dose.Consider basal dose reduction if the basal dose is > 0.5 units/kg and hyperglycemia is mildConsider renal function and hypoglycemia risk.Prandial Insulin Dose TitrationAverage 2–hour post meal OR next pre-meal glucose (may adjust every 2–3 days): Adjustment to prior prandial dose> 180 mg/dlIncrease dose by 10%141–180Increase dose by < 10%121–140Small adjustment or no change80–120No changeHypoglycemia Dose reduction Between meal glucose 60–70 mg/dL Reduce prior dose by 10–15% Between meal glucose < 60 Reduce prior by 20% or greater [Table IV-4]Social Determinants With Direct Impact on Glucose IndexFactorImpactsTherapeutic ConsiderationsFood insecurityEating inexpensive, high-carb foods; eating heavily in anticipation of having limited future access to foodHyperglycemia can occur from excessive carb intakeFood insecurityHaving no access to food; hoarding or meting out food in anticipation of having limited future access to foodHypoglycemia can result from inadequate carb intake when taking diabetes medications; consider medications less associated with hypoglycemiaHomelessness or inadequate housingLack of secure place to keep medications; lack of refrigerationInadequate or no medication adherenceFollowing the chronic care model, the ADA recommends supplementary care to lifestyle and medication therapies for patients in difficult circumstances. These include case management, educational resources and coordinated management by a care team consisting of a clinician, nurses, registered dietitian/nutritionist, diabetes educator, pharmacist, social worker and others. Patients experiencing social context challenges should be referred to local community resources, such as social workers, food pantries, churches and adult protective services. They may also draw on nonmedical health coaches and health system navigators when available.Since patients may not discuss their individual circumstances or larger social context unprompted, clinicians should systematically use validated tools to identify areas of concern with each patient. Educational materials should be available in patients’ native language, and if possible, multilingual diabetes educators or translators should be utilized.Remote consultations via telemedicine or e-consultation between care providers may allow clinicians to answer questions or provide support and guidance when the patient does not have easy access to a clinic. Such interventions have proven effective at helping patients in rural areas maintain glycemic control.Cost ManagementIt is appropriate to take cost of medical therapies into account when prescribing, in consultation with the patient. Depending on the patient’s insurance status and other factors, medication costs will differ from patient to patient. As patients move between jobs, become eligible for Medicare or go through other life changes, the cost for the same medication for the same patient may also change. An ongoing conversation about affordability of antihyperglycemics and other medications is always warranted. Response to a medication compliance survey, such as the ARMS-7, may provide a starting point to talk about costs.4191001270041910012700[Sidebar IV-1]Antihyperglycemics With Hypoglycemia RiskInsulin, especially regular and intermediate-actingSulfonylureasMeglitinidesOther drug interactions may contribute to hypoglycemia4191001270041910012700Working With an EndocrinologistWhile a primary care clinician can diagnose and treat most cases of type 2 diabetes successfully in collaboration with his or her chronic care team, certain clinical situations may warrant the involvement of an endocrinologist. Clinicians should consider referring patients to an endocrinologist when:LADA or type 1 diabetes is suspectedHyperglycemia persists despite medication dose increase and/or addition of second- and third-line antihyperglycemics to metforminPatient experiences relapse after successful disease managementPatient blood sugar is extremely labileHypoglycemia persists despite deprescribingPatients are receiving dialysis and having difficulty with glycemic controlPatients have steroid-induced hyperglycemia that is difficult to managePrimary care clinician desires to start an injectable therapy but does not have the resources to provide appropriate education in the officePatient may benefit from an insulin pump. See section V for comments on insulin pumps and continuous glucose monitors in type 2 diabetes.In addition, patients who are not responding to medication instructions and/or diabetes education may be referred to an endocrinologist to help the patient recognize the severity of their health situation and to hear a second perspective on management. For example, patients who frequently require an entire office visit focused on their diabetes may warrant referral to an endocrinologist. In general, if patients have not responded to medication therapy, including additional antihyperglycemics, within 12 to 18 months after diagnosis, referral should be considered.Once an endocrinologist has made recommendations and prescriptions, the primary care clinician can generally carry on his or her recommended treatment plan, consulting occasionally as needed. Particularly when patients have achieved their personalized glycemic control goals and are stable, endocrinologists should consider returning the patient to ongoing management by the primary care clinician. The primary care clinician and endocrinologist may elect to co-manage some patients, such as those with multiple diabetes-related hospitalizations or repeated loss of glycemic control. Continued endocrinologist care is appropriate for patients on insulin pumps or u500 insulin and for patients with multiple injection therapy who continue to require regular dose adjustments to maintain control.Patients sometimes relapse to poor control after initial improvement following consultation with an endocrinologist or other intervention. We recommend first assessing for adherence to the previously successful diet and medications. Using the ARMS-7 tool may help uncover non-adherence, and barriers such as medication costs can be explored. If resuming the previously successful regimen does not return the patient to goal control, re-consultation is appropriate.Where available, e-consultation may be appropriate for focused questions related to diabetes care, particularly for questions the clinician would consider asking as a “curbside” or to assist with co-management of a patient known to both providers. For example, if a patient has transitioned back to sole management by primary care but develops hypoglycemia, the primary care provider may consider an e-consultation from the endocrinologist to advise on medication adjustments. Clinicians caring for patients in rural areas in particular may find e-consultation with an endocrinologist useful in managing patients who would be challenged to travel to specialist visits.Peri-Procedural ManagementPeople with diabetes are at risk for hyperglycemia and hypoglycemia during hospital stays. Both conditions are associated with poor hospital outcomes. The ADA recommends that hospital care for patients with diabetes should have the goal of preventing complications and readmission while minimizing length of stay. Hospital management includes:All patients admitted with hyperglycemia should have an A1c test performed if they have not had one in the past three months.If new cases of diabetes are diagnosed, patients should learn self-care measures and receive initial medication orders in the hospital, along with referral for follow-up care.For persistent hyperglycemia, insulin therapy should be administered with a goal of glucose ranging from 140–180 mg/dL for most patients For patients who are not eating, the preferred approach is basal insulin or basal plus correction insulin.For patients who are eating, the preferred regimen is basal, mealtime and correction doses.A trained diabetes specialist or care team should be available for consultation.Glucose should be monitored before meals or every four to six hours for patients who are not eating. Patients on intravenous insulin should be monitored every half hour to two hours.Patients should also be monitored for hypoglycemia and treatment regimens altered when glucose levels of less than 70 mg/dL occur.To prevent hypoglycemia, medical and nutritional management should be integrated.Discharge planning should include:A tailored care planReferrals to the diabetes educator, primary care clinician or endocrinologist, with appointments scheduled before dischargePatient education about the condition, monitoring, self-care and any new medicationsMedication reconciliationFull patient records provided to primary care clinician and to next location of care (skilled nursing, etc.)Provision of sufficient medications and supplies (testing supplies, syringes, pen needles, etc.) until patient can meet with an outpatient clinicianDay of SurgeryBefore surgery, patients at risk for ischemic heart disease, autonomic neuropathy and/or renal failure should undergo a risk assessment. For periprocedural care for the patient with diabetes, the ADA recommends:Withholding metformin the day surgery is scheduledWithholding other antihyperglycemic agents except for a 60–80% of long-acting analog or pump basal insulinBlood glucose goal of between 80–180 mg/dL during the perioperative periodMonitoring of blood glucose four to six hours or more frequently during procedure; dose with rapid-acting insulin if neededTransitions of CareTransitions of care locations, especially transitions following acute hospital stays, provide opportunities for clinicians to review patient health status, prescriptions and abilities to ensure ongoing optimal care. Structured planning at discharge, tailored to meet individual patient needs, may leave patients with a clearer understanding of their health status, new medication regimen and any additional changes they need for their lifestyle or self-care practices. Gaps in Care TransitionsHospital admissions can be an opportunity to recognize and address poor glycemic control. However, one retrospective cohort study found that clinical inertia was present in 32% of admissions with A1c > 8%: These patients had no change made in therapy at discharge, no follow-up within 30 days, and no reassessment of A1c within 60 days.When adjustments are made at hospital discharge, timely communication to the outpatient provider is critical. If primary care clinicians do not receive information about medication adjustments made during their patients’ hospital visits, patients may be left to decide between at least two conflicting medication regimens after discharge from acute care stays.Medication Following Care TransitionMeasuring A1c at admission may help determine appropriate medication levels at discharge. In one study, the following medication adjustments (see table IV-5) were effective at managing A1c levels at 12 weeks post-discharge.[Table IV-5]Admission A1c levelDischarge therapy< 7%Preadmission diabetes therapy7–9 %Preadmission regimen plus glargine at 50% of hospital daily dose> 9%Oral antihyperglycemic agents plus glargine or basal bolus regimen at 80% of hospital dosePrinciples for Structured Discharge ManagementIn preparing structured discharge education and follow-up care for each patient, clinicians should take the following factors into account:Total health status. Consider the effects of other illnesses and medications on blood glucose levels. For example, infections and steroids may raise glucose and require more intense treatment temporarily. Changes in renal function may affect the metabolism of insulin and other medications.Medication continuity. Any patient going home on a new insulin should be instructed in its safe use, and all relevant supplies, including pen or syringe and testing tools, should be prescribed, along with the insulin checklist. Patients should leave the hospital with sufficient medication and supplies to last until they can access more; e.g., fill a prescription at a pharmacy.Patient and caregiver abilities. Consider patient capacity to take medications and monitor blood glucose levels. Patient capacity may changed due to acute care stay. Review any changes in health status and medication with the patient and their caregivers.Follow-up visit. At minimum, schedule a follow-up visit with the primary care clinician, endocrinologist, or diabetes educator within one month of discharge. However, if antihyperglycemic medications have changed or glycemic control is not optimal, schedule the follow-up appointment within one to two weeks after discharge. Also schedule the follow-up appointment within one to two weeks if health status is expected to change further; for instance, if the patient is overcoming an infection, going on dialysis or having non- antihyperglycemic medication changes.Transitions are also times to renew patient education about self-training and support. Patients may find themselves in settings with different food selections (for instance, they staying in a family member’s home or a long-term care facility) and need to review healthy food choices for that setting. A change in physical abilities may require review of injection techniques. Additionally, family caregivers may need diabetes education if they are providing more patient care. Consider scheduling an appointment with a diabetes educator if patient abilities or living situation or have changed following a care transition.Prevention and Management of Atherosclerotic Cardiovascular DiseasePatients with type 2 diabetes have increased risk for atherosclerotic cardiovascular disease (ASCVD). In fact, ASCVD is the most frequent cause of death for people with type 2 diabetes. The vectors of risk are twofold: diabetes often coexists with hypertension and high cholesterol, which are risk factors for ASCVD, and diabetes is in itself a risk factor for the condition. However, aggressively controlling ASCVD risk factors may help prevent or delay the condition in people with diabetes.Clinicians can help diabetes patients manage their risk of ASCVD by:Using a validated risk calculator, such as the American College of Cardiology’s ASCVD Risk Estimator Plus, to help people gauge and understand the severity of their risk.Measure blood pressure at each appointment.Set treatment goals for patients to manage their risk of ASCVD, including managing their blood glucose, keeping their blood pressure below 130/80, and managing cholesterol levels with statins.The lifestyle management guidance found in section III equally applies to patients with heightened risk of ASCVD: In addition, these patients should be encouraged to reduce sodium intake to less than 2,300 mg/day, increase potassium intake and increase physical activity.Patients with risk, history or symptoms of ASCVD also warrant medical management as outlined in algorithm IV-4.[Blurb]All persons with type 2 diabetes age 45–75 should be considered for statin therapy unless there is a contraindication, such as pregnancy or the ability to become pregnant (i.e. female and not on a reliable contraceptive). Statin use in type 2 diabetes is not dependent on lipid levels alone.Other Related ConditionsPatients with type 2 diabetes are also more likely to experience kidney disease, retinopathy, neuropathy and foot problems than the general population. Clinicians should routinely monitor for these conditions and refer patients to specialists when indicated.[V.] PATIENT EDUCATIONExcellent patient self-management education and support have the potential to improve patient outcomes, including feelings of well-being, efficacy at self-managing the condition and glucose control. A patient education baseline for people with type 2 diabetes includes:Helping patients understand the clinical aspect of their conditionHelping patients understand how to take medications correctly and why it is essential Nearly 25% of uncontrolled blood glucose issues, high blood pressure and high cholesterol are associated with medication adherence problems.Identifying lifestyle changes needed to improve disease managementTeaching patients how to set goals and solve problems in order to operationalize the medical understanding gained through diabetes educationBest Practices in Patient EducationTo achieve an excellent understanding and optimal management of their diabetes, patients should receive education and reinforcement from a number of sources. Clinicians, registered dietitian nutritionists, certified diabetes educators and community organizations are all sources for information and reinforcement for diabetes patients.Education and diabetes management coaching should be provided regularly, with office visits supplemented by community resources, if available. Numerous, efficient, diverse moments of education are supported over infrequent, lengthy or single-mode communication. The American Academy of Family Physicians suggests a high-touch model of patient contact, with weekly phone calls by a nurse manager and monthly calls by a clinician to support medication adherence and weight loss.At critical transitions, a patient’s need for education and support should be evaluated, and new self-management skills training added when necessary. The ADA recommends an evaluation of patient educational needs: At initial diagnosisWhen new or complicating factors like health conditions, physical limitations, emotional factors or basic living needs arise that affect the patient’s ability to self-manageAt transitions between care settingsAt least annually barring these eventsWhen possible, education should be provided in the patient’s native language and in an easy-to-navigate format. Multiple approaches are especially effective; patients should be encouraged to participate in face-to-face and technology-driven interactions, as well as educational meetings with support groups and classes.[Sidebar V-1]Insulin Pumps and Continuous Glucose MonitoringInsulin PumpsIt is rare for patients with type 2 diabetes to have a strong indication for insulin pump therapy. Patients should be referred to an endocrinologist when pump therapy is under consideration.Continuous Glucose Monitoring (CGM)While many patients find CGM technology appealing, there is not yet evidence to suggest that patients who are not adherent to blood sugar testing as recommended will be more adherent to proper use of CGM. To use CGM effectively, patients need to be trained in the use of the technology and pattern recognition. Additionally, a clinician who is prescribing the technology should be prepared to use the data to enhance patient care. The clinician should include ways to review data in the course of a visit and be comfortable with making recommendations based on patterns. Clinicians may meet this need by having trained personnel, such as a CDE, on the care team.While insurance criteria for approval may vary and include additional requirements, CGM may be appropriate in patients meeting the following criteria:Using two or more injections of insulin dailyTesting blood sugar four times per day (or, if physically unable to perform tests, demonstrate an interest in testing this frequently)Meeting at least one of the following conditions:Frequent hypoglycemia or hypoglycemia unawareness Suboptimal control with fluctuating glucose levelsPatient instructed and trained to adjust insulin dose based on data outputTraining in use of CGM by an experienced CDE or clinicianA number of continuous glucose monitors are available. Some CGM products provide a continuous display on a dedicated device or a patient’s smartphone or insulin pump while others require action by the patient to scan the device. Some CGM products include alarm features. The clinician should have a good understanding of CGM product capabilities before prescribing. Among currently available products, the Abbott Freestyle Libre system is less costly than the Dexcom system and should probably be favored for that reason, unless there is a need for alarm features.After an initial one- to three-month trial, consider the discontinuation of the CGM device prescription if the patient does not routinely adhere to the recommended scanning frequency.Type 2 Diabetes ResourcesVanderbilt Health Affiliated NetworksMy Insulin Pen GuideMy Insulin Guide These pamphlets cover where and how to inject insulin, as well as when to call a clinician about concerns or emergencies related to insulin and blood glucose.My Emergency PlanThis pamphlet covers planning ahead for being sick and unable to eat or take medications to control diabetes. When to call a diabetes care team member and 911 are also included.Taking Control of My DiabetesThis pamphlet covers ideas for setting and achieving healthy goals and provides a log to note weight, blood pressure, medication adherence, lab results and annual screenings and pneumonia vaccinations recommended for people with diabetes.PRIDE Interactive Teaching MaterialsThe PRIDE toolkit consists of a series of interactive diabetes education modules in English and Spanish. They are designed to help patients with low literacy and numeracy understand and manage their diabetes. Modules are illustrated with simple pictures and diagrams. The modules are arranged sequentially and intended to supplement conversations between patients and clinicians. PRIDE is available through the Vanderbilt University Medical Center online portal. Note: PRIDE tools are meant to be used by clinicians with patients.Other Approved MaterialsNational organizations, including the ADA, the American College of Cardiology/American Heart Association and the U. S. Department of Health and Human Services publish useful patient educational materials. Among our recommended resources are:American Association of Diabetes EducatorsThe American Association of Diabetes Educators website is full of easily-located patient-facing materials, including self-care documents about eating, exercising, monitoring, taking medications and problem-solving. The website is also geared to be used concurrently with face-to-face diabetes education.The website of the Family Caregiver Alliance, this site contains numerous educational materials for family caregivers, covering matters from estate planning to medication taking.Containing regularly updated dietary guidelines for Americans, this website uses the now-famous “four-sectioned plate” to succinctly illustrate nutrient balance and portion size. It also contains tip sheets, many in the form of vivid, printable infographics.The website of the ADA, this site contains a wide range of information conveyed in basic language, including a risk calculator, explanations of the disease, food and exercise advice, and materials tailored for specific age and cultural groups. There are also numerous how-to guides.The website of the Academy of Nutrition and Dietetics, this online destination provides a wealth of food-related information and instruction, including recipes, shopping, budgeting and reading food labels.National Diabetes Prevention ProgramThe National Diabetes Prevention Program (NDP) is an evidence-based prevention program for people at risk for diabetes. This CDC program site contains a mix of patient- and clinician-facing materials. Of interest are a risk calculator and links to guide the patient to participate in the NDPP either online or via local resources, often YMCAs. It takes several levels of clicks to get to actionable information, so a CDE or clinician may need to walk non-computer-savvy patients through the site the first time.Silver SneakersA health and fitness program for adults 65 and older, Silver Sneakers may be covered by Medicare Advantage. The website allows people to check their eligibility, locate classes or participate in exercise sessions via online instruction; however, the online instruction is paywalled.Tennessee Disability PathfinderA statewide database of social services, low-income medical clinics, recreational programs and other resources for disabled persons.Your Game Plan to Prevent Type 2 DiabetesA patient-facing site of the National Institute of Diabetes and Digestive and Kidney Disorders, this site contains information on goal-setting, diet, exercise and more.The following resource may be useful for patients with cost barriers to care:Applying for TennCare 1-800-318-2596Any Department of Health and Human Services office in Tennessee can help people apply and pick a plan.VI. APPENDICESAppendix APopulation Screening for Type 2 DiabetesBecause of the growing prevalence and cost burden of type 2 diabetes, the American Diabetes Association recommends population screening rather than case-by-case testing of symptomatic patients. While the recommendations in this care path guide may be tailored to meet individual patient needs, the overarching demand is for a systemic approach to identifying type 2 diabetes and for consistent, responsive care delivery systems ready to proactively identify and promptly begin care for each patient in a coordinated, team-based fashion. We follow the Chronic Care Model identified by the ADA as a proven, system-based framework for delivering high-quality diabetes care. The ADA provides more guidance on the appropriate patient population that should be screened but this is outside the scope of this specific care path.Appendix BGestational DiabetesDiabetes during pregnancy can result from existing type 1 or type 2 disease, or may first occur during pregnancy, in which case it is known as gestational diabetes. Any form of diabetes during pregnancy increases the risk of maternal and/or fetal death, miscarriage, birth defects, large fetal size, preeclampsia, neonatal hyperglycemia, and neonatal hyperbilirubinemia. Women who experience gestational diabetes are subsequently at greater risk for type 2 diabetes.All pregnant women without an existing diagnosis of diabetes should be tested for gestational diabetes at 24–28 weeks of gestation, using GDM-specific parameters for guidelines. Treatment for gestational diabetes includes blood glucose monitoring, with a goal of achieving fasting blood glucose of less than 95 mg/dL, one-hour postprandial blood glucose less than 140 mg/dL or two-hour postprandial blood glucose of less than 120 mg/dL, as well as A1c levels of less than 6%. Lifestyle changes should be recommended as treatment for women with gestational diabetes. Insulin may be prescribed to manage glucose levels; however, metformin should not be prescribed to pregnant women.Patients with existing prediabetes or type 2 diabetes who may become pregnant should be routinely counseled about the dangers of uncontrolled diabetes during pregnancy and the importance of self-care and tight glycemic control should they become pregnant. Family planning education is also important for these patients. Pregnant women with diabetes of any type should be managed by experienced providers, and management of GDM and pre-existing diabetes in pregnancy is outside the scope of this care path guide.Preconception and Pregnancy Blood Glucose GoalsPreconception (intending or attempting to conceive)Aim for tight control of less than 6.5% to reduce risk of preeclampsia and fetal abnormalitiesPregnancyGoal should be less than 6%, but may be relaxed to 7% if hypoglycemia occursPregnant patients with diabetes of any type should be managed by clinicians experienced in this areaAppendix CSpecial Considerations in Prescribing and DosingPatients with A1c Between 8.5 and 10A1c levels between 8.5% and 10% indicate that diabetes may not be well controlled. This can put patients at risk for microvascular complications and premature mortality. For these patients, the ADA recommends early introduction of insulin (see algorithm IV-1). Additionally, we recommend aiming to achieve control with a smaller number of drugs and choosing those more likely to be effective in this stage; please see algorithm. Using a smaller number of effective drugs, and discontinuing those not providing benefit when the entire regimen is viewed as a whole is cost effective, reduces polypharmacy and conceivably increases may increase patient satisfaction. Frail and Vulnerable PatientsDiabetes is a risk factor for frailty, and frail patients may have difficulty with blood glucose monitoring and medication management. Additionally, these patients may be at risk for hypoglycemia and benefit from less stringent goals.Other patients , while more physically robust, may have other areas of vulnerability, such as a lack of medication access, barriers to keeping refrigerated medications, difficulty manipulating medication containers or syringes, and/or cognitive disabilities or dementia. It is important to take patient circumstances into account when prescribing type 2 diabetes medications. Circumstances or social context includes such factors as regular access to a healthful diet, access to stable housing and reliable transportation, and language and financial barriers to care.Social determinants of health with direct impact on glycemic control include those outlined in table IV-4.Appendix DFoot CarePatients with type 2 diabetes often experience foot problems, ranging from peripheral neuropathy, peripheral vascular disease and poor wound healing. Since patients may lack sensation and proprioceptive sense, foot care should focus on avoiding injuries that could lead to ulcers or other long-term wounds. Patients should be encouraged to have their feet examined regularly by their clinician and should also inspect their own feet daily, as well as observe good foot safety and hygiene measures.Foot exams include:Check for problems, such as cuts, ulcers, open or slow healing wounds, redness or swelling.Assessment for neuropathy (burning, pain, numbness)Assessment for vascular disease (claudication or fatigue in the legs)Skin inspectionAssessment for deformitiesNeurological screening, including microfilament test and another measure, such as pinprick testVascular assessmentAdditionally, the clinician should take a history of foot problems and related conditions, including angioplasty or vascular surgery, amputation, Charcot foot, prior ulcers, renal disease, retinopathy and smoking. Instruct patient about how to maintain and monitor foot health.Foot maintenance and protection for patientsDo not use feet to check for hot pavement, bathwater, etc.Avoid going barefoot.Do not cut off corns or calluses—file carefully if needed.Cut nails straight across rather than crescents.Wear soft, deep shoes that are sufficiently wide.Wear specially designed diabetic footwear if ulcers or deformities are present.Check feet daily for cuts, ulcers, open or slow-healing wounds, redness, swelling. Wear white socks to help identify foot bleeding or drainage. Inspect underside of foot with handheld mirror placed on the floor if a direct view is inaccessible.Insurance may cover routine nail care for patients with neuropathy or peripheral vascular disease. Patients with open ulcers or wounds should be urgently referred to a podiatrist or other appropriate specialist.Appendix E Care Team RolesThe chronic care model is a patient-centric approach to healthcare, acknowledging the patient will need ongoing care. The chronic care model has proven effective at managing patients with diabetes. A team-based approach helps ensure patients with diabetes receive treatment, monitoring, disease management education, reassurance, referrals, resources and support. While not every care team will have all the members listed below, each member of the team should have a clearly defined function, while all members should coordinate to enable and sustain patient self-management.Primary care clinician. Clinicians diagnose the condition and prescribe medication and other treatment. They are also the primary point of contact to help with patient goal-setting and delegate to the other team members so those goals are met. The clinician investigates new clinical issues that arise and provides modified treatment plans.Registered nurse. Nurses help with monitoring blood sugar and other important metrics. They follow up with patients about medications and progress toward goals. They also coordinate care between the primary care clinician and the rest of the team.Medical assistant. Medical assistants schedule appointments, follow up on missed appointments and makes routine referrals. They take patient vitals and record data.Registered dietitian nutritionist. Registered dietitian nutritionists work with each patient to complete a medical nutrition therapy plan. They help the patient with behavioral management strategies to achieve nutritional and weight-loss goals. Patients are advised to visit an RDN once upon diagnosis of type 2 diabetes, approximately bimonthly for six months following and annually thereafter. The services of an RDN for people diagnosed with diabetes are covered by Medicare Parts A and B. MNT is covered at no cost, while 10 hours of DSME over the course of one year are covered at 20% of Medicare approved amount; Part B deductible applies.Certified diabetes educator. CDEs provide patients with detailed information about the disease and treatment goals. They answer questions and spend time with patients, going over glucose readings, identifying pattern recognition and helping patients create personal eating and medication schedules. The CDE’s role also includes aspects of a health navigator by putting patients in touch with services that can be beneficial in the healthcare network and across the community. CDEs increase patient comfort levels in managing and living with type 2 diabetes. Utilization of CDEs in a care team may reduce patient A1c levels by 0.2–0.8%. Typically, patients are referred to a CDE at first diagnosis and again at certain thresholds, such as when their A1c levels pass 8%. If the patient’s insurance will cover two visits on the same day, it may be helpful to see the CDE the same day as the clinician in order to reinforce information.Endocrinologist. Endocrinologists provide diagnosis and treatment plans for patients suspected of having LADA or type 1 diabetes. For patients with type 2 diabetes, the endocrinologist helps resolve challenging clinical situations and consults with the primary care clinician about medication prescribing, dosing and deprescribing. Some type 2 patients, particularly those on multiple-dose insulin therapy and those with other medical or lifestyle concerns that create lability in diabetes control, may need to be co-managed by endocrinologists over the long term. However, we recommend that stable, well-controlled patients primarily managed by non-insulin medications be regularly reassessed for potential return to primary care. Indications for referral to an endocrinologist are listed in section IV.Pharmacist. Pharmacists help provide patient education on treatment options, specifically medications, and reinforce proper understanding of the prescribed treatment. This typically involves an assessment of the plan to ensure proper indication, effectiveness, safety and accessibility of the prescribed medicine(s). The pharmacist can also assist in teaching patients how to use medical devices (i.e. glucometers) and medication in general (i.e. insulin or other injectables). Community experts. While not part of the formal medical care team, community resources may be cultivated as regular partners in patient care and well-being. Among these, individuals—such as fitness coaches and social workers—and organizations—such as YMCA, Silver Sneakers groups and Overeaters Anonymous—may provide additional support and fellowship for the patient. Appendix FCaregiver SupportWhen patients are especially frail, family members or other caregivers may in essence take on many of the patient roles—listening to and understanding information, making sure clinician instructions are followed and monitoring patient progress. This can be burdensome for caregivers. However, since families undertake a lion’s share of chronic care—providing 80% of the long-term care provided in the U.S.—it is important to include caregivers as part of the care delivery team, keeping them informed and also ensuring their own health is not compromised in the caregiving process.Clinicians can include family caregivers in the caregiving process by:Providing them with the same scheduling, medication and educational information patients receive, including the pathophysiology of type 2 diabetesProviding instruction about best practices for helping the patient avoid disease complications (medication adherence, home foot inspections, etc.) Helping them understand the symptoms that may warrant scheduling a clinician’s appointment or visiting the emergency roomHelping them understand how to identify low blood sugar in patients who may be unaware of it through timing of blood glucose testing and how to interpret resultsAssisting them in creating a plan to enhance diabetes management of their loved oneGuiding them to community caregiving resourcesWith permission, collaborating with the caregiver’s primary care clinician to ensure caregiving stresses are recognized and managedTo increase positive results, caregivers of the elderly can be directed to local supportive services, such as Tennessee Area Agencies on Aging/Disability. The Family Caregiving Alliance has detailed information and educational materials for caregivers in a variety of circumstances. Of particular importance are information about:Medical visits: How caregivers can talk with physicians about patient medicationsLocating community resources to help with caregivingAdvanced illness: DNR and end-of-life planning[VII. REFERENCES - WIP]Editor’s note: The reference section is a work in progress using keyed footnotes and will remain so until the editorial is finalized. At that time, the footnotes will be compiled as endnote citations, and the references will be consolidated.Section I ReferencesCenters for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion. National diabetes statistics report, 2017. diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed February 25, 2019.[CDC-1]American Diabetes Association. Introduction: Standards of Medical Care in Diabetes—2019. Diabetes Care 2019;42 (Suppl. 1):S1–S2. doi: org/10.2337/dc19-SINT01.[ADA-1]American Diabetes Association. Economic costs of diabetes in the U.S. in 2017. Diabetes Care 2018 Mar. doi: org/10.2337/dci18-0007.[ADA-2]Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion. National diabetes statistics report, 2017. diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed February 25, 2019.[CDC-2]Centers for Disease Control and Prevention CDC Newsroom. Number of Americans with diabetes projected to double or triple by 2050. . Accessed March 5, 2019.[CDC-3]Centers for Disease Control and Prevention. Diabetes state burden toolkit. . Published 2013. Accessed February 25, 2019.[CDC-4]Artiga S, Damico A. Health and health coverage in the South: A data update. Henry J. Kaiser Family Foundation Kaiser Commission. Kaiser Commission on Medicaid and the Uninsured. . Accessed February 25, 2019.[ArtigaS]American Diabetes Association (2018). The burden of diabetes in Alabama. . Accessed February 25, 2019.[ADA-3] American Diabetes Association (2018). The burden of diabetes in Mississippi. . Accessed February 25, 2019.[ADA-4]American Diabetes Association. Economic costs of diabetes in the U.S. in 2017. DiabetesCare 2018;41:917–928. doi: org/10.2337/dci18-0007. [ADA-5]American Diabetes Association (2018). The burden of diabetes in North Carolina. . Accessed February 25, 2019.[ADA-6]Hall MJ, Rui P, Schwartzman A. Emergency department visits by patients aged 45 and over with diabetes: United States, 2015. NCHS Data Brief, no 301. Hyattsville, MD: National Center for Health Statistics. February 2018. Int J Emerg Med. 2017; 10: 23. nchs/data/databriefs/db301.pdf.[HallMJ]Li R, Zhang P, Barker LE, Chowdhury FM, Zhang X. Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review. Diabetes Care 2010;33:1872–1894. 10.2337/dc10-0843. Cited by: Diabetes Care 2019;42(Suppl. 1):S1–S2. doi: org/10.2337/dc19-SINT01.[LiR]McEwen LN, Casagrande SS, Kuo S, Herman WH. Why Are Diabetes Medications So Expensive and What Can Be Done to Control Their Cost? Curr Diab Rep. 2017 Sep;17(9):71. doi: 10.1007/s11892-017-0893-0.[McEwenLN]McGuire B, Morrison T, Hermanns N et al. Short-form measures of diabetes-related emotional distress: the Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia 2010 Jan;53(66). doi: 10.1007/s00125-009-1559-5.[McGuireB]Ostling S, Wyckoff J, Ciarkowski S. The relationship between diabetes mellitus and 30-day readmission rates. Clinical Diabetes and Endocrinology 2017 Mar;3(3). doi: 10.1186/s40842-016-0040-x.[OstlingS]Stellefson M, Dipnarine K, Stopka C. The Chronic Care Model and diabetes managementin US primary care settings: a systematic review. Prev Chronic Dis 2013;10:E26. Cited by: Diabetes Care 2019;42(Suppl. 1):S1–S2. doi: org/10.2337/dc19-SINT01.[StellefsonM]Beverly E, Ivanov N, Court A et al. Is diabetes distress on your radar screen? Clinician Reviews. 2017 June;27(6):30-31,34-37. Accessed April 2, 2019. clinicianreviews/article/138722/diabetes/diabetes-distress-your-radar-screen.[BeverlyE]Mayberry L, Gonzalez J, Wallston K et al. The ARMS-D outperforms the SDSCA, but both are reliable, valid, and predict glycemic control. Diabetes Res Clin Pract. 2013 Nov; 102(2): 96–104.doi: 10.1016/j.diabres.2013.09.010.[MayberryL]Wolff K, Chambers L, Bumol, S et al. The PRIDE (partnership to improve diabetes education) toolkit. Diabetes Educ. 2016 Feb; 42(1): 23-33. doi: 10.1177/0145721715620019[WolffK]James B, Poulsen G. The Case for Capitation. Harvard Business Review. July–August 2016. . Accessed April 24, 2019.[JamesB - 22 (diabetes)]Dieleman JL, Baral R, Birger M, et al. US spending on personal health care and public health, 1996–2013. JAMA. 2016;316(24):2627–2646. [DielmanJL - 23 (diabetes)]Arnett et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, , Accessed May 9, 2019. [AHA-Arnett, et al.]Section II ReferencesAmerican Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. | .[ADA-DC]American Diabetes Association. Type 2 diabetes risk test. Adapted from Bang et al., Ann Intern Med 151:775–783, 2009. . Accessed February 28, 2019.[ADA-T2]Knowler WC, Barrett-Connor E, Fowler SE, et al.; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403. Cited by: American Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. .[KnowlerWC]National Institute of Diabetes and Digestive and Kidney Diseases Health Information Center. Your game plant to prevent prediabetes. . Accessed March 12, 2019.[NIDDKD-HIC]Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care 2002;25:2165–2171. Cited by: American Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. .[DPP-RG]Delahanty LM1, Nathan DM. Implications of the diabetes prevention program and Look AHEAD clinical trials for lifestyle interventions. J Am Diet Assoc. 2008 Apr;108(4 Suppl 1):S66-72. doi: 10.1016/j.jada.2008.01.026.[Delahanty]Ley SH, Hamdy O, Mohan V, Hu FB. Prevention and management of type 2 diabetes: dietary components and nutritional strategies. Lancet 2014;383:1999–2007. Cited by: American Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. .[LeySH]Thorp AA, Kingwell BA, Sethi P, Hammond L, Owen N, Dunstan DW. Alternating bouts of sitting and standing attenuate postprandial glucose responses. Med Sci Sports Exerc 2014;46: 2053–206. Cited by: American Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. .[ThorpAA]Riebe D, Franklin BA, Thompson PD et al. Updating ACSM’s recommendations for exercise preparticipation health screening. Med Sci Sports Exerc. 2015 Nov;47(11):2473-9. doi: 10.1249/MSS.0000000000000664.[RiebeD]Yeh H-C, Duncan BB, Schmidt MI, Wang N-Y, Brancati FL. Smoking, smoking cessation, and risk for type 2 diabetes mellitus: a cohort study. Ann Intern Med 2010;152:10–17. Cited by: American Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. .[YehH-C]Butcher MK, Vanderwood KK, Hall TO, Gohdes D, Helgerson SD, Harwell TS. Capacity of diabetes education programs to provide both diabetes self-management education and to implement diabetes prevention services. J Public Health Manag Pract 2011;17:242–247. Cited by: American Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. .[ButcherMK]Zhang X, Gregg EW, Williamson DF, et al. A1c level and future risk of diabetes: a systematic review. Diabetes Care 2010;33:1665–1673. Cited by: American Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. .[ZhangX]Section III References2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Washington, DC, U.S. Department of Health and Human Services, 2018. Cited by: American Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. . [PE Guide]The American Academy of Family Physicians. Lifestyle changes to manage type 2 diabetes. Am Fam Physician. 2009 Jan 1;79(1):42. Accessed March 13, 2019. [AAFP]American Diabetes Association. Standards of Medical Care in Diabetes—2019. Diabetes Care 2019;42 (Suppl. 1):S1–S2. . [ADA]Briggs Early K, Stanley K. Position of the Academy of Nutrition and Dietetics: the role ofmedical nutrition therapy and registered dietitian nutritionists in the prevention and treatmentof prediabetes and type 2 diabetes. J Acad Nutr Diet 2018;118:343–353. Cited by: American Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. . [Briggs]Dempsey PC, Larsen RN, Sethi P, et al. Benefits for type 2 diabetes of interrupting prolonged sitting with brief bouts of light walking or simple resistance activities. Diabetes Care 2016;39:964–972. Cited by: American Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. . [Dempsey]Dobson J, McMillan J, and Li L. Benefits of exercise intervention in reducing neuropathic pain. Front Cell Neurosci. 2014; 8: 102. doi: 10.3389/fncel.2014.00102.[Dobson]Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 2014;37(Suppl. 1):S120–S143. Cited by: American Diabetes Association. Diabetes Care 2019;42,(Suppl. 1):S1–S2. .[Evert]Foundation for Peripheral Neuropathy (2016). Exercise + physical therapy for neuropathy. Accessed March 13, 2019 at . [Peripheral]Lyon R, Slawson J. An organized approach to chronic disease care. Fam Pract Manag. 2011 May-June;18(3):27-31. Accessed March 15, 2019 at . [Lyon]Pippitt K, Li M, and Gurgle, H. Diabetes Mellitus: Screening and Diagnosis. Am Fam Physician. 2016 Jan 15;93(2):103-109. Accessed March 7, 2019 at . [Pippitt]Stellefson M, Dipnarine K, Stopka C. The Chronic Care Model and diabetes managementin US primary care settings: a systematic review. Prev Chronic Dis 2013;10:E26. Cited by: Diabetes Care 2019;42(Suppl. 1):S1–S2 | . [Stellefson]Streckmann F, Zopf EM, Lehmann HC. Exercise intervention studies in patients with peripheral neuropathy: a systematic review. Sports Med. 2014 Sep;44(9):1289-304. doi: 10.1007/s40279-014-0207-5. [Streckmann]United States Department of Agriculture. Choose MyPlate. Accessed March 14, 2019 at . [MyPlate]Section IV ReferencesAmerican Academy of Family Physicians. Type 2 diabetes mellitus: ACP releases updated guidance statement on a1c targets for pharmacologic glycemic control. Am Fam Physician. 2018 Nov 1;98(9):613-614. Accessed on March 19, 2019 at . [ACP]American College of Cardiology. ASCVD risk estimator plus. Accessed March 25, 2019 at . [Risk Estimator]American Diabetes Association. Standards of Medical Care in Diabetes—2019. Diabetes Care 2019;42 (Suppl. 1):S1–S2. . [ADA]Farrell B, Black C, Thompson W et al. Deprescribing antihyperglycemic agents in older persons: evidence-based clinical practice guideline. Can Fam Physician 2017;63:832-43. [Deprescribing]Faruque LI, Wiebe N, Ehteshami-Afshar A, et al.; Alberta Kidney Disease Network. Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials. CMAJ 2017;189:E341–E364. Cited in American Diabetes Association. Standards of Medical Care in Diabetes—2019. Diabetes Care 2019;42 (Suppl. 1):S1–S2. . [Faruque]Griffith M, Boord J, Eden S, Matheny M. Clinical inertia of discharge planning among patients with poorly controlled diabetes mellitus. J Clin. Endocrinol. Metabl. 201 Jun;97(6):2019-26. Doi: 10.1210/jc.2011-3216. [Griffith]Umpierrez G, Reyes D, Smiley D et al. Hospital discharge algorithm based on admission HbA1c for the management of patients with type 2 diabetes. Diabetes Care. 2014 Nov;37(11):2934-9. Doi: 10.2337/dc14-0479. [Umpierrez]Vander Veen B. Personal conversation on March 18, 2019. [Vander Veen]Abrahamson MJ., J.I.Barzilay, L.Blonde, et al. AACE/ACE Comprehensive Diabetes Management Algorithm. Endocrine Practice 2015; 2(4) e7.[Abrahamson]*Partners Health Care: Partners Guidelines for the Treatment of Type 2 Diabetes in the Non-Pregnant Adult, 2012. Available at . Accessed 9/14/17 [Partners Health Care]**From Dr. Griffith’s workSection V ReferencesAcademy of Nutrition and Dietetics. How an RDN can help with diabetes. 2018 Oct 1. Accessed on March 28, 2019. . [RDN]American Diabetes Association. Standards of Medical Care in Diabetes—2019. Diabetes Care 2019;42 (Suppl. 1):S1–S2. 10.2337/dc19-SINT01. [ADA]Centers for Medicare and Medicaid Services. Decision memo for intensive behavioral therapy for obesity (CAG-00423N). Accessed April 1, 2019. ;. [CMS]Family Caregiver Alliance National Center on Caregiving. Accessed March 23, 2019. [Caregiver]Herron, Jessica. Personal conversation. March 18, 2019. [Herron]Lyon C, Fields H, Langner S. Diabetes education and glycemic control. Am Fam Physician. 2018 Feb 15;97(4):269-270. Accessed March 28, 2019. . [Lyon]Raebel MA, Schmittdiel J, Karter AJ, Konieczny JL, Steiner JF. Standardizing terminology and definitions of medication adherence and persistence in research employing electronic databases. Med Care 2013;51(Suppl. 3):S11–S21 Cited in American Diabetes Association. Standards of Medical Care in Diabetes—2019. Diabetes Care 2019;42 (Suppl. 1):S1–S2. 10.2337/dc19-SINT01. [Raebel]Tennessee Commission on Aging and Disability. Tennessee area agencies on aging and disability. Accessed on March 24, 2019. . [TN]Thoesen Coleman M, Newton K. Supporting self-management in patients with chronic illness. Am Fam Physician. 2005 Oct 15;72(8):1503-1510. Accessed March 28, 2019. . [Thoesen] ................
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