DM Management

Question 1

Diabetes Self-management Education and Support

Answer 1

-All should participate in diabetes self-management education and support -> for knowledge, decision-making, and skills mastery for diabetes self-care
-Clinical outcomes, health status, and well-being are key goals of self-management education and support -> should be measured as part of routine care
-should be person-centered, may be offered in group or individual settings, and should be communicated with the entire diabetes care team
-Digital coaching and digital self-management interventions
-Reimbursement by 3rd party payers is recommended because self-management education and support can improve outcomes and reduce costs
-Identify and address barriers at the health system, payer, health care professional, and individual levels
-Include social determinants of health of the target population with the ultimate goal of health equity across all populations
-Consider addressing barriers to access through telehealth delivery of care

Question 2

4 critical time points for DSMES should be evaluated

Answer 2

-1. At diagnosis
-2. Annually and/or when not meeting treatment targets
-3. When complicating factors (health conditions, physical limitations, emotional factors, or basic living needs) develop that influence self-management
-4. When transitions in life and care occur

Question 3

goals of nutrition therapy for adults with diabetes

Answer 3

-1. promote healthy eating patterns, emphasizing nutrient-dense foods in appropriate portion
-achieve and maintain body weight goals
attain individualized glycemic, BP, and lipid goals
-delay or prevent complications of diabetes
-2. address individual nutrition needs based on personal and cultural preferences, health literacy, access to healthy foods, willingness and ability to make changes, and existing barriers to change
-3. maintain pleasure of eating by being nonjudgmental about food choices while limiting choices only when indicated by scientific evidence
-4. provide tools for developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods

Question 4

physical activity

Answer 4

-Children and adolescents with type 1 or 2 or prediabetes- 60 min/day or more of moderate- or vigorous-intensity aerobic activity, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days/week
-Most adults with type 1 or 2 diabetes- 150 min or more of moderate- to vigorous-intensity aerobic activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity
-Shorter durations (minimum 75 min/week) of vigorous-intensity or interval training may be sufficient for younger adult and more physically fit individuals
-Adults with type 1 and type 2 -> 2–3 sessions/week of resistance exercise on nonconsecutive days
-All adults, and particularly those with type 2 diabetes -> decrease amount of time spent in daily sedentary behavior -> Prolonged sitting should be interrupted every 30 min for blood glucose benefits
-Flexibility training and balance training are recommended 2–3 times/week for older adults with diabetes -> Yoga and tai chi increase flexibility, muscular strength, and balance
-Evaluate baseline physical activity and sedentary time
-Promote increase in non sedentary activities above baseline for sedentary individuals with type 1 and type 2
-ex- walking, yoga, housework, gardening, swimming, and dancing.

Question 5

smoking cessation: tobacco and e-cigs

Answer 5

-Advise all pts not to use cigarettes, tobacco, or e-cigarettes
-After identification of tobacco or e-cigarette use, include smoking cessation counseling and other forms of tx as a routine care
-address smoking cessation as part of diabetes education programs for those in need

Question 6

supporting positive health behaviors

Answer 6

-Behavioral strat should be used to support diabetes self-management and engagement in health behaviors (e.g., taking medications, using diabetes technologies, physical activity, healthy eating) to promote optimal diabetes health outcomes

Question 7

psychosocial care

Answer 7

-should be provided to all with diabetes
-goal of optimizing health-related quality of life and health outcomes
-care is integrated with routine medical care and delivered by trained professionals using collaborative, person-centered, culturally informed approach
-When indicated professionals provide targeted mental health care
-psychosocial screening protocols may include -> attitudes about diabetes, expectations, mood, stress and/or quality of life, available resources (financial, social, family, and emotional), and/or psychiatric history
-periodic screening intervals and when there is change in disease, tx, or life circumstances
-When indicated, refer to mental health for further assessment and tx for diabetes distress, depression, suicidality, anxiety, treatment-related fear of hypoglycemia, disordered eating, and/or cognitive capacities
-should use age-appropriate standardized and validated tools and treatment approaches
-Consider screening older adults (aged ≥65 years) with diabetes for cognitive impairment, frailty, and depressive symptoms -> Monitoring of cognitive capacity (decision-making regarding treatment plan behaviors)

Question 8

diabetes distress

Answer 8

-Routinely monitor pts with diabetes, caregivers, and family members for diabetes distress
-especially when tx targets are not met and/or at onset of complications
-Refer to mental health professional for further assessment and tx if indicated
-Screen for anxiety, depression, serious mental illness, and Cognitive Capacity/Impairment

Question 9

sleep health

Answer 9

-Consider screening including symptoms of sleep disorders, disruptions to sleep due to diabetes symptoms or management needs, and worries about sleep
-Refer to sleep medicine as indicated

Question 10

glycemic assessment

Answer 10

-Assess glycemic status (A1C or other glycemic measurement such as time in range or glucose management indicator) at least 2x a year in pts who are meeting tx goals (and who have stable glycemic control)
-Assess glycemic status at least quarterly and as needed in pts that tx has changed and/or not meeting glycemic goals

Question 11

standardized CGM metrics

Answer 11

-number of days CGM is worn (recommended 14 days)
-% of time CGM is active (recommend 70% od data from 14 days)
-mean glucose
-glucose management indicator
-glycemic variability (%CV) target <=36*
-TAR: % of readings and time > 250 - LEVEL 2 hyperglycemia
-TAR: % of readings and time 181-250- LEVEL 1 hyperglycemia
-TIR: % of readings and time 70-180- IN RANGE
-TBR: % of readings and time 54-69- LEVEL 1 hypoglycemia
-TBR: % of readings and time < 54- LEVEL 2 hypoglycemia

Question 12

glucose assessment by continuous glucose monitoring

Answer 12

-Standardized, single-page glucose reports from continuous glucose monitoring (CGM) devices with visual cues, such as the ambulatory glucose profile, should be considered as a standard summary for all CGM devices
-Time in range is associated with the risk of microvascular complications and can be used for assessment of glycemic control
-time below range and time above range are parameters for eval of tx plan

Question 13

glycemic goals

Answer 13

-A1C goal (nonpregnant) adults of <7% w/o significant hypoglycemia is appropriate
-If using ambulatory glucose profile/glucose management indicator -> time in range of >70% with time below range <4% and time <54 mg/dL <1%
-For those with frailty or at high risk of hypoglycemia -> target of >50% time in range with <1% time below range is recommended
-A1C levels lower than goal of 7% may be acceptable or beneficial if achieved safely w/o significant hypoglycemia or SE (at pts and providers preference)
-Less stringent A1C goals (such as <8%) may be appropriate for pts with limited life expectancy or if tx harm is greater than benefits
-consider deintensification of therapy if appropriate to reduce risk of hypoglycemia in pts with inappropriate stringent A1C targets
-Reassess glycemic targets based on individualized criteria
-Reassess Setting a glycemic goal during consultations is likely to improve pt outcomes

Question 14

glycemic recommendation for nonpregnant adults

Answer 14

-A1c <7
-preprandial capillary plasma glucose- 80-130
-peak postprandial capillary plasma glucose- <180

Question 15

hypoglycemia

Answer 15

-Occurrence and risk reviewed at every encounter and investigated as indicated
-Awareness of hypoglycemia considered using validated tools
-Glucose (approximately 15–20 g) is preferred tx for conscious individual with blood glucose <70 mg/dL -> although any carb that contains glucose may be used
-15 mins after tx, if blood glucose monitoring (BGM) shows continued hypoglycemia -> tx should be repeated
-Once BGM or glucose pattern is trending up -> pt should consume a meal or snack to prevent recurrence of hypoglycemia
-Glucagon should be prescribed for all pts at increased risk of level 2 or 3 hypoglycemia (just in case)
-Caregivers, school, or family providing support should know where it is, when and how to administer it
-Glucagon administration is NOT limited to health care
-Hypoglycemia unawareness or 1 or more episodes of level 3 hypoglycemia -> give hypoglycemia avoidance education and reevaluation and adjustment of tx
-Insulin-treated pts with hypoglycemia unawareness, 1 level 3 hypoglycemic event, or a pattern of unexplained level 2 hypoglycemia should be advised to raise their glycemic targets to avoid hypoglycemia for at least several weeks to partially reverse hypoglycemia unawareness and reduce risk of future episodes
-Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by clinician, pt, and caregivers if impaired or declining cognition is found

Question 16

classification of hypoglycemia

Answer 16

-level 1- glucose < 70 and >=54
-level 2- glucose <54
-level 3- severe event characterized by AMS and/or physical status requiring assistance for tx of hypoglycemia

Question 17

obesity assessment

Answer 17

-Use person-centered, nonjudgmental language -> collaboration
-person-first language (“person with obesity” rather than “obese person”)
-ht and wt and calculate BMI at annuals or more frequently -> Assess trajectory to inform tx
-Based on clinical considerations (comorbid HF or significant unexplained weight gain or loss -> weight may need to be monitored and eval more frequently)
-If deterioration of health is assoc with weight gain or loss -> inpatient eval should be considered -> especially focused on assoc between medication use, food intake, and glycemic status
-overweight/obese pts may benefit from modest or larger wt loss
-small weight loss (approx 3–7% of baseline weight) improves glycemia and other intermediate cardiovascular risk*
-Larger, sustained weight losses (>10%) usually confer greater benefits -> disease-modifying effects and possible remission of type 2 diabetes, and may improve long-term cardiovascular outcomes and mortality

Question 18

nutritional, physical activity, and behavioral therapy

Answer 18

-achieve and maintain ≥5% wt loss -> recommended for most people with type 2 diabetes and overweight/obesity
-wt loss results in further improvements in management of diabetes and cardiovascular risk
-interventions should include high frequency of counseling (≥16 sessions in 6 months) and focus on nutrition changes, physical activity, and behavioral strats to achieve a 500–750 kcal/day energy deficit
-pts preferences, motivation, and life circumstances should be considered, along with medical status, when wt loss interventions are recommended
-Behavioral changes that create energy deficit, regardless of macronutrient composition, will result in weight loss
-Nutrition recommendations should be individualized to pts preferences and nutritional needs
-Eval systemic, structural, and socioeconomic factors that may impact nutrition patterns and food choices -> food insecurity and hunger, access to options, cultural circumstances, and social determinants of health
-pts who achieve wt loss goals, long-term (≥1 year) -> wt maintenance programs are recommended
-programs should provide monthly contact and support, recommend ongoing monitoring of body weight (weekly or more frequently) and other self-monitoring strategies, and encourage regular physical activity (200– 300 min/week)
-Short-term nutrition intervention using structured, very-low-calorie meals (800–1,000 kcal/day) may be prescribed for carefully selected pts with close monitoring -> Long-term, comprehensive weight maintenance strategies and counseling should be integrated to maintain wt loss
-no clear evidence that nutrition supplements are effective for wt loss

Question 19

pharmacotherapy

Answer 19

-when choosing meds for type 2 -> consider meds effect on weight
-minimize meds for comorbid conditions that are associated with wt gain if you can
-Obesity pharmacotherapy is effective as an adjunct to nutrition, physical activity, and behavioral counseling for selected people with type 2 diabetes and BMI ≥27 kg/m2
-Potential benefits and risks must be considered
-If obesity pharmacotherapy is effective (typically defined as ≥5% weight loss after 3 months’ use) -> further wt loss is likely with continued use
-When early response is insufficient (typically <5% weight loss after 3 months’ use) or if significant safety or tolerability issues -> consider d/c of meds and evaluate alternative meds or tx approaches

Question 20

metabolic surgery

Answer 20

-should be recommended option to treat type 2 diabetes in screened surgical candidates with BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asian American individuals) and in adults with BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian American individuals) who dont achieve wt loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods
-CONSIDER as an option to treat type 2 diabetes in adults with BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian American individuals) who do not achieve durable wt loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods
-performed in high-volume centers with multidisciplinary teams knowledgeable about and experienced in managing obesity, diabetes, and GI surgery
-pts being considered should be evaluated for comorbid psychological conditions and social and situational circumstances that have the potential to interfere with surgery outcomes

Question 21

pharm therapy for adults with type 1

Answer 21

-Most pts with type 1 should be treated with multiple daily injections of prandial and basal insulin, or continuous subcutaneous insulin infusion
-rapid-acting insulin analogs are used to reduce hypoglycemia risk
-pts are educated on how to match mealtime insulin doses to carb intake, fat, and protein content, and anticipated physical activity

Question 22

pharm therapy for adults with type 2

Answer 22

-lifestyle behaviors, diabetes self-management education and support, avoidance of clinical inertia, and social determinants of health
-Pharm therapy guided by person-centered tx factors -> comorbidities and tx goals
-if high risk of atherosclerotic/cardiovascular disease, HF, and/or chronic kidney disease -> tx includes meds to reduce cardiorenal risk
-Pharm approaches that can achieve and maintain tx goals should be considered -> metformin or other agents, including combination therapy
-Wt management
-Metformin should be continued upon initiation of insulin therapy (unless contraindicated or not tolerated) for ongoing glycemic and metabolic benefits
-Early combo therapy can be considered in pts at tx initiation to extend the time to tx failure
-early intro of insulin considered if evidence of ongoing catabolism (weight loss), symptoms of hyperglycemia are present, or A1C levels (>10% or blood glucose levels (≥300mg/dL) are very high
-person-centered approach -> consider effects on cardiovascular and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost and access, risk for SE, and individual preferences
-atherosclerotic/cardiovascular disease or indicators of high cardiovascular risk, established kidney disease, or HF -> sodium–glucose cotransporter 2 inhibitor and/or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit is recommended -> independent of A1C and in consideration of person-specific factors
-for ALL - glucagon-like peptide 1 receptor agonist is preferred to insulin when possible
-If insulin is used, combo therapy with glucagon-like peptide 1 receptor agonist is recommended for greater efficacy, durability of tx effect, and wt and hypoglycemia benefit
-Recommendation for tx intensification for individuals not meeting tx goals should not be delayed
-Medication regimen and medication-taking behavior should be reevaluated at regular intervals (every 3–6 months) and adjusted as needed
-Clinicians should be aware of overbasalization with insulin therapy -> eval if basal dose > ~0.5 units/kg/day, high bedtime–morning or postpreprandial glucose differential, hypoglycemia (aware or unaware), and high glycemic variability
-Indication of overbasalization should prompt reevaluation to further individualize therapy

Question 23

cost of noninsulin glucose lowering agents

Answer 23

Median monthly cost AWP and NADAC of maximum approved daily dose of noninsulin glucose-lowering agents in the U.S.

Question 24

cardiovascular disease and risk management

Answer 24

-glycemia management
-BP management
-lipid management
-agents with cardiovascular and kidney benefit

Question 25

cardiovascular disease and risk management: screening and dx

Answer 25

-measured at every routine clinical visit
-if BP is high (120–129/<80 mmHg) -> BP confirmed including measurements on a separate day for def dx
-HTN- ≥130 OR ≥80 mmHg based on an average of ≥2 measurements obtained on ≥2 occasions
-≥180/110 mmHg and cardiovascular disease could be dx with HTN at a single visit
-All pts with HTN and diabetes should monitor their BP at home

Question 26

cardiovascular ds and risk management: tx goals

Answer 26

-pts with diabetes and HTN- BP targets should be individualized through shared decision-making process that addresses cardiovascular risk, potential adverse effects of antihypertensive medications, and pt preferences
-pts with diabetes and HTN qualify for antihypertensive drug therapy when BP is persistently elevated ≥130/80 mmHg
-on-tx (meds) target BP goal is <130/80 mmHg, if it can be safely attained

Question 27

cardiovascular ds and risk management: tx: lifestyle

Answer 27

-pts with BP >120/80 mmHg -> lifestyle intervention -> weight loss when indicated, DASH diet (reducing sodium and increasing potassium intake), moderation of alcohol intake, and increased physical activity

Question 28

cardiovascular ds and risk management: tx: pharm

Answer 28

-pts with confirmed BP ≥130/80 qualify for initiation and titration of pharm therapy to achieve BP goal of <130/80
-pts with confirmed BP ≥160/100 should, in addition to lifestyle therapy, have prompt initiation and titration of 2 drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in pts with diabetes
-tx for HTN should include drugs that reduce cardiovascular events in people with diabetes -> ACE inhibitors or ARB are 1st line therapy for HTN in pts with diabetes and CAD
-Multiple-drug therapy generally required to achieve BP targets -> However, combo of ACE inhibitors and ARB and combo of ACE inhibitors or ARB with direct renin inhibitors should NOT be used
-ACE inhibitor or ARB, at max tolerated dose indicated for BP tx is recommended 1st-line tx for HTN in pts with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine or 30–299 mg/g creatinine -> If one class is not tolerated, the other should be substituted
-pts taking ACE inhibitor, angiotensin receptor blocker, or diuretic -> serum creatinine/GFR and serum K levels should be monitored at least annually

Question 29

lipid management- lifestyle tx

Answer 29

-Lifestyle mod focusing on wt loss (if indicated)
-Mediterranean or dash diet -> reduction of saturated fat and trans fat; increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity
-intensify lifestyle therapy and optimize glycemic control for pts with elevated triglyceride levels (≥150mg/dL) and/or low HDL cholesterol (<40 mg/dL for men, <50 mg/dL for women)

Question 30

lipid management- ongoing therapy and monitoring with lipid panel

Answer 30

-adults not taking statins or other lipid-lowering therapy -> obtain lipid profile at the time of diabetes dx, at initial medical eval, and every 5 years thereafter if under the age of
-Obtain lipid profile at initiation of statins or other lipid-lowering therapy, 4–12 weeks after initiation or change in dose, and annually thereafter as it may help to monitor the response to therapy and inform medication taking

Question 31

statin tx- primary prevention

Answer 31

-diabetes aged 40–75 years w/o atherosclerotic/cardiovascular disease -> moderate-intensity statin therapy in addition to lifestyle therapy
-diabetes aged 20–39 years with additional atherosclerotic/cardiovascular disease risk factors -> may be reasonable to initiate statin therapy in addition to lifestyle therapy
-diabetes aged 40–75 at higher cardiovascular risk -> pts with 1 or more atherosclerotic cardiovascular disease risk factors -> high-intensity statin therapy to reduce LDL cholesterol by ≥50% of baseline and to target an LDL cholesterol goal of <70 mg/dL
-diabetes aged 40–75 years at higher cardiovascular risk -> especially those with multiple atherosclerotic cardiovascular disease risk factors and an LDL cholesterol ≥70 mg/dL -> add ezetimibe or a PCSK9 inhibitor to max tolerated statin therapy
-diabetes aged >75 years already on statin therapy -> continue statin tx
-diabetes aged >75 years -> it may be reasonable to initiate moderate-intensity statin therapy after discussion of potential benefits and risks
-Statin therapy is contraindicated in pregnancy

Question 32

statin tx- secondary prevention

Answer 32

-all ages with diabetes and atherosclerotic cardiovascular disease -> high intensity statin therapy should be added to lifestyle therapy
-diabetes and atherosclerotic cardiovascular disease -> tx with high intensity statin therapy is recommended to target an LDL cholesterol reduction of ≥50% from baseline and an LDL cholesterol goal of <55 mg/dL
-Addition of ezetimibe or PCSK9 inhibitor recommended if goal is not achieved on max tolerated statin therapy
-pts who dont tolerate the intended intensity, the max tolerated statin dose should be used

Question 33

tx of other lipoprotein fractions or targets

Answer 33

-pts with fasting triglyceride levels ≥500 mg/dL -> eval for secondary causes of hypertriglyceridemia and consider medical therapy to reduce risk of pancreatitis.
-adults with moderate hypertriglyceridemia (fasting or nonfasting triglycerides 175–499 mg/dL) -> address lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that raise triglycerides
-pts with atherosclerotic cardiovascular ds or other cardiovascular risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL) ->he addition of icosapent ethyl can be considered to reduce cardiovascular risk

Question 34

antiplatelet agents

Answer 34

-Use aspirin therapy (75–162 mg/day) as secondary prevention in pts with diabetes and hx of atherosclerotic cardiovascular disease
-pts with atherosclerotic cardiovascular disease and documented aspirin allergy -> clopidogrel (75 mg/day) should be used
-Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) -> reasonable for 1 year after acute coronary syndrome and may have benefits beyond this period
-Long-term treatment with dual antiplatelet therapy should be considered for pts with prior coronary intervention, high ischemic risk, and low bleeding risk to prevent major adverse cardiovascular events
-Combo therapy with aspirin plus low-dose rivaroxaban -> considered for pts with stable coronary and/or PAD and low bleeding risk to prevent major adverse limb and cardiovascular events
-Aspirin therapy (75–162 mg/day) may be considered as a primary prevention in pts with diabetes with increased cardiovascular risk, after discussion with pt on benefits vs risk of bleeding

Question 35

chronic kidney disease- screening

Answer 35

-At least annually, urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and estimated GFR should be assessed in pts with type 1 with duration of ≥5 years and in all pts with type 2 regardless of tx
-pts with diabetic kidney disease, urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and estimated GFR should be monitored 1–4x per year depending on the stage of disease

Question 36

chronic kidney disease- tx

Answer 36

-Optimize glucose control to reduce risk or slow progression of chronic kidney disease
-Optimize BP control and reduce BP variability to reduce risk or slow progression of chronic kidney disease
-nonpregnant pts with diabetes and HTN -> either ACE inhibitor or ARB is recommended for pts with moderately increased albuminuria (urinary albumin-to-creatinine ratio 30– 299 mg/g creatinine) -> strongly recommended for pts with severely increased albuminuria (urinary albuminto-creatinine ratio ≥300 mg/g creatinine) and/or estimated GFR <60 mL/min/1.73 m2
-refer to nephrologist for uncertainty about etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease

Question 37

hospital care delivery standards

Answer 37

-Perform A1C on all pts with diabetes or hyperglycemia (blood glucose >140 mg/dL) admitted to hospital if not performed in prior 3 months.
-Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in insulin dosage based on glycemic fluctuations
-consult with specialized diabetes or glucose management team when possible