2013 ADA Clinical Practice Recommendations (Part 2)

Eileen Wyner, NP

By Eileen B. Wyner, NP
Bulfinch Medical Group

This week I want to finish reviewing the revisions to the ADA Standards of Care (click here to review Part 1). Please remember that these are guidelines.  Always review your personal health care plan with your health care providers


Many people associate immunizations with childhood, but there are several immunizations that are required throughout the lifespan. I reviewed these in the past (which you can find here), so today I will just address the ADA revisions. Annual influenza and appropriate pneumococcal vaccination is still strongly recommended for all people living with diabetes. Late in 2012 the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices decided to recommend vaccination against hepatitis B virus (HBV) for all people living with diabetes between 19 and 59 years old. People older than 60 are also considered vaccination candidates, but will first need to first be assessed by their providers as the immune response is sometimes decreased in seniors.

The CDC was prompted to make this recommendation after reviewing reports of outbreaks of HBV in long-term care facilities and hospitals where monitoring devices may have been shared by patients.  HBV is a highly contagious disease transmitted through contact with blood and infected bodily fluids. This virus can live for a long period of time on surfaces such as lancet devices, glucometers, and the reservoirs of insulin pens (even when there is no visible blood). This is the reason that these tools shouldn’t be shared with others.

Many people are vaccinated against HBV as this is a required childhood vaccine.  Many professions require this vaccine as well.  I suggest discussing this with your health care provider at your next appointment.

Blood Pressure Control

Well controlled blood pressure is imperative for people living with diabetes and this year the ADA changed their target goal for well controlled blood pressure to <140/<80 (previously <130/<80). This recommendation was developed after reviewing several randomized controlled trials published within the last 5 years demonstrating  little improvement in the reduction of cardiovascular events with the previous target.  Instances when a lower blood pressure goal is appropriate will be determined by the health care provider on an individual basis.

Retinopathy Screening and Treatment

The revised recommendations to this standard have to do with the treatment options for Diabetic Macular Edema (DME), a complication of long term and/or poorly controlled diabetes. DME occurs when damaged blood vessels in the eye leak fluid into the macula, causing swelling and blurry vision. Since 1985 the only treatment available for this condition was laser photocoagulation therapy, which could help reduce the risk of future visual loss but had no effect on damage that had already occurred. In August 2012 the FDA approved Ranibizumab (Lucentis), a medication that is given as a monthly eye injection, for DME treatment.  Studies have shown improvement in vision for people treated with this medication.

Lipid Management

Lowering LDL (“bad” cholesterol) levels with the use of statins has been well documented as a method to reduce cardiovascular events. However, many people have trouble tolerating these medications due to side effects. The ADA is advising  providers work with patients to find a dose or alternative statin  that is better tolerated as the benefits of this therapy is well proven. It is documented that very low, even less than daily, doses of statins can be beneficial.

Diabetes Care in the Hospitalized Patient

The ADA is recommending that patients admitted to the hospital may need some level of screening for diabetes. Providers should consider obtaining an A1C if there is no recent value available and/or  if the patient has any risk factors for diabetes and hyperglycemia while in the hospital.  In the latter case, follow up care needs to be set up to address these results.

There are several more updates and recommendations we did not touch on.  To view the full set of 2013 Clinical Practice Recommendations, click here.


2013 ADA Clinical Practice Recommendations (Part 1)

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen W

Every year the multidisciplinary Professional Practice Committee of the American Diabetes Association (ADA) publishes a set of guidelines and recommendations on the diagnosis and treatment of diabetes for both adults and children. These standards guide us in how and when to screen for, diagnose and treat diabetes; how to monitor for complications; and how to educate patients in their self-management strategies.

These standards of care provide concrete data about goals of treatment, but they are not meant to be the only approach to care. Rather, they provide a guideline for the care of a person with diabetes;  providers rely on their best clinical judgment for each individual they care for and adapt the guidelines as needed.  Last year I did a review of the ADA Guidelines along with the specific updates published (you can refer to that post here). This year there were 12 revisions published which I will highlight this week and next. Please remember that these are guidelines— always review your personal health care plan with your health care provider(s).

Screening for Type 1 Diabetes

Type 1 Diabetes is generally diagnosed with an acute presentation of hyperglycemia and even ketoacidosis. There is no evidence that screening the general population for Type 1 Diabetes is helpful, but there is valid evidence that measuring islet autoantibodies in relatives of people with Type 1 Diabetes will identify at-risk individuals. Those identified can be referred to clinical studies where they can learn about their potential for developing Type 1 Diabetes and what symptoms to watch for.  Lifestyle education would also be provided and more frequent screening instituted.

Prevention/Delay of Type 2 Diabetes

There are several random controlled studies showing that people at high risk for developing Type 2 Diabetes can decrease their rate of onset with certain interventions. These interventions may include lifestyle changes and even medication in some instances. ADA supports formal education for people with impaired glucose tolerance and an A1C between 5.7 and 6.4%. People who fall into this category also need to be monitored annually for their blood sugar values and assessed for cardiovascular risk factors (obesity, hypertension, and high cholesterol).

Glucose Monitoring

I think one of the most important things we do as diabetes providers is helping people learn how to monitor their blood sugars at home and follow these patterns for better control. However, there has been some discussion in the literature about the clinical utility and expense for self-monitoring of blood glucose (SMBG) in people who aren’t on aggressive insulin or not on insulin at all. ADA has approached this issue by stating that frequency and timing of SMBG should be decided on an individual basis based on the person’s needs and goals for treatment. People using MDI or an insulin pump need frequent SMBG to assess for control and monitor for hypoglycemia. People using less frequent insulin or non-insulin therapies may check SMBG on a more variable schedule that should be determined with the health care provider. It’s also important to review testing technique at times to be sure the results are accurate.

DSME and Support Groups

ADA has always advocated for education and support for people with diabetes, and now is supporting formal education for pre-diabetic patients. ADA supports third-party payer reimbursement for both these services.


Hypoglycemia awareness and management should be frequently reviewed with patients. The self-management plan should always be re-evaluated if there have been one (1) or more episodes of severe hypoglycemia (inability to handle the episode on your own).  People with severe hypoglycemia or hypoglycemia unawareness may need the targets for glycemic control raised. People with declining cognition need to be assessed frequently for hypoglycemia by their providers and family members.  Adjustments in their glycemic management plan will also need to be made.

To view the full set of Clinical Practice Recommendations for 2013, click here.