ADA2021

ADA 2021
Diabetes can be classified into the following

general categories
 1. Type 1 diabetes (due to autoimmuneb-cell destruction,
 usually leading to absolute insulin deficiency, including
 latent autoimmune diabetes of adulthood)
 2. Type 2 diabetes (due to a progressive loss of b-cell

 insulin secretion frequently on the background of insulin resistance)
 3. Specific types of diabetes due to other causes, e.g.,
 monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of
the young),
 diseases of the exocrine pancreas (such as cystic fibrosis
 and pancreatitis), and drug- or chemical-induced diabetes (such as with glucocorticoid use,
in the treatment of HIV/AIDS, or after organ transplantation)
 4. Gestational diabetes mellitus (GDM; diabetes diagnosed in the second or third trimester
of pregnancy that was not clearly overt diabetes prior to gestation)
Diagnoses
 diagnosis requires two abnormal test results
 from the same sample or in two separate
test samples.
 If using two separate test samples, it is
recommended that the second test, which may
either be
 a repeat of the initial test or a different
test, be performed without delay.
 If the patient has a test result near the
margins of the diagnostic threshold, the
provider should follow the patient closely and
DIAGNOSES
Screening for prediabetes and type 2
diabetes
 For all people, testing should begin at age 45 years If tests are
normal
 repeat testing carried out at a minimum of 3-year intervals is

reasonable,
 sooner with symptoms.
 Testing for prediabetes and/or type 2 diabetes in asymptomatic

people should be considered in
 adults of any age with overweight (BMI 25–29.9 kg/m2
 or 23–27.4 kg/m2 in Asian Americans) or obesity
 (BMI $30 kg/m2 or$27.5 kg/m2 in Asian Americans)

 Annuallyscreen people who are
prescribed atypical antipsychotic
medications for prediabetes or
diabetes
To test for prediabetes
 fasting plasma
glucose 2-h plasma glucose during75-g
oral glucose tolerance test
A1C
are equally appropriate
Screen women with a recent history of GDM
 AT 4–12 weeks postpartum, using the 75-

g oral glucose tolerance test and clinically
appropriate nonpregnancy diagnostic
criteria.
 Women with a history of GDM found to have
prediabetes should receive intensive
lifestyle interventions and/or metformin
to prevent diabetes
 Women with a history of GDM should have
lifelong screening for the development of
 type 2 diabetes or prediabetes every 1–3
 Consider screening patients with type 1 diabetes for
 autoimmune thyroid disease and celiac disease
 soon after diagnosis.
Pharmacologic Interventions
 Metformin therapy for prevention of
type 2 diabetes
 should be considered in those with
prediabetes,
 especially for those with BMI >35
kg/m2
 aged <60 years
 and women with prior GDM
 Pharmacologic agents including metformin
 a-glucosidase inhibitors
 orlistat
 glucagon-like peptide 1 (GLP-1) receptor agonists
 thiazolidinediones
 have each been shown to decrease incident diabetes to various degrees in those
with prediabetes
Follow up A1C
 at least two times a year in patients

 who are meeting treatment goals
 (and who have stable glycemic control).
 Assess glycemic status at least
quarterly,
 and as needed, in patients whose
 therapy has recently changed
 and/or who are not meeting glycemic
goals.
Metformin is the preferred initial pharmacologic
agent for the treatment of type 2 diabetes.
Once initiated, metformin should be continued
as long as it is tolerated and not contraindicated
 The early introduction of insulin should be considered

if
 there is evidence of ongoing catabolism(weight
loss)
 if symptoms of hyperglycemia are present
 or when A1C levels (10% [86 mmol/mol])
 or blood glucose levels (300 mg/dL [16.7mmol/L)
 Metabolic surgery
 should be a recommended option to

treat type 2 diabetes in screened
surgical candidates with BMI >=40
kg/m2
 and
in adults with BMI 35.0–39.9 kg/m2
who do not achieve durable weight loss
 and improvement in comorbidities
(including hyperglycemia) with
nonsurgical methods
diabetes and hypertension
 at higher CV risk (existing ASCVD or 10-year

ASCVD risk>15%) a blood pressure target of
130/80mmHg
 may be appropriate, if it can be safely attained.
 For individuals with diabetes and hypertension at
lower risk for CVD
 (10-year ASCVD risk <15%)treat to a blood pressure
target of ,140/90 mmHg
 Patients
with hypertension who are not
meeting blood pressure targets on three
classes of antihypertensive medications
(including a diuretic)
 shouldbe considered for
mineralocorticoid receptor antagonist
therapy
DYSLIPEDIMIA
 For patients with diabetes aged 40–75 years

 without ASCVD, use moderate-intensity statin therapy in addition to lifestyle
therapy.
 For patients with diabetes aged 20–39 years with additional ASCVD risk factors
 it may be reasonable to initiate statin therapy in addition to lifestyle
In patients with diabetes at higher risk, especially those with multiple ASCVD risk
factors
or aged 50–70 years, it is reasonable to use high-intensity statin therapy.
 In adults with diabetes and 10-year ASCVD risk of 20%or higher
 it may be reasonable to add ezetimibe to maximally tolerated statin therapy to
 reduce LDL cholesterol levels by 50% or more
retinopathy SCREEINING
 Adults with type 1 diabetes should have an initial dilated
and comprehensive eye examination by ophthalmologist
or optometrist within 5 years after the onset of diabetes.
 Patients with type 2 diabetes should have an initial
dilated and comprehensive eye examination by an
ophthalmologist or optometrist at the time of the
diabetes diagnosis.
 If there is no evidence of retinopathy for one or more
annual eye exams and glycaemia is well controlled, then
screening every 1–2 years may be considered.
 Ifany level of diabetic retinopathy is present,
TREATMENT
Pregabalin,duloxetine, or gabapentin are
recommended as initial pharmacologic
treatments for neuropathic pain in diabetes

ADA2021

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ADA 2021

Diabetes can be classified into the following

 2. Type 2 diabetes (due to a progressive loss of b-cell

 repeat testing carried out at a minimum of 3-year intervals is

 Testing for prediabetes and/or type 2 diabetes in asymptomatic

 AT 4–12 weeks postpartum, using the 75-

 at least two times a year in patients

 The early introduction of insulin should be considered

 should be a recommended option to

 at higher CV risk (existing ASCVD or 10-year

 For patients with diabetes aged 40–75 years

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