James J. Chamberlain, MD; Andrew S. Rhinehart, MD; Charles F. Shaefer, Jr., MD; Annie Neuman, PA-C
Acknowledgment: The authors thank Sarah Bradley; Jane Chiang, MD; Matt Petersen; and Jay Shubrook, DO, for their invaluable assistance in the writing of this manuscript.
Disclosures: Dr. Chamberlain reports personal fees (speakers bureau) from Merck, Sanofi Aventis, and Janssen during the conduct of the study. Dr. Rhinehart reports personal fees from Sanofi, Novo Nordisk, AstraZeneca, Boehringer Ingelheim, Janssen, Eli Lilly, Forest, and Glytec outside the submitted work. Dr. Shaefer reports personal fees from Sanofi, Eli Lilly, AstraZeneca, Boehringer Ingelheim, Janssen, Forest Pharmaceuticals, and Vivus; and nonfinancial support from Sanofi outside the submitted work. Ms. Neuman has disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-3016.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: James J. Chamberlain, MD, St. Mark's Hospital and St. Mark's Diabetes Center, Internal Medicine at St. Mark's, 1160 East 3900 South, Suite 1200, Salt Lake City, UT 84124; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Chamberlain and Ms. Neuman: St. Mark's Hospital and St. Mark's Diabetes Center, Internal Medicine at St. Mark's, 1160 East 3900 South, Suite 1200, Salt Lake City, UT 84124.
Dr. Rhinehart: Glytec, 770 Pelham Road, Suite 210, Greenville, SC 29615.
Dr. Shaefer: University Physicians Primary Care, 820 St. Sebastian Way, Suite 4C, Augusta, GA 30901.
Author Contributions: Conception and design: J.J. Chamberlain, A.S. Rhinehart, C.F. Schaefer.
Analysis and interpretation of the data: J.J. Chamberlain, A.S. Rhinehart.
Drafting of the article: J.J. Chamberlain, A.S. Rhinehart.
Critical revision of the article for important intellectual content: J.J. Chamberlain, A.S. Rhinehart, A. Neuman.
Final approval of the article: J.J. Chamberlain, A.S. Rhinehart, C.F. Schaefer.
Collection and assembly of data: J.J. Chamberlain, A.S. Rhinehart.
The American Diabetes Association (ADA) published the 2016 Standards of Medical Care in Diabetes (Standards) to provide clinicians, patients, researchers, payers, and other interested parties with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care.
The ADA Professional Practice Committee performed a systematic search on MEDLINE to revise or clarify recommendations based on new evidence. The committee assigns the recommendations a rating of A, B, or C, depending on the quality of evidence. The E rating for expert opinion is assigned to recommendations based on expert consensus or clinical experience. The Standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community was incorporated into the 2016 revision.
The synopsis focuses on 8 key areas that are important to primary care providers. The recommendations highlight individualized care to manage the disease, prevent or delay complications, and improve outcomes.
Table 1. Criteria for the Diagnosis of Prediabetes and Diabetes
Table 2. Mean Glucose Levels for Specified Hemoglobin A1c Levels*
Appendix Table. Summary of Glycemic Recommendations for Nonpregnant Adults With Diabetes
Approach to the management of hyperglycemia.
Depicted are patient and disease factors used to determine optimal HbA1c targets. Characteristics and predicaments toward the left justify more stringent efforts to lower HbA1c level, and those toward the right suggest less stringent efforts. Adapted with permission from Inzucchi and colleagues (18) and the American Diabetes Association. HbA1c = hemoglobin A1c.
Antihyperglycemic therapy for type 2 diabetes mellitus: general recommendations.
The order in the chart was determined by historical availability and the route of administration, with injectables to the right; it is not meant to denote any specific preference. Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes mellitus are displayed, with the usual transition moving vertically from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). Adapted with permission from Inzucchi and colleagues (18) and the American Diabetes Association. DPP-4 = dipeptidyl peptidase-4; GI = gastrointestinal; GLP-1 = glucagon-like peptide-1; GU = genitourinary; HbA1c = hemoglobin A1c; HF = heart failure; SGLT2 = sodium–glucose cotransporter 2; SU = sulfonylurea; TZD = thiazolidinedione.
* See reference 18 for description of efficacy categorization.
† Consider starting at this stage when the HbA1c level is 9% or greater.
‡ Consider starting at this stage when blood glucose levels are 16.7 to 19.4 mmol/L (300 to 350 mg/dL) or greater and/or HbA1c levels are 10% to 12%, especially if symptomatic or catabolic features are present (in which case basal insulin plus mealtime insulin is the preferred initial regimen).
§ Usually a basal insulin (neutral protamine Hagedorn, glargine, detemir, or degludec).
Table 3. Recommendations for Statin and Combination Treatment in Persons With Diabetes
Table 4. High- and Moderate-Intensity Statin Therapy*
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Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A. Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Ann Intern Med. 2016;164:542-552. doi: 10.7326/M15-3016
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Published: Ann Intern Med. 2016;164(8):542-552.
Published at www.annals.org on 1 March 2016
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Guidelines.
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