Essentials from the 2016 American Diabetes Association guidelines

The 2016 American Diabetes Association diabetes guidelines is a lengthy document outlining many aspects of diabetes care including evaluation, diagnosis, prevention, management of glycemia, and management of nonglycemic issues.  Here are some of the more common elements that come up in the internal medicine setting regarding glycemic control.

Criteria for the diagnosis of diabetes:

1. Fasting plasma glucose ≥126 mg/dL (fasting means no caloric intake for 8 hours)
2. 2 hr plasma glucose ≥200 mg/dL during an OGTT (oral glucose tolerance test) – the test involves drinking 75 g anhydrous glucose dissolved in water
3. A1C ≥6.5%
4. Random plasma glucose ≥200 mg/dL plus classic symptoms of hyperglycemia – ie. polydipsia, polyuria, weight loss

*If these results are somewhat close to the diagnostic threshold, a repeat test is recommended

Glycemic goals:

• A1C <7%
• Preprandial plasma glucose 80-130 mg/dL
• Peak postprandial plasma glucose <180 mg/dL (1-2 hours after beginning of meal)

*Goals should be individualized based on individual characteristics and comorbidities

Potency of antihyperglycemics and recommendations for use:

• Start with metformin therapy and continue metformin as additional agents added (including insulin)
• As long as no contraindications present

• Each noninsulin agent added lowers A1C by 0.9-1.1%
• Insulins have theoretically unlimited efficacy
• Consider combination noninsulin agents if A1C ≥9%
• Consider combination insulin therapy if A1C ≥10-12%

References:

American Diabetes Association. Standards of medical care in diabetes – 2016.  Diabetes Care  2016;39(Suppl. 1):S1-112.

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