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Guidelines Summary

ADA: Position statement on type 1 diabetes in children and adolescents

In August 2018, the American Diabetes Association released a position statement on type 1 diabetes in children and adolescents, which included the following guidelines^{[199, 200]}:

Consult a pediatric endocrinologist before diagnosing type 1 diabetes when isolated glycosuria or hyperglycemia is discovered in patients with acute illness in the absence of classic symptoms
Differentiating type 1 diabetes, type 2 diabetes, monogenic diabetes, and other forms of diabetes is based on patient history and characteristics, as well as on laboratory tests, such as an islet autoantibody panel
The majority of children with type 1 diabetes should be treated with intensive insulin regimens using multiple daily injections of prandial insulin and basal insulin or continuous subcutaneous insulin infusion
A _1C should be measured every 3 months
Blood glucose levels should be monitored up to 6-10 times daily
Continuous glucose monitors (CGM) should be considered in all children and adolescents with type 1 diabetes; the benefits of CGM correlate with adherence to ongoing use of the device
Blood or urine ketone levels should be monitored in children with type 1 diabetes in the presence of prolonged/severe hyperglycemia or acute illness
Individualized medical nutrition therapy is recommended for children and adolescents
Exercise is recommended, with a goal of 60 minutes a day of moderate to vigorous aerobic activity, along with vigorous muscle-strengthening and bone-strengthening activities at least 3 days a week
It is important to frequently monitor glucose before, during, and after exercise (with or without CGM use) to prevent, detect, and treat hypoglycemia and hyperglycemia
All individuals with type 1 diabetes should have access to an uninterrupted supply of insulin; lack of access and insulin omissions are major causes of diabetic ketoacidosis
Glucagon should be prescribed for all individuals with type 1 diabetes, and caregivers or family members should be instructed regarding administration
Once the child has had diabetes for 5 years, annual screening for albuminuria, using a random spot urine sample (morning sample preferred to avoid effects of exercise) to assess the albumin-to-creatinine ratio, should be considered at puberty or at age greater than 10 years, whichever occurs earlier
Once the youth has had diabetes for 3-5 years, an initial dilated and comprehensive eye examination is recommended at age 10 years or after puberty has started, whichever is earlier, and an annual routine follow-up is generally recommended
For adolescents who have had type 1 diabetes for 5 years, consider an annual comprehensive foot exam at the start of puberty or at age 10 years, whichever is earlier
Blood pressure should be measured at each routine visit; children who have high-normal blood pressure (systolic blood pressure [SBP] or diastolic blood pressure [DBP] at 90th percentile for age, sex, and height) or hypertension (SBP or DBP at 95th percentile for age, sex, and height) should have blood pressure confirmed on 3 separate days
Initial treatment of high-normal blood pressure (SBP or DBP consistently at the 90th percentile for age, sex, and height) includes dietary modification and increased exercise for weight control; if target blood pressure is not reached within 3-6 months after lifestyle intervention, consider pharmacologic treatment
Because of their potential teratogenic effects, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) should be considered for initial pharmacologic treatment of hypertension after reproductive counseling
The blood pressure treatment goal is consistently less than the 90th percentile for age, sex, and height
If low-density lipoprotein (LDL) cholesterol is within an acceptable risk level (< 100 mg/dL [2.6 mmol/L]), a lipid profile every 3-5 years is reasonable
If lipid levels are abnormal, initial therapy should consist of optimizing glucose control and initiating a Step 2 American Heart Association diet (restricting saturated fat to 7% of total calories and dietary cholesterol to 200 mg/day)
After age 10 years, consider adding a statin if, despite 6 months of medical nutrition therapy and lifestyle changes, LDL cholesterol remains greater than 160 mg/dL (4.1 mmol/L) or LDL cholesterol remains greater than 130 mg/dL (3.4 mmol/L) with one or more cardiovascular disease (CVD) risk factors present (after reproductive counseling because of the potential teratogenic effects of statins)
The LDL therapy goal is less than 100 mg/dL (2.6 mmol/L)
In children with type 1 diabetes, consider testing for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis
In children and adolescents with type 1 diabetes, an A _1C target of less than 7.5% should be considered but individualized
Glucose (15 g) is preferred treatment for conscious individuals with hypoglycemia (blood glucose < 70 mg/dL [3.9 mmol/L]), but any form of carbohydrate may be used; treatment should be repeated if self-monitoring blood glucose (SMBG) 15 minutes after treatment shows hypoglycemia is still present; when blood glucose concentration returns to normal, consider a meal or snack and/or reduce insulin to prevent recurrence of hypoglycemia
In patients with classic symptoms, blood glucose measurement is sufficient to diagnose diabetes (symptoms of hyperglycemia or hyperglycemic crisis and random plasma glucose ≥200 mg/dL [11.1 mmol/L])
Measure thyroid-stimulating hormone concentrations when the patient is clinically stable or once glycemic control has been established; if normal, suggest rechecking every 1-2 years (or sooner if the patient develops symptoms or signs that suggest thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability)
Screen children for celiac disease by measuring IgA tissue transglutaminase antibodies
Criteria for diagnosis of diabetes is fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L)
In asymptomatic children and adolescents at high risk for diabetes, if FPG ≥126 mg/dL (7 mmol/L), if 2-hr PG ≥200 mg/dL (11.1 mmol/L), or if A _1C ≥6.5%, testing should be repeated on a separate day to confirm the diagnosis

ADA: Standards of Medical Care in Diabetes

The American Diabetes Association’s Standards of Medical Care in Diabetes-2018 include the following A-grade recommendations, ie, recommendations based on “[c]lear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered”^[116]:

Align approaches to diabetes management with the Chronic Care Model, emphasizing productive interactions between a prepared, proactive care team and an informed, activated patient
Providers should assess social factors that can affect patients with diabetes, such as potential food insecurity, housing stability, and financial barriers, and apply that information to treatment decisions
Provide patients with self-management support from lay health coaches, navigators, or community health workers, when available
Effective diabetes self-management education and support should be patient centered, may be given in group or individual settings or using technology, and should help guide clinical decisions
Psychosocial care should be integrated with a collaborative, patient-centered approach and provided to all people with diabetes, with the goal of optimizing health outcomes and health-related quality of life
A reasonable A _1C goal for many nonpregnant adults is below 7% (53 mmol/mol)
Insulin-treated patients with hypoglycemia unawareness or an episode of clinically significant hypoglycemia should be advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes
Most people with type 1 diabetes should be treated with a multiple daily injection regimen of prandial insulin and basal insulin or continuous subcutaneous insulin infusion
Most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk
These guidelines state that most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of less than 140 mm Hg and a diastolic blood pressure goal of under 90 mmHg; however, the ADA’s Standards of Care in Diabetes—2023 advised that the target blood pressure for people with diabetes be below 130/80 mmHg, if it can be safely achieved ^{[184, 185]}
Patients with a confirmed office-based blood pressure of 160/100 mmHg or above should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes
Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes (angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], thiazide-like diuretics, or dihydropyridine calcium channel blockers)
Multiple-drug therapy is generally required to achieve blood pressure targets; however, combinations of ACE inhibitors and ARBs and combinations of ACE inhibitors or ARBs with direct renin inhibitors should not be used
Lifestyle modifications focusing on weight loss (if indicated); the reduction of saturated fat, trans fat, and cholesterol intake; an increase in dietary omega-3 fatty acids, viscous fiber, and plant stanol/sterol intake; and increased physical activity should be recommended to improve the lipid profile in patients with diabetes
High-intensity statin therapy should be added to lifestyle therapy for patients of all ages with diabetes and atherosclerotic cardiovascular disease (ASCVD)
For patients aged 40-75 years who have diabetes but do not have ASCVD, use moderate-intensity statin treatment in addition to lifestyle therapy
For patients with diabetes and ASCVD, if the low-density lipoprotein (LDL) cholesterol level is 70 mg/dL (3.9 mmol/L) or above on maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or a proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitor) after evaluating the potential for further ASCVD risk reduction, drug-specific adverse effects, and patient preferences; ezetimibe may be preferred due to lower cost
Combination therapy (statin/fibrate) has not been shown to improve ASCVD outcomes and is generally not recommended
Combination therapy (statin/niacin) has not been shown to provide additional cardiovascular benefit above statin therapy alone, may increase the risk of stroke with additional side effects, and is generally not recommended
Use aspirin therapy (75-162 mg/day) as a secondary prevention strategy in patients with diabetes and a history of ASCVD
In asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as ASCVD risk factors are treated
Optimize glucose control to reduce the risk or slow the progression of diabetic kidney disease
Optimize blood pressure control to reduce the risk or slow the progression of diabetic kidney disease
Patients should be referred for evaluation for renal replacement treatment if they have an estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m ²
Optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy
Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy
Promptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy (a precursor of proliferative diabetic retinopathy), or any proliferative diabetic retinopathy to an ophthalmologist who is knowledgeable and experienced in the management of diabetic retinopathy
The traditional standard treatment, panretinal laser photocoagulation therapy, is indicated to reduce the risk of vision loss in patients with high-risk proliferative diabetic retinopathy and, in some cases, severe nonproliferative diabetic retinopathy
Intravitreous injections of the vascular endothelial growth factor inhibitor ranibizumab are not inferior to traditional panretinal laser photocoagulation and are also indicated to reduce the risk of vision loss in patients with proliferative diabetic retinopathy
Intravitreous injections of vascular endothelial growth factor inhibitor are indicated for central-involved diabetic macular edema, which occurs beneath the foveal center and may threaten reading vision
The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage
Either pregabalin or duloxetine is recommended as initial pharmacologic treatment for neuropathic pain in diabetes

In the 2022 edition of the ADA’s Standards of Medical Care in Diabetes, changes include the following^[201]:

It is recommended that, in a research study setting or perhaps in first-degree family members of a proband with type 1 diabetes, screening tests that detect autoantibodies to insulin, glutamic acid decarboxylase (GAD), islet antigen 2, or zinc transporter 8 be used to screen for presymptomatic type 1 diabetes
A risk factor for clinical diabetes, the development and persistence of multiple islet autoantibodies may indicate the need “for intervention in the setting of a clinical trial or screening for stage 2 type 1 diabetes”

ADA: hypertension guidelines

Guidelines published in 2017 by the American Diabetes Association on managing hypertension in patients with diabetes state the following^{[202, 203]}:

Blood pressure should be measured at every routine clinical care visit; patients found to have an elevated blood pressure (≥140/90 mm Hg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension; in the ADA’s Standards of Care in Diabetes—2023, hypertension was redefined as a blood pressure ≥130/80 mm Hg ^{[184, 185]}
All hypertensive patients with diabetes should have home blood pressure monitored to identify white-coat hypertension
Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed
These guidelines state that most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of < 140 mm Hg and a diastolic blood pressure goal of < 90 mm Hg; however, in the ADA's Standards of Care in Diabetes—2023, these numbers were reduced, with the the target blood pressure for people with diabetes advised to be below 130/80 mm Hg, if it can be safely achieved ^{[184, 185]}
For patients with systolic blood pressure >120 mm Hg or diastolic blood pressure >80 mm Hg, lifestyle intervention consists of weight loss if the patients are overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)–style dietary pattern, including reduced sodium and increased potassium intake, increased fruit and vegetable consumption, moderation of alcohol intake, and increased physical activity
Patients with confirmed office-based blood pressure ≥160/100 mm Hg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes
Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes: angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), thiazide-like diuretics, or dihydropyridine calcium channel blockers; multiple-drug therapy is generally required to achieve blood pressure targets (but not a combination of ACE inhibitors and ARBs)
An ACE inhibitor or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and a urine albumin-to-creatinine ratio of ≥300 mg/g creatinine or 30–299 mg/g creatinine; if one class is not tolerated, the other should be substituted
For patients treated with an ACE inhibitor, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored
Pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with systolic blood pressure < 160 mm Hg, diastolic blood pressure < 105 mm Hg, and no evidence of end-organ damage do not need to be treated with pharmacologic antihypertensive therapy
In pregnant patients with diabetes and preexisting hypertension who are treated with antihypertensive therapy, systolic or diastolic blood pressure targets of 120-160/80-105 mm Hg are suggested in the interest of optimizing long-term maternal health and fetal growth

ISPAD: Diabetic vascular complications in children and adolescents

In August 2018, the International Society for Pediatric and Adolescent Diabetes (ISPAD) released clinical practice consensus guidelines on diabetic microvascular and macrovascular complications in children and adolescents. These include the following^[204]:

Commence screening for microvascular complications at age 11 years
Screening for microvascular disease should be performed preconception and during each trimester of pregnancy
Intensive education and treatment should be provided to children and adolescents to prevent or delay the onset and progression of vascular complications
Achievement of target glycemic control will reduce the risk for onset and progression of diabetic vascular complications
Prevention or cessation of smoking will reduce progression of albuminuria and cardiovascular disease
Screening for diabetic retinopathy should start at age 11 years with 2 to 5 years’ diabetes duration
Screening for diabetic retinopathy should be performed by an ophthalmologist or optometrist or a trained, experienced observer, through dilated pupils, with assessment carried out via biomicroscopic examination or fundal photography
Laser treatment and intravitreal injections of anti–vascular endothelial growth factor (VEGF) agents reduce the rate of vision loss for individuals in vision-threatening stages of retinopathy (severe nonproliferative retinopathy or worse and/or diabetic macular edema)
Screen for renal disease using first morning albumin/creatinine ratio as the preferred method.
Blood pressure (BP) should be measured at least annually; hypertension is defined as average systolic BP (SBP) and/or diastolic BP (DBP) that is at or above the 95th percentile for gender, age, and height on three or more occasions
Angiotensin-converting enzyme (ACE) inhibitors are recommended for use in children with diabetes and hypertension; they have been effective and safe in children in short-term studies but are not safe during pregnancy
Screen for lipid abnormalities in the nonfasting state
With regard to macrovascular disease, screening of BP and lipids is recommended, as above; the benefit of routine screening for other markers of macrovascular complications outside the research setting is unclear

ISPAD: Glycemic control targets and glucose monitoring in children, adolescents, and young adults

In July 2018, the ISPAD released clinical practice consensus guidelines on glycemic control targets and glucose monitoring in children, adolescents, and young adults with diabetes. These include the following^[205]:

Glycemic control of children and adolescents must be assessed by both quarterly hemoglobin A1c (HbA1c) measurements and by regular home glucose monitoring; these permit achievement of optimal health in the following ways: (1) by determining with accuracy and precision an individual's glycemic control, including through assessment of each individual's glycemic determinants; (2) by reducing the risks of acute and chronic disease complications; and (3) by minimizing the effects of hypoglycemia and hyperglycemia on brain development, cognitive function, and mood
Regular self-monitoring of glucose (using accurate finger-stick blood glucose [BG] measurements, with or without continuous glucose monitoring [CGM] or intermittently scanned CGM [isCGM]), is essential for diabetes management for all children and adolescents with diabetes
Each child should have access to technology and materials for self-monitoring of glucose measurements to provide for enough testing for optimized diabetes care
When finger-stick BG measurements are used, testing may need to be performed 6-10 times per day to optimize intensive control; regular review of these BG values should be performed with adjustments to medication/nutritional therapies to optimize control
Real-time CGM data particularly benefit children who cannot articulate symptoms of hypoglycemia or hyperglycemia and those with hypoglycemic unawareness
Intermittently scanned CGM can complement finger-stick BG assessments. Although isCGM provides some benefits similar to those of CGM, it does not alert users to hypoglycemia or hyperglycemia in real time, nor does it permit calibration. Without robust pediatric use efficacy data, it cannot fully replace BG monitoring
For children, adolescents, and young adults aged 25 years or younger, ISPAD recommends individualized targets, aiming for the lowest achievable HbA1c without undue exposure to severe hypoglycemia, balanced with quality of life and burden of care
For children, adolescents, and young adults aged 25 years or younger who have access to comprehensive care, a target HbA1c of less than 53 mmol/mol (7.0%) is recommended
A higher HbA1c goal (in most cases below 58 mmol/mol [7.5%]) is appropriate in the following contexts: (1) inability to articulate symptoms of hypoglycemia; (2) hypoglycemia unawareness/history of severe hypoglycemia; (3) lack of access to analog insulins, advanced insulin delivery technology, and CGM, and lack of ability to regularly check BG; and (4) individuals who are “high glycators,” in whom an at-target HbA1c would reflect a significantly lower mean glucose level than 8.6 mmoL/L (155 mg/dL)
A lower goal (6.5%) or 47.5 mmol/mol may be appropriate if achievable without excessive hypoglycemia, impairment of quality of life, and undue burden of care
A lower goal may be appropriate during the honeymoon phase of type 1 diabetes
For patients who have elevated HbA1c, a stepwise approach to improve glycemic control is advised, including individualized attention to the following: (1) dose adjustments, (2) personal factors limiting achievement of the target, (3) assessment of the psychological effect of goal setting on the individual, and (4) incorporation of available technology to improve glucose monitoring and insulin delivery modalities
HbA1c measurement should be available in all centers caring for persons with diabetes
HbA1c measurements should be performed at least every 3 months
Examining variations in HbA1c between centers can assist in evaluating the care provided by health-care centers, including compliance with agreed-to standards to improve therapies and delivery of pediatric diabetes care

Endocrine Society guidelines on diabetes management in older adults

In 2019, the Endocrine Society released the following clinical practice guidelines on the diagnosis and management of diabetes and its comorbidities in older adults^{[206, 207]}:

Screening for diabetes or prediabetes with the fasting plasma glucose test or HbA1c analysis is recommended for patients aged 65 years or older without known diabetes
A 2-hour glucose post–oral glucose tolerance test is suggested for patients aged 65 years or older without known diabetes in whom results from fasting plasma glucose or HbA1c analysis have indicated that prediabetes is present
To delay the onset of diabetes, it is recommended that patients aged 65 years or older with prediabetes adopt a lifestyle in line with that presented in the Diabetes Prevention Program
It is recommended that patients aged 65 years or older with diabetes participate in outpatient regimens specifically conceived to minimize hypoglycemia
Lifestyle modification is recommended as the first-line treatment for hyperglycemia in ambulatory individuals aged 65 years or older with diabetes
Nutritional status assessment for the detection and management of malnutrition is recommended in patients aged 65 years or older with diabetes
It is recommended that along with lifestyle changes, patients aged 65 years or older with diabetes undergo initial oral drug treatment with metformin, for glycemic management; significant kidney function impairment (estimated glomerular filtration rate < 30 mL/min/1.73 m ²) or gastrointestinal intolerance should preclude implementation of this recommendation
If metformin therapy and lifestyle changes have not led a patient aged 65 years or older with diabetes to achieve his/her glycemic target, it is recommended that metformin treatment be combined with therapy employing other oral or injectable agents and/or insulin
To reduce the risk of cardiovascular disease outcomes, stroke, and progressive chronic kidney disease, it is recommended that the target blood pressure in patients aged 65-85 years with diabetes be 140/90 mm Hg
It is recommended that an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker be administered as first-line therapy in patients aged 65 years or older with diabetes and hypertension
Statin therapy and an annual lipid profile are recommended in patients aged 65 years or older with diabetes to reduce absolute cardiovascular disease events and all-cause mortality
For detection of retinal disease, annual comprehensive eye examinations are recommended for patients aged 65 years or older with diabetes
It is recommended that patients aged 65 years or older with diabetes who are not on dialysis be screened annually for chronic kidney disease, with determination of the estimated glomerular filtration rate and urine albumin-to-creatinine ratio

Expert panel: management of diabetes in patients with coronavirus disease 2019 (COVID-19)

Recommendations for the management of diabetes in patients with COVID-19 were published on April 23, 2020, by an international panel of diabetes experts.^{[208, 209]}

Regarding infection prevention and outpatient care:

Patients with diabetes, particularly those with type I diabetes mellitus, should be sensitized to the importance of optimal metabolic control
Current therapy should, if appropriate, be optimized
Telemedicine and connected health models should be used, if possible, to maintain maximal self-containment

All patients hospitalized with COVID-19 should be monitored for new-onset diabetes.

Regarding management in the intensive care unit (ICU) of infected patients with diabetes:

Plasma glucose monitoring, electrolytes, pH, blood ketones, or β-hydroxybutyrate
There is liberal indication for early intravenous insulin therapy in severe disease courses (acute respiratory distress syndrome, hyperinflammation) for exact titration, with variable subcutaneous resorption avoided, and management of commonly encountered very high insulin consumption

Therapeutic goals include the following:

Plasma glucose concentration: 4-8 mmol/L (72-144 mg/dL) for outpatients or 4-10 mmol/L (72-180 mg/dL) for inpatients/intensive care, with, for frail individuals, the lower value possibly adjusted upward to 5 mmol/L (90 mg/dL)
A _1c< 53 mmol/mol (7%)
Continuous glucose monitoring/flash glucose monitoring targets: Time-in-range (3.9-10 mmol/L) >70% of time (or >50% in frail and older patients)
Hypoglycemia < 3.9 mmol/L (< 70 mg/dL): < 4% (< 1% in frail and older patients)

The panel advises stopping administration of metformin and sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with COVID-19 and type 2 diabetes in order to lower the risk of acute metabolic decompensation.

Fluid balance requires considerable care, “as there is a risk that excess fluid can exacerbate pulmonary edema in the severely inflamed lung.”

Potassium balance requires careful consideration in the context of insulin treatment, “as hypokalemia is a common feature in COVID-19,” with initiation of insulin possibly exacerbating it.

The panel recommends screening for hyperinflammation, owing to the possibility of increased risk for cytokine storm and severe COVID-19 in patients with type 2 diabetes and fatty liver disease.

AACE guidelines for use of advanced technology

In May 2021, the American Association of Clinical Endocrinology (AACE) released guidelines on the use of advanced technologies in diabetes management. The following recommendations are among those published.^{[210, 211]}

The percentage of time in range (%TIR) and below range (%TBR) should serve as a starting point for the evaluation of the quality of glycemic control and form the basis for therapy adjustment.

For all persons with diabetes who are undergoing intensive insulin therapy (ie, three or more injections of insulin per day or treatment with an insulin pump), continuous glucose monitoring (CGM) is strongly recommended. For individuals on insulin therapy for whom success with CGM has been limited (or for those who are unable or unwilling to use CGM), structured self-monitoring of blood glucose (SMBG) is recommended. CGM is recommended for all individuals with problematic hypoglycemia (frequent/severe hypoglycemia, nocturnal hypoglycemia, hypoglycemia unawareness), for children/adolescents with type 1 diabetes; for pregnant women with type 1 or type 2 diabetes treated with intensive insulin therapy, and for women with gestational diabetes mellitus (GDM) on insulin therapy. CGM may be recommended for women with GDM who are not undergoing insulin treatment and for individuals with type 2 diabetes who are undergoing less intensive insulin therapy.

For persons with diabetes who have problematic hypoglycemia (frequent/severe hypoglycemia, nocturnal hypoglycemia, hypoglycemia unawareness) and need predictive alarms/alerts, real-time CGM (rtCGM) should be recommended over intermittently scanned CGM (isCGM). Consideration should also be given, however, to a patient’s lifestyle and to other factors.

The management of persons with diabetes who meet one or more of the following criteria should entail the use of diagnostic/professional CGM:

Newly diagnosed with diabetes mellitus
Not using CGM
No access to personal CGM, despite having problematic hypoglycemia
Persons with type 2 diabetes who, although undergoing non-insulin therapy, would derive educational benefit from episodic use of CGM
Persons who, before committing to daily use of CGM, wish to know more about it

Importantly, continued adjunctive use of SMBG must be employed by patients who are using “masked” or “blinded” diagnostic/professional CGM, to assist in daily diabetes self-care.

Persons with diabetes in whom glycemic targets are being reached with minimal TBR, infrequent episodes of symptomatic hypoglycemia are being reported, and SMBG is being used on a regular basis (at least 4 times daily for persons with type 1 diabetes) could employ an insulin pump without CGM.

In all persons with diabetes who are undergoing intensive insulin management but who prefer to forgo the use of automated insulin suspension/dosing systems or have no access to them, use of an insulin pump with CGM or a sensor-augmented pump (SAP) is recommended.

To reduce hypoglycemia’s severity and duration in persons with type 1 diabetes, low-glucose suspend (LGS) is strongly recommended; for mitigation of hypoglycemia in these patients, predictive low-glucose suspend (PLGS) is strongly recommended.

It is strongly recommended that all persons with type 1 diabetes use automated insulin dosing (AID) systems; these have been shown to raise the TIR, especially in the overnight period, without increasing the hypoglycemia risk.

In persons with diabetes who are hospitalized but are suffering no cognitive impairment, consideration should be given to the continuation of CGM and/or continuous subcutaneous insulin injection (CSII) (insulin pump, SAP, LGS/PLGS). The presence of a family member who is knowledgeable and educated in the use of these devices or the availability of a specialized inpatient diabetes team for advice and support is ideal in such situations.

To enable persons aged 65 years or older with insulin-requiring diabetes to improve glycemic control, reduce episodes of severe hypoglycemia, and improve quality of life, use of rtCGM is recommended. Owing, however, to this population’s increased comorbidities and lowered capacity to detect and counter-regulate against severe hypoglycemia, glycemic goals should be individualized.

As a means of tracking glucose before, during, and after exercise in persons with diabetes; monitoring the glycemic response to exercise; and helping to direct insulin and carbohydrate consumption to prevent the development of hypoglycemia and hyperglycemia, clinicians should prescribe CGM.

It is strongly recommended that telemedicine be used in the treatment of diabetes, provision of diabetes education, remote monitoring of glucose and/or insulin data, and improvement of diabetes-related outcomes/control.

As a means of teaching/reinforcing diabetes self-management skills, encouraging engagement, and supporting/encouraging desired health behaviors, clinically validated smartphone applications should be recommended to persons with diabetes.

Comprehensive training in the proper use and care of insulin delivery technology should be provided to all persons with diabetes using that equipment.

It is strongly recommended that, in the absence of pump therapy, FDA-cleared and clinically validated smartphone bolus calculators be used to reduce the frequency of hypoglycemia or severe postprandial hyperglycemia.

Medication

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Author

Romesh Khardori, MD, PhD, FACP (Retired) Professor, Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for Physician Leadership, American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society, International Society for Clinical Densitometry, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgements

Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy ofSciences,and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Aneela Naureen Hussain, MD, FAAFM Assistant Professor, Department of Family Medicine, State University of New York Downstate Medical Center; Consulting Staff, Department of Family Medicine, University Hospital of Brooklyn

Aneela Naureen Hussain, MD, FAAFM is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, American Medical Women's Association, Medical Society of the State of New York, and Society of Teachers of Family Medicine

Disclosure: Nothing to disclose.

Anne L Peters, MD, CDE Director of Clinical Diabetes Programs, Professor, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California, Los Angeles County/University of Southern California Medical Center

Anne L Peters, MD, CDE is a member of the following medical societies: American College of Physicians and American Diabetes Association

Disclosure: Amylin Honoraria Speaking and teaching; AstraZeneca Consulting fee Consulting; Lilly Consulting fee Consulting; Takeda Consulting fee Consulting; Bristol Myers Squibb Honoraria Speaking and teaching; NovoNordisk Consulting fee Consulting; Medtronic Minimed Consulting fee Consulting; Dexcom Honoraria Speaking and teaching; Roche Honoraria Speaking and teaching

Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Miriam T Vincent, MD, PhD Professor and Chair, Department of Family Practice, State University of New York Downstate Medical Center

Miriam T Vincent, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association for the Advancement of Science, Medical Society of the State of New York, North American Primary Care Research Group, Sigma Xi, and Society of Teachers of Family Medicine

Disclosure: Joslin Diabetes Group, Harvard Honoraria Speaking and teaching

Scott R Votey, MD Director of Emergency Medicine Residency, Ronald Reagan UCLA Medical Center; Professor of Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine

Scott R Votey, MD is a member of the following medical societies: Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Frederick H Ziel, MD Associate Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Physician-In-Charge, Endocrinology/Diabetes Center, Director of Medical Education, Kaiser Permanente Woodland Hills; Chair of Endocrinology, Co-Chair of Diabetes Complete Care Program, Southern California Permanente Medical Group

Frederick H Ziel, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Federation for Medical Research, American Medical Association, American Society for Bone and Mineral Research, California Medical Association, Endocrine Society, andInternational Society for Clinical Densitometry

Disclosure: Nothing to disclose.