Comprehensive Medical Evaluation and Assessment of

Comorbidities: Standards of

Medical Care in Diabetesd2019

Diabetes Care 2019;42(Suppl. 1):S34–S45|https://doi.org/10.2337/dc19-S004

The American Diabetes Association (ADA)“Standards of Medical Care in Diabetes”

includes ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence- grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

PATIENT-CENTERED COLLABORATIVE CARE Recommendations

4.1 A patient-centered communication style that uses person-centered and strength-based language and active listening, elicits patient preferences and beliefs, and assesses literacy, numeracy, and potential barriers to care should be used to optimize patient health outcomes and health-related quality of life.B

4.2 Diabetes care should be managed by a multidisciplinary team that may draw from primary care physicians, subspecialty physicians, nurse practitioners, physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals.E

A successful medical evaluation depends on beneficial interactions between the patient and the care team. The Chronic Care Model (1–3) (see Section 1“Improving Care and Promoting Health in Populations”) is a patient-centered approach to care that requires a close working relationship between the patient and clinicians involved in treatment planning. People with diabetes should receive health care from an interdisciplinary team that may include physicians, nurse practitioners, physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals. Individuals with diabetes must assume an active role in their care. The patient, family or support people, physicians, and health care team should together formulate the management plan, which includes lifestyle management (see Section 5“Lifestyle Management”).

The goals of treatment for diabetes are to prevent or delay complications and maintain quality of life (Fig. 4.1). Treatment goals and plans should be created

Suggested citation: American Diabetes Associa- tion. 4. Comprehensive medical evaluation and assessment of comorbidities: Standards of Medical Care in Diabetesd2019. Diabetes Care 2019;42(Suppl. 1):S34–S45

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S34 Diabetes Care Volume 42, Supplement 1, January 2019

4.MEDICALEVALUATIONANDCOMORBIDITIES

with the patients based on their individ- ual preferences, values, and goals. The management plan should take into account the patient’s age, cognitive abil- ities, school/work schedule and condi- tions, health beliefs, support systems, eating patterns, physical activity, social situation,financial concerns, cultural fac- tors, literacy and numeracy (mathemat- ical literacy), diabetes complications and duration of disease, comorbidities, health priorities, other medical condi- tions, preferences for care, and life expectancy. Various strategies and tech- niques should be used to support patients’ self-management efforts, in- cluding providing education on problem- solving skills for all aspects of diabetes management.

Provider communications with patients and families should acknowledge that multiple factors impact glycemic manage- ment but also emphasize that collab- oratively developed treatment plans and a healthy lifestyle can significantly improve disease outcomes and well- being (4–7). Thus, the goal of provider- patient communication is to establish a collaborative relationship and to

assess and address self-management barriers without blaming patients for

“noncompliance” or “nonadherence” when the outcomes of self-management are not optimal (8). The familiar terms

“noncompliance” and “nonadherence” denote a passive, obedient role for a person with diabetes in“following doc- tor’s orders” that is at odds with the active role people with diabetes take in directing the day-to-day decision mak- ing, planning, monitoring, evaluation, and problem-solving involved in diabetes self-management. Using a nonjudg- mental approach that normalizes peri- odic lapses in self-management may help minimize patients’resistance to report- ing problems with self-management.

Empathizing and using active listening techniques, such as open-ended ques- tions, reflective statements, and summa- rizing what the patient said, can help facilitate communication. Patients’per- ceptions about their own ability, or self- efficacy, to self-manage diabetes are one important psychosocial factor related to improved diabetes self-management and treatment outcomes in diabetes (9– 13) and should be a target of ongoing

assessment, patient education, and treatment planning.

Language has a strong impact on per- ceptions and behavior. The use of em- powering language in diabetes care and education can help to inform and motivate people, yet language that shames and judges may undermine this effort. The American Diabetes Association (ADA) and American Association of Diabetes Educa- tors consensus report,“The Use of Lan- guage in Diabetes Care and Education,” provides the authors’expert opinion re- garding the use of language by health care professionals when speaking or writing about diabetes for people with diabetes or for professional audiences (14). Although further research is needed to address the impact of language on diabetes outcomes, the report includesfive key consensus recommendations for language use:

○ Use language that is neutral, nonjudg- mental, and based on facts, actions, or physiology/biology.

○ Use language that is free from stigma.

○ Use language that is strength based, respectful, and inclusive and that im- parts hope.

Figure 4.1—Decision cycle for patient-centered glycemic management in type 2 diabetes. Adapted from Davies et al. (119).

care.diabetesjournals.org Comprehensive Medical Evaluation and Assessment of Comorbidities S35

○ Use language that fosters collabora- tion between patients and providers.

○ Use language that is person centered (e.g., “person with diabetes” is pre- ferred over“diabetic”).

COMPREHENSIVE MEDICAL EVALUATION

Recommendations

4.3 A complete medical evaluation should be performed at the ini- tial visit to:

○ Confirm the diagnosis and classify diabetes.B

○ Evaluate for diabetes complica- tions and potential comorbid conditions.B

○ Review previous treatment and risk factor control in patients with established diabetes.B

○ Begin patient engagement in the formulation of a care manage- ment plan.B

○ Develop a plan for continuing care.B

4.4 A follow-up visit should include most components of the initial comprehensive medical evalua- tion including: interval medical history, assessment of medication- taking behavior and intolerance/

side effects, physical examina- tion, laboratory evaluation as ap- propriate to assess attainment of A1C and metabolic targets, and assessment of risk for compli- cations, diabetes self-management behaviors, nutrition, psychosocial health, and the need for referrals, immunizations, or other routine health maintenance screening.B 4.5 Ongoing management should be guided by the assessment of di- abetes complications and shared decision making to set therapeu- tic goals.B

4.6 The 10-year risk of afirst athero- sclerotic cardiovascular disease event should be assessed using the race- and sex-specific Pooled Cohort Equations to better strat- ify atherosclerotic cardiovascular disease risk.B

The comprehensive medical evaluation includes the initial and follow-up evalua- tions, assessment of complications, psy- chosocial assessment, management of comorbid conditions, and engagement

of the patient throughout the process.

While a comprehensive list is provided in Table 4.1, in clinical practice, the provider may need to prioritize the com- ponents of the medical evaluation given the available resources and time. The goal is to provide the health care team information to optimally support a pa- tient. In addition to the medical history, physical examination, and laboratory tests, providers should assess diabetes self-management behaviors, nutrition, and psychosocial health (see Section 5

“Lifestyle Management”) and give guid- ance on routine immunizations. The assessment of sleep pattern and dura- tion should be considered; a recent meta- analysis found that poor sleep quality, short sleep, and long sleep were associ- ated with higher A1C in people with type 2 diabetes (15). Interval follow-up visits should occur at least every 3–6 months, individualized to the patient, and then annually.

Lifestyle management and psychoso- cial care are the cornerstones of diabe- tes management. Patients should be referred for diabetes self-management education and support, medical nutri- tion therapy, and assessment of psy- chosocial/emotional health concerns if indicated. Patients should receive rec- ommended preventive care services (e.g., immunizations, cancer screening, etc.), smoking cessation counseling, and ophthalmological, dental, and podiatric referrals.

The assessment of risk of acute and chronic diabetes complications and treat- ment planning are key components of initial and follow-up visits (Table 4.2).

The risk of atherosclerotic cardiovascu- lar disease and heart failure (Section 10 “Cardiovascular Disease and Risk Management”), chronic kidney disease staging (Section 11 “Microvascular Complications and Foot Care”), and risk of treatment-associated hypogly- cemia (Table 4.3) should be used to individualize targets for glycemia (Sec- tion 6“Glycemic Targets”), blood pres- sure, and lipids and to select specific glucose-lowering medication (Section 9

“Pharmacologic Approaches to Glycemic Treatment”), antihypertension medica- tion, or statin treatment intensity.

Additional referrals should be ar- ranged as necessary (Table 4.4). Clini- cians should ensure that individuals with diabetes are appropriately screened

for complications and comorbidities. Dis- cussing and implementing an approach to glycemic control with the patient is a part, not the sole goal, of the patient encounter.

Immunizations Recommendations

4.7 Provide routinely recommended vaccinations for children and adults with diabetes by age.C 4.8 Annual vaccination against in-

fluenza is recommended for all people $6 months of age,es- peciallythose with diabetes.C 4.9 Vaccination against pneumo- coccal disease, including pneu- mococcal pneumonia, with 13-valent pneumococcal conju- gate vaccine (PCV13) is recom- mended for children before age 2 years. People with diabetes ages 2 through 64 years should also receive 23-valent pneu- mococcal polysaccharide vaccine (PPSV23). At age $65 years, regardless of vaccination his- tory, additional PPSV23 vacci- nation is necessary.C

4.10 Administer a 2- or 3-dose series of hepatitis B vaccine, depend- ing on the vaccine, to unvacci- nated adults with diabetes ages 18 through 59 years.C 4.11 Consider administering 3-dose

series of hepatitis B vaccine to unvaccinated adults with dia- betes ages$60 years.C Children and adults with diabetes should receive vaccinations according to age-appropriate recommendations (16,17). The child and adolescent (#18 years of age) vaccination schedule is available at www.cdc.gov/vaccines/

schedules/hcp/imz/child-adolescent.html, and the adult ($19 years of age) vacci- nation schedule is available at www.cdc .gov/vaccines/schedules/hcp/imz/adult .html. These immunization schedules in- clude vaccination schedules specifically for children, adolescents, and adults with diabetes.

People with diabetes are at higher risk for hepatitis B infection and are more likely to develop complications from influenza and pneumococcal dis- ease. The Centers for Disease Control and Prevention (CDC) Advisory Committee

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Continued on p. S38

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on Immunization Practices (ACIP) recom- mends influenza, pneumococcal, and hepatitis B vaccinations specifically for people with diabetes. Vaccinations against tetanus-diphtheria-pertussis, measles-mumps-rubella, human papillo- mavirus, and shingles are also important for adults with diabetes, as they are for the general population.

Influenza

Influenza is a common, preventable in- fectious disease associated with high mortality and morbidity in vulnerable populations including the young and

the elderly and people with chronic dis- eases. Influenza vaccination in people with diabetes has been found to signif- icantly reduce influenza and diabetes- related hospital admissions (18).

Pneumococcal Pneumonia

Like influenza, pneumococcal pneumo- nia is a common, preventable disease.

People with diabetes are at increased risk for the bacteremic form of pneu- mococcal infection and have been re- ported to have a high risk of nosocomial bacteremia, with a mortality rate as high as 50% (19). The ADA endorses

recommendations from the CDC ACIP that adults age$65 years, who are at higher risk for pneumococcal disease, receive an additional 23-valent pneumo- coccal polysaccharide vaccine (PPSV23), regardless of prior pneumococcal vacci- nation history. See detailed recommen- dations at www.cdc.gov/vaccines/hcp/

acip-recs/vacc-specific/pneumo.html.

Hepatitis B

Compared with the general population, people with type 1 or type 2 diabetes have higher rates of hepatitis B. This may be due to contact with infected blood

S38 Comprehensive Medical Evaluation and Assessment of Comorbidities Diabetes Care Volume 42, Supplement 1, January 2019

or through improper equipment use (glucose monitoring devices or infected needles). Because of the higher likeli- hood of transmission, hepatitis B vac- cine is recommended for adults with diabetes age,60 years. For adults age

$60 years, hepatitis B vaccine may be administered at the discretion of the treating clinician based on the patient’s likelihood of acquiring hepatitis B infection.

ASSESSMENT OF COMORBIDITIES Besides assessing diabetes-related com- plications, clinicians and their patients need to be aware of common comorbid- ities that affect people with diabetes and may complicate management (20–24). Diabetes comorbidities are con- ditions that affect people with diabetes more often than age-matched people without diabetes. This section includes many of the common comorbidities ob- served in patients with diabetes but is not necessarily inclusive of all the conditions that have been reported.

Autoimmune Diseases Recommendation

4.12 Consider screening patients with type 1 diabetes for auto- immune thyroid disease and celiac disease soon after diag- nosis. B

People with type 1 diabetes are at in- creased risk for other autoimmune diseases including thyroid disease, pri- mary adrenal insufficiency, celiac disease, autoimmune gastritis, autoimmune hep- atitis, dermatomyositis, and myasthenia gravis (25–27). Type 1 diabetes may also occur with other autoimmune diseases in the context of specific genetic dis- orders or polyglandular autoimmune syn- dromes (28). In autoimmune diseases, the immune system fails to maintain self-tolerance to specific peptides within target organs. It is likely that many factors trigger autoimmune disease; however, common triggering factors are known for only some autoimmune condi- tions (i.e., gliadin peptides in celiac

disease) (see Section 13 “Children and Adolescents”).

Cancer

Diabetes is associated with increased risk of cancers of the liver, pancreas, endometrium, colon/rectum, breast, and bladder (29). The association may result from shared risk factors between type 2 diabetes and cancer (older age, obesity, and physical inactivity) but may also be due to diabetes-related factors (30), such as underlying disease physiol- ogy or diabetes treatments, although evidence for these links is scarce. Patients with diabetes should be encouraged to undergo recommended age- and sex- appropriate cancer screenings and to reduce their modifiable cancer risk fac- tors (obesity, physical inactivity, and smoking). New onset of atypical diabetes (lean body habitus, negative family his- tory) in a middle-aged or older patient may precede the diagnosis of pancre- atic adenocarcinoma (31). However, in the absence of other symptoms (e.g., weight loss, abdominal pain), routine screening of all such patients is not currently recommended.

Cognitive Impairment/Dementia Recommendation

4.13 In people with a history of cog- nitive impairment/dementia, in- tensive glucose control cannot be expected to remediate def- icits. Treatment should be tailored to avoid significant hypoglycemia. B

Diabetes is associated with a significantly increased risk and rate of cognitive de- cline and an increased risk of demen- tia (32,33). A recent meta-analysis of prospective observational studies in peo- ple with diabetes showed 73% in- creased risk of all types of dementia, 56% increased risk of Alzheimer de- mentia, and 127% increased risk of vascular dementia compared with in- dividuals without diabetes (34). The reverse is also true: people with Alz- heimer dementia are more likely to develop diabetes than people without Alzheimer dementia. In a 15-year pro- spective study of community-dwelling people.60 years of age, the presence of diabetes at baseline significantly increased the age- and sex-adjusted

Table 4.3—Assessment of hypoglycemia risk

Factors that increase risk of treatment-associated hypoglycemia

cUse of insulin or insulin secretagogues (i.e., sulfonylureas, meglitinides)

cImpaired kidney or hepatic function

cLonger duration of diabetes

cFrailty and older age

cCognitive impairment

cImpaired counterregulatory response, hypoglycemia unawareness

cPhysical or intellectual disability that may impair behavioral response to hypoglycemia

cAlcohol use

cPolypharmacy (especially ACE inhibitors, angiotensin receptor blockers, nonselective b-blockers)

See references 114–118.

Table 4.2—Assessment and treatment plan*

Assess risk of diabetes complications

cASCVD and heart failure history

cASCVD risk factors (seeTable 10.2) and 10-year ASCVD risk assessment

cStaging of chronic kidney disease (seeTable 11.1)

cHypoglycemia risk (Table 4.3) Goal setting

cSet A1C/blood glucose target

cIf hypertension present, establish blood pressure target

cDiabetes self-management goals (e.g., monitoring frequency) Therapeutic treatment plan

cLifestyle management

cPharmacologic therapy (glucose lowering)

cPharmacologic therapy (cardiovascular disease risk factors and renal)

cUse of glucose monitoring and insulin delivery devices

cReferral to diabetes education and medical specialists (as needed)

ASCVD, atherosclerotic cardiovascular disease. *Assessment and treatment planning is an essential component of initial and all follow-up visits.

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incidence of all-cause dementia, Alz- heimer dementia, and vascular demen- tia compared with rates in those with normal glucose tolerance (35).

Hyperglycemia

In those with type 2 diabetes, the degree and duration of hyperglycemia are related todementia.Morerapidcognitivedeclineis associated with both increased A1C and longer duration of diabetes (34). The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study found that each 1% higher A1C level was associated with lower cog- nitive function in individuals with type 2 diabetes (36). However, the ACCORD study found no difference in cognitive outcomes in participants randomly assigned to intensive and standard glycemic control, supporting the recom- mendation that intensive glucose con- trol should not be advised for the improvement of cognitive function in individuals with type 2 diabetes (37).

Hypoglycemia

In type 2 diabetes, severe hypoglycemia is associated with reduced cognitive function, and those with poor cognitive function have more severe hypoglyce- mia. In a long-term study of older pa- tients with type 2 diabetes, individuals with one or more recorded episode of severe hypoglycemia had a stepwise in- crease in risk of dementia (38). Likewise, the ACCORD trial found that as cog- nitive function decreased, the risk of severe hypoglycemia increased (39).

Tailoring glycemic therapy may help to prevent hypoglycemia in individuals with cognitive dysfunction.

Nutrition

In one study, adherence to the Mediter- ranean diet correlated with improved cognitive function (40). However, a re- cent Cochrane review found insufficient

evidence to recommend any dietary change for the prevention or treatment of cognitive dysfunction (41).

Statins

A systematic review has reported that data do not support an adverse effect of statins on cognition (42). The U.S. Food and Drug Administration postmarket- ing surveillance databases have also revealed a low reporting rate for cog- nitive-related adverse events, including cognitive dysfunction or dementia, with statin therapy, similar to rates seen with other commonly prescribed cardiovas- cular medications (42). Therefore, fear of cognitive decline should not be a bar- rier to statin use in individuals with di- abetes and a high risk for cardiovascular disease.

Nonalcoholic Fatty Liver Disease Recommendation

4.14 Patients with type 2 diabetes or prediabetes and elevated liver enzymes (alanine aminotrans- ferase) or fatty liver on ultra- sound should be evaluated for presence of nonalcoholic steato- hepatitis and liverfibrosis.C Diabetes is associated with the develop- ment of nonalcoholic fatty liver disease, including its more severe manifesta- tions of nonalcoholic steatohepatitis, liver fibrosis, cirrhosis, and hepatocel- lular carcinoma (43). Elevations of he- patic transaminase concentrations are associated with higher BMI, waist cir- cumference, and triglyceride levels and lower HDL cholesterol levels. Noninva- sive tests, such as elastography or fi- brosis biomarkers, may be used to assess risk of fibrosis, but referral to a liver specialist and liver biopsy may be required for definitive diagnosis (43a). Interventions that improve met- abolic abnormalities in patients with diabetes (weight loss, glycemic control, and treatment with specific drugs for hyperglycemia or dyslipidemia) are also beneficial for fatty liver disease (44,45).

Pioglitazone and vitamin E treatment of biopsy-proven nonalcoholic steatohe- patitis have been shown to improve liver histology, but effects on longer- term clinical outcomes are not known (46,47). Treatment with liraglutide and with sodium–glucose cotransporter 2 in- hibitors (dapagliflozin and empagliflozin)

has also shown some promise in pre- liminary studies, although benefits may be mediated, at least in part, by weight loss (48–50).

Pancreatitis Recommendation

4.15 Islet autotransplantation should be considered for patients re- quiring total pancreatectomy for medically refractory chronic pancreatitis to prevent postsur- gical diabetes.C

Diabetes is linked to diseases of the exocrine pancreas such as pancreatitis, which may disrupt the global architecture or physiology of the pancreas, often re- sulting in both exocrine and endocrine dysfunction. Up to half of patients with diabetes may have impaired exocrine pan- creas function (51). People with diabetes are at an approximately twofold higher risk of developing acute pancreatitis (52).

Conversely, prediabetes and/or dia- betes has been found to develop in ap- proximately one-third of patients after an episode of acute pancreatitis (53), thus the relationship is likely bidirec- tional. Postpancreatitis diabetes may include either new-onset disease or previ- ously unrecognized diabetes (54). Studies of patients treated with incretin-based therapies for diabetes have also reported that pancreatitis may occur more fre- quently with these medications, but re- sults have been mixed (55,56).

Islet autotransplantation should be considered for patients requiring total pancreatectomy for medically refractory chronic pancreatitis to prevent postsur- gical diabetes. Approximately one-third of patients undergoing total pancreatec- tomy with islet autotransplantation are insulin free 1 year postoperatively, and observational studies from different centers have demonstrated islet graft function up to a decade after the surgery in some patients (57–61). Both patient and disease factors should be carefully considered when deciding the indica- tions and timing of this surgery. Surger- ies should be performed in skilled facilities that have demonstrated exper- tise in islet autotransplantation.

Fractures

Age-specific hip fracture risk is signifi- cantly increased in people with both

Table 4.4—Referrals for initial care management

cEye care professional for annual dilated eye exam

cFamily planning for women of reproductive age

cRegistered dietitian for medical nutrition therapy

cDiabetes self-management education and support

cDentist for comprehensive dental and periodontal examination

cMental health professional, if indicated

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No documento Standards of Medical Care in Diabetes — 2019 (páginas 42-54)