all topics are updated as new evidence becomes available and ou1.docx

8/9/2019 All topics are updated as new evidence becomes available and ou1.docx

1/23

All topics are updated as new evidence becomes available and our peer review process iscomplete.Literature review current through: Feb 2015. | This topic last updated: Feb 26, 2015.

INTRODUCTION — The estimated overall prevalence o diabetes amon! adults in the "nited

#tates ran!es rom 5.$ to 12.% percent &median $.' percent( )1,2*. +owever, because o the

associated microvascular and macrovascular disease, diabetes accounts or almost 1' percent o"nited #tates health care ependitures, at least one-hal o which are related to complications such

as mocardial inarction &/(, stroe, end-sta!e renal disease, retinopath, and oot ulcers )*.

3umerous actors, in addition to directl related medical complications, contribute to the impact o

diabetes on 4ualit o lie and economics. iabetes is associated with a hi!h prevalence o

depression )'* and adversel impacts emploment, absenteeism, and wor productivit )5*.

This review will provide an overview o the medical care or patients with diabetes & table 1(. The

mana!ement approach is consistent with !uidelines rom the American iabetes Association &AA(

or health maintenance in patients with diabetes, which are published earl )6*. onsensus

recommendations or the mana!ement o !lcemia in tpe 2 diabetes were published in 2006 and

are updated re!ularl. etailed discussions relatin! to screenin!, dia!nosis, and mana!ement ohper!lcemia are discussed separatel. ee 7#creenin! or tpe 2 diabetes mellitus7 and 7linical

presentation and dia!nosis o diabetes mellitus in adults7 and 7nitial mana!ement o blood !lucose

in adults with tpe 2 diabetes mellitus7 and 7/ana!ement o persistent hper!lcemia in tpe 2

diabetes mellitus7.(

EVALUATION

Initial — 8atients with newl dia!nosed diabetes re4uire a histor and phsical eamination to

assess the characteristics o onset o diabetes &asmptomatic laborator indin! or smptomatic

poluria and poldipsia(, nutrition and wei!ht histor, phsical activit, cardiovascular ris actors,

histor o diabetes-related complications, hpo!lcemic episodes, diabetic etoacidosis &9A(

re4uenc &tpe 1 diabetes onl(, and current mana!ement. not measured in the past two to three

months, we measure !lcated hemo!lobin &A1( &see 7:stimation o blood !lucose control in

diabetes mellitus7, section on ;


2/23

ran!e and therap re4uires adustment, and ever si months in patients with stable !lcemic

control who are meetin! A1 !oals. @e measure astin! lipids and urine albumin-to-creatinine ratio

annuall.

/orbidit rom diabetes is a conse4uence o both macrovascular disease &atherosclerosis( and

microvascular disease &retinopath, nephropath, and neuropath(. n tpe 2 diabetes, disease

onset is insidious, and dia!nosis is oten delaed. As a result, diabetic complications ma be

present at the time o dia!nosis o diabetes )B*, and their re4uenc increases over time &i!ure 1(.

>nce present, the pro!ression o these complications can be slowed with interventions such as

a!!ressive mana!ement o !lcemia, blood pressure, and lipids= laser therap or advanced

retinopath= and administration o an an!iotensin-convertin! enCme &A:( inhibitor or an!iotensin

receptor blocer &ADE( or nephropath. ee 7Treatment o lipids &includin!

hpercholesterolemia( in secondar prevention7, section on ;Treatment in diabetes; and 7iabetic

retinopath 8revention and treatment7 and 7/oderatel increased albuminuria &microalbuminuria(

in tpe 1 diabetes mellitus7 and 7/oderatel increased albuminuria &microalbuminuria( in tpe 2

diabetes mellitus7 and 7Treatment o diabetic nephropath7.(

These interventions appear to be reducin! the incidence o several diabetes-related complications,includin! mocardial inarction &/(, stroe, lower-etremit amputation, and end-sta!e renal

disease. n the "nited #tates, the !reatest absolute declines have been reported or acute / and

stroe &between 1%%0 and 2010, %5.6 and 5$.% ewer cases per 10,000 persons per ear or / and

stroe, respectivel( )$*. >ther countries have similarl reported reductions in the rate o

cardiovascular complications and lower etremit amputation )%-11*.

Routine e#e e$a"ination — 8atients with diabetes are at increased ris or visual loss, related

both to reractive errors &correctable visual impairment(, cataracts and !laucoma, which are more

prevalent in persons with diabetes )12,1*, and to retinopath.

Diaetic retinopath# — Decommendations or the tpe and re4uenc o routine ee eaminations

var, based upon the tpe o diabetes mellitus and the presence o speciic ee indin!s &table (

)6*. #erial eaminations are indicated because o the increased incidence o retinopath over time in

patients with either tpe 1 or tpe 2 diabetes &i!ure 2(. #creenin! or diabetic retinopath is

reviewed in detail separatel. ee 7iabetic retinopath #creenin!7.(


3/23

perormed annuall on patients with diabetes to identi ris actors predictive o ulcers and

amputation )6*. Foot problems due to vascular and neurolo!ic disease are a common and important

source o morbidit in diabetic patients. #stematic screenin! eaminations or neuropathic and

vascular involvement o the lower etremities and careul inspection o eet ma substantiall

reduce morbidit rom oot problems. ee 7:valuation o the diabetic oot7.(

The comprehensive oot eamination can be accomplished in the primar care settin! and should

include inspection, assessment o oot pulses, and testin! or loss o protective sensation, as

ollows

IThe sin should be assessed or inte!rit, especiall between the toes and under the

metatarsal heads. The presence o erthema, warmth, or callus ormation ma indicate areas

o tissue dama!e. Eon deormities, oint mobilit, and !ait and balance should also be

assessed.

I#creen or peripheral arter disease b asin! about a histor o claudication and assessin!

the pedal pulses. onsider obtainin! an anle brachial inde as man patients with peripheral

arter disease are asmptomatic. The presence o peripheral arter disease also su!!ests a

hi!h lielihood o cardiovascular disease &J(. ee7:valuation o the diabetic oot7, section

on ;8hsical si!ns o peripheral arter disease; and 73oninvasive dia!nosis o arterial

disease7, section on ;Anle-brachial inde;.(

ITest or loss o protective sensation usin! a #emmes-@einstein 5.0B &10 !( monoilament at

speciic sites to detect loss o sensation in the oot &i!ure (, plus an one o the ollowin!

vibration usin! a 12$-+C tunin! or, pinpric sensation, anle relees, or vibration perception

threshold with a biothesiometer. ee 7:valuation o the diabetic oot7, section on ;#creenin!

tests or peripheral neuropath;.(

IAdvice or prophlactic oot care should be !iven to all patients &see 78atient inormation

Foot care in diabetes mellitus &Eeond the Easics(7(

KAvoid !oin! bareoot, even in the home.

KTest water temperature beore steppin! into a bath.

KTrim toenails to shape o the toe= remove sharp ed!es with a nail ile. o not cut

cuticles.

K@ash and chec eet dail.

K#hoes should be snu! but not ti!ht and customiCed i eet are misshapen or have

ulcers.

K#ocs should it and be chan!ed dail.

8atients who ma have neuropath, based on abnormal results rom a microilament and one other

test, or who have calluses or other oot deormities should be reerred to clinicians with epertise in

diabetic oot care &podiatrist, nurse, diabetes oot clinic, or other, dependin! on available localresources(.

&creening %or increased urinar# alu"in e$cretion — /easurement o the urine albumin-to-

creatinine ratio in an untimed urinar sample is the preerred screenin! strate! or moderatel

increased albuminuria in all patients with diabetes, and should be repeated earl. #creenin! or

increased urinar albumin ecretion can be deerred or ive ears ater the onset o disease in

patients with tpe 1 diabetes because increased albumin ecretion is uncommon beore this time=

screenin! should be!in at dia!nosis in patients with tpe 2 diabetes because man have had

http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/6http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_linkhttp://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_linkhttp://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_link&anchor=H11#H11http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_link&anchor=H11#H11http://www.uptodate.com/contents/noninvasive-diagnosis-of-arterial-disease?source=see_link&anchor=H58544655#H58544655http://www.uptodate.com/contents/noninvasive-diagnosis-of-arterial-disease?source=see_link&anchor=H58544655#H58544655http://www.uptodate.com/contents/noninvasive-diagnosis-of-arterial-disease?source=see_link&anchor=H58544655#H58544655http://www.uptodate.com/contents/image?imageKey=ENDO%2F52481&topicKey=ENDO%2F1750&rank=1~150&source=see_link&search=diabetes+mellitus+criterios++2015http://www.uptodate.com/contents/image?imageKey=ENDO%2F52481&topicKey=ENDO%2F1750&rank=1~150&source=see_link&search=diabetes+mellitus+criterios++2015http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_link&anchor=H7#H7http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_link&anchor=H7#H7http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_link&anchor=H7#H7http://www.uptodate.com/contents/foot-care-in-diabetes-mellitus-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/foot-care-in-diabetes-mellitus-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/6http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_linkhttp://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_link&anchor=H11#H11http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_link&anchor=H11#H11http://www.uptodate.com/contents/noninvasive-diagnosis-of-arterial-disease?source=see_link&anchor=H58544655#H58544655http://www.uptodate.com/contents/noninvasive-diagnosis-of-arterial-disease?source=see_link&anchor=H58544655#H58544655http://www.uptodate.com/contents/image?imageKey=ENDO%2F52481&topicKey=ENDO%2F1750&rank=1~150&source=see_link&search=diabetes+mellitus+criterios++2015http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_link&anchor=H7#H7http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot?source=see_link&anchor=H7#H7http://www.uptodate.com/contents/foot-care-in-diabetes-mellitus-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/foot-care-in-diabetes-mellitus-beyond-the-basics?source=see_link


4/23

diabetes or several ears beore dia!nosis )6*. Abnormal results should be repeated at least two or

three times over a three to si-month period because o the lar!e number o alse positives that can

occur )15*. :stablishin! the dia!nosis o increased urinar albumin ecretion re4uires the

demonstration o a persistent &at least two abnormal tests( elevation in albumin ecretion. Fever,

eercise, heart ailure, and poor !lcemic control are amon! the actors that can cause transient

microalbuminuria )15*.

ncreased urinar protein ecretion is the earliest clinical indin! o diabetic nephropath. The

routine urine dipstic, however, is a relativel insensitive marer or proteinuria, not detectin! protein

until ecretion eceeds 00 to 500m!Hda. "sin! a speciic assa or albumin is a more sensitive

techni4ue. The normal rate o albumin ecretion is less than 0 m!Hda &20 mc!Hmin(= persistent

values between 0 and 00 m!Hda &20 to 200 mc!Hmin( in a patient with diabetes is called

persistent albuminuria or moderatel increased albuminuria &historicall called microalbuminuria(

and is usuall indicative o diabetic nephropath &unless there is some other coeistent renal

disease( )16*. Jalues above 00 m!Hda &200 mc!Hmin( are considered to represent severel

increased albuminuria &the new terminolo! or what was ormerl called macroalbuminuria( and

which is also called overt proteinuria, clinical renal disease, or dipstic positive proteinuria.

ee 7/oderatel increased albuminuria &microalbuminuria( in tpe 1 diabetes

mellitus7 and7/oderatel increased albuminuria &microalbuminuria( in tpe 2 diabetes mellitus7.(

The availabilit o eective therap or diabetic nephropath with A: inhibitors and ADEs is the

rationale or earl screenin! o all patients with either tpe 1 or tpe 2 diabetes or increased

albumin ecretion &i!ure 'A-E(. >nce a patient with diabetes is tain! an A: or an ADE or

increased urinar albumin ecretion, the value o continued earl monitorin! o the urine albumin-

to-creatinine ratio is uncertain )1B*. The treatment o increased urinar albumin ecretion and

diabetic nephropath is reviewed in detail elsewhere. ee 7/oderatel increased albuminuria

&microalbuminuria( in tpe 2 diabetes mellitus7, section on ;Treatment; and 7/oderatel increased

albuminuria &microalbuminuria( in tpe 1 diabetes mellitus7, section on ;Treatment; and 7Treatment

o diabetic nephropath7.(

&creening %or coronar# heart disease — @e perorm an annual assessment o ris criteria &blood

pressure, astin! lipid proile, smoin! histor( to identi patients at hi!h ris or coronar heart

disease &+( who mi!ht beneit rom interventions such as aspirin, A: inhibitors, and statin

therap. @e no lon!er recommend that these criteria be used to identi patients or stress testin!

)6*. @e do not routinel perorm eercise stress testin! in asmptomatic patients with diabetes.

8atients with diabetes have an increased ris or atherosclerosis due both to diabetes and to the

re4uent presence o other ris actors. Furthermore, diabetic patients with + are more liel to

be asmptomatic or have atpical smptoms than nondiabetic patients with + &see 78revalence

o and ris actors or coronar heart disease in diabetes mellitus7, section on ;#ilent ischemia and

inarction;(. espite the re4uenc o silent ischemia, however, it has not been proven thatidentiin! asmptomatic disease or providin! earl intervention will improve outcomes in this

population. n addition, + ris actors &dslipidemia, hpertension, smoin!, positive amil

histor o earl coronar disease, and presence o increased urinar albumin ecretion( )6* do not

predict the lielihood o havin! ischemic indin!s on stress testin! or coronar an!io!raph )1$,1%*.

For sedentar adults &a!e L50 ears( with diabetes who are be!innin! an eercise pro!ram, we

tpicall perorm a phsical eamination and a restin! electrocardio!ram &:


5/23

J ris actors should be treated &see;Elood pressure control; below and ;slipidemia; below(.

There are no randomiCed trial data to support the routine perormance o eercise stress testin! in

asmptomatic patients with diabetes who are plannin! to be!in an eercise pro!ram )20,21*. The

decision to perorm stress testin! prior to be!innin! an eercise pro!ram should be individualiCed.

@e do not tpicall perorm eercise stress testin! in asmptomatic patients as lon! as the are

be!innin! a !entle eercise pro!ram with !radual pro!ression as tolerated. +owever, the increased

ris or asmptomatic coronar arter disease in those with diabetes and other ris actors su!!ests

that an eercise tolerance test be considered prior to chan!in! eercise levels in patients with

diabetes who also have peripheral or carotid or coronar arter disease. ee7#creenin! or

coronar heart disease in patients with diabetes mellitus7.(

The evaluation and treatment o diabetic patients with nown + is reviewed in detail elsewhere.

ee 7Treatment o acute mocardial inarction in diabetes mellitus7 and 7oronar arter

revasculariCation in patients with diabetes mellitus and multivessel coronar arter disease7.(

Co"orid conditions — Adults with tpe 2 diabetes are at ris or comorbidities other than

obesit, hpertension, and dslipidemia. These disorders, which ma be present at dia!nosis or

ma develop over time, include hearin! impairment, sleep apnea, att liver disease, periodontal

disease, co!nitive impairment, depression, and ractures )6*. For patients with si!ns or smptoms o

these conditions, additional assessment is warranted. Annual eamination b a dentist is

recommended in both dentate and non-dentate diabetic patients )22*. ee 7:tiolo! o hearin! loss

in adults7and 7>verview o obstructive sleep apnea in adults7 and 7:pidemiolo!, clinical eatures,

and dia!nosis o nonalcoholic att liver disease in adults7 and 7


6/23

dela in microvascular complications with the ris o hpo!lcemia. A reasonable !oal o therap

mi!ht be an A1 value o NB.0 percent or most patients &usin! an assa ali!ned to the iabetes

ontrol and omplications Trial )T* in which the upper limit o normal is 6.0 percent( &calculator

1(.


7/23

Iietar modiication

I:ercise

I@ei!ht reduction

n addition to improvin! !lcemic control, these chan!es in liestle also slow pro!ression o

impaired !lucose tolerance to overt diabetes )$* &see 78revention o tpe 2 diabetes mellitus7(. iet

and eercise are important components o therap in patients with tpe 1 diabetes. ee 73utritional

considerations in tpe 1 diabetes mellitus7 and 73utritional considerations in tpe 2 diabetes

mellitus7 and 7:ects o eercise in adults with diabetes mellitus7.(

#ur!ical treatment o obese patients with diabetes results in a lar!e de!ree o sustained wei!ht loss

and, in parallel, the lar!est improvements in blood !lucose control &see 7/ana!ement o persistent

hper!lcemia in tpe 2 diabetes mellitus7, section on ;#ur!ical treatment o obesit;(.

8harmacotherap or wei!ht loss ma also be used or patients with tpe 2 diabetes, but ma not be

eectivel sustained due to side eects. ee 7>besit in adults ru! therap7.(

,har"acologic therap# %or t#pe + diaetes — The AA and the :uropean Association or the

#tud o iabetes &:A#( issued a 2006 consensus statement or the mana!ement o !lcemia intpe 2 diabetes, which has been updated re!ularl )%-'1*. Eecause o the diicult in achievin!

and sustainin! !oal !lcemia and si!niicant wei!ht loss, the consensus !roup concluded

that metormin therap should be initiated concurrent with liestle intervention at the time o

dia!nosis. ee 7nitial mana!ement o blood !lucose in adults with tpe 2 diabetes mellitus7.(

The therapeutic options or patients who ail initial therap with liestle intervention

and metormin are to add a second oral or inectable a!ent, includin! insulin, or to switch to insulin

&al!orithm 1(. ee 7/ana!ement o persistent hper!lcemia in tpe 2 diabetes

mellitus7 and 7nsulin therap in tpe 2 diabetes mellitus7.(

De!ardless o the initial response to therap, the natural histor o most patients with tpe 2

diabetes is or blood !lucose concentrations and A1 to rise over time &i!ure 5( )1,'2*. The"98# su!!ested that worsenin! beta cell dsunction with decreased insulin release was

primaril responsible or disease pro!ression )'2*. /ore severe insulin resistance or decreased

compliance with the dietar re!imen also ma contribute to pro!ression.

Tpe 2 diabetic patients oten need lar!e dail doses o insulin &L65 units per da, and oten much

more( to achieve acceptable !lcemic control. /ost patients with tpe 2 diabetes can be treated

initiall with one or two dail inections, in contrast to patients with tpe 1 diabetes or whom

intensive insulin therap with multiple dail inections is indicated. ee 7nsulin therap in tpe 2

diabetes mellitus7 and 7/ana!ement o blood !lucose in adults with tpe 1 diabetes mellitus7.(

REDUCIN' T-E RI&. O/ )ACROVA&CULAR DI&EA&E — A!!ressive ris actor reduction

lowers the ris o macrovascular complications in patients with diabetes. Thus, smoin! cessation is

essential or patients who smoe. ardiovascular morbidit can also be si!niicantl reduced with

a!!ressive mana!ement o hpertension, cholesterol &!oal low-densit lipoprotein )OO* less than

100 m!HdO )2.6 mmolHO*(, and use o aspirin &B5 to 162 m!Hda( in patients with or at hi!h ris or

cardiovascular disease &J(.

/en and women with diabetes are at increased ris or developin! and din! rom J )0,',''*.

ompared with nondiabetics, men and women with diabetes have decreased lie epectanc &si to

http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/38http://www.uptodate.com/contents/prevention-of-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/nutritional-considerations-in-type-1-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/nutritional-considerations-in-type-1-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/nutritional-considerations-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/nutritional-considerations-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/nutritional-considerations-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/effects-of-exercise-in-adults-with-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus?source=see_link&anchor=H1665282#H1665282http://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus?source=see_link&anchor=H1665282#H1665282http://www.uptodate.com/contents/obesity-in-adults-drug-therapy?source=see_linkhttp://www.uptodate.com/contents/obesity-in-adults-drug-therapy?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/39-41http://www.uptodate.com/contents/metformin-drug-information?source=see_linkhttp://www.uptodate.com/contents/metformin-drug-information?source=see_linkhttp://www.uptodate.com/contents/initial-management-of-blood-glucose-in-adults-with-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/metformin-drug-information?source=see_linkhttp://www.uptodate.com/contents/metformin-drug-information?source=see_linkhttp://www.uptodate.com/contents/image?imageKey=ENDO%2F73793&topicKey=ENDO%2F1750&rank=1~150&source=see_link&search=diabetes+mellitus+criterios++2015http://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/insulin-therapy-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/image?imageKey=ENDO%2F81706&topicKey=ENDO%2F1750&rank=1~150&source=see_link&search=diabetes+mellitus+criterios++2015http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/31,42http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/42http://www.uptodate.com/contents/insulin-therapy-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/insulin-therapy-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/insulin-therapy-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/management-of-blood-glucose-in-adults-with-type-1-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/management-of-blood-glucose-in-adults-with-type-1-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/management-of-blood-glucose-in-adults-with-type-1-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/30,43,44http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/38http://www.uptodate.com/contents/prevention-of-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/nutritional-considerations-in-type-1-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/nutritional-considerations-in-type-1-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/nutritional-considerations-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/nutritional-considerations-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/effects-of-exercise-in-adults-with-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus?source=see_link&anchor=H1665282#H1665282http://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus?source=see_link&anchor=H1665282#H1665282http://www.uptodate.com/contents/obesity-in-adults-drug-therapy?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/39-41http://www.uptodate.com/contents/metformin-drug-information?source=see_linkhttp://www.uptodate.com/contents/initial-management-of-blood-glucose-in-adults-with-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/metformin-drug-information?source=see_linkhttp://www.uptodate.com/contents/image?imageKey=ENDO%2F73793&topicKey=ENDO%2F1750&rank=1~150&source=see_link&search=diabetes+mellitus+criterios++2015http://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/insulin-therapy-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/image?imageKey=ENDO%2F81706&topicKey=ENDO%2F1750&rank=1~150&source=see_link&search=diabetes+mellitus+criterios++2015http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/31,42http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/42http://www.uptodate.com/contents/insulin-therapy-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/insulin-therapy-in-type-2-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/management-of-blood-glucose-in-adults-with-type-1-diabetes-mellitus?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/30,43,44


8/23

ei!ht ears less(. At the time o dia!nosis o tpe 2 diabetes, man patients alread have one or

more ris actors or macrovascular disease &obesit, hpertension, dslipidemia, smoin!( and

man have evidence o overt atherosclerosis &past mocardial inarction )/*, ischemic chan!es on

electrocardio!ram, or peripheral vascular disease( )B,'5,'6*. ee 7The metabolic sndrome &insulin

resistance sndrome or sndrome P(7.(

A number o modiiable ris actors or coronar heart disease &+= increased OO cholesterol,

decreased hi!h-densit lipoprotein )+O* cholesterol, elevated sstolic blood pressure,

hper!lcemia, smoin!( were identiied in a cohort o over 000 tpe 2 diabetics rom the "nited

9in!dom 8rospective iabetes #tud &"98#( )'B*. These and other observations su!!est that a

substantial reduction in cardiovascular mortalit could be achieved b smoin! cessation,

a!!ressive treatment o hpertension and dslipidemia, and possibl dail low-dose aspirin &i!ure

6( )'$*. ee;/ultiactorial ris actor reduction; below.(

@ith re!ard to J ris reduction amon! patients with tpe 2 diabetes, the beneit o !ood blood

pressure control has been conirmed, whereas beneit rom strict !lcemic control has not been

conclusivel demonstrated )'%*. Amon! patients with tpe 1 diabetes, the iabetes ontrol and

omplications TrialH:pidemiolo! o iabetes nterventions and omplications &TH:( studdemonstrated lon!-term beneit o intensive !lcemic mana!ement on cardiovascular outcomes,

reducin! atal and nonatal heart disease and stroe b 5B percent compared with conventional

diabetes mana!ement )5*. ee 7


9/23

n the subset o patients with diabetes, there was a nonsi!niicant B percent decrease in serious

cardiovascular events )51*. #imilarl, in the 8rimar 8revention 8roect, aspirin &100 m!Hda( was

associated with a nonsi!niicant 10 percent reduction in total cardiovascular events in the subset o

patients with diabetes &relative ris )DD* 0.$%, %5M 0.62-1.26( compared with a 0 percent

reduction in nondiabetic subects &DD 0.6%, %5M 0.5-0.%0( )52*. ee 7Eeneits and riss o

aspirin in secondar and primar prevention o cardiovascular disease7.(

These trials su!!est that aspirin ma be less eective in the prevention o cardiovascular events in

patients with diabetes. Trials that assess the beneit o dail aspirin therap speciicall in patients

with diabetes show the ollowin! )5-56*

In the :arl Treatment o iabetic Detinopath #tud &:TD#(, patients with diabetes with

and without J were randoml assi!ned to aspirin &650 m! dail( or placebo )5*. The

relative ris amon! all aspirin-treated patients was 0.%1 &%%M 0.B5-1.11( or death and 0.$

&%%M 0.66-1.0'( or atal and nonatal /.

In the 8revention o 8ro!ression o Arterial isease and iabetes &8>8AA( trial, 12B6

"nited 9in!dom adults with tpe 1 or tpe 2 diabetes with asmptomatic peripheral arter

disease &anle brachial pressure inde o N0.%%( were randoml assi!ned to aspirin &100 m!

dail( plus an antioidant, aspirin alone, antioidant alone, or double placebo )55*. urin! a

median 6.B ears o ollow-up, there were 116 and 11B atal and nonatal cardiovascular

events in the aspirin and nonaspirin !roups, respectivel &+D or primar composite endpoint

o death rom + or stroe, nonatal / or stroe, or above-anle amputation or critical limb

ischemia 0.%$, %5M 0.B6-1.26(.

In the Qapanese 8rimar 8revention 8roect, 1',65$ patients &60 to $5 ears( with

cardiovascular ris actors &hpertension, dslipidemia, or diabetes(, but without a histor o

J, were randoml assi!ned to low-dose enteric coated aspirin &100 m! once dail( or no

aspirin )56*. Approimatel one-third o the patients had diabetes. The trial was stopped earl

ater a median ollow-up o ive ears due to utilit. There was no dierence in the rate o the

composite primar endpoint &total number o atherosclerotic events )nonatal /, nonatal

stoe, cardiovascular death*, 1% versus 20B events in the control !roup, +D 0.%', %5M

0.BB-1.15(. There were si!niicant reductions in the number o patients with nonatal / &20

versus $( and transient ischemic attac &1% versus '(, both secondar outcomes, but there

was an increased ris o serious bleedin! events &62 versus '(. n the subset o patients with

diabetes, the total number o atherosclerotic events was lower in the aspirin !roup, but the

dierence was not statisticall si!niicant &$6 versus %$, +D 0.$%, %5M 0.66-1.1$(.

>verall, the cardiovascular event rate was low, which limits the abilit o the trial to detect

dierences between the treatment !roups. n addition, the trial was not blinded or placebo-

controlled, and 10 percent o controls were tain!aspirin b the end o the trial. The

!eneraliCabilit o this stud to @estern populations with hi!her cardiovascular ris isunnown.

Thus, trials in patients with diabetes do not show a si!niicant beneit o aspirin or the primar

prevention o cardiovascular events. The decision to use aspirin or the prevention o cardiovascular

events in patients with diabetes should be made usin! shared decision-main! on an individual

basis, tain! into account potential beneits and riss. t is liel that there is some level o ris o

J events that would result in a positive beneit-to-ris ratio. Oar!er trials in patients without overt

vascular disease but who are at hi!h ris to develop it are re4uired to clari this issue. Two lar!e

http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/51http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/51http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/52http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/52http://www.uptodate.com/contents/benefits-and-risks-of-aspirin-in-secondary-and-primary-prevention-of-cardiovascular-disease?source=see_linkhttp://www.uptodate.com/contents/benefits-and-risks-of-aspirin-in-secondary-and-primary-prevention-of-cardiovascular-disease?source=see_linkhttp://www.uptodate.com/contents/benefits-and-risks-of-aspirin-in-secondary-and-primary-prevention-of-cardiovascular-disease?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/53-56http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/53http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/55http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/56http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/56http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/51http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/52http://www.uptodate.com/contents/benefits-and-risks-of-aspirin-in-secondary-and-primary-prevention-of-cardiovascular-disease?source=see_linkhttp://www.uptodate.com/contents/benefits-and-risks-of-aspirin-in-secondary-and-primary-prevention-of-cardiovascular-disease?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/53-56http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/53http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/55http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/56http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_link


10/23

trials investi!atin! the role o aspirin or the primar prevention o cardiovascular events in patients

with diabetes are underwa )5B-5%*.

1leeding — >ne o the main adverse eects o aspirin is bleedin!. The "nited #tates 8hsicians;

+ealth #tud ound a nonsi!niicant trend toward an increase in hemorrha!ic stroe and an

increased ris o !astrointestinal bleedin! in those who too aspirin )60*. n the Qapanese trial

described above, there was an increase in nonatal intracranial hemorrha!e &2 versus 10 events(

and subarachnoid hemorrha!e &ei!ht versus our events( in patients assi!ned to the aspirin !roup

)56*. :tracranial hemorrha!e re4uirin! transusion or hospitaliCation was also more common in the

aspirin !roup &62 versus ' events, +D 1.$5, %5M 1.22-2.$1(.

n a population-based cohort stud eaminin! the incidence o !astrointestinal and intracranial

bleedin! in patients with and without diabetes tain! aspirin, the incident rate o maor bleedin! was

similar in those with and without diabetes &5.5 and 5.$ per 1000 person-ears( )61*. The presence o

diabetes itsel increased the incidence o maor bleedin!, independent o aspirin use. n the

absence o aspirin use, the incidence rate o maor bleedin! was 5.5 and .2 per 1000 person-

ears in those with and without diabetes. These data su!!est that treatment with aspirin onl

mar!inall increases the ris o bleedin! in patients with diabetes. this indin! is due to reducedeicac o aspirin in suppressin! platelet unction in patients with diabetes, it ma eplain wh

aspirin is less eective in the primar prevention o cardiovascular events in patients with diabetes

than in those without diabetes.

Aspirin does not appear to increase retinal hemorrha!ic complications in patients with diabetic

retinopath, even i advanced. n the :arl Treatment iabetic Detinopath #tud, patients with mild

to severe nonprolierative or earl prolierative diabetic retinopath had one ee treated with scatter

retinal photocoa!ulation. The B11 participants were also randoml assi!ned to receive either

aspirin &650 m!Hda( or placebo. urin! the stud, periodic undus photo!raph o the ees not

receivin! photocoa!ulation detected vitreous or preretinal hemorrha!es in 2 versus 0 percent o

patients treated with aspirin or placebo, respectivel )62*. Approimatel '0 percent o thesehemorrha!es produced a loss o visual acuit to less than 20H'0. +owever, the severit and rate o

resolution o these hemorrha!es were not dierent between the aspirin and placebo-treated !roups.

This stud, as well as a meta-analsis o other randomiCed clinical trials, concluded that there were

no ocular contraindications to the use o aspirin &650 m!Hda( in persons with diabetes who re4uire

this medicine or treatment o J or or other medical indications )62,6*.

'uidelines — Eased upon these data, the American iabetes Association &AA( and American

+eart Association &A+A( recommend the ollowin! approach )6,6'*.

I Aspirin &B5 to 162 m!Hda( is recommended or secondar prevention in diabetic patients

with a histor o /, vascular bpass, stroe or transient ischemic attac, peripheral vascular

disease, claudication, or an!ina.

I Aspirin &B5 to 162 m!Hda( is recommended or primar prevention in an patient with

diabetes at increased cardiovascular ris &10-ear ris L10 percent(, which would include most

men L50 ears and women L60 ears who have at least one additional cardiovascular ris

actor &e!, ci!arette smoin!, hpertension, obesit, albuminuria, dslipidemia, or a amil

histor o +(. The AA reco!niCes that the evidence to support this recommendation is

wea.

http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/57-59http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/60http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/56http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/61http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/61http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/62http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/62http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/62,63http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/62,63http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/6,64http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/6,64http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/57-59http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/60http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/56http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/61http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/62http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/62,63http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/6,64http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_link


11/23

I Aspirin is not recommended or diabetic patients under the a!e o 0 ears due to a lac o

evidence o beneit, and aspirin is contraindicated under the a!e o 21 ears because o an

increased ris o Dee;s sndrome.

Ilopido!rel &B5 m!Hda( is recommended or patients with J and

documented aspirin aller!. ee 7#econdar prevention o cardiovascular disease7, section

on ;Antithrombotic therap;.(

n spite o these recommendations, aspirin use in patients with diabetes is 4uite low B' and $

percent in patients with or without J, respectivel )65*.

1lood pressure control — +pertension is a common problem in tpe 1 and especiall in tpe 2

diabetes. The AA recommends measurin! blood pressure at ever routine diabetes visit )21,66*.

:arl and eective treatment o blood pressure is important, both to prevent J and to minimiCe

the rate o pro!ression o diabetic nephropath and retinopath.

Amon! patients with diabetes, there is moderate evidence supportin! a !oal blood pressure less

than 1'0H%0 mm+! in all patients and weaer evidence supportin! a !oal blood pressure less

than 10H$0 mm+!. These issues and the choice o antihpertensive dru!s are discussed in detailseparatel. ee 7Treatment o hpertension in patients with diabetes mellitus7, section on ;


12/23

)ulti%actorial ris0 %actor reduction — The beneit o multiple ris actor intervention to reduce

coronar ris in tpe 2 diabetes was demonstrated in the relativel small #teno-2 trial o 160

subects with microalbuminuria who were randoml assi!ned to either conventional therap or an

intensive therap re!imen, which included the ollowin! )6B*

IDeduced dietar at

IOi!ht to moderate eercise

I#moin! cessation

ITi!ht !lcemic control &tar!et A1 G6.5 percent with intensive therap(

ITi!ht blood pressure control &tar!et G1'0H$5 mm+! or most o the stud and G10H$0 mm+!

or the last two ears(

IAn!iotensin-convertin! enCme &A:( inhibitor therap re!ardless o blood pressure

IOipid-lowerin! therap &tar!et total cholesterol G1%0 m!HdO )'.% mmolHO* or most o the stud

and G1B5 m!HdO )'.5mmolHO* or the last two ears= tar!et astin! serum tri!lceride

G150 m!HdO )1.B mmolHO*(

I Aspirin

IJitamin , vitamin , olate, and chrome picolinate

The attained dierences between the two !roups revealed si!niicantl !reater improvements with

intensive therap in !lcemic control &A1 -0.5 versus R0.2 percent with conventional therap(,

blood pressure control &-1'H12 versus -H$mm+!(, and total cholesterol &-50 versus - m!HdO )-1.

versus -0.0$ mmolHO*(.

At a mean o B.$ ears, patients on intensive therap had a si!niicant reduction in the primar

a!!re!ate end point o cardiovascular death, nonatal /, coronar arter bpass !ratin!,

percutaneous coronar intervention, stroe, amputation, or peripheral vascular sur!er &1$ versus

$ percent, +D 0.'B, %5M 0.22-0.B'(. #i!niicant reductions were also seen in pro!ression o

nephropath, retinopath, and autonomic neuropath.

Ater the intervention stud ended, 10 remainin! patients participated in an observational ollow-up

stud &5.5 ears(, durin! which time all participants were encoura!ed to ollow intensive

multiactorial treatment re!imens )6$*. At the end o the ollow-up period, A1 values were similar in

the !roups previousl assi!ned to intensive and conventional therap &B.B and $.0 percent,

respectivel(. Elood pressure, bod mass inde &E/(, and astin! serum cholesterol and

tri!lcerides were also similar.

urin! the entire ollow-up period &1. ears(, there were ewer deaths &0 versus 50 percent( in

the intensive therap !roup &+D or death 0.5', %5M 0.2-0.$%(. ntensive therap was also

associated with a lower ris o cardiovascular deaths &+D 0.', %5M 0.1%-0.%'(, which was a

predeined secondar endpoint. 8ro!ression o diabetic retinopath, nephropath, and autonomicneuropath occurred less re4uentl in the intensive !roup. These results su!!est a sustained

beneit o multiactorial ris reduction.

n spite o evidence that a!!ressive ris actor reduction lowers the ris o both micro- and

macrovascular complications in patients with diabetes, the vast maorit o patients do not achieve

recommended !oals or A1, blood pressure control, and mana!ement o dslipidemia )6B,6%*. t is

notable that onl one patient in the observational #teno stud described above reached all ive

treatment !oals at the end o ollow-up. Thus, renewed eorts to implement multiactorial ris actor

http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/67http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/67http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/68http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/67,69http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/67http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/68http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/67,69


13/23

reduction strate!ies earl in the course o tpe 2 diabetes are necessar. ee ;Ade4uac o

care; below.(

OT-ER A&,ECT& O/ -EALT- )AINTENANCE

Routine health "aintenance — The potential eists or the clinician to overloo health

maintenance not speciicall tar!eted at diabetes, !iven the intensit and compleit o carere4uired or prevention and treatment o complications in diabetic patients )B0*. ee 78reventive

care in adults Decommendations7.(

Vaccination — 8atients with diabetes mellitus should receive inluenCa vaccination earl and

pneumococcal vaccination, repeatin! the pneumococcal vaccine once ater a!e 65 ears i the

initial vaccination was prior to a!e 65. The hepatitis E vaccination should be !iven to unvaccinated

adults with diabetes mellitus who are a!es 1% to 5% ears. For older patients with diabetes,

vaccination can be administered at the discretion o the treatin! clinician based upon the ris o

ac4uirin! hepatitis E virus &+EJ( and the lielihood o an ade4uate immune response to

vaccination. This recommendation is based on outbreas o hepatitis E in patients who were

under!oin! blood !lucose monitorin! in nursin! homes or assisted-livin! acilities, a subse4uent

analsis o the ris o ac4uirin! +EJ amon! all diabetics in the "nited #tates, and a cost-

eectiveness analsis )B1*. n observational studies, inluenCa vaccine has been shown to be

similarl eective in adults G65 ears o a!e with diabetes as in the elderl with or without diabetes

)B2,B*. Tetanus and diphtheria vaccinations should also be updated. ee 7+epatitis E virus

vaccination7 and 7Tetanus-diphtheria tooid vaccination in adults7.(

2o"en o% childearing age — ontraception and pre!nanc plannin! should be discussed with

all diabetic women who are premenopausal. For women who do not wish to become pre!nant,

American iabetes Association &AA( !uidelines state that the selection o a contraceptive method

or an individual patient should use the same !uidelines that appl to women without diabetes )B'*

&see 7>verview o contraception7(. bstetricians and


14/23

There are several reasons or the lar!e discrepanc between what should be done and what is

bein! done

ITreatment o acute and chronic disease S Traditional medical practice is or!aniCed to

respond 4uicl to acute patient problems, but does not ade4uatel serve the needs o those

with a chronic illness such as diabetes mellitus )$2*.

Ilinical inertia S Failure to mae adustments in a therapeutic re!imen in response to an

abnormal clinical result has been termed 7clinical inertia7 )$*. 3umerous actors ma be

contributor lac o awareness o therapeutic !oals, reluctance to treat asmptomatic

conditions, concern about patient;s pill burden, time limitations, or attention to acute medical

issues that tae priorit over ris actor mana!ement )$'*. n one stud o modiications in

therap or various cardiovascular ris conditions, medication adustments were made or 66

percent o patients whose !lcated hemo!lobin &A1( level was L$ percent )$'*.

IOac o an or!aniCed sstem or care S >utcomes are better when diabetic patients are seen

in the contet o or!aniCed pro!rams with a coordinated team o health proessionals )21,$5*.

+owever, most the o trials eaminin! the eectiveness o disease mana!ement pro!rams

report surro!ate outcomes &e!, A1, low-densit lipoprotein )OO* cholesterol( rather thanpatient-important outcomes, such as 4ualit o lie, cardiovascular disease &J(, and

mortalit )$6*.

#everal approaches have been tried in order to improve the care o patients with diabetes. These

include the ollowin!

Iiabetes miniclinicsU )$B,$$*

IEetter or!aniCation and deliver o patient education )$%,%0*

I#tructured behavioral intervention )%1,%2*

I/ana!ement b nurse specialists under the supervision o a diabetolo!ist )%,%'*

I/ultidisciplinar disease mana!ement pro!rams )%5-%B*

I


15/23

INDICATION& /OR RE/ERRAL — ntensive insulin therap is recommended or the maorit o

patients with tpe 1 diabetes, and thereore patients with tpe 1 diabetes should be reerred to an

endocrinolo!ist or mana!ement o diabetes.

The maorit o patients with tpe 2 diabetes &!reater than %0 percent( receive their routine care

rom primar care providers. A maor unresolved controvers is the place o the !eneralist and the

specialist in the treatment o patients with tpe 2 diabetes. #tudies comparin! care b specialists

and !eneralists have !enerated conlictin! indin!s )%%-10*. For most patients with tpe 2 diabetes,

care can be delivered b primar care providers and their health care teams in coordination with

other specialists where appropriate. 8atients in need o insulin therap should be mana!ed b or in

consultation with an endocrinolo!ist, i at all possible.

The decision to reer to an endocrinolo!ist with epertise in diabetes mana!ement usuall hin!es

on the compleit o the patient, the abilit o the primar care team to achieve established !oals o

care in an individual, the need to mana!e diverse complications, and other actors such as the

capacit o the primar care practitioner to teach sel-mana!ement sills such as monitorin! and

insulin inections. onversel, some specialt diabetes treatment practices have reco!niCed the

lar!e overlap in the care that the provide with primar care and have taen on the responsibilit oprovidin! primar care or their patients. The ideal balance between primar and subspecialt care

or the ever-increasin! population o patients with tpe 2 diabetes will var based on the resources

and epertise available in dierent communities.

IN/OR)ATION /OR ,ATIENT& — "pToate oers two tpes o patient education materials, The

EasicsU and Eeond the Easics.U The Easics patient education pieces are written in plain lan!ua!e,

at the 5th to 6th !rade readin! level, and the answer the our or ive e 4uestions a patient mi!ht

have about a !iven condition. These articles are best or patients who want a !eneral overview and

who preer short, eas-to-read materials. Eeond the Easics patient education pieces are lon!er,

more sophisticated, and more detailed. These articles are written at the 10th to 12th !rade readin!

level and are best or patients who want in-depth inormation and are comortable with somemedical ar!on.

+ere are the patient education articles that are relevant to this topic. @e encoura!e ou to print or

e-mail these topics to our patients. &?ou can also locate patient education articles on a variet o

subects b searchin! on patient inoU and the eword&s( o interest.(

IEasics topics &see 78atient inormation The AEs o diabetes &The Easics(7 and 78atient

inormation Tpe 1 diabetes &The Easics(7 and 78atient inormation Tpe 2 diabetes &The

Easics(7 and 78atient inormation Treatment or tpe 2 diabetes &The Easics(7 and 78atient

inormation iabetic retinopath &The Easics(7 and 78atient inormation Deducin! the costs o

medicines &The Easics(7(

IEeond the Easics topics &see 78atient inormation iabetes mellitus tpe 1 >verview&Eeond the Easics(7 and78atient inormation iabetes mellitus tpe 2 >verview &Eeond the

Easics(7 and 78atient inormation iabetes mellitus tpe 2 Treatment &Eeond the

Easics(7 and 78atient inormation Deducin! the costs o medicines &Eeond the Easics(7(

&U))AR( AND RECO))ENDATION&

I/orbidit rom diabetes involves both macrovascular &atherosclerosis( and microvascular

&retinopath, nephropath, and neuropath( disease. nterventions can limit end or!an

http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/99-103http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/99-103http://www.uptodate.com/contents/the-abcs-of-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/the-abcs-of-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/type-1-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/type-1-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/type-2-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/type-2-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/type-2-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/treatment-for-type-2-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetic-retinopathy-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetic-retinopathy-the-basics?source=see_linkhttp://www.uptodate.com/contents/reducing-the-costs-of-medicines-the-basics?source=see_linkhttp://www.uptodate.com/contents/reducing-the-costs-of-medicines-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-1-overview-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-1-overview-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-2-overview-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-2-overview-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-2-overview-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-2-treatment-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-2-treatment-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-2-treatment-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/reducing-the-costs-of-medicines-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/99-103http://www.uptodate.com/contents/the-abcs-of-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/type-1-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/type-1-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/type-2-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/type-2-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/treatment-for-type-2-diabetes-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetic-retinopathy-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetic-retinopathy-the-basics?source=see_linkhttp://www.uptodate.com/contents/reducing-the-costs-of-medicines-the-basics?source=see_linkhttp://www.uptodate.com/contents/reducing-the-costs-of-medicines-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-1-overview-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-1-overview-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-2-overview-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-2-overview-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-2-treatment-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/diabetes-mellitus-type-2-treatment-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/reducing-the-costs-of-medicines-beyond-the-basics?source=see_link


16/23

dama!e, and thereore patients with diabetes re4uire initial and on!oin! evaluation or

diabetes-related complications. @e perorm a histor and phsical eam two to three times

earl to obtain inormation on nutrition, phsical activit, reduction o cardiovascular ris

actors, current mana!ement, and diabetes-related complications &table 1(. ee ;nitial; above

and ;iabetes-related complications; above.(

I


17/23

1. Oi , EalluC O#, >oro A, et al. #urveillance o certain health behaviors and conditionsamon! states and selected local areas --- Eehavioral Dis Factor #urveillance #stem, "nited#tates, 200%. //@D #urveill #umm 2011= 601.

2. enters or isease ontrol and 8revention. 2011 3ational iabetes Fact #heethttpHHwww.cdc.!ovHdiabetesHpubsHpdHndsW2011.pd &Accessed on Qune 20, 201(.

. /odad A+, Ford :#, Eowman EA, et al. 8revalence o obesit, diabetes, and obesit-related health ris actors, 2001. QA/A 200= 2$%B6.

'. 9an , #ilva 3, nset o 3/ occurs at least '-B rbeore clinical dia!nosis. iabetes are 1%%2= 15$15.

$.


18/23

1B. Vaseem A, +opins D+ Qr, #weet :, et al. #creenin!, monitorin!, and treatment o sta!e1 to chronic idne disease A clinical practice !uideline rom the American olle!e o 8hsicians.

Ann ntern /ed 201= 15%$5.

1$. @acers FQ, ?oun! O+, nCucchi #:, et al. etection o silent mocardial ischemia inasmptomatic diabetic subects the A stud. iabetes are 200'= 2B1%5'.

1%. #co!nami!lio D, 3e!ut , Damondo A, et al. etection o coronar arter disease inasmptomatic patients with tpe 2 diabetes mellitus. Q Am oll ardiol 2006= 'B65.

20. olber! #D, #i!al DQ, Fernhall E, et al. :ercise and tpe 2 diabetes the American olle!eo #ports /edicine and the American iabetes Association oint position statement. iabetes are2010= e1'B.

21. American iabetes Association. #tandards o medical care in diabetes--201'. iabetesare 201'= B #uppl 1#1'.

22. enters or isease ontrol and 8revention &(. ental visits amon! dentate adults withdiabetes--"nited #tates, 1%%% and 200'. //@D /orb /ortal @l Dep 2005= 5'11$1.

2. noue /, wasai /, >tani T, et al. iabetes mellitus and the ris o cancer results rom alar!e-scale population-based cohort stud in Qapan. Arch ntern /ed 2006= 1661$B1.

2'. #tattin 8, EYr >, Ferrari 8, et al. 8rospective stud o hper!lcemia and cancer ris.iabetes are 200B= 0561.

25. +emmini 9, Oi P, #und4uist Q, #und4uist 9. Dis o cancer ollowin! hospitaliCation ortpe 2 diabetes. >ncolo!ist 2010= 155'$.

26.


19/23

. "nited 9in!dom 8rospective iabetes #tud &"98#(. 1 Delative eicac o randomlallocated diet, sulphonlurea, insulin, or metormin in patients with newl dia!nosed non-insulindependent diabetes ollowed or three ears. E/Q 1%%5= 10$.

'. >hubo ?, 9ishiawa +, Arai :, et al. ntensive insulin therap prevents the pro!ression odiabetic microvascular complications in Qapanese patients with non-insulin-dependent diabetes

mellitus a randomiCed prospective 6-ear stud. iabetes Des lin 8ract 1%%5= 2$10.

5. 3athan /, lear 8A, Eaclund Q?, et al. ntensive diabetes treatment and cardiovasculardisease in patients with tpe 1 diabetes. 3 :n!l Q /ed 2005= 526'.

6. AJA3: ollaborative +, #teerber! :@, +u FE, et al. Associations o diabetes mellitus with total lieepectanc and lie epectanc with and without cardiovascular disease. Arch ntern /ed 200B=16B11'5.

''. Oivin!stone #Q, Oevin , Oooer +, et al. :stimated lie epectanc in a #cottish cohortwith tpe 1 diabetes, 200$-2010. QA/A 2015= 1B.

'5. "usitupa /, 3isanen O9, #iitonen >, et al. Ten-ear cardiovascular mortalit in relation toris actors and abnormalities in lipoprotein composition in tpe 2 &non-insulin-dependent( diabeticand non-diabetic subects. iabetolo!ia 1%%= 611B5.

'6. #tamler Q, Jaccaro >, 3eaton Q, @entworth . iabetes, other ris actors, and 12-rcardiovascular mortalit or men screened in the /ultiple Dis Factor ntervention Trial. iabetesare 1%%= 16''.

http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/33http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/33http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/33http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/34http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/34http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/34http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/35http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/35http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/36http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/36http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/37http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/37http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/38http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/38http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/39http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/39http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/39http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/39http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/40http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/40http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/40http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/40http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/41http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/41http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/41http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/41http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/42http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/42http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/43http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/43http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/43http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/44http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/44http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/45http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/45http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/45http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/46http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/46http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/46http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/33http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/33http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/33http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/34http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/34http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/34http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/35http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/35http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/36http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/36http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/37http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/37http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/38http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/38http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/39http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/39http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/39http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/40http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/40http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/40http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/41http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/41http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/41http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/42http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/42http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/43http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/43http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/43http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/44http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/44http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/45http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/45http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/45http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/46http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/46http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus/abstract/46


20/23

'B. Turner D, /illns +, 3eil +A, et al. Dis actors or coronar arter disease in non-insulindependent diabetes mellitus "nited 9in!dom 8rospective iabetes #tud &"98# 2(. E/Q 1%%$=16$2.

'$. ?udin Q#. +ow can we best prolon! lieX Eeneits o coronar ris actor reduction in non-diabetic and diabetic subects. E/Q 1%%= 0611.

'%. /o!ensen :. ombined hi!h blood pressure and !lucose in tpe 2 diabetes double eopard. Eritish trial shows clear eects o treatment, especiall blood pressure reduction. E/Q1%%$= 1B6%.

50. Fan AZ, Doc J, Zhan! P, et al. Trends in ci!arette smoin! rates and 4uit attempts amon!adults with and without dia!nosed diabetes, "nited #tates, 2001-2010. 8rev hronic is 201=10:160.

51. Antithrombotic Trialists; ollaboration. ollaborative meta-analsis o randomised trials oantiplatelet therap or prevention o death, mocardial inarction, and stroe in hi!h ris patients.E/Q 2002= 2'B1.

52. #acco /, 8elle!rini F, Donca!lioni /, et al. 8rimar prevention o cardiovascular eventswith low-dose aspirin and vitamin : in tpe 2 diabetic patients results o the 8rimar 8revention8roect &888( trial. iabetes are 200= 2626'.

5. Aspirin eects on mortalit and morbidit in patients with diabetes mellitus. :arl Treatmentiabetic Detinopath #tud report 1'. :TD# nvesti!ators. QA/A 1%%2= 26$12%2.

5'. >!awa +, 3aaama /, /orimoto T, et al. Oow-dose aspirin or primar prevention oatherosclerotic events in patients with tpe 2 diabetes a randomiCed controlled trial. QA/A 200$=0021'.

55. Eelch Q, /acuish A, ampbell , et al. The prevention o pro!ression o arterial disease

and diabetes &8>8AA( trial actorial randomised placebo controlled trial o aspirin andantioidants in patients with diabetes and asmptomatic peripheral arterial disease. E/Q 200$=Ba1$'0.

56. eda ?, #himada 9, Teramoto T, et al. Oow-dose aspirin or primar prevention ocardiovascular events in Qapanese patients 60 ears or older with atherosclerotic ris actors arandomiCed clinical trial. QA/A 201'= 122510.

5B. e Eerardis


21/23

61. e Eerardis


22/23

B6. Outia /3, /cullou!h Q:, /itchell O, et al. Ade4uac o diabetes care or older ".#. ruraladults a cross-sectional population based stud usin! 200% EDF## data. E/ 8ublic +ealth 2011=11%'0.

BB. /cEean A/, ?u P. The underuse o screenin! services amon! elderl women withdiabetes. iabetes are 200B= 01'66.

B$. FernandeC A, #chillin!er , @arton :/, et al. Oan!ua!e barriers, phsician-patientlan!ua!e concordance, and !lcemic control amon! insured Oatinos with diabetes the iabetes#tud o 3orthern aliornia &#TA3:(. Q


23/23

%2. Frosch O, " J, >choa #, /an!ione /. :valuation o a behavior support intervention orpatients with poorl controlled diabetes. Arch ntern /ed 2011= 1B12011.

%. Thompson /, 9oCa #:, #heps #. nsulin adustment b a diabetes nurse educatorimproves !lucose control in insulin-re4uirin! diabetic patients a randomiCed trial. /AQ 1%%%=161%5%.

%'. Oe!orreta A8, 8eters AO, >ssorio D, et al. :ect o a comprehensive nurse-mana!edpro!ram an +/> prospective stud. Am Q /ana! are 1%%6= 2102'.

%5. :spinet O/, >smic /Q, Ahmed T, Jilla!ra J

all topics are updated as new evidence becomes available and ou1.docx

Documents