IN THIS ISSUE

Chapter 1.Clinical Guideline for Adults With Diabetes, SP209.

Chapter 2.Clinical Nutrition Guideline for Overweight and Obese Adults With Type 2 Diabetes (T2D) or Prediabetes, or Those at High Risk for Developing T2D, SP226.

Chapter 3.Guideline for Detection and Management of Diabetes in Pregnancy, SP232.

Chapter 4.Guideline for the Care of the Older Adult With Diabetes, SP240.

Chapter 5.Clinical Guideline for Pharmacological Management of Adults With Type 2 Diabetes, SP253.

CLINICAL GUIDELINES

RESEARCH & LEADERSHIP

1995 • 2018

Y E A R S

Top: Joslin Diabetes Center, Boston, MassachusettsBottom right: Patient education in the clinic, Joslin Diabetes CenterBottom left: A test to measure blood glucose

Top, bottom right photos courtesy of: Joslin Diabetes Center

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For a message from the editors and a downloadable PDF of the Joslin Clinical Guidelines:ajmc.com/link/2921

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Collaborating With Joslin Diabetes Center to Save LivesAT THE AMERICAN JOURNAL OF MANAGED CARE®, we say it often: Collaboration saves lives. Bringing the most recent developments in research, clinical practice, and quality measurement to a wider audience gives clinicians the ability to learn from one another no matter where they practice.

With this issue of Evidence-Based Diabetes Management™ (EBDM™), we are taking our long-term partnership with Joslin Diabetes Center to the next level as we publish the Joslin Clinical Guidelines. Dr Robert A. Gabbay, who serves as editor in chief of EBDM ™, brought this idea to us last fall, and we shared his enthusiasm for bringing the best practices of the world-renowned Joslin Diabetes Center to physicians, nurses, pharmacists, nutritionists, diabetes educators, and others who care for those learning to manage this disease. Our editorial team worked with Dr Om P. Ganda, chair of the Clinical Oversight Committee at Joslin, to organize updated editions of the guidelines, which have been in use at Joslin for several years. Drs Ganda, Gabbay, and their colleagues have ensured that the guidelines reflect the latest announce-ments from the FDA, as clinicians have a growing array of therapeutic options for treating people with diabetes.

Most people living with type 2 diabetes receive treatment from their primary care physician, and it is our hope that sharing the Joslin Clinical Guidelines through the leading source of managed care research will serve this group of physicians as well as health plans as they strive to deliver the best care possible.

Sincerely,Michael J. Hennessy, SrChairman and CEO

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The American Journal of Managed Care® ISSN 1088-0224 (print) & ISSN 1936-2692 (online) is published monthly by Managed Care & Healthcare Communications, LLC, 2 Clarke Drive, Suite 100, Cranbury, NJ 08512. Copyright© 2018 by Managed Care & Healthcare Communications, LLC. All rights reserved. As provided by US copyright law, no part of this publication may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, without the prior written permission of the publisher. For subscription inquiries or change of address, please call 888-826-3066. For permission to photocopy or reuse material from this journal, please contact the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923; Tel: 978-750-8400; Web: www.copyright.com. Reprints of articles are available in minimum quantities of 250 copies. To order custom reprints, please contact Jeff Prescott, The American Journal of Managed Care®, jprescott@ajmc.com; Tel: 609-716-7777. The American Journal of Managed Care is a registered trademark of Managed Care & Healthcare Communications, LLC. www.ajmc.com • Printed on acid-free paper.

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F R O M T H E C H A I R M A N

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SP209  C H A P T E R 1. Clinical Guideline for Adults With DiabetesSAMAR HAFIDA, MD; OM P. GANDA, MD, CHAIR, CLINICAL OVERSIGHT COMMITTEE; ROBERT A. GABBAY, MD, PHD, FACP; AND THE MEMBERS OF THE JOSLIN CLINICAL OVERSIGHT COMMITTEE

SP226C H A P T E R 2. Clinical Nutrition Guideline for Overweight and Obese Adults With Type 2 Diabetes (T2D) or Prediabetes, or Those at High Risk for Developing T2DOSAMA HAMDY, MD, PHD; OM P. GANDA, MD, CHAIR, CLINICAL OVERSIGHT COMMITTEE; MELINDA MARYNIUK, MED, RD, CDE; ROBERT A. GABBAY, MD, PHD, FACP; AND THE MEMBERS OF THE JOSLIN CLINICAL OVERSIGHT COMMITTEE

SP232C H A P T E R 3. Guideline for Detection and Management of Diabetes in PregnancyFLORENCE M. BROWN, MD; SUE-ELLEN ANDERSON-HAYNES, RD, CDE; ELIZABETH BLAIR, MSN, ANP-BC, CDE, CDTC; SHANTI SERDY, MD; ELIZABETH HALPRIN, MD; ANNA FELDMAN, MD; KAREN O’BRIEN, MD; SUE GHILONI, RN, CDE; EMMY SUHL, MED, RD, CDE; JO-ANNE RIZZOTTO, MED, RD, CDE; OM P. GANDA, MD, CHAIR, CLINICAL OVERSIGHT COMMITTEE; ROBERT A. GABBAY, MD, PHD, FACP; AND THE MEMBERS OF THE JOSLIN CLINICAL OVERSIGHT COMMITTEE, WITH ADMINISTRATIVE SUPPORT FROM BREDA CURRAN.

SP240C H A P T E R 4. Guideline for the Care of the Older Adult With DiabetesMEDHA MUNSHI, MD; ELIZABETH BLAIR, MSN, ANP-BC, CDE, CDTC; OM P. GANDA, MD, CHAIR, CLINICAL OVERSIGHT COMMITTEE; ROBERT A. GABBAY, MD, PHD, FACP; AND THE MEMBERS OF THE JOSLIN GUIDELINES COMMITTEE

SP253C H A P T E R 5. Clinical Guideline for Pharmacological Management of Adults With Type 2 DiabetesOM P. GANDA MD, CHAIR, CLINICAL OVERSIGHT COMMITTEE; ALISSA SEGAL, PHARMD, CDTC; ELIZABETH BLAIR, MS, ANP-BC, CDE, CDTC; RICHARD BEASER, MD; JASON GAGLIA, MD; ELIZABETH HALPRIN, MD MD; ROBERT A. GABBAY, MD, PHD, FACP; AND THE MEMBERS OF THE JOSLIN GUIDELINES COMMITTEE

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F R O M T H E E d I T O R S

WITH THIS ISSUE OF Evidence-Based Diabetes Management™, we present publication of the first installment of the Joslin Clinical Guidelines, which are the principles that influence our clinical behavior every day at Joslin Diabetes Center and our affiliates and partners around the world. Although some sections of the guidelines have been in use for years, our collaboration with The American Journal of Managed Care® represents our first cohesive effort to update and publish the guidelines in a searchable format, one more easily shared with audiences beyond Joslin. It is our hope that publication of the guidelines, in partnership with the leading peer-reviewed journal dedicated to research and leadership in health outcomes, will bring the Joslin Clinical Guidelines into wider use. Through use of

these guidelines, patients around the world can benefit from the knowledge, research, and practices developed over more than a century of focus on the care of people with diabetes.

As explained in the overview, the Joslin Clinical Guidelines are developed by the Clinical Oversight Committee at Joslin Diabetes Center, for which we serve as chair and ex-officio members, respectively. Our Clinical Oversight Committee includes physicians, nurses, certi-fied diabetes educators, and behavioral health specialists who are experts in treating individuals with diabetes of all ages. More importantly, our committee members are leaders in developing strategies to help those living with diabetes self-manage their disease. Our process invites the participation of faculty with special expertise who are not on the Clinical Oversight Committee; these experts serve on working groups for individual guidelines. We thank all who have participated in the development of the guidelines over many years for your contributions.

The guidelines are evidence based, and the overview explains our use of a modified form of the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation). For this installment, we present the following: the Clinical Guideline for Adults With Diabetes; the Clinical Nutrition Guideline for Overweight and Obese Adults With Type 2 Diabetes (T2D) or Prediabetes, or Those at High Risk for Developing T2D; the Guideline for

Detection and Management of Diabetes in Pregnancy; the Guideline for the Care of the Older Adult With Diabetes; and the Clinical Guideline for Pharmacological Management of Adults With Type 2 Diabetes. With this installment, we have covered the major issues that most physicians, registered dietitians, certified diabetes educa-tors, nurse practitioners, physician assistants, and phar-macists will encounter in clinical practice. The Clinical Guideline for Pharmacological Management of Adults With Type 2 Diabetes has been revised to reflect recent scientific advances and regulatory developments that offer more choices than ever for diabetes management. We repeat the position that Joslin Diabetes Center announced earlier this year, when we concurred with the American Diabetes Association, the American Association of Clinical Endocrinologists, the Endocrine Society, and the American Association of Diabetes Educators that those with diabetes should aim for glycated hemoglobin of 7% or lower, not between 7% and 8%.

Is diabetes self-management challenging? Yes. But as these guidelines reflect, and as we see at the Joslin Diabetes Center every day, self-management can succeed through empowering our patients and engaging them alongside appropriate pharmacotherapy. We hope this publication serves as both a resource and an inspiration to providers who are struggling with what to do next for their patients. We invite your feedback and look forward to sharing more of the best practices developed at Joslin—so that individuals with diabetes can live the best lives possible.

Sincerely,

GABBAY

GANDA

Bringing the Joslin Clinical Guidelines to the Diabetes Care Community

Robert A. Gabbay, MD, PhD, FACPSenior Vice President,Chief Medical Officer Joslin Diabetes Center

Om P. Ganda, MDMedical Director of the Lipid ClinicChair, Clinical Oversight CommitteeJoslin Diabetes Center

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Om P. Ganda, MDMedical Director of the Lipid Clinic Chair, Clinical Oversight CommitteeJoslin Guideline Committees: Clinical Guideline for Adults With Diabetes, Nutrition, Pregnancy, Older Adults, Pharmacological Management

Robert Gabbay, MD, PhD, FACP (ex officio)Chief Medical Officer, Senior Vice PresidentJoslin Guideline Committees: Clinical Guideline for Adults With Diabetes, Nutrition, Older Adults, Pharmacological Management

Richard Beaser, MDSenior Physician; Chair, Continuing Medical Education CommitteeJoslin Guideline Committees: Clinical Guideline for Adults With Diabetes, Pharmacological Management

Elizabeth Blair, MSN, ANP-BC, CDE, CDTC*

Staff Adult Nurse PractitionerJoslin Guideline Committees: Clinical Guideline for Adults With Diabetes, Nutrition, Pregnancy, Older Adults, Pharmacological Management

Cathy Carver, MS, ANP-BC, CDE* Nurse Leader, Nurse Practitioner at Health Care Without WallsJoslin Guideline Committee: Older Adults

Jerry Cavallerano, OD, PhD Associate Professor of Ophthalmology at Harvard Medical School, affiliation with Joslin Diabetes Center/Beetham Eye InstituteJoslin Guideline Committee: Clinical Guideline for Adults With Diabetes

Samar Hafida, MDStaff EndocrinologistJoslin Guideline Committee: Clinical Guidelines for Adults With Diabetes

Elizabeth Halprin, MDClinical Director, Adult DiabetesJoslin Guideline Committees: Pregnancy, Pharmacological Management

William Hsu, MDDirector of the Asian Clinic, assistant investigator in the section on clinical research, Co-Director of Joslin’s Asian American Diabetes InitiativeJoslin Guideline Committee: Clinical Guideline for Adults With Diabetes

Lori Laffel, MD, MPHChief, Pediatric, Adolescent, and Young Adult SectionJoslin Guideline Committees: Clinical Guideline for Adults With Diabetes, Nutrition, Pregnancy, Older Adults, Pharmacological Management

Melinda Maryniuk, MEd, RD, CDE* Director, Clinical and Education ProgramsJoslin Guideline Committees: Clinical Guideline for Adults With Diabetes, Nutrition

Medha Munshi, MDDirector, Joslin Geriatric Diabetes ProgramJoslin Guideline Committees: Clinical Guideline for Adults With Diabetes, Older Adults

Sethu Reddy, MD, MBA, FRCPC, FACP, MACE*

Chief, Adult DiabetesJoslin Guideline Committee: Older Adults

Jo-Anne Rizzotto, MEd, RD, LDN, CDE Director of Educational Services Joslin Guideline Committee: Clinical Guideline for Adults With Diabetes, Nutrition, Pregnancy

Sylvia Rosas, MDStaff Physician, Kidney and Hypertension Section; Director, Latino Kidney ClinicJoslin Guideline Committee: Clinical Guideline for Adults With Diabetes

Susan Sjostrom, JD Director, Healthcare Services and Publications Joslin Guideline Committees: Clinical Guideline for Adults With Diabetes, Nutrition, Pregnancy, Older Adults, Pharmacological Management

William Sullivan, MDAdult Diabetes Senior PhysicianJoslin Guideline Committees: Clinical Guideline for Adults With Diabetes, Nutrition, Pregnancy, Older Adults

CLINICAL OVERSIGHT COMMITTEE JOSLIN DIABETES CENTER

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Howard Wolpert, MD*

Senior Physician, Director, Joslin Institute of Technology TranslationJoslin Guideline Committee: Older Adults

John Zrebiec, LICSW*

Director, Behavioral HealthJoslin Guideline Committee: Clinical Guideline for Adults With Diabetes

WORKING GROUP MEMBERSAll working group members are primarily affiliated with Joslin Diabetes Center unless otherwise noted. Clinical Oversight Committee members who served on working groups are listed below members who served on working groups only.

Clinical Guidelines for Adults With DiabetesWilliam Conners, MD*

Director of the Men’s Health Clinic

Christopher Gibbons, MD, MMSc, FAANDirector, Neuropathy Clinic

John Giurini, DPM Podiatric foot surgery, Harvard Beth Israel Deaconess Medical Center

Jacqueline Shahar, MEd, RCEP, CDEClinical Exercise Physiology Department Manager

Also: Ganda, Gabbay, Beaser, Cavallerano, Hafida, Hsu, Laffel, Maryniuk, Munshi, Rizzotto, Rosas, Sjostrom, Sullivan, Zrebiec

NutritionOsama Hamdy, MD, PhDMedical Director, Obesity Clinical ProgramCo-chair, Nutrition

Nuha El Sayed, MDStaff Physician, Director of International Training Programs at Joslin

Joanna Mitri, MD, MSStaff Physician

Jacqueline Shahar, MEd, RCEP, CDEClinical Exercise Physiology Department Manager

Emmy Suhl, MEd, MS RD, CDE*

Diabetes Educator

Also: Ganda, Blair, Maryniuk, Rizzotto

PregnancySue-Ellen Anderson-Haynes, MS, RD, CDE, CPT Nutrition Educator

Florence M. Brown, MD Director, Joslin-Beth Israel Deaconess Diabetes and Pregnancy Program

Anna Z. Feldman, MDStaff Physician, Harvard Beth Israel Deaconess Medical Center

Suzanne Ghiloni, BSN, RN, CDE Nurse Educator

Karen E. O’Brien, MDMaternal and Fetal Medicine, Beth Israel Deaconess Medical Center

Emmy Suhl, MEd, MS RD, CDE*

Diabetes Educator

Shanti Serdy, MDStaff Physician, Adult Diabetes

Breda Curran, administrative support

Also: Blair, Gabbay, Halprin, Rizzotto

Older AdultsJacqueline Shahar, MEd, RCEP, CDEClinical Exercise Physiology Department Manager

Emmy Suhl, MEd, MS RD, CDE*

Diabetes Educator

Mark Williams, MDSenior Staff Physician, Director of Dialysis

Also: Munshi, Blair, Ganda

Pharmacological ManagementJason Gaglia, MD, MMScDirector of Hood Center for the Prevention of Childhood Diabetes

Alissa Segal, PharmD, CDE, CDTC Associate Professor and Clinical Pharmacist

Also: Ganda, Gabbay, Blair, Beaser, Halprin

*Formerly with Joslin. Title reflects role at time of participation in guideline development.