Week 5 discussion

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IN APA FORMATThis week, complete the Aquifer case titled Family Medicine 06: 57-year-old female diabetes care visit.After completing your Aquifer case study, answer the following questions:What is your list of appropriate differential diagnoses and why?What is the final diagnosis, and what assessment findings serve to support this? Discuss normal versus abnormal findings.Describe the pathophysiology that may lead up to the final diagnoses.What pharmacology treatment would you recommend and why?

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Family Medicine 06: 57-year-old female diabetes care visit
User: ARIADNA ZARZUELA
Email: [email protected]
Date: March 4, 2024 1:38 PM
Learning Objectives
The student should be able to:
Incorporate appropriate psychosocial, cultural, health literacy, and family data into the management plan of a patient with type 2 diabetes.
Find and apply diagnostic criteria and surveillance strategies for Diabetes Mellitus.
Elicit a focused history that includes information about adherence, self-management, and barriers to care for Diabetes Mellitus.
Perform a focused physical that includes identification of complications of Diabetes Mellitus.
Perform a focused physical that includes identification of improvement or progression of Diabetes Mellitus.
Propose an evidence-based management plan that includes pharmacologic and non-pharmacologic treatments and appropriate surveillance and
tertiary prevention for diabetes mellitus including vaccines and dental care.
Communicate appropriately about Diabetes Mellitus with members of the interprofessional team.
Document a chronic care visit for Diabetes Mellitus.
Communicate respectfully with a patient who does not fully adhere to their treatment plan for Diabetes Mellitus.
Educate patients about diabetes respectfully, using language that they understand including information about diabetes, diet, and foot care.
Describe major treatment modalities of Diabetes Mellitus.
Document an encounter using a Diabetes Mellitus flowsheet or template.
Recognize the signs and symptoms associated with hypoglycemia or hyperglycemia including diabetic ketoacidoses and hyperosmolar
hyperglycemic state.
Counsel patients on strategies to reduce their cardiovascular risks.
Discuss the roles and benefits of the interdisciplinary health care team, in patient care (e.g. pharmacy, nursing, social work, and allied health.
Knowledge
Comprehensive Annual Diabetes Visit
The American Diabetes Association (ADA) provides standards of care for diabetes management that are updated annually and can be downloaded
to a smartphone.
Clinician tasks for diabetes care:
Confirm the diagnosis and classify diabetes.
Evaluate for diabetes complications and potential comorbid conditions.
Review previous treatment and risk factor control in patients with established diabetes.
Begin patient engagement in the formulation of a care-management plan.
Develop a plan for continuing care.
See the American Diabetes Association’s “Components of the Comprehensive diabetes medical evaluation at initial, follow-up, and annual visits”:
Table 4.1
Electronic Medical Record
An electronic medical record system:
Offers templates and care gap checklists that can increase the likelihood that patients will receive recommended care.
May improve the quality of care by allowing increased patient participation and care coordination.
Provides tools to improve patient care across an entire population.
Allows documentation of improved physician performance, which may increase reimbursements by some insurers.
Can limit direct communication between the clinician and patient as well as potentially contribute to provider burnout.
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Pathophysiology of Diabetes
Type 1 diabetes mellitus
The pancreas is damaged through autoimmune inflammation leading to the destruction of the beta cells. The loss of beta cells leads to the complete
inability to produce insulin, (immunologic etiology).
Type 2 diabetes mellitus
The body is unable to recognize the insulin produced by the pancreas and use it properly (insulin resistance). Increased beta cell insulin secretion
may initially compensate, but over time beta cells fail.
Chronic complications
Both types of diabetes can cause the same end-organ damage. High blood glucose eventually affects blood vessels and therefore organs throughout
the entire body. The heart, brain, kidneys, eyes, and the nerves that control sensation and autonomic function are affected.
Remember: High blood pressure, which many patients with diabetes have, makes the vascular disease much worse.
Diabetes: Common Manifestations of End-Organ Damage
Cardiovascular disease, including coronary heart disease, cerebrovascular disease, and peripheral arterial disease
People with diabetes are two to four times more likely to have heart disease or stroke than people without diabetes. Patients with diabetes who have
a myocardial infarction have worse outcomes than patients without diabetes, and a diagnosis of diabetes is considered equivalent in risk to having
had a previous myocardial infarction. Management of the cardiovascular risk factors so commonly found in diabetes is therefore essential in
preventing morbidity and mortality in these patients.
The American College of Cardiology/American Heart Association ASCVD risk calculator (Risk Estimator Plus) is generally a useful tool to estimate
10-year ASCVD risk. These calculators include diabetes as a risk factor, since diabetes itself confers increased risk for ASCVD, although it should be
acknowledged that these risk calculators do not account for the duration of diabetes or the presence of diabetes complications, such as albuminuria.
Of note, this calculator includes inputs based on race, which may (or may not) provide more accurate estimates of risk in any given individual.
Additionally, it is important to remember that race is a poor substitute for the diversity of human backgrounds, and that race alone does not confer
increased risk for disease; rather, race often serves as a marker for structural issues (such as racism) that themselves may confer that increased risk.
Retinopathy
Diabetes is the most common cause of new cases of blindness among adults aged 18-64 years. The estimated prevalence of diabetic retinopathy is
28.5%, and for vision-threatening diabetic retinopathy, 4.4% among U.S. adults with diabetes. Factors associated with a higher incidence of diabetic
retinopathy include higher hemoglobin A1c level, a longer duration of diabetes, insulin use, dyslipidemia, nephropathy, and higher systolic blood
pressure. Large prospective randomized studies have shown that achieving optimal glycemic control can prevent and/or delay the onset and
progression of diabetic retinopathy. In addition to optimizing glycemic control, optimizing blood pressure and serum lipid control can also slow the
progression of diabetic retinopathy.
Neuropathy
Neuropathy is a heterogeneous condition that is associated with nerve pathology. Diabetic peripheral neuropathy can affect nearly 50% of adults
with diabetes and can put patients at risk for pain, foot ulcers, and lower limb amputation. The condition is a diagnosis of exclusion (other
neuropathies may be present in people with diabetes and may be treatable). It also may be asymptomatic, but if not recognized, patients are still at
risk for injury. Glycemic control can prevent some neuropathies in type 1 diabetes, and may slow its progression in type 2 diabetes, but does not
reverse neuronal loss.
Nephropathy
Nephropathy is common in diabetes: 20-40% of people with diabetes develop diabetic nephropathy. Diabetes was listed as the primary cause of
kidney failure in 39% of all new cases in 2017. Treatment includes optimizing glycemic and blood pressure control in all patients, and the use of
medications in certain patients to reduce the progression of chronic kidney disease as well as cardiovascular events.
Acute Diabetic Decompensations (DKA and HHS)
Type 1 diabetes
In patients with type 1 diabetes, without sufficient insulin, blood sugar runs high, and diabetic ketoacidosis (DKA) can develop.
Type 2 diabetes
Patients with type 2 diabetes with hyperglycemia more often develop hyperosmolar hyperglycemic state (HHS).
Typically it is the patient with type 1 diabetes who is most at risk for developing DKA; however, patients with type 2 diabetes can also develop
DKA. This happens because, over time, type 2 diabetes starts to resemble type 1 diabetes as pancreatic function dwindles and patients with type 2
diabetes may begin to require insulin. If insulin deficiency is severe enough, a patient with type 2 diabetes may produce ketones and develop
hyperglycemia. For example, an older adult patient with longstanding type 2 diabetes who becomes acutely ill with pneumonia could easily develop
DKA.
Screening Recommendations for Type 2 Diabetes
American Diabetes Association recommendations
1. Screening should begin at age 35 for all people. If results are normal, testing should be repeated at a minimum of three-year intervals, with
consideration of more frequent testing depending on initial results and risk status.
2. Screening should begin earlier in adults who are overweight or obese (BMI ≥ 25 kg/m 2 or ≥ 23 kg/m 2 in Asian Americans*) who have one or more
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of the following risk factors:
First-degree relative with diabetes
High-risk race/ethnicity** (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
History of CVD
Hypertension (≥ 140/90 mmHg or on therapy for hypertension)
HDL cholesterol level < 35 mg/dL (0.90 mmol/L) and/or a triglyceride level > 250 mg/dL (2.82 mmol/L)
Women with polycystic ovary syndrome
History of gestational diabetes
Physical inactivity
Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
If results are normal, testing should be repeated at a minimum of three-year intervals, with consideration of more frequent testing depending on initial
results and risk status.
3. People with HIV: prior to starting antiretroviral therapy, at the time of switching antiretroviral therapy, and 3-6 months after starting or switching
antiretroviral therapy. If initial screening results are normal, fasting glucose should be checked annually.
4. Patients with prediabetes (A1C ≥ 5.7%, impaired glucose tolerance (two-hour plasma glucose > 140 mg/dL following a 75 gram glucose load)
should be tested annually.
5. People who were diagnosed with Gestational Diabetes Mellitus (GDM) should have lifelong testing at least every three years.
* This lower BMI cut-off is due to the difference in distribution of fat. Asian Americans tend to exhibit more visceral than peripheral fat, which is more
closely associated with insulin resistance and type 2 diabetes.
** The American Diabetes Association recommends screening in these groups because they are disproportionately affected by type 2 diabetes. It is
important to keep in mind that race/ethnicity alone are not causal factors in the development of diabetes, rather, race/ethnicity may be serving as
proxies for the social and structural factors that impact the health of different groups of people.
United States Preventive Services Task Force (USPSTF) Recommendations
Adults aged 35 to 70 years whose weight is in the overweight or obesity category :
​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​○ Screen for prediabetes and type 2 diabetes.
​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​○ Offer or refer patients with prediabetes to effective preventive interventions.
Diagnostic Criteria for Diabetes Mellitus
1. A random glucose of 200 mg/dL or above, plus symptoms of hyperglycemia, such as polyuria or unexplained weight loss, or hyperglycemic
crisis.
2. A fasting plasma glucose of greater than or equal to 126 mg/dL. Fasting is defined as no caloric intake for at least eight hours.
3. A hemoglobin A1C greater than or equal to 6.5%.
4. Two-hour plasma glucose ≥ 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test (OGTT).
The diagnosis requires two abnormal test results from the same sample or in two separate test samples unless there is a clear clinical diagnosis
(e.g., patient in a hyperglycemic crisis or with classic symptoms of hyperglycemia and a random plasma glucose ≥ 200 mg/dL).
Epidemiology of Diabetes
The 2020 National Diabetes Statistics Report from the CDC examines trends in the incidence and prevalence of diabetes in the United States. (The
report does not distinguish between cases of type 1 and type 2, but the majority (90-95%) of adults with diabetes have type 2). According to this
report:
Prevalence of diabetes in the United States, all ages, 2018:
Total: 34.2 million people (10.5% of the population) have diabetes
Diagnosed: 26.9 million people
Undiagnosed: 7.3 million people (21.4% of the total number of Americans with diabetes)
Prevalence of diabetes (diagnosed and undiagnosed) among people aged 18 years or older, United States, 2018:
Age 18 years or older: 34.1 million, 13% of all people in this age group have diabetes.
Age 65 years or older: 14.3 million, 26.8% of all people in this age group have diabetes.
After adjusting for population age differences, the following percentages of people aged 18 years or older, by race/ethnicity, have diagnosed
diabetes:
7.5% of non-Hispanic Whites
9.2% of Asian Americans
12.5% of Hispanics
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11.7% of non-Hispanic Blacks
14.7% of American Indians/Alaska natives
Prediabetes
In 2018 prediabetes affected roughly 88 million adults in the U.S. Prediabetes is defined as the presence of either impaired fasting glucose-IFG
(fasting glucose 100—125 mg/dl) or impaired glucose tolerance-IGT (2 hr values of oral glucose tolerance testing 140—199 mg/dl). New evidence
shows that damage to end-organs is already occurring during prediabetes and that progression to diabetes can be delayed or prevented with lifestyle
modification and to a lesser degree with medication.
The Diabetes Prevention Program (DPP) was a randomized, five-year study to evaluate intensive lifestyle modification (education, coaching in diet
and exercise, etc.) versus diet/exercise information along with 850 mg of metformin twice a day. The study population included 3,200 participants
with impaired glucose tolerance. Intensive lifestyle modification produced a 58% reduction in risk for type 2 diabetes or a delay of about 11 years.
The metformin group showed a less impressive 31% risk reduction, but over 15 years of follow-up, certain groups were identified as having the most
benefit from metformin: those with a higher baseline fasting glucose (≥ 110 mg/dL versus 95–109 mg/dL), those with a higher A1C (6.0–6.4% versus
< 6.0%), and women with a history of GDM (versus women without a history of GDM). Diabetic Retinopathy The most frequent cause of new blindness among adults (aged 20—74 years). Laser photocoagulation treatment can slow the progression of retinopathy and reduce vision loss, but it doesn't restore lost vision. Since the treatment is aimed at preventing vision loss, and retinopathy is asymptomatic during its initial course, it's important to identify and treat patients early. In severe, non-proliferative retinopathy, look for the following findings on a fundoscopic exam: Retinal hemorrhages are dark blots with indistinct borders that indicate partial obstruction and infarction. Cotton wool spots are white spots with fuzzy borders and they indicate areas of previous infarction. They accompany hemorrhages. Microaneurysms are more punctate dark lesions that indicate vascular dilatation. Neovascularization is the hallmark of proliferative retinopathy. The growth of new blood vessels is prompted by retinal vessel occlusion and hypoxia. Diabetes Education: Blood Glucose Optimal range for blood glucose: Fasting blood glucose goal between 80—120 mg/dl Postprandial blood glucose (1-2 hours after a meal) goal of < 180 mg/dl Conditions that can contribute to hyperglycemia: Overeating, missing doses of medication, dehydration, infection and illness, stress. Clinical Skills Understanding the Patient's Experience of Their Illness Often in practice, clinicians use one-way communication to describe the biomedical explanation for the disease and the recommended treatment. The LEARN model, developed by Berlin and Fowkes, is a simple way to remember the importance of two-way dialogue with your patient about their understanding of their own disease. Listen with empathy and understanding to the patient's perception of the problem. Explain your perceptions of the problem and your strategy for treatment. Acknowledge and discuss the differences and similarities between these perceptions. Recommended treatment while remembering the patient's cultural parameters. Negotiate an agreement. It is important to understand the patient's explanatory model so that medical treatment fits in their cultural framework. Think Cultural Health offers a Guide to Providing Effective Communication and Language Assistance Services . This is a tool from the Office of Minority Health of the U.S. Department of Health and Human Services designed to help facilitate communication with patients from various cultural and linguistic backgrounds. Annual Foot Exam for Patients with Diabetes The American Diabetes Association recommends that all patients with diabetes have an annual foot exam and provides the standard of care guidelines for this exam to assess risk for ulcerations and amputations. Those with evidence of sensory loss, or prior ulceration or amputation, should have their feet inspected at every visit. Foot ulceration is the result of impaired sensation (distal symmetric polyneuropathy) and impaired perfusion (diabetes vasculopathy and peripheral vascular disease), both of which are independent, strong risk factors for foot ulceration and amputation. © 2024 Aquifer, Inc. - ARIADNA ZARZUELA ([email protected]) - 2024-03-04 13:38 EST 4/11 The early recognition and appropriate management of neuropathy in the patient with diabetes is important because: 1. Up to 50% of diabetic peripheral neuropathy (DPN) may be asymptomatic but leave patients at risk of foot ulceration. 2. Nondiabetic neuropathies may be present in patients with diabetes and may be treatable. 3. While specific treatment for the underlying nerve damage is currently not available—other than improved glycemic control, which may slow progression but not reverse neuronal loss—effective symptomatic treatments are available for some manifestations of DPN. 4. Specialized footwear can help prevent plantar foot ulceration recurrence or worsening. The foot exam should include: Testing for loss of protective sensation Sensory testing, according to the ADA, should be conducted with a 10-gram monofilament PLUS any one of the following: 1. Vibration using a 128-Hz tuning fork 2. Pinprick sensation 3. Temperature Assessment of pedal pulses (dorsalis pedis and posterior tibial arteries). Assessing the arterial supply to the lower limbs and feet is essential in the evaluation for peripheral vascular disease, the strongest risk factor for delayed ulcer healing and amputation in diabetes patients. Patients with symptoms of claudication or with decreased pedal pulses should be referred for ankle-brachial indexes. Inspection: Skin changes such as hair loss and color changes may signal vascular insufficiency. Since foot ulceration is usually caused by breaks in the skin due to accidental trauma or poorly fitted footwear, the patient's feet should be inspected for breaks in the skin, pressure calluses that precede ulceration, existing ulceration, infection, and bony abnormalities that lead to abnormal pressure distribution and ulceration. The patient's footwear should also be inspected for abnormal patterns of wear and appropriate sizing. Monofilament Testing for Patients with Diabetes Video on Monofilament Sensory Testing How to Request a Referral Include pertinent patient information and a clear request or question to be addressed by the consultant. Sending a patient summary that includes the past medical history, medication list, allergies, and insurance information is very helpful. If there are relevant laboratory or imaging results, these should be included or summarized. Diabetes Education: Conversation Map Health Interactions Conversation Maps are ADA-approved tools for facilitating diabetes education. Based on adult learning principles, the maps are designed to engage the group participants in a discussion of various aspects of diabetes care (nutrition, glucose monitoring, exercise, complications, etc). The U.S. Conversation Map tools meet the ADA Recognition criteria from a complete DSME curriculum. Management Management of Specific ASCVD Risk Factors Atherosclerotic cardiovascular disease or ASCVD (i.e., coronary heart disease and stroke) is the leading cause of death in patients with diabetes. People with diabetes are two to four times more likely to have heart disease or stroke than people without diabetes. Myocardial infarction in people with diabetes leads to worse outcomes than in people without diabetes, and a diagnosis of diabetes is considered equivalent in risk to having had a previous myocardial infarction. Management of the cardiovascular risk factors so commonly present in people with diabetes is essential in preventing morbidity and mortality in patients with diabetes. Management of specific ASCVD risk factors: Smoking cessation: Advise all patients not to use cigarettes and other tobacco products or e-cigarettes (ADA, level of evidence A). Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care (level of evidence A). Advising all patients to cut back on their smoking has not been shown to improve cardiovascular outcomes; rather, patients should be advised not to use tobacco products. Strong and convincing evidence exists for a causal link between cigarette smoking and health risk, making smoking the most important modifiable cause of premature death. Patients with diabetes who smoke have a higher risk of premature development of microvascular complications, CVD, and premature death. A number of large randomized clinical trials have demonstrated the efficacy and cost-effectiveness of smoking cessation counseling in changing smoking behavior. There is no evidence that e-cigarettes are a healthier alternative to smoking or that ecigarettes can facilitate smoking cessation. Hypertension: For patients with diabetes and hypertension, blood pressure targets should be individualized through a shared decision-making process that addresses cardiovascular risk, potential adverse effects of antihypertensive medications, and patient preferences. (ADA, level of evidence B) For individuals with diabetes and hypertension at higher cardiovascular risk (existing ASCVD or 10-year ASCVD risk ≥ 15%), a blood pressure target of < 130/80 mmHg may be appropriate if it can be safely attained. (ADA, level of evidence B) © 2024 Aquifer, Inc. - ARIADNA ZARZUELA ([email protected]) - 2024-03-04 13:38 EST 5/11 For individuals with diabetes and hypertension at lower risk for cardiovascular disease (10-year ASCVD risk < 15%), treat to a blood pressure target of < 140/90 mmHg. (ADA, level of evidence A) In adults with diabetes and hypertension, antihypertensive drug treatment should be initiated at a BP of 130/80 mmHg or higher with a treatment goal of less than 130/80 mmHg. (ACC/AHA guidelines) Clear observational evidence indicates that lower blood pressures are associated with improved cardiovascular and renal outcomes for patients with diabetes, and this relationship extends as low as systolic pressures of 115 mmHg. In the meta-analysis produced for the 2017 ACC/AHA blood pressure guideline, researchers found evidence that treating patients to a blood pressure < 130/80 mmHg helped prevent such outcomes, and they found similar outcomes for patients with and without diabetes. Thus, the guideline recommends using both behavioral interventions and medications to lower blood pressures in adults with diabetes to below a goal of 130/80 mmHg. The ADA guidelines differ slightly (as above), mainly due to the findings of the ACCORD BP trial, which suggested that blood pressure targets more intensive than < 140/90 mmHg are not likely to improve cardiovascular outcomes among most people with type 2 diabetes. However, they may be reasonable for patients who may derive the most benefit and have been educated about added treatment burden, side effects, and costs. Thus, the ADA guidelines recommend a more individualized approach. All first-line classes of anti-hypertensive (thiazides, ACE inhibitors, angiotensin receptor blockers (ARBs), or calcium channel blockers) are useful and effective medications for patients with diabetes. For more required information about hypertension management in patients with diabetes, read the Aquifer Hypertension Guidelines Module. Dyslipidemia: Dyslipidemia is a known risk factor for CVD in patients with and without diabetes. Abundant evidence supports the use of statins in the prevention of cardiovascular morbidity and mortality in patients with diabetes. Measurement of a lipid profile is recommended at the time of diagnosis of diabetes and then annually for patients on statins (every five years for those not on statins), or with any change in medication that may impact the lipid profile. The American College of Cardiology and American Heart Association (ACC/AHA) recommends the following treatment for patients with diabetes and LDL-c 70—189 mg/dL (the ADA’s guidelines are worded slightly differently, but recommend essentially the same, with additional focus on lifestyle therapy): Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus (level of evidence A). High-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus and multiple ASCVD risk factors (level of evidence B). High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥ 7.5% estimated 10-year ASCVD risk unless contraindicated (level of evidence B). Ezetimibe may be added to maximally tolerated statin therapy in adults with diabetes mellitus and ASCVD risk ≥ 20% (level of evidence C). In adults with diabetes mellitus who are younger than 40 or older than 75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy (level of evidence C). Note, the ACC/AHA recommends all patients older than 21 (with or without diabetes) who have an LDLc > 190 should be started on statin therapy (level of evidence B).
For more required information about cholesterol management in patients with diabetes, read the Aquifer Cholesterol Guidelines Module.
Lifestyle therapy to improve the lipid profile and to reduce the risk of developing ASCVD in patients with diabetes mellitus is also
important. The ADA recommends focusing on weight loss (if indicated); application of a Mediterranean style or Dietary Approaches to Stop
Hypertension (DASH) eating pattern; reduction of saturated fat and trans fat; increase of dietary n-3 fatty acids, viscous fiber, and plant
stanols/sterols intake; and increased physical activity (level of evidence A).
Aspirin:
Aspirin is effective in reducing cardiovascular morbidity and mortality in patients with previous MI or stroke (secondary prevention). For patients with
no previous cardiovascular events (primary prevention), the net benefit is not as evident.
Aspirin therapy for primary prevention can be discussed with a patient through a process of shared decision-making, weighing the potential
cardiovascular benefits with the risk of bleeding. According to the USPSTF (2022), the decision to initiate low-dose aspirin for the primary prevention
of CVD in adults aged 40 to 59 years who have a 10% or greater 10-year CVD risk should be an individual one. Evidence indicates that the net
benefit of aspirin use in this group is small. Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more
likely to benefit (Grade C).
The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older (Grade D).
The American Diabetes Association (ADA) recommends:
Aspirin therapy (75 to 162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased
cardiovascular risk, after a discussion with the patient on the benefits versus increased risk of bleeding (level of evidence A).
Use aspirin therapy (75 to 162 mg/day) as a secondary prevention strategy in those with diabetes and a history ASCVD (level of evidence
A).
For patients with ASCVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used (level of evidence B).
Long-term treatment with dual antiplatelet therapy should be considered for patients with prior coronary intervention, high ischemic risk, and
low bleeding risk (level of evidence A).
Combination therapy with aspirin and low-dose rivaroxaban should be considered for patients with stable coronary and/or peripheral artery
disease and low bleeding risk to prevent major adverse limb and cardiovascular events (level of evidence A).
Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary syndrome and may
have benefits beyond this period (level of evidence A).
Glycemic control:
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Lowering patients’ A1Cs to < 7% has been shown to prevent microvascular disease (retinopathy and nephropathy). Whether this glycemic control prevents macrovascular disease has been less clear. A meta-analysis of 5 randomized controlled trials of intensive (A1C of 6–6.5) versus standard (A1C of 7%) glycemic control showed a significant reduction in fatal and non-fatal myocardial infarctions, but failed to show a decrease in stroke or all-cause mortality. A different randomized trial of intensive glycemic control found no benefit for preventing CVD over five years but found an increase in all-cause mortality. This isolated finding warrants further study, but the current ADA guidelines recommend that the A1C goal is still close to or less than 7% and that treatment should be tailored to avoid hypoglycemia and weight gain. More or less stringent goals may be appropriate for individual patients if achieved without significant hypoglycemia or adverse events. Other organizations interpret the evidence differently and may recommend higher or lower A1C goals. For example, the American College of Physicians (ACP) recommends aiming to achieve an A1C between 7% and 8%. ADA Standards of Medical Care in Diabetes The American Diabetes Association recommends a patient-centered approach to choosing appropriate pharmacologic treatment of blood glucose. This includes consideration of key factors: Use of technology (for medication administration and/or for glucose monitoring) The type(s) and selection of devices should be individualized based on availability as well as a person’s specific needs, desires, and skill level. People with diabetes should be provided with blood glucose monitoring devices as indicated by their circumstances, preferences, and treatment. People using continuous glucose monitoring devices must have access to blood glucose monitoring at all times. For people with diabetes who require insulin, insulin pens are preferred in most cases, but insulin syringes may be used for insulin delivery with consideration of patient/caregiver preference, insulin type and dosing regimen, cost, and self-management capabilities. First-line therapy depends on comorbidities, patient-centered treatment factors, and management needs, and generally includes metformin and comprehensive lifestyle modification (ADA, level of evidence A). Other medications (glucagon-like peptide 1 receptor agonists, sodium–glucose cotransporter 2 inhibitors), with or without metformin based on glycemic needs, are appropriate initial therapy for individuals with type 2 diabetes with or at high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease (ADA, level of evidence A). The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss) if symptoms of hyperglycemia are present, or when A1C levels (> 10%) or blood glucose levels (≥ 300 mg/dL) are very high (ADA, level of evidence E).
A glucagon-like peptide 1 receptor agonist is preferred to insulin when possible. If insulin is used, combination therapy with a glucagon-lik