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Complete Summary

GUIDELINE TITLE

Prevention of secondary disease: diabetes.

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Prevention of secondary disease: diabetes. New York (NY): New York State Department of Health; 2007. 4 p. [6 references]

GUIDELINE STATUS

This is the current release of the guideline.

COMPLETE SUMMARY CONTENT

 
SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

  • Human immunodeficiency virus (HIV) infection
  • Type 2 diabetes

GUIDELINE CATEGORY

Prevention
Risk Assessment

CLINICAL SPECIALTY

Allergy and Immunology
Endocrinology
Family Practice
Infectious Diseases
Internal Medicine
Preventive Medicine

INTENDED USERS

Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Public Health Departments

GUIDELINE OBJECTIVE(S)

To provide guidelines for prevention of diabetes and/or diabetes progression in human immunodeficiency virus (HIV)-infected patients

TARGET POPULATION

Human immunodeficiency virus (HIV)-infected patients

INTERVENTIONS AND PRACTICES CONSIDERED

  1. Assessment of risk factors for type 2 diabetes
  2. Lifestyle modifications including appropriate diet, weight control, and exercise
  3. Fasting blood glucose test or random blood glucose values measurement
  4. Prevention of disease progression including prescribing alternatives to a protease inhibitor-based antiretroviral regimen, life style interventions, nutrition plan, and referral to an endocrinologist

MAJOR OUTCOMES CONSIDERED

Efficacy of identifying and reducing risk

METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

METHODS USED TO ANALYZE THE EVIDENCE

Review

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

AIDS Institute clinical guidelines are developed by distinguished committees of clinicians and others with extensive experience providing care to people with HIV infection. Committees* meet regularly to assess current recommendations and to write and update guidelines in accordance with newly emerging clinical and research developments.

The Committees* rely on evidence to the extent possible in formulating recommendations. When data from randomized clinical trials are not available, Committees rely on developing guidelines based on consensus, balancing the use of new information with sound clinical judgment that results in recommendations that are in the best interest of patients.

* Current committees include:

  • Medical Care Criteria Committee
  • Committee for the Care of Children and Adolescents with HIV Infection
  • Dental Standards of Care Committee
  • Mental Health Committee
  • Women's Health Committee
  • Substance Use Committee
  • Physician's Prevention Advisory Committee
  • Pharmacy Committee

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

COST ANALYSIS

A formal cost analysis was not performed and published cost analyses were not reviewed.

METHOD OF GUIDELINE VALIDATION

Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

All guidelines developed by the Committee are externally peer reviewed by at least two experts in that particular area of patient care, which ensures depth and quality of the guidelines.

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Assessment and Prevention of Diabetes

Clinicians should assess for risk factors for type 2 diabetes in HIV-infected patients at baseline and annually (see Table 1 below).

Clinicians should emphasize appropriate diet, weight control, and exercise as methods to avoid the development of type 2 diabetes.

Clinicians should assess fasting blood glucose before initiating highly active antiretroviral therapy (HAART), 3 to 6 months after initiation, and at least annually thereafter.

Clinicians should administer 75 g of oral glucose (2-hour glucose tolerance test) to distinguish between impaired glucose tolerance (glucose level ≥140 mg/dL 2 hours after oral glucose) and diabetes (glucose level ≥200 mg/dL after oral glucose) in patients with repeated borderline fasting glucose values.

Table 1: Risk Factors for Type 2 Diabetes in HIV-infected Patients*

  • PI use
  • Severe body fat changes
  • Hepatitis C infection
  • Age ≥45 years
  • Overweight (BMI ≥25 kg/m²)
  • Habitual physical inactivity
  • First-degree relative with diabetes
  • Specific racial or ethnic groups
    • African American
    • Latino
    • Native American
    • Asian American
    • Pacific Islander
  • Previously identified glucose metabolism disturbance (e.g., IGT or IFG on previous testing)
  • History of vascular disease
    • Blood pressure ≥140/90 mmHg
  • High-density lipoprotein cholesterol (HDL-C) ˂35 mg/dL
  • Triglycerides >250 mg/dL
  • History of gestational diabetes or delivery of infant >9 lbs
  • Polycystic ovary syndrome or acanthosis nigricans

IFG, impaired fasting glucose; IGT, impaired glucose tolerance; PI, protease inhibitor

*Except for HIV-related risk factors (i.e., PI use, severe body fat changes, and hepatitis C), the information provided is based on criteria established by the American Diabetes Association for diabetes testing in asymptomatic non-HIV-infected adults.

Key Point:

If fasting blood glucose tests are not feasible, random blood glucose values may be used as an alternative screening method. Patients with random glucose consistently <100 mg/dL do not require follow-up testing. A random glucose >140 mg/dL should prompt use of a standardized diagnostic test, such as a glucose tolerance test. A random plasma glucose ≥200 mg/dL, either repeated on a subsequent day or in the presence of unequivocal symptoms of hyperglycemia (e.g., serum glucose >400 mg/dL, lactic acidosis, small to moderate amounts of ketones, serum pH of <7.3, bicarbonate of <15 mEq/L, anion gap >12), meets the threshold for the diagnosis of diabetes.

Prevention of Diabetes Disease Progression

Clinicians who lack experience in treating diabetic patients should refer patients for evaluation by clinicians experienced in managing diabetes.

When possible, clinicians should prescribe alternatives to a protease inhibitor-based HAART regimen in patients with preexisting glucose intolerance or diabetes.

Clinicians should recommend life-style interventions, including diet, exercise, weight management, and smoking cessation, for HIV-infected patients with glucose intolerance or diabetes.

When possible, HIV-infected patients with diabetes should develop and maintain a nutrition plan with a qualified nutrition counselor.

Clinicians should refer diabetic patients who are not responsive to medical intervention or who have symptoms and signs of worsening diabetes to an endocrinologist.

For additional information regarding the management of diabetes in the setting of antiretroviral (ARV) therapy, see the National Guideline Clearinghouse summary of the New York State Department of Health guideline, Long-Term Complications of Antiretroviral Therapy.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each recommendation.

BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

Appropriate assessment and prevention of diabetes and diabetes disease progression in human immunodeficiency virus (HIV)-infected patients

POTENTIAL HARMS

Not stated

IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

The AIDS Institute's Office of the Medical Director directly oversees the development, publication, dissemination and implementation of clinical practice guidelines, in collaboration with The Johns Hopkins University, Division of Infectious Diseases. These guidelines address the medical management of adults, adolescents and children with HIV infection; primary and secondary prevention in medical settings; and include informational brochures for care providers and the public.

The HIV Clinical Guidelines Program works with other programs in the AIDS Institute to promote adoption of guidelines. Clinicians, for example, are targeted through the Clinical Education Initiative (CEI) and the AIDS Education and Training Centers (AETC). The CEI provides tailored educational programming on site for health care providers on important topics in HIV care, including those addressed by the HIV Clinical Guidelines Program. The AETC provides conferences, grand rounds and other programs that cover topics contained in AIDS Institute guidelines.

Support service providers are targeted through the HIV Education and Training initiative which provides training on important HIV topics to non-physician health and human services providers. Education is carried out across the State as well as through video conferencing and audio conferencing.

The HIV Clinical Guidelines Program also works in a coordinated manner with the HIV Quality of Care Program to promote implementation of HIV guidelines in New York State. By developing quality indicators based on the guidelines, the AIDS Institute has created a mechanism for measurement of performance that allows providers and consumers to know to what extent specific guidelines have been implemented.

Finally, best practices booklets are developed through the HIV Clinical Guidelines Program. These contain practical solutions to common problems related to access, delivery or coordination of care, in an effort to ensure that HIV guidelines are implemented and that patients receive the highest level of HIV care possible.

IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Living with Illness
Staying Healthy

IOM DOMAIN

Effectiveness

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Prevention of secondary disease: diabetes. New York (NY): New York State Department of Health; 2007. 4 p. [6 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2007 May

GUIDELINE DEVELOPER(S)

New York State Department of Health - State/Local Government Agency [U.S.]

SOURCE(S) OF FUNDING

New York State Department of Health

GUIDELINE COMMITTEE

Not stated

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Not stated

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on June 28, 2007.

COPYRIGHT STATEMENT

DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.


 

 

   
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