• Kaiser Permanente Care Management Institute. Adult diabetes clinical practice guidelines. Oakland (CA): Kaiser Permanente Care Management Institute; 2005 Dec. 206 p. [127 references]

This is the current release of the guideline.

This guideline updates a previous version: Kaiser Permanente Care Management Institute. Adult diabetes clinical practice guidelines. Oakland (CA): Kaiser Permanente Care Management Institute; 2004 Mar. 167 p.

To keep current with changing medical practices, all guidelines are reviewed, and if appropriate, revised at least every two years.

Recommendations are identified as either "evidence-based (A-D, I)" or "consensus." For definitions of the levels of recommendations see the end of the "Major Recommendations" field.

Summary of Revisions to the 2006 Adult Diabetes Guidelines

Prevention of Diabetes: The Diabetes Guideline Development Team revised these recommendations to clarify that drug therapy with metformin for prevention of type 2 diabetes should only be prescribed after lifestyle intervention has been attempted.

Management of Hypertension in Patients with Diabetes: The Diabetes Guideline Development Team added combination therapy of hydrochlorothiazide/angiotensin converting enzyme inhibitors (HCTZ/ACE inhibitors) as a first-line option in the treatment of hypertension in patients with diabetes. Combination therapy of hydrochlorothiazide/ACE inhibitors was also clarified to be "recommended" when blood pressure (BP) is more than 20/10 mmHg to 30/10 mmHg above goal.

Drug Therapy for Microalbuminuria in Normotensive Patients: There was no evidence found which altered the previous recommendation. However, the Diabetes Guideline Development Team added a consensus-based statement recommending that angiotensin II blockers (ARBs) may be substituted for the treatment of microalbuminuria if the patient is intolerant to ACE inhibitors.

Lipid Management in Patients with Diabetes: The Diabetes Guidelines Development Team adopted the work of the Kaiser Permanente (KP) National Dyslipidemia guidelines for these recommendations. The most substantive revision was a consensus-based recommendation for a recommended low-density lipoprotein (LDL) target of <100 for patients age >40 with diabetes, and an optional LDL target of <70 for patients age >40 with diabetes and coronary artery disease (CAD).

Drug Therapy for the Primary and Secondary Prevention of Cardiovascular Disease (CVD) Events in Patients with Diabetes:

• The recommendations for aspirin for patients with diabetes were revised to include a minimum age (>40 years old) and to indicate an aspirin dose readily available in the United States (81 mg/day). Contraindications for aspirin (aspirin allergy, bleeding tendency, recent gastrointestinal bleeding, age >85, and clinically active hepatic disease) were also clarified.
• There was no new evidence found regarding beta-blocker treatment. However, based on existing evidence, the group decided to focus on those patients with diabetes, CVD, and who have had a myocardial infarction (MI), and recommend beta-blocker therapy for this group. For those patients with CVD and diabetes but no history of MI beta-blockers remain an option.

Management of Blood Glucose:

• The Diabetes Guideline Development Team added an additional clinical question regarding the optimal medication combination for those patients who fail to reach goals on monotherapy. More than one medication is often needed to achieve goals; however, there is insufficient evidence to recommend an optimal medication combination for type 2 diabetes which is not controlled with a single agent.
• The overall treatment goal for glycosylated hemoglobin (HbA1c) is <7%. The Diabetes Guideline Development Team added more direct guidance on individualizing these goals based on shared decision-making.

Guidelines Summary

1. Prevention of Diabetes
   1. Intervention to Delay the Onset of Type 2 Diabetes

      In patients with impaired glucose tolerance (IGT) or impaired fasting glucose (IFG),* methods to promote healthy eating and increase physical activity, which are targeted to achieve a sustained weight loss (5 to 7%), delayed the onset of diabetes and are strongly recommended as first-line therapy. If therapy goals are not achieved in a reasonable time frame through lifestyle interventions alone, the evidence supports the option of adding drug therapy with metformin.
      Evidence-based (A)

      *Included studies defined impaired glucose tolerance as a glucose level of 140 to 199 post 75 g glucose load. The American Diabetes Association (ADA) defines impaired fasting glucose as fasting plasma glucose (FPG) levels >100 mg/dL (5.6 mmol/L) but <126 mg/dL (7.0 mmol/L).
      Consensus-based

   2. Postpartum Follow-Up of Gestational Diabetes Mellitus (GDM) to Prevent Future Progression to Type 2 Diabetes

      In women with GDM, long-term postpartum follow-up including weight control and lifestyle advice is recommended to prevent future progression to type 2 diabetes. Patients with GDM should be educated on their higher risk of developing type 2 diabetes after delivery.
      Consensus-based

2. Screening
   1. Candidates for Screening for Type 2 Diabetes
      • Screening for type 2 diabetes in patients with hyperlipidemia (LDL >130) and hypertension (defined as a blood pressure >140/90 mmHg) is recommended regardless of age.
      • There is insufficient evidence for screening patients with other risk factors.*
        Screening for these patients is optional.
      • There is insufficient evidence to recommend an optimal screening interval.  Regions are encouraged to set appropriate screening intervals.

        Consensus-based

      * Risk factors are defined as a family history of type 2 diabetes in first- and second-degree relatives; belonging to a certain racial/ethnic group (Native Americans, African Americans, Hispanic Americans, Asians/South Pacific Islanders); or body mass index (BMI) >25kg/m²; or having signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovary syndrome).

   2. Test to Screen for Impaired Glucose Tolerance

      If a test for impaired glucose control is desired, a fasting plasma glucose (FPG) is the recommended test. HbA1c should not be used as a routine screening test.
      Consensus-based

3. Pharmacological Management of Diabetes
   1. Management of Hypertension in Patients with Diabetes

      Blood pressure threshold to initiate drug therapy in patients with diabetes and hypertension

      Initiate antihypertensive therapy in patients with diabetes with a systolic blood pressure (BP) of >140 mmHg and/or diastolic >85-90 mmHg. After three months of lifestyle therapy, if systolic BP is 130 to 139 or diastolic BP is 80 to 89, initiate drug therapy.
      Consensus-based

      Blood pressure threshold to initiate combination drug therapy in patients with diabetes and hypertension

      When BP is more than 20/10 mmHg to 30/10 mmHg above goal, initiating therapy with two drugs, either as a separate prescription or in fixed dose combinations is recommended.

      Note: For patients with diabetes and hypertension, the target blood pressure should be <130/80 mmHg.
      Consensus-based

      Initial Treatment of Diabetes and Hypertension in the Absence of Heart Failure or Known Coronary Heart Disease or Microalbuminuria

      For the treatment of diabetes and hypertension in the absence of heart failure, known coronary heart disease, or microalbuminuria, either a thiazide type diuretic or an ACE inhibitor is the preferred first-line drug. Combination therapy of hydrochlorothiazide/ACE inhibitors as first-line therapy is an option.
      Consensus-based

      Step therapy in the treatment of diabetes and hypertension

      • For two drugs: When a second drug is required for hypertension control, it should be either an ACE inhibitor or a diuretic.
      • For three drugs: If blood pressure is not controlled on a thiazide-type diuretic in addition to an ACE inhibitor, then treatment with a thiazide-type diuretic, an ACE inhibitor AND a beta-blocker are recommended.

      Consensus-based

      Drug Therapy for Patients with Diabetes, Hypertension, and Microalbuminuria or Diabetic Nephropathy

      If a person with diabetes, hypertension, and microalbuminuria (or albuminuria) is intolerant to an ACE Inhibitor, then, in the absence of contraindications, it is recommended that an angiotensin receptor blocker (ARB) be substituted to prevent progression of renal disease.
      Consensus-based

      Target Blood Pressure For People With Diabetes And Hypertension

      For patients with diabetes and hypertension, the target blood pressure should be <130/80 mmHg.
      Evidence-based (A): Diastolic blood pressure; Consensus-based:  Systolic blood pressure

   2. Drug Therapy for Microalbuminuria in Normotensive Patients

      ACE Inhibitors should be used in normotensive patients with diabetes and microalbuminuria (or albuminuria).
      Evidence-based (A)

      If a person is intolerant to an ACE Inhibitor, then, in the absence of contraindications, it is recommended that an ARB be substituted to prevent progression of renal disease.
      Consensus-based

   3. Lipid Management in Patients with Diabetes

      Statin therapy: Aged 40 to 80 years

      Statin Therapy is recommended for all patients aged 40 to 80 years with diabetes and total cholesterol (TC) >135, regardless of baseline LDL.
      Evidence-based (A)

      Initiate statin therapy with at least lovastatin 40 mg daily.*
      Consensus-based

      Clinical judgment is advised when considering lipid-lowering medications in people with diabetes who are at a very low ten-year CAD risk (<7 to 10% as determined from the "10-Year CAD Risk (%) and Recommendations for Dyslipidemia Drug Treatment" tables; or no history of CVD and less than two cardiovascular risk factors)**
      Consensus-based

      Statin therapy: Age < 40 years

      In patients with diabetes under age 40 who have no known CAD and who have two or more CV risk factors,** treat with lipid lowering drug therapy. Alternatively, use the "10-Year CAD Risk (%) and Recommendations for Dyslipidemia Drug Treatment" tables to identify candidates for treatment with lipid-lowering drug therapy.
      Consensus-based

      For patients under age 40 with diabetes and established CAD, treatment with a statin is recommended.
      Consensus-based

      Statin therapy: Age >80 years

      For patients over age 80 with diabetes and no established CAD, while statins are generally recommended, shared decision-making is also recommended.
      Consensus-based

      For patients over age 80 with diabetes and established CAD, treatment with a statin is recommended.
      Consensus-based

      * Lower doses recommended for patients at high risk for rhabdomyolysis.

      ** Total cholesterol >200 mg/dL, high-density lipoprotein (HDL) cholesterol <40 mg/dL, hypertension, microalbuminuria, or current smoking.

      LDL Goals for Patients with Diabetes

      • The LDL target for patients age 40 or greater with diabetes is LDL <100 mg/dL.
      • For patients age 40 or older with diabetes and CAD, an LDL target <70 mg/dL is an option.

      Note: In some people, an LDL <70 to 100 mg/dL may be difficult to achieve. In these cases, use clinical judgment to weigh the benefits and risks of intensifying drug therapy.

      Consensus-based

   4. Drug Therapy for the Primary and Secondary Prevention of Cardiovascular Disease (CVD) Events in Patients with Diabetes

      ACE Inhibitor Therapy for Primary and Secondary Prevention of CVD in Diabetes

      ACE inhibitors should be prescribed to patients with diabetes age >55 years with one or more cardiovascular factors (Total cholesterol >200 mg/dL, HDL cholesterol <40 mg/dL, hypertension, microalbuminuria, or current smoking) or a history of CVD (CAD, stroke, or peripheral vascular disease).
      Evidence-based (B)

      Aspirin Therapy in Diabetes for Prevention of CVD

      Patients with diabetes >40 years old should be treated with at least 81 mg/day aspirin unless contraindicated. People with aspirin allergy, bleeding tendency, recent gastrointestinal bleeding, age >85, and clinically active hepatic disease are not candidates for aspirin therapy.
      Consensus-based

      Beta-Blocker Therapy for Secondary Prevention of CVD in Diabetes

      Beta-blockers are recommended for patients with diabetes with a history of MI.
      Evidence-based (A)

      Beta-blockers are an option for secondary prevention of CVD without MI in patients with diabetes.
      Consensus-based

      Multifactorial Interventions for Preventing CVD in Patients with Diabetes

      Concurrent treatment of cardiovascular (CV) risk factors is recommended for the prevention of cardiovascular events in patients with type 2 diabetes.
      Consensus-based

   5. Management of Glucose

      Glucose Control

      Intensive glucose control is recommended in patients with diabetes, if not contraindicated.
      Evidence-based (A)

      Initial Drug Therapy for Glucose Lowering in Type 2 Diabetes

      Metformin is recommended as the first-line glucose lowering drug in overweight patients with type 2 diabetes.
      Evidence-based (B)

      Medical Step Therapy for Glucose Control

      • Following failure to achieve goals on monotherapy, more than one medication is recommended.
      • There is insufficient evidence to recommend an optimal medication combination for type 2 diabetes not controlled with a single agent.

      Consensus-based

      Target Blood Glucose

      The overall treatment goal for HbA1c is <7%.

      The HbA1c goal should be individualized based on shared decision-making.

      • Patients with comorbid diseases, older adults, and patients with unusual conditions may need less stringent treatment goals.
      • Conversely, more stringent goals are an option in individual patients.

      Consensus-based

   6. Monitoring Microalbumin in Patients on ACE Inhibitors with Documented Microalbuminuria

      Continued monitoring of microalbumin is optional in people with diabetes and established microalbuminuria, who are on an ACE Inhibitor or ARB.
      Consensus-based

   7. Screening for Retinopathy

      Diabetes patients with background retinopathy or more severe disease should be monitored at least annually, and those without retinopathy should be screened every one to two years.
      Consensus-based

   8. Foot Screening

      All patients with diabetes should have a foot screening that includes a monofilament test. Patients with an abnormal monofilament test are at a high risk for lower limb complications and are candidates for entry into a podiatry population-based foot care program, or equivalent.
      Consensus-based

      Annual foot screening is recommended for patients with diabetes.
      Consensus-based

   Self-Management

   9. Diabetes Self-Management Education

      Patient training in self-care behaviors is recommended as a component of any diabetes management program.
      Evidence-based (A): Effect on glucose control; Consensus-based: Effect on other outcomes

   10. Self-Monitoring of Blood Glucose (Type 1 and Type 2 Diabetes)

       Patients with type 1 and 2 diabetes should monitor their blood glucose. When self-monitoring of blood glucose (SMBG) is used, results should be accompanied by an appropriate adjustment in therapy.
       Evidence-based (A): Type 1 Diabetes; Consensus-based:  Type 2 Diabetes

Definitions:

Recommendations are classified as either "evidence-based (A-D, I)" or "consensus." Refer to the table below for full definitions.

• Evidence-based: sufficient number of high-quality studies from which to draw a conclusion, and the recommended practice is consistent with the findings of the evidence. A recommendation can also be considered "evidence-based" if there is insufficient evidence and no practice is recommended.
• Consensus: insufficient evidence and a practice is recommended based on the consensus or expert opinion of the Guideline Development Team.

Label and Language of Recommendations*

^[a] All statements specify the population for which the recommendation is intended.

* Recommendations should be labeled and given an evidence grade. The evidence grade should appear in the rationale. Evidence is graded with respect to the degree it supports the specific clinical recommendation. For example, there may be good evidence that Drugs 1 and 2 are effective for Condition A, but no evidence that Drug 1 is more effective than Drug 2. If the recommendation is to use either Drug 1 or 2, the evidence is good. If the recommendation is to use Drug 1 in preference to Drug 2, the evidence is insufficient.

None provided

The type of supporting evidence is specifically stated for each recommendation.

• Kaiser Permanente Care Management Institute. Adult diabetes clinical practice guidelines. Oakland (CA): Kaiser Permanente Care Management Institute; 2005 Dec. 206 p. [127 references]

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

2004 Mar (revised 2006)

Kaiser Permanente Care Management Institute - Managed Care Organization

Kaiser Permanente Care Management Institute

Kaiser Permanente Diabetes Guidelines Project Management Team
Kaiser Permanente Adult Diabetes Guideline Development Team

Diabetes Guidelines Project Management Team Members: Jim Dudl, MD, Clinical Lead, Care Management Institute; Michelle Wong, MPH, MPP, Project Manager, Care Management Institute; Paul Barrett, MD, EBM Methodologist, Care Management Institute; Tabitha Pousson, Staff Assistant, Care Management Institute

Adult Diabetes Guideline Development Team Members: Yerado Abrahamian, MHS, Med Tech Assessment & Guidelines, Southern California; Jill Arnold, PharmD, Pharmacy, Ohio; Larry Ballonoff, MD, Endocrinology, Colorado; Radhika Breaden, MD, Internal Medicine, Northwest; Jennifer Day, PharmD, Drug Information Services, California Division; Michael Herson, MD, Endocrinology, Northwest; James Hipkens, MD, Internal Medicine, Georgia; Fred Hom, MD, Endocrinology, Northern California; Timothy Hsieh, MD, Endocrinology, Southern California; Shannon Just, Pharmacy, Ohio; Dean Klopfenstein, RPh, CDE, Pharmacy, Northwest; Ivie Kumura, PharmD, CDE, BCPS, Pharmacy, Hawaii; Kathleen Martin, Quality and Operations Support, Northern California; Janice Marsteller, PharmD, Pharmacy, Ohio; David McCulloch, MD, Endocrinology, Group Health Cooperative; John Merenich, MD, Endocrinology, Colorado; Nancy Moline, RN, MEd, CDE, Regional Diabetes Care Mgt, Northern California; Brian O'Connor, MD, Internal Medicine, Hawaii; Denise Portello, MPH, RD, Regional Health Education, Northern California; Mark Roth, MD, Medicine, Ohio; Melissa Stern, MPH, Quality and Operations Support, Northern California; Susan Stevens, MD, Endocrinology, Northern California; Lucy Thomas, PharmD, Pharmacy, Ohio; Howard Tracer, MD, Endocrinology, Mid-Atlantic States; Mongthuong Tran, PharmD, BCPS, CDE, Pharmacy, Colorado; Frederick Ziel, MD, CDE, Endocrinology, Southern California

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Kaiser Permanente Care Management Institute. Adult diabetes clinical practice guidelines. Oakland (CA): Kaiser Permanente Care Management Institute; 2004 Mar. 167 p.

To keep current with changing medical practices, all guidelines are reviewed, and if appropriate, revised at least every two years.

Electronic copies: Not available at this time.

Print copies: Available from the Kaiser Permanente Care Management Institute, One Kaiser Plaza, 16^th Floor, Oakland, CA 94612

The following is available:

• Kaiser Permanente Care Management Institute. Guidelines for the management of adult diabetes in Primary Care. Oakland (CA): Kaiser Permanente Care Management Institute; 2006. 10 p.

Electronic copies: Not available at this time.

Print copies: Available from the Kaiser Permanente Care Management Institute, One Kaiser Plaza, 16^th Floor, Oakland, CA 94612

None available

This NGC summary was completed by ECRI on September 15, 2004. The information was verified by the guideline developer on September 16, 2004. This NGC summary was updated by ECRI on September 28, 2006. The updated information was verified by the guideline developer on October 30, 2006.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.