• Vermont Program for Quality Health Care, Vermont Department of Health. Recommendations for management of diabetes in Vermont. 4th ed. Montpelier (VT): Vermont Department of Health (VDH); 2004 May. Various p. [107 references]

This is the current release of the guideline.

A summary of recommendations is provided below. For the full recommendations see original guideline document.

Hemoglobin A1C (A1C)

• The American Diabetes Association (ADA) suggests a target A1C <7 percent.
• The ADA recommends re-evaluation of the management plan for anyone unable to achieve desired goals.
• Measure A1C every three to six months.

Ophthalmic Exams

• Type 1 diabetes

  Schedule yearly complete dilated and comprehensive eye examinations starting 3 to 5 years after diagnosis and/or at 10 years of age, whichever is later.

• Type 2 diabetes

  Schedule yearly complete dilated and comprehensive eye examinations starting shortly after diagnosis.

• Pregnant women with pre-existing type 1 or type 2 diabetes

  Schedule a first trimester examination with close follow-up during pregnancy and for one year postpartum.

• Women with type 1 or type 2 diabetes who are planning pregnancies

  Schedule a complete dilated and comprehensive eye examination pre-conception, with counseling on the risk of development and/or progression of diabetic retinopathy.

• Cataracts and glaucoma are more common in people with diabetes.

Foot Exams, Ulcers, and Infections

• Perform an annual comprehensive foot exam.
• Identify patients with high-risk feet.
• Closely monitor high-risk feet.
• Consider peripheral vascular studies in patients with signs or symptoms of vascular compromise.
• Ulcers should respond to treatment within a month.
• Treat foot infections aggressively.

Blood Pressure Measurement

• Measure blood pressure at every visit.
• The goal for blood pressure is less than 130/80 mmHg.

Renal Disease

• Screen urine for evidence of renal disease every year in both type 1 and type 2 diabetes.
• For patients with nephropathy, the major goals are to maintain blood pressure (BP) <130/80 mmHg and to minimize proteinuria or albuminuria.

Lipid Management for Adults

• The primary treatment goal is a low-density lipoprotein (LDL) <100 mg/dL both for people with known macrovascular disease and those without macrovascular disease.
• Obtain a fasting lipid profile annually for both type 1 and type 2 diabetes, more frequently if needed to achieve goals.
• If lipid values are low risk (LDL <100 mg/dL, high-density lipoprotein [HDL] >50 mg/dL, and triglycerides <150 mg/dL) repeat lipid profile every two years depending on cardiovascular disease (CVD) status.
• Consider statin therapy for all patients with diabetes over age 40 and a total cholesterol >135 mg/dL, based on evidence from the Heart Protection Study.

Self-Management Education

• Diabetes self-management education involves a continuum of services ranging from the teaching of Survival Skills to Comprehensive Self-Management Education Programs to Intensive Management.
• Educational needs should be assessed at time of diagnosis and whenever there is poor clinical control or a major change in therapy.
• Licensed health care professionals with specific training in diabetes and training in education of people with diabetes should teach self-management education.
• Self-management education needs and plans should be documented in the medical record and acknowledged by all providers.

Medical Nutrition Therapy

• Medical Nutrition Therapy is an integral component of diabetes management and of diabetes self-management education.
• A registered dietitian (RD), certified in Vermont (CD) who is knowledgeable and skilled in implementing diabetes medical nutrition therapy should be the team member with primary responsibility for nutrition care and education.

Self-Monitored Blood Glucose Testing (SMBG)

• SMBG is an important tool for achieving glycemic control.
• The frequency of SMBG should be individualized based on type of diabetes, glucose goals, and other factors.

Tobacco Use Status and Counseling

• Screen at time of initial diabetes diagnosis.
• Ask tobacco users about status of tobacco use at each visit.
• Advise every tobacco user to quit.
• Assist every tobacco user who is willing to make a quit attempt to access treatment.
• Follow up with every tobacco user at every visit.

Diabetes Mellitus And Exercise

• Exercise is an important therapeutic tool for people with diabetes.
• Exercise programs should be individualized to maximize benefit and minimize risk.

Obesity Treatment And Management For Type 2 Diabetes

• Weight loss is recommended to lower elevated blood glucose levels in overweight and obese persons with type 2 diabetes.
• Weight loss and weight maintenance therapy should employ the combination of low-calorie diets, increased physical activity, and behavior therapy.

Immunization

• Annual influenza vaccine is recommended for all patients with diabetes.
• Pneumococcal vaccine is recommended for all patients with diabetes.

Screening For Type 2 Diabetes Mellitus

• Individuals who are at high-risk for type 2 diabetes should be screened for disease.
• A fasting plasma glucose test (FPG) is the simplest and least expensive screening test.
• A FPG result >126 mg/dL on two separate occasions is diagnostic of diabetes; values of 100 to 125 mg/dL are termed impaired fasting glucose, and values <100 mg/dL are considered normal.
• Individuals with impaired glucose tolerance can significantly reduce the risk of developing type 2 diabetes through intervention with diet and exercise.

Gestational Diabetes Mellitus (GDM)

• Prenatal screening for GDM is important; however, there is controversy about whether screening should be universal or selective.
• Women with GDM are at extremely high risk for developing type 2 diabetes later in life and should be monitored closely.

Medications

• Medication Therapy can involve oral agents, insulin, or a combination of these two therapies.
• Medication Therapy is a therapeutic tool for use in lowering and maintaining blood glucose levels.

Intensive Insulin Management

• Candidates for Intensive Insulin Management must be motivated to improve glucose control and able to assume responsibility for their day-to-day care.
• Use of Intensive Insulin Management should be initiated, monitored, and supported by a Comprehensive Diabetes Team.
• Intensive Insulin Management is essential during pregnancy and recommended for all who wish to reduce their risk of diabetes complications.

Psychosocial Issues in Diabetes Care

• Assess key psychosocial factors affecting chronic care.
• Choose appropriate behavioral strategies to enhance diabetes management.

Primary Prevention

• Counsel people at high risk for the development of diabetes on the benefits of moderate weight loss and exercise (weight loss of 5 to 7% with 150 minutes of exercise per week).
• Screen people at high risk.
• Monitor people with pre-diabetes for the development of diabetes every 1 to 2 years.
• Based on current knowledge, the ADA does not support the routine use of drug therapy in the prevention of Type 2 diabetes.

Clinical algorithms are provided in the original guideline document for:

• Foot Ulcer in Diabetic Patient
• Foot Infection in Patient with Diabetes
• Screening for Renal Disease
• Screen for Tobacco Use

The type of supporting evidence is not specifically stated for each recommendation. Recommendations are based on a combination of clinical experience and research-based evidence.

• Vermont Program for Quality Health Care, Vermont Department of Health. Recommendations for management of diabetes in Vermont. 4th ed. Montpelier (VT): Vermont Department of Health (VDH); 2004 May. Various p. [107 references]

The guideline was adapted from American Diabetes Association: Clinical Practice Recommendations 2004. Diabetes Care. 2004 Jan; 27 Suppl 1.

2004 May

Vermont Program for Quality in Health Care - Private Nonprofit Organization

Vermont Program for Quality in Health Care and the Vermont Department of Health

Diabetes Steering Committee

Committee Members: Janice Waterman, RD, CDE; Joel Schnure, MD; David J. Weissgold, MD; Stephen Feltus, OD; Michael Ricci, MD; Marc R. Sarnow, DPM; Virginia Hood, MD; Charles MacLean, MD; Sarah Narkewicz, MS, RN CDE; Margaret Costello, MS, RN, CDE; Robin Edelman, MS, RD, CDE; Philip Lapp, MD; Donna Hunt, RD, CDE; Anthony Williams, MD; Monica Valovic, RD, CDE; Theodore Marcy, MD; Moira L. Cook, MS; David Gorson, MD; Jodi Lawless-Corrado, PT, HFI; Jayne Collins, PT, MS, ATC; Jill Nye-McKeown, MS, RD; Jean Harvey-Berino, PhD; W. Kemper Alston, MD; Ira Bernstein, MD; Michele Lauria, MD; Edward Chien, MD; Annette Halasz, RN, CDE; Elizabeth Hallock, RN, CDE; Margaret Terrien, RN, MSN, ANP, CDE; Mary Wood, RN, CDE; Robin Myers, RN, CDE; Mark J. Detzer, PhD; Roger Kessler, PhD

Not stated

Blue Cross and Blue Shield of Vermont - Managed Care Organization
Cigna HealthCare - Managed Care Organization
MVP Health Care - Managed Care Organization
Office of Vermont Health Access - State/Local Government Agency [U.S.]

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on April 6, 2005. The information was verified by the guideline developer on May 3, 2005. This summary was updated by ECRI on January 11, 2006 following the U.S. Food and Drug Administration advisory on rosiglitazone. This summary was updated by ECRI Institute on September 5, 2007 following the U.S. Food and Drug Administration advisory on the Thiazolidinedione class of antidiabetic drugs. This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by ECRI Institute on November 28, 2007 following the U.S. Food and Drug Administration advisory on the Avandia (rosiglitazone maleate) Tablets. This summary was updated by ECRI Institute on March 10, 2008 following the U.S. Food and Drug Administration advisory on Avandia (rosiglitazone maleate).

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