• AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. AACE diabetes mellitus guidelines. Microvascular complications. Endocr Pract 2007 May-Jun;13(Suppl 1):50-5. [72 references]

This is the current release of the guideline.

This guideline updates a previously published version: American Association of Clinical Endocrinologists, American College of Endocrinology. Medical guidelines for the management of diabetes mellitus: the AACE system of intensive diabetes self-management--2002 update. Endocr Pract 2002 Jan-Feb;8(Suppl 1):40-82.

The levels of evidence (1–4) and the recommendation grades (A–D) are defined at the end of the "Major Recommendations" field.

Microvascular Complications

All Patients With Diabetes Mellitus

• Encourage all patients to strive to achieve glycemic goals (grade A).
• Use results from postprandial glucose monitoring and the calculated standard deviation of downloaded meter results of self-monitoring of blood glucose when considering glycemic management strategies (grade B); evidence demonstrates that glycemic variability is an independent risk factor for microvascular disease (grade B).
• Consider preprandial and postprandial self-monitoring of blood glucose readings separately; adjust therapy if 25% of measurements exceed glycemic targets (grade C).
• Control other risk factors including (grade A):
  • Hypertension—treat blood pressure to the target of less than 130/80 mm Hg
  • Dyslipidemia—strive to achieve all lipid level goals
  • Smoking—refer patients to smoking cessation program as needed
  • Lifestyle—initiate weight reduction/control and individualized exercise regimen
• Select drug therapy with attention to cardiovascular risk (grade A).

Nephropathy

• Screen all patients with diabetes mellitus for chronic kidney disease annually; screening should begin 5 years after diagnosis in patients with T1DM and at the time of diagnosis in patients with type 2 diabetes mellitus (T2DM) (grade A). Testing includes:
  • Measurement of albumin-to-creatinine ratio in a spot urine specimen and measurement of the estimated glomerular filtration rate derived from serum creatinine
  • The following are diagnostic criteria for chronic kidney disease:
    • Estimated glomerular filtration rate <60 mL/min/1.73 m² or albumin-to-creatinine ratio ≥30 mg albumin/g creatinine
    • Microalbuminuria ≥30 mg albumin/g creatinine
    • Macroalbuminuria ≥300 mg albumin/g creatinine
• Prescribe an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker in the antihypertensive regimen in the absence of contraindications (grade A).
• Consider prescribing non–dihydropyridine calcium channel blockers, beta-adrenergic blockers, or diuretics to manage blood pressure in the setting of albuminuria or nephropathy in patients unable to tolerate angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers; taking non–dihydropyridine calcium channel blockers may reduce albuminuria in patients with diabetes mellitus, including those patients who are pregnant (grade C).
• Reduce protein intake to 0.8 to 1.0 g/kg per day in patients who are in the earlier stages of chronic kidney disease and to 0.8 g/kg per day in patients who are in the later stages of chronic kidney disease (grade B).
• The diagnosis of anemia is established if the hemoglobin level is less than 13.5 g/dL in adult men and less than 12 g/dL in adult women (grade B).
• When the estimated glomerular filtration rate is less than 30 mL/min/1.73 m², refer patients for consultation and evaluation for renal replacement therapy by a nephrologist (grade B); kidney transplantation, in-center hemodialysis, home hemodialysis, and peritoneal dialysis should be considered (grade B).
• Monitor diuretic and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy with periodic electrolyte measurement and estimation of glomerular filtration rate (grade C).
• Monitor intact parathyroid hormone levels for secondary hyperparathyroidism if the glomerular filtration rate is less than 60 mL/min/1.73 m² (grade D); consider treatment with paricalcitol (grade D).
• Monitor for anemia associated with chronic kidney disease (grade B).
• Use perioperative intravenous insulin infusion for glycemic control at the time of renal transplantation (grade B).
• American College of Endocrinology/American Association of Clinical Endocrinologists (ACE/AACE) does not recommend pancreas-only transplantation for the isolated indications of retinopathy or neuropathy in patients without life-threatening or disabling metabolic complications of diabetes mellitus who do not require renal replacement therapy (grade C).

Retinopathy

• Refer the patient to a trained examiner (ophthalmologist and/or retinal specialist) for annual dilated retinal examination at the time type 2 diabetes mellitus (T2DM) is diagnosed, or 5 years after type 1 diabetes mellitus (T1DM) is diagnosed; annual examinations should be performed thereafter (grade A).
• Alternatively, the results from 7-field stereo color fundus photography or digital retinal imaging may be read by a qualified reading center, as long as the center operates under the direction of a medical director who is a retinal specialist (grade B).
• Promptly refer the patient to a retinal specialist if there is evidence that early retinopathy is progressing or if advanced retinopathy exists (grade A).

Neuropathy

• All patients with T2DM should be assessed for neuropathy at the time of diagnosis, and all patients with T1DM should be assessed 5 years after diagnosis (grade A); annual examinations should be performed thereafter in all patients. Screening may include:
  • History and examination eliciting signs of autonomic dysfunction
  • Testing for heart rate variability, if indicated, which may include expiration-to-inspiration ratio and response to the Valsalva maneuver and standing.
• Inspect the patient's feet at every visit; evaluate skin, nails, pulses, temperature, evidence of pressure, and hygiene (grade B).
• Perform an annual comprehensive foot examination (grade B); assess sensory function by pinprick, temperature and vibration sensation using a tuning fork, or pressure using a monofilament.
• Refer the patient to a qualified podiatrist, orthopedist, or neurologist if there is a lack sensation or mechanical foot changes (grade C).
• Consider treatment with duloxetine or pregabalin, both of which are indicated to treat diabetic neuropathy (grade C).
• When treating patients with cardiac autonomic neuropathy, choose strategies appropriate for protection against cardiovascular disease (grade A).
• Tricyclic antidepressants; topical capsaicin; and antiepileptic drugs such as carbamazepine, gabapentin, pregabalin, topiramate, and lamotrigine may provide symptomatic relief, but must be prescribed with knowledge of potential toxicities (grade C).
• Further study is required before botanical preparations and dietary supplements can be advocated to treat neuropathic symptoms (grade C).
• Maintain a referral network for podiatric and peripheral vascular studies and care (grade C).

Definitions:

Levels of Substantiation in Evidence-Based Medicine^a

^aAdapted from the American Association of Clinical Endocrinologists Protocol for the Standardized Production of Clinical Practice Guidelines.

^bLevel-of-evidence categories 1 through 3 indicate scientific substantiation or proof; level-of-evidence category 4 indicates unproven claims.

Recommendation Grades in Evidence-Based Medicine^a

^aAdapted from the American Association of Clinical Endocrinologists Protocol for the Standardized Production of Clinical Practice Guidelines.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. AACE diabetes mellitus guidelines. Microvascular complications. Endocr Pract 2007 May-Jun;13(Suppl 1):50-5. [72 references]

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

2000 Jan (revised 2007)

American Association of Clinical Endocrinologists - Medical Specialty Society
American College of Endocrinology - Medical Specialty Society

American Association of Clinical Endocrinologists (AACE)

American Association of Clinical Endocrinologists (AACE) Diabetes Mellitus Clinical Practice Guidelines Task Force

Task Force Members: Helena W. Rodbard, MD, FACP, MACE (Chairperson) Medical Director, Endocrine and Metabolic Consultants Past President, American Association of Clinical Endocrinologists Past President, American College of Endocrinology, Rockville, Maryland; Lawrence Blonde, MD, FACP, FACE, Director, Ochsner Diabetes Clinical Research Unit; Section on Endocrinology, Diabetes, and Metabolic Diseases Associate Residency Program Director, Department of Internal Medicine, New Orleans, Louisiana; Susan S. Braithwaite, MD, FACP, FACE, Clinical Professor of Medicine, University of North Carolina, Division of Endocrinology, Chapel Hill, NC; Elise M. Brett, MD, FACE, Assistant Clinical Professor of Medicine; Division of Endocrinology, Diabetes, and Bone Disease; Mount Sinai School of Medicine, New York, New York; Rhoda H. Cobin, MD, MACE, Clinical Professor of Medicine; Division of Endocrinology, Diabetes, and Bone Disease; Mount Sinai School of Medicine, Immediate Past President, American College of Endocrinology, Past President, American Association of Clinical Endocrinologists, New York, New York; Yehuda Handelsman, MD, FACP, FACE, Medical Director, Metabolic Institute of America, Senior Scientific Consultant, Metabolic Endocrine Education Foundation, Tarzana, California; Richard Hellman, MD, FACP, FACE, Clinical Professor of Medicine, University of Missouri-Kansas City School of Medicine, President, American Association of Clinical Endocrinologists, North Kansas City, Missouri; Paul S. Jellinger, MD, MACE, Professor of Medicine and Voluntary Faculty, University of Miami School of Medicine, Past President, American College of Endocrinology Past President, American Association of Clinical Endocrinologists, Hollywood, Florida; Lois G. Jovanovic, MD, FACE, CEO & Chief Scientific Officer, Sansum Diabetes Research Institute, Adjunct Professor Biomolecular Science and Engineering, University of California-Santa Barbara, Clinical Professor of Medicine, University of Southern California, Keck School of Medicine, Santa Barbara, CA; Philip Levy, MD, FACE, Clinical Professor of Medicine, University of Arizona College of Medicine, Past President, American College of Endocrinology, Phoenix, Arizona; Jeffrey I. Mechanick, MD, FACP, FACE, FACN, Associate Clinical Professor of Medicine and Director of Metabolic Support; Division of Endocrinology, Diabetes, and Bone Disease; Mount Sinai School of Medicine, New York, New York; Farhad Zangeneh, MD, FACP, FACE, Assistant Clinical Professor of Medicine, George Washington University School of Medicine, Washington, DC, Endocrine, Diabetes and Osteoporosis Clinic (EDOC), Sterling, Virginia

Medical Writer: Christopher G. Parkin, MS

Reviewers: Lewis E. Braverman, MD; Samuel Dagogo-Jack, MD, FACE; Vivian A. Fonseca, MD, FACE; Martin M. Grajower, MD, FACP, FACE; Virginia A. LiVolsi, MD; Fernando Ovalle, MD, FACE; Herbert I. Rettinger, MD, FACE; Talla P. Shankar, MD, FACE; Joseph J. Torre, MD, FACP, FACE; Dace L. Trence, MD, FACE

Dr. Lawrence Blonde reports that he has received grant/research support from Amylin Pharmaceuticals, Inc.; AstraZeneca LP; Bristol-Myers Squibb Company; Eli Lilly and Company; MannKind Corporation; Merck & Co., Inc.; Novo Nordisk Inc.; Novartis Corporation; Pfizer Inc.; and sanofi-aventis U.S. He has received speaker and consultant honoraria from Abbott Laboratories; Amylin Pharmaceuticals, Inc.; Eli Lilly and Company; GlaxoSmithKline; LifeScan, Inc.; Merck & Co., Inc.; Novartis, Novo Nordisk Inc.; Pfizer Inc.; and sanofi-aventis U.S. He has received consultant honoraria from Kos Pharmaceuticals, Inc. and U.S. Surgical. Dr. Blonde has also disclosed that his spouse is a stock shareholder of Amylin Pharmaceuticals, Inc. and Pfizer Inc., in an account that is not part of their community property.

Dr. Susan S. Braithwaite reports that she does not have any financial relationships with any commercial interests.

Dr. Elise M. Brett reports that her spouse is an employee of Novo Nordisk Inc.

Dr. Rhoda H. Cobin reports that she has received speaker honoraria from GlaxoSmithKline; Pfizer Inc.; sanofi-aventis U.S.; and Novartis and consultant honoraria from Abbott Laboratories.

Dr. Yehuda Handelsman reports that he has received speaker honoraria from Abbott Laboratories; Amylin Pharmaceuticals, Inc.; AstraZeneca LP; Bristol-Myers Squibb Company; GlaxoSmithKline; Merck & Co., Inc.; Novartis; and sanofi-aventis U.S. and consultant honoraria from Abbott Laboratories; Daiichi Sankyo, Inc.; Novartis; and sanofi-aventis U.S.

Dr. Richard Hellman reports that he has received speaker honoraria from Daiichi Sankyo, Inc. and Pfizer Inc. and research grants for his role as an independent contractor from Abbott Laboratories; Pfizer Inc.; and Medtronic, Inc.

Dr. Paul S. Jellinger reports that he has received speaker honoraria from Eli Lilly and Company; Merck & Co., Inc.; Novartis; Novo Nordisk Inc.; and Takeda Pharmaceuticals North America, Inc.

Dr. Lois G. Jovanovic reports that she has received research grants for her role as investigator from Eli Lilly and Company; DexCom Inc.; LifeScan, Inc.; Novo Nordisk Inc.; Pfizer Inc.; Roche Pharmaceuticals; sanofi-aventis U.S.; and Sensys Medical, Inc.

Dr. Philip Levy reports that he has received speaker honoraria from Abbott Laboratories; Amylin Pharmaceuticals, Inc.; GlaxoSmithKline; Eli Lilly and Company; Merck & Co., Inc.; Novo Nordisk Inc.; Novartis; Pfizer Inc.; and sanofi-aventis U.S. and research grants from Amylin Pharmaceuticals, Inc.; MannKind Corporation; Novo Nordisk Inc.; Pfizer Inc.; and sanofi-aventis U.S.

Dr. Jeffrey I. Mechanick reports that he does not have any financial relationships with any commercial interests.

Dr. Helena W. Rodbard reports that she has received consultant honoraria from Ortho-McNeil, Inc.; Pfizer Inc.; sanofi-aventis U.S.; and Takeda Pharmaceuticals North America, Inc.; speaker honoraria from Abbott; GlaxoSmithKline; Merck & Co., Inc.; Novo Nordisk; Pfizer Inc.; and sanofi-aventis U.S. and research support from Biodel, Inc. and sanofi-aventis U. S.

Dr. Farhad Zangeneh reports that he has received speaker honoraria from Eli Lilly and Company; GlaxoSmithKline; Novartis; Novo Nordisk Inc.; Pfizer Inc.; Roche Pharmaceuticals; sanofi-aventis U.S.; and Takeda Pharmaceuticals North America, Inc.

This is the current release of the guideline.

This guideline updates a previously published version: American Association of Clinical Endocrinologists, American College of Endocrinology. Medical guidelines for the management of diabetes mellitus: the AACE system of intensive diabetes self-management--2002 update. Endocr Pract 2002 Jan-Feb;8(Suppl 1):40-82.

None available

This NGC summary was completed by ECRI on March 1, 2000. The summary was verified by the guideline developer as of March 8, 2000. This summary was updated on April 16, 2002. The information was verified by the guideline developer on November 11, 2002. This summary was updated by ECRI Institute on September 27, 2007. The updated information was verified by the guideline developer on November 12, 2007. This summary was updated by ECRI Institute on January 10, 2008, following the U.S. Food and Drug Administration advisory on Carbamazepine.

All rights reserved. No part of these materials may be reproduced or retransmitted in any manner without the prior written permission of American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE).