Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. Though some variability exists among different individuals, generally the association between mean glucose and A1C within an individual correlates over time (42). Epidemiological analyses of the DCCT (2) and UKPDS (57) demonstrate a curvilinear relationship between A1C and microvascular complications. 1):S1–S159. Appropriately trained specialists or specialty teams may reduce length of stay, improve glycemic control, and improve outcomes, but studies are few (11,12). However, the following approach (61) may be considered: Target glucose range for the perioperative period should be 80–180 mg/dL (4.4–10.0 mmol/L). // Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. An association between self-reported severe hypoglycemia and 5-year mortality has also been reported in clinical practice (81). Transition from the acute care setting is a risky time for all patients. In the 9-year post-DCCT follow-up of the EDIC cohort, participants previously randomized to the intensive arm had a significant 57% reduction in the risk of nonfatal myocardial infarction (MI), stroke, or cardiovascular death compared with those previously randomized to the standard arm (62). An outpatient follow-up visit with the primary care provider, endocrinologist, or diabetes educator within 1 month of discharge is advised for all patients having hyperglycemia in the hospital. Hospitals should promote the shortest safe hospital stay and provide an effective transition out of the hospital that prevents acute complications and readmission. In, Agency for Healthcare Research and Quality, Readmission and adverse events after hospital discharge [Internet], 2017. In noncardiac general surgery patients, basal insulin plus premeal regular or short-acting insulin (basal-bolus) coverage has been associated with improved glycemic control and lower rates of perioperative complications compared with the traditional sliding scale regimen (regular or short-acting insulin coverage only with no basal dosing) (31,64). Therefore, if an A1C from the prior 3 months is unavailable, measuring the A1C in all patients with diabetes or hyperglycemia admitted to the hospital is recommended. ADA plans on updating this document throughout the year in light of new technology, research, and therapy developments, Cefalu said. It is also important to treat any correctable underlying cause of DKA such as sepsis. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. Other small, short-term studies have demonstrated similar A1C reductions using CGM compared with SMBG in adults with A1C levels ≥7% (53 mmol/mol) (24,25). Because inpatient insulin use (5) and discharge orders (6) can be more effective if based on an A1C level on admission (7), perform an A1C test on all patients with diabetes or hyperglycemia admitted to the hospital if the test has not been performed in the prior 3 months. ADA previously recommended that CGM take place in adults 25 years or older with type 1 diabetes. E, Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. Improving Care and Promoting Health in Populations: 10. E, When prescribing SMBG, ensure that patients receive ongoing instruction and regular evaluation of SMBG technique, SMBG results, and their ability to use SMBG data to adjust therapy. Details of team formation are available from the Society of Hospital Medicine and the Joint Commission standards for programs. For these patients, A1C testing should take place quarterly. Hypoglycemia prevention is a critical component of diabetes management. When the nutritional issues in the hospital are complex, a registered dietitian, knowledgeable and skilled in medical nutrition therapy, can serve as an individual inpatient team member. Available from, Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group, Continuous glucose monitoring and intensive treatment of type 1 diabetes, Continuous glucose monitoring vs conventional therapy for glycemic control in adults with type 1 diabetes treated with multiple daily insulin injections: the GOLD randomized clinical trial, Effect of continuous glucose monitoring on glycemic control in adults with type 1 diabetes using insulin injections: the DIAMOND randomized clinical trial, Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring, Glycaemic impact of patient-led use of sensor-guided pump therapy in type 1 diabetes: a randomised controlled trial, Real-time continuous glucose monitoring among participants in the T1D Exchange clinic registry, Impact of continuous glucose monitoring on quality of life, treatment satisfaction, and use of medical care resources: analyses from the SWITCH study, Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes, The effect of continuous glucose monitoring in well-controlled type 1 diabetes, Sustained benefit of continuous glucose monitoring on A1C, glucose profiles, and hypoglycemia in adults with type 1 diabetes, Comparative effectiveness and safety of methods of insulin delivery and glucose monitoring for diabetes mellitus: a systematic review and meta-analysis, Real-time continuous glucose monitoring significantly reduces severe hypoglycemia in hypoglycemia-unaware patients with type 1 diabetes, Evidence-informed clinical practice recommendations for treatment of type 1 diabetes complicated by problematic hypoglycemia, Threshold-based insulin-pump interruption for reduction of hypoglycemia, Safety of a hybrid closed-loop insulin delivery system in patients with type 1 diabetes, Closed-loop insulin delivery during pregnancy in women with type 1 diabetes, Empirically establishing blood glucose targets to achieve HbA, A clinical trial of continuous subcutaneous insulin infusion versus multiple daily injections in older adults with type 2 diabetes, Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group, Effect of prior intensive insulin treatment during the Diabetes Control and Complications Trial (DCCT) on peripheral neuropathy in type 1 diabetes during the Epidemiology of Diabetes Interventions and Complications (EDIC) Study, Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study, Frequent monitoring of A1C during pregnancy as a treatment tool to guide therapy, Translating the A1C assay into estimated average glucose values, Are there clinical implications of racial differences in HbA, T1D Exchange Racial Differences Study Group, Racial differences in the relationship of glucose concentrations and hemoglobin A1c levels, Association of sickle cell trait with hemoglobin A1c in African Americans, Impact of common genetic determinants of hemoglobin A1c on type 2 diabetes risk and diagnosis in ancestrally diverse populations: a transethnic genome-wide meta-analysis, Diabetes Research in Children Network (DirecNet) Study Group, Relationship of A1C to glucose concentrations in children with type 1 diabetes: assessments by high-frequency glucose determinations by sensors, Racial disparity in A1C independent of mean blood glucose in children with type 1 diabetes, Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Research Group. Thus, where feasible, there should be structured order sets that provide computerized advice for glucose control. Table 6.1 shows the correlation between A1C levels and mean glucose levels based on two studies: the international A1C-Derived Average Glucose (ADAG) study, which assessed the correlation between A1C and frequent SMBG and CGM in 507 adults (83% non-Hispanic whites) with type 1, type 2, and no diabetes (43), and an empirical study of the average blood glucose levels at premeal, postmeal, and bedtime associated with specified A1C levels using data from the ADAG trial (37). There is evidence for a cardiovascular benefit of intensive glycemic control after long-term follow-up of cohorts treated early in the course of type 1 diabetes. A study in adults with well-controlled type 1 diabetes found that flash CGM users spent less time in hypoglycemia than those using SMBG (19). Those patients with long duration of diabetes, a known history of hypoglycemia, advanced atherosclerosis, or advanced age/frailty may benefit from less aggressive targets (70,71). Patients should be advised against purchasing or reselling preowned or secondhand test strips, as these may give incorrect results. C, Given the variable adherence to CGM, assess individual readiness for continuing CGM use prior to prescribing. E, Glucagon should be prescribed for all individuals at increased risk of clinically significant hypoglycemia, defined as blood glucose <54 mg/dL (3.0 mmol/L), so it is available should it be needed. Compared with baseline, two such studies found that hypoglycemic events fell by 56% to 80% (49,50). Two sections in this guidance—classification and diagnosis of diabetes and glycemic targets—specifically address the limitations of A1C measurements. In patients with diabetes, the readmission rate is between 14 and 20% (76). Sign In to Email Alerts with your Email Address. The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines… Enter multiple addresses on separate lines or separate them with commas. Among patients with type 1 diabetes, there is a correlation between greater SMBG frequency and lower A1C (3). Orders should also indicate that the meal delivery and nutritional insulin coverage should be coordinated, as their variability often creates the possibility of hyperglycemic and hypoglycemic events. Diabetes is a complex, chronic illness requiring continuous medical care with multifactorial risk-reduction strategies beyond glycemic control. Therefore, it is reasonable for postprandial testing to be recommended for individuals who have premeal glucose values within target but have A1C values above target. Teaching people with diabetes to balance insulin use and carbohydrate intake and exercise are necessary, but these strategies are not always sufficient for prevention. During the UKPDS, there was a 16% reduction in CVD events (combined fatal or nonfatal MI and sudden death) in the intensive glycemic control arm that did not reach statistical significance (P = 0.052), and there was no suggestion of benefit on other CVD outcomes (e.g., stroke).