2012年糖尿病诊疗标准

StandardsofMedicalCareinDiabetesd2012

D

iabetesmellitusisachronicillnessthatrequirescontinuingmedicalcareandongoingpatientself-managementeducationandsupporttopreventacutecomplicationsandtoreducetheriskoflong-termcomplications.Diabetescareiscomplexandrequiresthatmanyissues,beyondglycemiccontrol,beaddressed.Alargebodyofevidenceexiststhatsup-portsarangeofinterventionstoimprovediabetesoutcomes.

Thesestandardsofcareareintendedtoprovideclinicians,patients,researchers,payers,andotherinterestedinpidualswiththecomponentsofdiabetescare,generaltreatmentgoals,andtoolstoeval-uatethequalityofcare.Whileinpidualpreferences,comorbidities,andotherpa-tientfactorsmayrequiremodi cationofgoals,targetsthataredesirableformostpatientswithdiabetesareprovided.Spe-ci callytitledsectionsofthestandardsaddresschildrenwithdiabetes,pregnantwomen,andpeoplewithprediabetes.Thesestandardsarenotintendedtoprecludeclinicaljudgmentormoreextensiveeval-uationandmanagementofthepatientbyotherspecialistsasneeded.Formorede-tailedinformationaboutmanagementofdiabetes,refertoreferences1–3.

Therecommendationsincludedarescreening,diagnostic,andtherapeuticac-tionsthatareknownorbelievedtofavor-ablyaffecthealthoutcomesofpatientswithdiabetes.Alargenumberoftheseinterven-tionshavebeenshowntobecost-effective(4).Agradingsystem(Table1),developedbytheAmericanDiabetesAssociation(ADA)andmodeledafterexistingmethods,wasutilizedtoclarifyandcodifytheevi-dencethatformsthebasisfortherecom-mendations.Thelevelofevidencethatsupportseachrecommendationislistedaf-tereachrecommendationusingthelettersA,B,C,orE.

Thesestandardsofcarearerevisedan-nuallybytheADA’smultidisciplinaryPro-fessionalPracticeCommittee,incorporating

newevidence.Forthecurrentrevision,committeememberssystematicallysearchedMedlineforhumanstudiesrelatedtoeachsubsectionandpublishedsince1January2010.Recommendations(bulletedatthebeginningofeachsubsectionandalsolistedinthe“ExecutiveSummary:StandardsofMedicalCareinDiabetesd2012”)werere-visedbasedonnewevidenceor,insomecases,toclarifythepriorrecommendationormatchthestrengthofthewordingtothestrengthoftheevidence.Atablelink-ingthechangesinrecommendationstonewevidencecanbereviewedathttp://www.77cn.com.cn/CPR_Search.aspx.Subsequently,asisthecaseforallPositionStatements,thestandardsofcarewerereviewedandapprovedbytheExecu-tiveCommitteeofADA’sBoardofDirectors,whichincludeshealthcareprofessionals,scientists,andlaypeople.

Feedbackfromthelargerclinicalcom-munitywasvaluableforthe2012revisionofthestandards.Readerswhowishtocommentonthe“StandardsofMedicalCareinDiabetesd2012”areinvitedtodosoathttp://www.77cn.com.cn/CPR_Search.aspx.

MembersoftheProfessionalPracticeCommitteediscloseallpotential nancialcon ictsofinterestwithindustry.Thesedisclosureswerediscussedattheonsetofthestandardsrevisionmeeting.Membersofthecommittee,theiremployer,andtheirdisclosedcon ictsofinterestarelistedinthe“ProfessionalPracticeCommitteeMembers”table(seepg.S109).TheAmericanDiabetesAssociationfundsdevelopmentofthestandardsandallitspositionstatementsoutofitsgeneralrevenuesanddoesnotuti-lizeindustrysupportforthesepurposes.I.CLASSIFICATIONANDDIAGNOSIS

A.Classi cation

Theclassi cationofdiabetesincludesfourclinicalclasses:

c

c

c

c

Type1diabetes(resultsfromb-celldestruction,usuallyleadingtoabsoluteinsulinde ciency)

Type2diabetes(resultsfromapro-gressiveinsulinsecretorydefectonthebackgroundofinsulinresistance)

Otherspeci ctypesofdiabetesduetoothercauses,e.g.,geneticdefectsinb-cellfunction,geneticdefectsininsulinaction,diseasesoftheexocrinepancreas(suchascystic brosis),anddrug-orchemical-induced(suchasinthetreatmentofHIV/AIDSorafterorgantransplantation)Gestationaldiabetesmellitus(GDM)(diabetesdiagnosedduringpregnancythatisnotclearlyovertdiabetes)

Somepatientscannotbeclearlyclas-si edashavingtype1ortype2diabetes.Clinicalpresentationanddiseaseprogres-sionvaryconsiderablyinbothtypesofdiabetes.Occasionally,patientswhooth-erwisehavetype2diabetesmaypresentwithketoacidosis.Similarly,patientswithtype1mayhavealateonsetandslow(butrelentless)progressionofdiseasedespitehavingfeaturesofautoimmunedisease.Suchdif cultiesindiagnosismayoccurinchildren,adolescents,andadults.Thetruediagnosismaybecomemoreobviousovertime.

B.DiagnosisofdiabetesRecommendations

Fordecades,thediagnosisofdiabeteswasbasedonplasmaglucosecriteria,eitherthefastingplasmaglucose(FPG)orthe2-hvalueinthe75-goralglucosetoler-ancetest(OGTT)(5).

In2009,anInternationalExpertCom-mitteethatincludedrepresentativesoftheAmericanDiabetesAssociation(ADA),theInternationalDiabetesFederation(IDF),andtheEuropeanAssociationfortheStudyofDiabetes(EASD)recommendedtheuseoftheA1Ctesttodiagnosediabetes,withathresholdof$6.5%(6),andADAadoptedthiscriterionin2010(5).Thedi-agnostictestshouldbeperformedusingamethodthatiscerti edbytheNationalGlycohemoglobinStandardizationPro-gram(NGSP)andstandardizedortraceabletotheDiabetesControlandComplicationsTrial(DCCT)referenceassay.Point-of-care

S11

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Originallyapproved1988.Mostrecentreview/revisionOctober2011.DOI:10.2337/dc12-s011

©2012bytheAmericanDiabetesAssociation.Readersmayusethisarticleaslongastheworkisproperlycited,theuseiseducationalandnotforpro t,andtheworkisnotaltered.Seehttp://www.77cn.com.cn/licenses/by-nc-nd/3.0/fordetails.

http://www.77cn.com.cnDIABETESCARE,VOLUME35,SUPPLEMENT1,JANUARY2012

PositionStatement

Table1dADAevidencegradingsystemforclinicalpracticerecommendationsLevelofevidenceA

Table2dCriteriaforthediagnosisofdiabetes

A1C$6.5%.ThetestshouldbeperformedinalaboratoryusingamethodthatisNGSPcerti edandstandardizedtotheDCCTassay.*

OR

FPG$126mg/dL(7.0mmol/L).Fastingisde nedasnocaloricintakeforatleast8h.*

OR

2-hplasmaglucose$200mg/dL(11.1mmol/L)duringanOGTT.Thetestshouldbe

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