December 2010 OH&S FAST FACTS: Drugs that fight cancer and other hazardous agents are valuable and vital to the care of patients. Health care workers need to know the hazards they Your Health. Your Safety. are dealing with to ensure they remain safe while caring for their patients. Hazardous Drugs in Health Care Drugs that meet one or more of
Strategies for Improving Care :
A patient-centered communication style that incorporates
patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care should be used. B
Treatment decisions should be timely and based on evidence-
based guidelines that are tailored to individual patient
preferences, prognoses, and comorbidities. B
Care should be aligned with components of the Chronic Care Model to ensure productive interactions between a prepared proactive practice team and an informed activated patient. A
When feasible, care systems should support team-based care,
community involvement, patient registries, and decision
support tools to meet patient needs. B
Diabetes Diagnosis The patient 45 years old, AC sugar : 120, PC sugar:170, A1C : 6.9 AC sugar : 130, PC sugar:170, A1C : 6.2 AC sugar : 110, PC sugar:230, A1C : 6.2 AC sugar : 110, OGTT PC sugar:230, A1C : 6.2 Confirming the Diagnosis for Diabetes
Unless there is a clear clinical diagnosis (e.g., patient in a hyperglycemic crisis or with classic symptoms of hyperglycemia and a random plasma glucose ≥200 mg/dL [11.1 mmol/L]), a second test is required for confirmation.
It is recommended that the same test be repeated without delay using a new blood sample for confirmation because there will be a greater likelihood of concurrence.
If a patient has discordant results from two different tests, then the test result that is above the diagnostic cut point should be
repeated. The diagnosis is made on the basis of the confirmed test.
For example, if a patient meets the diabetes criterion of the A1C (two results ≥6.5% [48 mmol/mol]) but not FPG (<126 mg/dL [7.0 mmol/L]), that person should nevertheless be considered to have Criteria for testing for diabetes or prediabetes in asymptomatic adults • Testing should be in all adults who are overweight (BMI≧25 kg/m2
Obesity or≧23 kg/m2 in Asian Americans)
• Testing should begin at age 45
Testing for diabetes or prediabetes in asymptomatic adults Physical inactivityFirst-degree relative with diabetesHigh-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American,Pacific Women who delivered a baby weighing >9 lb or were diagnosed with GDM Hypertension (≧140/90 mmHg or on therapy for Testing for diabetes or prediabetes in asymptomatic adults HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level ≧250 mg/dL(2.82 mmol/L) Women with polycystic ovary syndrome A1C ≧5.7% (39 mmol/mol), IGT, or IFG on previous testing Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) History of CVD Prevention or Delay of Type 2 Diabetes
Patients with prediabetes should be referred to an intensive diet and physical activity behavioral counseling program adhering to the tenets of the Diabetes Prevention Program (DPP) targeting a loss of 7% of body weight and should increase their moderate-intensity physical activity (such as brisk walking) to at least 150 min/week. A
Follow-up counseling and maintenance programs should be offered for long- term success in preventing diabetes. B
Based on the cost-effectiveness of diabetes prevention, such programs should be covered by third-party payers. B
Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially in those with BMI >35 kg/m2, those aged <60 years, and women with prior gestational diabetes mellitus. A
Prevention or Delay of Type 2 Diabetes
At least annual monitoring for the development of diabetes in those with prediabetes is suggested. E
Screening for and treatment of modifiable risk factors for cardiovascular disease is suggested. B
Diabetes self-management education and support programs are appropriate venues for people with prediabetes to receive education and support to develop and maintain behaviors that can prevent or delay the onset of diabetes. B
Technology-assisted tools including Internet-based social networks, distance learning, DVD-based content, and mobile applications can be useful elements of effective lifestyle modification to prevent diabetes. B
Obesity Management for the Treatment of Type 2
Diabetes : Recommendation
At each patient encounter, BMI should be calculated and documented in the medical record. B
Diet, Physical Activity, and Behavioral Therapy :
Diet, physical activity, and behavioral therapy designed to achieve 5% weight loss should be prescribed for overweight and obese patients with type 2 diabetes ready to achieve weight loss. A
Such interventions should be high intensity (≥16 sessions in 6 months) and focus on diet, physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit. A
Diets that provide the same caloric restriction but differ in protein, carbohydrate, and fat content are equally effective in achieving weight loss. A
Diet, Physical Activity, and Behavioral Therapy :
For patients who achieve short-term weight loss goals, long-term (≥1-year) comprehensive weight maintenance programs should be prescribed. Such programs should provide at least monthly contact and encourage ongoing monitoring of body weight (weekly or more frequently), continued consumption of a reduced calorie diet, and participation in high levels of physical activity (200– 300 min/week). A
To achieve weight loss of >5%, short-term (3-month) high-intensity lifestyle interventions that use very low-calorie diets (≤800 kcal/day) and total meal replacements may be prescribed for carefully selected patients by trained practitioners in medical care settings with close medical monitoring. To maintain weight loss, such programs must incorporate long-term comprehensive weight maintenance counseling. B
Pharmacotherapy : Recommendations
When choosing glucose-lowering medications for overweight or obese patients with type 2 diabetes, consider their effect on weight. E
Whenever possible, minimize the medications for comorbid conditions that are associated with weight gain. E
Weight loss medications may be effective as adjuncts to diet, physical activity, and behavioral counseling for selected patients with type 2 diabetes and BMI ≥27 kg/m2. Potential benefits must be weighed against the potential risks of the If a patient's response to weight loss medications is <5% after 3 months or if there are any safety or tolerability issues at any time, the medication should be discontinued and alternative medications or treatment approaches should be Bariatric Surgery : Recommendations
Bariatric surgery may be considered for adults with BMI >35 kg/m2 and type 2 diabetes, especially if diabetes or associated comorbidities are difficult to control with lifestyle and pharmacological therapy. B
Patients with type 2 diabetes who have undergone bariatric surgery need lifelong lifestyle support and annual medical monitoring, at a minimum. B
Although small trials have shown a glycemic benefit of bariatric surgery in patients with type 2 diabetes and BMI 30–35 kg/m2, there is currently insufficient evidence to generally recommend surgery in patients with BMI ≤35 kg/m2. E
Pharmacological Therapy for Type 1 Diabetes :
Most people with type 1 diabetes should be treated with multiple-dose insulin injections (three to four injections per day of basal and prandial insulin) or continuous subcutaneous insulin infusion. A
Consider educating individuals with type 1 diabetes on matching prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated activity. E
Most individuals with type 1 diabetes should use insulin analogs to reduce hypoglycemia risk. A
Individuals who have been successfully using continuous subcutaneous insulin infusion should have continued access after they turn 65 years of age. E
CARDIOVASCULAR DISEASE AND
"Atherosclerotic cardiovascular disease" (ASCVD) has replaced the former term "cardiovascular disease" (CVD), as ASCVD is a more specific term.
Hypertension/Blood Pressure Control : Recommendations
Screening and Diagnosis
Blood pressure should be measured at every routine visit. Patients found to have elevated blood pressure should have blood pressure confirmed on a separate Goals
People with diabetes and hypertension should be treated to a systolic blood pressure goal of <140 mmHg. A
Lower systolic targets, such as <130 mmHg, may be appropriate for certain individuals with diabetes, such as younger patients, those with albuminuria, and/or those with hypertension and one or more additional atherosclerotic cardiovascular disease risk factors, if they can be achieved without undue treatment burden. C
Hypertension/Blood Pressure Control : Recommendations
Individuals with diabetes should be treated to a diastolic blood pressure goal of <90 mmHg. A
Lower diastolic targets, such as <80 mmHg, may be appropriate for certain individuals with diabetes, such as younger patients, those with albuminuria, and/or those with hypertension and one or more additional atherosclerotic cardiovascular disease risk factors, if they can be achieved without undue treatment burden. B
Antiplatelet Agents : Recommendations
Consider aspirin therapy (75–162 mg/day) as a primary prevention strategy in those with type 1 or type 2 diabetes who are at increased cardiovascular risk (10- year risk >10%). This includes most men or women with diabetes aged ≥50 years who have at least one additional major risk factor (family history of premature atherosclerotic cardiovascular disease, hypertension, smoking, dyslipidemia, or albuminuria) and are not at increased risk of bleeding. C
Aspirin should not be recommended for atherosclerotic cardiovascular disease prevention for adults with diabetes at low atherosclerotic cardiovascular disease risk (10-year atherosclerotic cardiovascular disease risk <5%), such as in men or women with diabetes aged <50 years with no major additional atherosclerotic cardiovascular disease risk factors, as the potential adverse effects from bleeding likely offset the potential benefits. C
Antiplatelet Agents : Recommendations
In patients with diabetes <50 years of age with multiple other risk factors (e.g., 10- year risk 5–10%), clinical judgment is required. E
Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes and a history of atherosclerotic cardiovascular disease. A
For patients with atherosclerotic cardiovascular disease and documented aspirin allergy, clopidogrel (75 mg/day) should be used. B
Dual antiplatelet therapy is reasonable for up to a year after an acute coronary syndrome. B
DIABETIC KIDNEY DISEASE "Nephropathy" was changed to "diabetic kidney disease" to emphasize that, while nephropathy may stem from a variety of causes, attention is placed on kidney disease that is directly related to diabetes.
Referral to a Nephrologist
Consider referral to a physician experienced in the care of kidney disease when there is uncertainty about the etiology of kidney disease (absence of retinopathy, heavy proteinuria, active urine sediment, or rapid decline in GFR). Other triggers for referral may include difficult management issues (anemia, secondary hyperparathyroidism, metabolic bone disease, resistant hypertension, or electrolyte disturbances) or advanced kidney disease. The threshold for referral may vary depending on the frequency with which a provider encounters patients with diabetes and kidney disease. Consultation with a nephrologist when stage 4 CKD develops (eGFR ≤30 mL/min/1.73 m2) has been found to reduce cost, improve quality of care, and delay dialysis (). However, other specialists and providers should also educate their patients about the progressive nature of diabetic kidney disease, the kidney preservation benefits of proactive treatment of blood pressure and blood glucose, and the potential need for renal replacement therapy.
Diabetic Retinopathy Antivascular Endothelial Growth Factor Treatment
While the ETDRS established the benefit of focal laser photocoagulation surgery in eyes with clinically significant macular edema (defined as retinal edema located at or within 500 μm of the center of the macula), current data from multiple well- designed clinical trials demonstrate that intravitreal antivascular endothelial growth factor (anti-VEGF) agents provide a more effective treatment regimen for center-involved diabetic macular edema than monotherapy or even combination therapy with laser.
Diabetic Retinopathy Historically, laser photocoagulation surgery in both trials was beneficial in reducing the risk of further visual loss in affected patients but generally not beneficial in reversing already diminished acuity. Now, intravitreal therapy with recombinant monoclonal neutralizing antibody to VEGF improves vision and has replaced the need for laser photocoagulation in the vast majority of patients with diabetic macular edema. Most patients require near-monthly administration of intravitreal therapy with anti-VEGF agents during the first 12 months of treatment with fewer injections needed in subsequent years to maintain remission from center-involved diabetic macular edema. Other emerging therapies for retinopathy that may use sustained intravitreal delivery of pharmacological agents are currently under investigation.
This represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes. The patient characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consideration of patient and caregiver preferences is an important aspect of treatment individualization. Additionally, a patient's health status and preferences may change over time. ADL, activities of daily living. ‡A lower A1C goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden.
*Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, congestive heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. By "multiple," we mean at least three, but many patients may have five or more **The presence of a single end-stage chronic illness, such as stage 3–4 congestive heart failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer, may cause significant symptoms or impairment of functional status and significantly reduce life expectancy.
†A1C of 8.5% (69mmol/mol) equates to an estimated average glucose of;200 mg/dL (11.1 mmol/L). Looser A1C targets above 8.5% (69mmol/mol) are not recommended as they may expose patients to more frequent higher glucose values and the acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing.
CHILDREN AND ADOLESCENTS
Diabetes Self-management Education and Support :
Youth with type 1 diabetes and parents/caregivers (for patients aged <18 years) should receive culturally sensitive and developmentally appropriate individualized diabetes self-management education and support according to national standards at diagnosis and routinely thereafter. B
Psychosocial Issues : Recommendations
At diagnosis and during routine follow-up care, assess psychosocial issues and family stresses that could impact adherence to diabetes management and provide appropriate referrals to trained mental health professionals, preferably experienced in childhood diabetes. E
Encourage developmentally appropriate family involvement in diabetes management tasks for children and adolescents, recognizing that premature transfer of diabetes care to the child can result in nonadherence and deterioration in glycemic control. B
Consider mental health professionals as integral members of the pediatric diabetes multidisciplinary team. E
Glycemic Control : Recommendation
An A1C goal of <7.5% (58 mmol/mol) is recommended across all pediatric age- groups. E
Assess for the presence of additional autoimmune conditions soon after the diagnosis and if symptoms develop. E
Thyroid Disease : Recommendations
Consider testing children with type 1 diabetes for antithyroid peroxidase and antithyroglobulin antibodies soon after the diagnosis. E
Measure thyroid-stimulating hormone concentrations soon after the diagnosis of type 1 diabetes and after glucose control has been established. If normal, consider rechecking every 1–2 years or sooner if the patient develops symptoms suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or an unexplained glycemic variation. E
Hypertension ： Recommendations
Blood pressure should be measured at each routine visit. Children found to have high-normal blood pressure (systolic blood pressure or diastolic blood pressure ≥90th percentile for age, sex, and height) or hypertension (systolic blood pressure or diastolic blood pressure ≥95th percentile for age, sex, and height) should have blood pressure confirmed on 3 separate days. B
Initial treatment of high-normal blood pressure (systolic blood pressure or diastolic blood pressure consistently ≥90th percentile for age, sex, and height) includes dietary modification and increased exercise, if appropriate, aimed at weight control. If target blood pressure is not reached with 3–6 months of initiating lifestyle intervention, pharmacological treatment should be In addition to lifestyle modification, pharmacological treatment of hypertension (systolic blood pressure or diastolic blood pressure consistently ≥95th percentile for age, sex, and height) should be considered as soon as hypertension is confirmed. E
ACE inhibitors or angiotensin receptor blockers should be considered for the initial pharmacological treatment of hypertension, following reproductive counseling due to the potential teratogenic effects of both drug classes. E
The goal of treatment is blood pressure consistently <90th percentile for age, sex, and height. E
Dyslipidemia : Recommendations
Obtain a fasting lipid profile in children ≥10 years of age soon after the diagnosis (after glucose control has been established). E
If lipids are abnormal, annual monitoring is reasonable. If LDL cholesterol values are within the accepted risk level (<100 mg/dL [2.6 mmol/L]), a lipid profile repeated every 3–5 years is reasonable. E
Initial therapy should consist of optimizing glucose control and medical nutrition therapy using a Step 2 American Heart Association diet to decrease the amount of saturated fat in the diet. B
After the age of 10 years, addition of a statin is suggested in patients who, despite medical nutrition therapy and lifestyle changes, continue to have LDL cholesterol >160 mg/dL (4.1 mmol/L) or LDL cholesterol >130 mg/dL (3.4 mmol/L) and one or more cardiovascular disease risk factors. E
The goal of therapy is an LDL cholesterol value <100 mg/dL (2.6 mmol/L). E
Diabetic Kidney Disease Annual screening for albuminuria with a random spot urine sample for albumin– to–creatinine ratio should be considered once the child has had diabetes for 5 Estimate glomerular filtration rate at initial evaluation and then based on age, diabetes duration, and treatment. E
Treatment with an ACE inhibitor, titrated to normalization of albumin excretion, should be considered when elevated urinary albumin–to–creatinine ratio (>30 mg/g) is documented with at least two of three urine samples. These should be obtained over a 6-month interval following efforts to improve glycemic control and normalize blood pressure.B
Consider an annual comprehensive foot exam for the child at the start of puberty or at age ≥10 years, whichever is earlier, once the youth has had type 1 diabetes for 5 years. E
Pregestational Diabetes : Recommendations
Provide preconception counseling that addresses the importance of glycemic control as close to normal as is safely possible, ideally A1C <6.5% (48 mmol/mol), to reduce the risk of congenital anomalies. B
Family planning should be discussed and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant. A
Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Eye examinations should occur before pregnancy or in the first trimester and then be monitored every trimester and for 1 year postpartum as indicated by degree of retinopathy. B
Gestational Diabetes Mellitus
Lifestyle change is an essential component of management of gestational diabetes mellitus and may suffice for treatment for many women. Medications should be added if needed to achieve glycemic targets. A
Preferred medications in gestational diabetes mellitus are insulin and metformin; glyburide may be used but may have a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin. Other agents have not been adequately studied. Most oral agents cross the placenta, and all lack long-term safety data. A
General Principles for Management of Diabetes in
Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable Fasting, preprandial, and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and pregestational diabetes in pregnancy to achieve glycemic control. B
Due to increased red blood cell turnover, A1C is lower in normal pregnancy than in normal nonpregnant women. The A1C target in pregnancy is 6–6.5% (42–48 mmol/mol); <6% (42 mmol/mol) may be optimal if this can be achieved without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia. B
The American College of Obstetricians and Gynecologists (ACOG) ( recommends the following targets for women with pregestational type 1 or type 2 Fasting ≤90 mg/dL (5.0 mmol/L) One-hour postprandial ≤130–140 mg/dL (7.2–7.8 mmol/L) Two-hour postprandial ≤120 mg/dL (6.7 mmol/L) After diagnosis, treatment starts with medical nutrition therapy, physical activity, and weight management depending on pregestational weight, as outlined in the section on pregestational type 2 diabetes below, and glucose monitoring aiming for the targets recommended by the Fifth International Workshop-Conference on Gestational Diabetes Mellitus ): Fasting ≤95 mg/dL (5.3 mmol/L) and either One-hour postprandial ≤140 mg/dL (7.8 mmol/L) or Two-hour postprandial ≤120 mg/dL (6.7 mmol/L) A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. Planning pregnancy is critical in women with pregestational diabetes due to the need for preconception glycemic control and preventive health services. Therefore, all women with diabetes of childbearing age should have family planning options reviewed at regular intervals. This applies to women in the immediate postpartum period. Women with diabetes have the same contraception options and recommendations as those without diabetes. The risk of an unplanned pregnancy outweighs the risk of any given contraception Women with greater initial degrees of hyperglycemia may require early initiation of pharmacological therapy. Treatment has been demonstrated to improve perinatal outcomes in two large randomized studies as summarized in a U.S. Preventive Services Task Force review . Insulin is the first-line agent recommended for treatment of GDM in the U.S. Individual randomized controlled trials support the efficacy and short-term safety of metformin (pregnancy category B) and glyburide (pregnancy category B) for the treatment of GDM. However, both agents cross the placenta, and long-term safety data are not available for either Insulin
Insulin may be required to treat hyperglycemia, and its use should follow the More recently, several meta-analyses and large observational studies examining maternal and fetal outcomes have suggested that sulfonylureas, such as glyburide, may be inferior to insulin and metformin due to increased risk of neonatal hypoglycemia and macrosomia with this class.
Metformin, which is associated with a lower risk of hypoglycemia and potential lower weight gain, may be preferable to insulin for maternal health if it suffices to control hyperglycemia (however, metformin may slightly increase the risk of prematurity. None of these studies or meta-analyses evaluated long-term outcomes in the offspring. Thus, patients treated with oral agents should be informed that they cross the placenta and, while no adverse effects on the fetus have been demonstrated, long-term studies are lacking.
Perioperative Care Standards for perioperative care Target glucose range for the perioperative period should be 80–180mg/dL (4.4– Preoperative risk assessment for patients at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure.
The morning of surgery or procedure, hold any oral hypoglycemic agents and give half of NPH dose or full doses of a long-acting analog or pump basal insulin.
Monitor blood glucose every 4–6 h while NPO and dose with shortacting insulin as needed.
Diabetes Care in the Hospital A basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for patients with good nutritional intake. A The sole use of sliding scale insulin in the inpatient hospital setting is strongly Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≧180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients A and noncritically ill patients. C
Land West of Horsham Stakeholders Consultation Report November 2006 Table of Contents 1. Introduction 2. The Core Strategy 3. Masterplan 4. Transport Stakeholders Consultation 22nd November 5. Community & Leisure Stakeholders Consultation 30th Appendix 1. Event Horsham District Council