The American Diabetes Association published its first series of Clinical Practice Recommendations in January as a supplement to the journal Diabetes Care.
Throughout the year, the recommendations are often altered, amended, deleted or added, so the ADA is planning to publish a supplement annually. The supplement is a compilation of suggestions on a variety of topics that are of interest in the care of diabetes.
The following are summaries of some of the recommendations and statements made by the ADA to educate doctors and health care professional – as well as patients – about the recommended care of diabetes:
Since diabetes is a disease that requires frequent medical attention, the hospitalization of a patient with diabetes for some other illness mandates treatment by a diabetes specialist and a physician who can treat the other illness.
Bed-side blood glucose monitoring in the hospital can be done by qualified non-laboratory personnel, such as a nurse, who has been well trained in the procedure. Bedside monitoring should be used for management, but not diagnosis of diabetes.
Insulin Pump Therapy
The use of the pump in carefully selected patients, who have undergone extensive training, and are using reliable equipment, can provide an added measure of glycemic control.
The pump has been shown to be as safe as multiple injection therapy in patients who are willing to take on the responsibility of using a pump. Users and prescribers are encouraged to help the CDC and FDA with any research that may be ongoing about the effectiveness of this method.
Pancreas transplants have few beneficial side-effects in patients who are not suffering from end-stage renal failure.
In patients who are in need of a kidney transplant, the pancreas transplant may be considered a viable alternative to continued insulin therapy.
The life-long immune-suppressant drugs needed to prevent rejection of the graft make in inadvisable in all but the most debilitating cases of diabetes. In correlation with a kidney transplant, which itself requires the use of suppressing drugs, the transplant is an option.
Transplantation of islet cells shows some promise, however the procedure is experimental at this time.
Inmates with Diabetes
In order to ensure that people with diabetes in correctional facilities are given care equivalent to the general public, it was stated that inmates with diabetes should:
- Receive medications regularly at prescribed times.
- Receive meals properly planned at time consistent with the treatment schedule.
- Be monitored for hypoglycemia and have access to prompt treatment.
- Be monitored for blood glucose, urine ketones, and glycosylated hemoglobin.
- Have an annual eye exam through dilated pupils.
- Be monitored for hypertension and lipid disorders annually.
- Medication and dietary regimen should be provided when a prisoner goes to court.
- Receive prompt medical treatment when there are symptoms of diabetic complications, including access to a specialist.
- Participate in an exercise program that provides appropriate physical activity.
- Receive follow-up evaluations.
- Have arrangements made for continuation of therapy if transferred to another site.
It was also noted that patients receiving insulin must not be placed in isolation without frequent observations for hypoglycemia, and that patients should have immediate access to food, juice, or other sugar sources.
The American Diabetes Association recently clarifed its definition of “unproven therapies” – a significant step as the ADA will not sponsor therapies it deems “unproven.”
In a postion statement published in a supplement to the January 1995 issue of Diabetes Care magazine, the ADA released what it says are certain characteristics shared by unproven therapies. According to the ADA, unproven therapies often:
- Tend to be developed and promoted in isolation from established scientific facilities and associations and their developers/promoters generally do not possess strong scientific or clinical credentials.
- In addition, the rationales for these therapies often contain misapplication of data from the scientific literature;
- Proposers often provvide exaggerated or unrealistic claims about their methods;
- They are generally communicated outside regular channels of scientific and clinical channels and details of the therapies are often secretive;
- Their proponents sometimes discourage or refuse consultation or review by reputable physicians or scientists; and
- Their developers and promoters often claim that a medical or scientific “conspiracy” has been convened against them.
Steps on the way to ADA approval include reviewing: the effectivesness of the therapy, including the number and quality of studies performed; the degree to which independent validation has been accomplished; and, the potential risk of harm to patients. After review, the ADA classifies the treatment into one of four categories, ranging from “clearly effective” to “clearly ineffective.”
Finally, the ADA considers a diagnostic or theraputic method to be safe and effective only after it has been endorsed by a scientifically developed practice guideline under the auspices of a recognized authority in the field and has been one of the following:
- Approved for use by the FDA; or
- Supported by data obtained in at least two independent, well-controlled studies published in peer-reviewed scientific publications; or
- Endorsed or recommended by the ADA’s Professional Practice Committee; or
- Endorsed by a relevant or appropriate medical specialty organization.
Save for certain exceptions, new and unproven diagnostic and theraputic measures must go through the above process in order to be approved for sponsorship.
Urine Tests are Inadvisable
The use of urine tests to estimate blood glucose levels was deemed inadvisable in the recommendations for a variety of reasons.
It was recommended that blood tests should be used to test glucose, and, when blood glucose levels are consistently above 240 mg/dl, during pregnancy, stress, illness, or when there are signs of ketoacidosis, the urine should be tested for ketones.
Sufficient evidence has been found that it is indeed possible to predict, with a high degree of certainty, the first-degree relatives of people with diabetes that will go on to develop the disease.
For this reason, studies on intervention and immune treatment to prevent the onset of diabetes have been supported in the clinical recommendations. The studies should be well-documented to help provide the diabetes community with the latest findings, and all persons who are screened and prove to be at high risk should be referred to centers participating in intervention studies.
All patients screened and not entered into such a program should be counseled on their risk and given proper follow-up care.