COMPREHENSIVE MEDICAL EVALUATION AND ASSESSMENT OF COMORBIDITIES: STANDARDSOF MEDICALCAREINDIABETESD2021
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S40 Diabetes Care Volume 44, Supplement 1, January 2021
4. Comprehensive Medical American Diabetes Association
Evaluation and Assessment of
Comorbidities: Standards of
Medical Care in Diabetesd2021
Diabetes Care 2021;44(Suppl. 1):S40–S52 | https://doi.org/10.2337/dc21-S004
4. MEDICAL EVALUATION AND COMORBIDITIES
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,
and tools to evaluate quality of care. Members of the ADA Professional Practice
Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-
SPPC), are responsible for updating the Standards of Care annually, or more
frequently as warranted. For a detailed description of ADA standards, statements,
and reports, as well as the evidence grading system for ADA’s clinical practice
recommendations, please refer to the Standards of Care Introduction (https://doi
.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care
are invited to do so at professional.diabetes.org/SOC.
PATIENT-CENTERED COLLABORATIVE CARE
Recommendations
4.1 A patient-centered communication style that uses person-centered and
strength-based language and active listening; elicits patient preferences and
beliefs; and assesses literacy, numeracy, and potential barriers to care
should be used to optimize patient health outcomes and health-related
quality of life. B
4.2 People with diabetes can benefit from a coordinated multidisciplinary team
that may draw from diabetes care and education specialists, primary care
providers, subspecialty providers, nurses, dietitians, exercise specialists,
pharmacists, dentists, podiatrists, and mental health professionals. E
A successful medical evaluation depends on beneficial interactions between the
patient and the care team. The Chronic Care Model (1–3) (see Section 1 “Improving
Suggested citation: American Diabetes Associa-
Care and Promoting Health in Populations,” https://doi.org/10.2337/dc21-S001) is a tion. 4. Comprehensive medical evaluation and
patient-centered approach to care that requires a close working relationship between assessment of comorbidities: Standards of Med-
the patient and clinicians involved in treatment planning. People with diabetes should ical Care in Diabetesd2021. Diabetes Care
receive health care from a coordinated interdisciplinary team that may include 2021;44(Suppl. 1):S40–S52
diabetes care and education specialists, physicians, nurse practitioners, physician © 2020 by the American Diabetes Association.
assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, Readers may use this article as long as the work is
properly cited, the use is educational and not for
and mental health professionals. Individuals with diabetes must assume an active profit, and the work is not altered. More infor-
role in their care. The patient, family or support people, physicians, and health care mation is available at https://www.diabetesjournals
team should together formulate the management plan, which includes lifestyle .org/content/license.care.diabetesjournals.org Comprehensive Medical Evaluation and Assessment of Comorbidities S41 management (see Section 5 “Facilitating Provider communication with patients self-management. Empathizing and us- Behavior Change and Well-being to Im- and families should acknowledge that ing active listening techniques, such as prove Health Outcomes,” https://doi.org/ multiple factors impact glycemic man- open-ended questions, reflective state- 10.2337/dc21-S005). agement but also emphasize that collab- ments, and summarizing what the patient The goals of treatment for diabetes are oratively developed treatment plans said, can help facilitate communication. to prevent or delay complications and and a healthy lifestyle can significantly Patients’ perceptions about their own optimize quality of life (Fig. 4.1). Treat- improve disease outcomes and well- ability, or self-efficacy, to self-manage ment goals and plans should be created being (4–7). Thus, the goal of provider- diabetes are one important psychosocial with patients based on their individual patient communication is to establish a factor related to improved diabetes self- preferences, values, and goals. This in- collaborative relationship and to assess management and treatment outcomes in dividualized management plan should and address self-management barriers diabetes (9–13) and should be a target of take into account the patient’s age, cog- without blaming patients for “noncom- ongoing assessment, patient education, nitive abilities, school/work schedule and pliance” or “nonadherence” when the and treatment planning. conditions, health beliefs, support sys- outcomes of self-management are not Language has a strong impact on per- tems, eating patterns, physical activity, optimal (8). The familiar terms “noncom- ceptions and behavior. The use of em- social situation, financial concerns, cultural pliance” and “nonadherence” denote a powering language in diabetes care and factors, literacy and numeracy (mathemat- passive, obedient role for a person with education can help to inform and moti- ical literacy), diabetes history (duration, diabetes in “following doctor’s orders” vate people, yet language that shames complications, current use of medica- that is at odds with the active role people and judges may undermine this effort. tions), comorbidities, health priorities, with diabetes take in directing the day- The American Diabetes Association (ADA) other medical conditions, preferences for to-day decision-making, planning, mon- and the Association of Diabetes Care & care, and life expectancy. Various strate- itoring, evaluation, and problem-solving Education Specialists (formerly called gies and techniques should be used to involved in diabetes self-management. American Association of Diabetes Edu- support patients’ self-management ef- Using a nonjudgmental approach that cators) joint consensus report, “The Use forts, including providing education on normalizes periodic lapses in self-man- of Language in Diabetes Care and Edu- problem-solving skills for all aspects of agement may help minimize patients’ cation,” provides the authors’ expert diabetes management. resistance to reporting problems with opinion regarding the use of language by Figure 4.1—Decision cycle for patient-centered glycemic management in type 2 diabetes. Reprinted from Davies et al. (101).
S42 Comprehensive Medical Evaluation and Assessment of Comorbidities Diabetes Care Volume 44, Supplement 1, January 2021
health care professionals when speaking assessment, management of comorbid Glycemic Treatment,” https://doi.org/10
or writing about diabetes for people with conditions, and engagement of the pa- .2337/dc21-S009), antihypertension med-
diabetes or for professional audiences tient throughout the process. While a ication, and statin treatment intensity.
(14). Although further research is needed comprehensive list is provided in Table Additional referrals should be arranged
to address the impact of language on 4.1, in clinical practice the provider may as necessary (Table 4.4). Clinicians should
diabetes outcomes, the report includes need to prioritize the components of the ensure that individuals with diabetes are
five key consensus recommendations for medical evaluation given the available appropriately screened for complications
language use: resources and time. The goal is to provide and comorbidities. Discussing and imple-
the health care team information so it can menting an approach to glycemic control
c Use language that is neutral, nonjudg- optimally support a patient. In addition to with the patient is a part, not the sole goal,
mental, and based on facts, actions, or themedicalhistory,physical examination, of the patient encounter.
physiology/biology. and laboratory tests, providers should
c Use language free from stigma. assess diabetes self-management be-
IMMUNIZATIONS
c Use language that is strength based, haviors, nutrition, social determinants
respectful, and inclusive and that of health, and psychosocial health (see Recommendation
imparts hope. Section 5 “Facilitating Behavior Change 4.6 Provide routinely recommended
c Use language that fosters collabora- and Well-being to Improve Health Out- vaccinations for childrenand adults
tion between patients and providers. comes,”https://doi.org/10.2337/dc21-S005) with diabetes as indicated by age
c Use language that is person centered and give guidance on routine immuniza- (see Table 4.5 for highly recom-
(e.g., “person with diabetes” is pre- tions. The assessment of sleep pattern mended vaccinations for adults
ferred over “diabetic”). and duration should be considered; a meta- with diabetes). A
analysis found that poor sleep quality,
short sleep, and long sleep were associ- The importance of routine vaccinations
COMPREHENSIVE MEDICAL for people living with diabetes has been
ated with higher A1C in people with
EVALUATION elevated by the coronavirus disease
type 2 diabetes (15). Interval follow-up
Recommendations visits should occur at least every 3– 2019 (COVID-19) pandemic. Preventing
4.3 A complete medical evaluation 6 months individualized to the patient, avoidable infections not only directly
should be performed at the initial and then at least annually. prevents morbidity but also reduces hos-
visit to: Lifestyle management and psychoso- pitalizations, which may additionally re-
c Confirm the diagnosis and classify cial care are the cornerstones of diabetes duce risk of acquiring infections such as
diabetes. A management. Patients should be re- COVID-19. Children and adults with di-
c Evaluate for diabetes complica- ferred for diabetes self-management ed- abetes should receive vaccinations accord-
tions and potential comorbid ucation and support, medical nutrition ing to age-appropriate recommendations
conditions. A therapy, and assessment of psychosocial/ (16,17). The Centers for Disease Control
c Review previous treatment and emotional health concerns if indicated. and Prevention (CDC) provides vaccination
risk factor control in patients with Patients should receive recommended pre- schedules specifically for children, adoles-
established diabetes. A ventive care services (e.g., immunizations, cents, and adults with diabetes (see https://
c Begin patient engagement in the cancer screening, etc.); smoking cessation www.cdc.gov/vaccines/). The CDC Advisory
formulation of a care manage- counseling; and ophthalmological, dental, Committee on Immunization Practices
ment plan. A and podiatric referrals. (ACIP) makes recommendations based on
c Develop a plan for continuing The assessment of risk of acute and its own review and rating of the evidence,
care. A chronic diabetes complications and treat- provided in Table 4.5 for selected vaccina-
4.4 A follow-up visit should include ment planning are key components of tions. The ACIP evidence review has evolved
most components of the initial initial and follow-up visits (Table 4.2). The over time with the adoption of Grading
comprehensive medical evalua- risk of atherosclerotic cardiovascular dis- of Recommendations Assessment, De-
tion (see Table 4.1). A ease and heart failure (see Section 10 velopment and Evaluation (GRADE) in
4.5 Ongoing management should be “Cardiovascular Disease and Risk Man- 2010 and then the Evidence to Decision
guided by the assessment of agement,” https://doi.org/10.2337/dc21- or Evidence to Recommendation (EtR)
overallhealthstatus,diabetescom- S010), chronic kidney disease staging (see frameworks in 2018 (18). Here we dis-
plications, cardiovascular risk (see Section 11 “Microvascular Complications cuss the particular importance of specific
THE RISK CALCULATOR, Section 10 “Car- and Foot Care,” https://doi.org/10.2337/ vaccines.
diovascular Disease and Risk Man- dc21-S011), presence of retinopathy, and
agement,” https://doi.org/10.2337/ risk of treatment-associated hypoglyce- Influenza
dc21-S010),hypoglycemia risk,and mia (Table 4.3) should be used to in- Influenza is a common, preventable in-
shared decision-making to set dividualize targets for glycemia (see fectious disease associated with high
therapeutic goals. B Section 6 “Glycemic Targets,” https:// mortality and morbidity in vulnerable
doi.org/10.2337/dc21-S006), blood pres- populations, including youth, older adults,
The comprehensive medical evaluation in- sure, and lipids and to select specific and people with chronic diseases. Influ-
cludes the initial and follow-up evaluations, glucose-lowering medication (see Sec- enza vaccination in people with diabetes
assessment of complications, psychosocial tion 9 “Pharmacologic Approaches to has been found to significantly reducecare.diabetesjournals.org Comprehensive Medical Evaluation and Assessment of Comorbidities S43
Continued on p. S44S44 Comprehensive Medical Evaluation and Assessment of Comorbidities Diabetes Care Volume 44, Supplement 1, January 2021
influenza and diabetes-related hospital conditions such as diabetes are cautioned (21). There are two vaccination types, the
admissions (19). Given the benefits of the against taking the LAIV and are instead 23-valent pneumococcal polysaccharide
annual influenza vaccination, it is recom- recommended to receive the inactive or vaccine (PPSV23) and the 13-valent pneu-
mended for all individuals $6 months recombinant influenza vaccination. For in- mococcal conjugate vaccine (PCV13), with
of age who do not have a contraindica- dividuals $65 years of age, there may be distinct schedules for children and adults.
tion. Influenza vaccination is critically additional benefit from the high-dose quad- All children are recommended to re-
important in the next year as the severe rivalent inactivated influenza vaccine (20). ceive a four-dose series of PCV13 by 15
acute respiratory syndrome coronavirus months of age. For children with diabe-
2 (SARS-CoV-2) and influenza viruses will Pneumococcal Pneumonia tes who have incomplete series by ages
both be active in the U.S. during the Like influenza, pneumococcal pneumo- 2–5 years, the CDC recommends a
2020–2021 season (20). The live atten- nia is a common, preventable disease. catch-up schedule to ensure that these
uated influenza vaccine (LAIV), which is People with diabetes are at increased risk children have four doses. Children with
delivered by nasal spray, is an option for for the bacteremic form of pneumococ- diabetes between 6–18 years of age
patients beginning at age 2 years through cal infection and have been reported to are also advised to receive one dose
age 49 years, for those who are not have a high risk of nosocomial bacter- of PPSV23, preferably after receipt of
pregnant, but patients with chronic emia, with a mortality rate as high as 50% PCV13.care.diabetesjournals.org Comprehensive Medical Evaluation and Assessment of Comorbidities S45
Table 4.2—Assessment and treatment plan* that affect people with diabetes and may
Assessing risk of diabetes complications complicate management (24–28). Dia-
c ASCVD and heart failure history betes comorbidities are conditions that
c ASCVD risk factors and 10-year ASCVD risk assessment affect people with diabetes more often
c Staging of chronic kidney disease (see Table 11.1) than age-matched people without dia-
c Hypoglycemia risk (see Table 4.3)
betes. This section discusses many of the
Goal setting common comorbidities observed in pa-
c Set A1C/blood glucose target
tients with diabetes but is not necessarily
c If hypertension is present, establish blood pressure target
c Diabetes self-management goals
inclusive of all the conditions that have
Therapeutic treatment plans
been reported.
c Lifestyle management
c Pharmacologic therapy: glucose lowering Autoimmune Diseases
c Pharmacologic therapy: cardiovascular disease risk factors and renal
c Use of glucose monitoring and insulin delivery devices Recommendations
c Referral to diabetes education and medical specialists (as needed) 4.7 Patients with type 1 diabetes
ASCVD, atherosclerotic cardiovascular disease. *Assessment and treatment planning are essential should be screened for autoim-
components of initial and all follow-up visits. mune thyroid disease soon after
diagnosis and periodically there-
after. B
4.8 Adult patients with type 1 diabe-
For adults with diabetes, one dose of blood or through improper equipment tes should be screened for celiac
PPSV23 is recommended between the use (glucose monitoring devices or in- disease in the presence of gas-
ages of 19–64 years and another dose fected needles). Because of the higher trointestinal symptoms, signs, or
at $65 years of age. The PCV13 is no likelihood of transmission, hepatitis B laboratory manifestations sugges-
longer routinely recommended for pa- vaccine is recommended for adults with tive of celiac disease. B
tients over 65 years of age because of diabetes aged ,60 years. For adults aged
the declining rates of pneumonia due to $60 years, hepatitis B vaccine may be People with type 1 diabetes are at in-
these strains (22). Older patients should administered at the discretion of the creased risk for other autoimmune
have a shared decision-making discus- treating clinician based on the patient’s diseases, with thyroid disease, celiac
sion with their provider to determine likelihood of acquiring hepatitis B infection. disease, and pernicious anemia (vitamin
individualized risks and benefits. PCV13 B12 deficiency) being among the most
is recommended for patients with immu- COVID-19 common (29). Other associated condi-
nocompromising conditions such as as- During the coming year, it is expected tions include autoimmune hepatitis, pri-
plenia, advanced kidney disease, cochlear that vaccines for COVID-19 will become mary adrenal insufficiency (Addison
implants, or cerebrospinal fluid leaks (23). available and that people with diabe- disease), dermatomyositis, and myasthe-
Some older patients residing in assisted tes should be a priority population. The nia gravis (30–33). Type 1 diabetes may
living facilities may also consider PCV13. If COVID-19 vaccine will likely become a also occur with other autoimmune dis-
the PCV13 is to be administered, it should routine part of the annual preventive eases in the context of specific genetic
be given prior to the next dose of PPSV23. schedule for people with diabetes. disorders or polyglandular autoimmune
syndromes (34). Given the high preva-
Hepatitis B lence, nonspecific symptoms, and insid-
Compared with the general population, ASSESSMENT OF COMORBIDITIES
ious onset of primary hypothyroidism,
people with type 1 or type 2 diabetes Besides assessing diabetes-related compli- routine screening for thyroid dysfunc-
have higher rates of hepatitis B. This cations, clinicians and their patients need tion is recommended for all patients with
may be due to contact with infected to be aware of common comorbidities type 1 diabetes. Screening for celiac dis-
ease should be considered in adult pa-
tients with suggestive symptoms (e.g.,
Table 4.3—Assessment of hypoglycemia risk diarrhea, malabsorption, abdominal pain)
Factors that increase risk of treatment-associated hypoglycemia or signs (e.g., osteoporosis, vitamin de-
c Use of insulin or insulin secretagogues (i.e., sulfonylureas, meglitinides)
ficiencies, iron deficiency anemia) (35,36).
c Impaired kidney or hepatic function
c Longer duration of diabetes
Measurement of vitamin B12 levels should
c Frailty and older age
be considered for patients with type 1
c Cognitive impairment diabetes and peripheral neuropathy or
c Impaired counterregulatory response, hypoglycemia unawareness unexplained anemia.
c Physical or intellectual disability that may impair behavioral response to hypoglycemia
c Alcohol use
c Polypharmacy (especially ACE inhibitors, angiotensin receptor blockers, nonselective Cancer
b-blockers) Diabetes is associated with increased risk
In addition to individual risk factors, consider use of comprehensive risk prediction models (102). of cancers of the liver, pancreas, endo-
metrium, colon/rectum, breast, and blad-
See references 103–107.
der (37). The association may result fromS46 Comprehensive Medical Evaluation and Assessment of Comorbidities Diabetes Care Volume 44, Supplement 1, January 2021
Nutrition
Table 4.4—Referrals for initial care management
c Eye care professional for annual dilated eye exam
In one study, adherence to the Mediter-
c Family planning for women of reproductive age
ranean diet correlated with improved
c Registered dietitian nutritionist for medical nutrition therapy
cognitive function (48). However, a re-
c Diabetes self-management education and support cent Cochrane review found insufficient
c Dentist for comprehensive dental and periodontal examination evidence to recommend any specific di-
c Mental health professional, if indicated etary change for the prevention or treat-
c Audiology, if indicated ment of cognitive dysfunction (49).
Statins
A systematic review has reported that
shared risk factors between type 2 di- all-cause dementia, Alzheimer dementia, data do not support an adverse effect of
abetes and cancer (older age, obesity, and vascular dementia compared with statins on cognition (50). The U.S. Food
and physical inactivity) but may also be rates in those with normal glucose tol- and Drug Administration postmarketing
due to diabetes-related factors (38), such erance (43). See Section 12 “Older surveillance databases have also revealed
as underlying disease physiology or di- Adults” (https://doi.org/10.2337/dc21-S012) a low reporting rate for cognitive-related
abetes treatments, although evidence for a more detailed discussion regarding adverse events, including cognitive dys-
for these links is scarce. Patients with di- screening for cognitive impairment. function or dementia, with statin ther-
abetes should be encouraged to undergo apy, similar to rates seen with other
recommended age- and sex-appropriate commonly prescribed cardiovascular med-
cancer screenings and to reduce their Hyperglycemia ications (50). Therefore, fear of cognitive
modifiable cancer risk factors (obesity, In those with type 2 diabetes, the degree decline should not be a barrier to statin
physical inactivity, and smoking). New and duration of hyperglycemia are re- use in individuals with diabetes and a
onset of atypical diabetes (lean body lated to dementia. More rapid cognitive high risk for cardiovascular disease.
habitus, negative family history) in a decline is associated with both increased
middle-aged or older patient may pre- A1C and longer duration of diabetes (42).
The Action to Control Cardiovascular Risk Nonalcoholic Fatty Liver Disease
cede the diagnosis of pancreatic adeno-
carcinoma (39). However, in the absence in Diabetes (ACCORD) study found that Recommendation
of other symptoms (e.g., weight loss, each 1% higher A1C level was associated 4.10 Patients with type 2 diabetes or
abdominal pain), routine screening of all with lower cognitive function in individ- prediabetes and elevated liver
such patients is not currently recommended. uals with type 2 diabetes (44). However, enzymes (ALT) or fatty liver on
the ACCORD study found no difference in ultrasound should be evaluated
cognitive outcomes in participants ran- for presence of nonalcoholic stea-
Cognitive Impairment/Dementia domly assigned to intensive and standard tohepatitis and liver fibrosis. C
Recommendation glycemic control, supporting the recom-
4.9 In the presence of cognitive im- mendation that intensive glucose control Diabetes is associated with the develop-
pairment, diabetes treatment should not be advised for the improve- ment of nonalcoholic fatty liver disease,
regimens should be simplified ment of cognitive function in individuals including its more severe manifestations
as much as possible and tailored with type 2 diabetes (45). of nonalcoholic steatohepatitis, liver fibro-
to minimize the risk of hypogly- sis, cirrhosis, and hepatocellular carcinoma
cemia. B Hypoglycemia (51). Elevations of hepatic transaminase
In type 2 diabetes, severe hypoglycemia is concentrations are associated with higher
Diabetes is associated with a significantly associated with reduced cognitive func- BMI, waist circumference, and triglyceride
increased risk and rate of cognitive de- tion, and those with poor cognitive func- levels and lower HDL cholesterol levels.
cline and an increased risk of dementia tion have more severe hypoglycemia. In a Noninvasive tests, such as elastography
(40,41). A recent meta-analysis of pro- long-term study of older patients with or fibrosis biomarkers, may be used to
spective observational studies in people type 2 diabetes, individuals with one or assess risk of fibrosis, but referral to a
with diabetes showed 73% increased risk more recorded episodes of severe hypo- liver specialist and liver biopsy may
of all types of dementia, 56% increased glycemia had a stepwise increase in risk be required for definitive diagnosis
risk of Alzheimer dementia, and 127% of dementia (46). Likewise, the ACCORD (52). Interventions that improve meta-
increased risk of vascular dementia com- trial found that as cognitive function bolic abnormalities in patients with di-
pared with individuals without diabetes decreased, the risk of severe hypoglyce- abetes (weight loss, glycemic control,
(42). The reverse is also true: people with mia increased (47). Tailoring glycemic and treatment with specific drugs for hy-
Alzheimer dementia are more likely to therapy may help to prevent hypoglyce- perglycemia or dyslipidemia) are also
develop diabetes than people without mia in individuals with cognitive dys- beneficial for fatty liver disease (53,54).
Alzheimer dementia. In a 15-year pro- function. See Section 12 “Older Adults” Pioglitazone, vitamin E treatment, and
spective study of community-dwelling (https://doi.org/10.2337/dc21-S012) for liraglutide treatment of biopsy-proven
people .60 years of age, the presence of more detailed discussion of hypoglyce- nonalcoholic steatohepatitis have each
diabetes at baseline significantly increased mia in older patients with type 1 and been shown to improve liver histol-
the age- and sex-adjusted incidence of type 2 diabetes. ogy, but effects on longer-term clinicalcare.diabetesjournals.org Comprehensive Medical Evaluation and Assessment of Comorbidities S47
Table 4.5—Highly recommended immunizations for adult patients with diabetes (Advisory Committee on Immunization
Practices, Centers for Disease Control and Prevention)
GRADE evidence
Vaccination Age-group recommendations Frequency type* Reference
Hepatitis B ,60 years of age; $60 years Two- or three-dose 2 Centers for Disease Control
of age discuss with doctor series and Prevention (CDC). Use
of hepatitis B vaccination
for adults with diabetes
mellitus: recommendations
of the Advisory Committee
on Immunization Practices
(ACIP). MMWR 2011;60:
1709–1711
Human papilloma virus #26 years of age; 27–45 years Three doses over 2 for females, Meites E, Szilagyi PG, Chesson
(HPV) of age may also be 6 months 3 for males HW, Unger ER, Romero JR,
vaccinated against HPV after Markowitz LE. Human
a discussion with their health papillomavirus vaccination
care provider for adults: updated
recommendations of the
Advisory Committee on
Immunization Practices.
MMWR 2019;68:698–702
Influenza All patients; advised not to Annual – Demicheli V, Jefferson T, Di
receive live attenuated Pietrantonj C, Ferroni E,
influenza vaccine Thorning S, Thomas RE,
Rivetti A. Vaccines for
preventing influenza in the
elderly. Cochrane Database
Syst Rev 2018;2:CD004876
Pneumonia (PPSV23 19–64 years of age, vaccinate One dose 2 CDC. Updated recommendations
[Pneumovax]) with Pneumovax for prevention of invasive
pneumococcal disease
among adults using the
23-valent pneumococcal
polysaccaride vaccine
(PPSV23). MMWR
2010;59:1102–1106
$65 years of age, obtain One dose; if PCV13 has been 2 Falkenhorst G, Remschmidt C,
second dose of Pneumovax, given, then give PPSV23 $1 Harder T, Hummers-Pradier
at least 5 years from prior year after PCV13 and $5 E, Wichmann O, Bogdan C.
Pneumovax vaccine years after any PPSV23 at Effectiveness of the
age ,65 years 23-valent pneumococcal
polysaccharide vaccine
(PPV23) against
pneumococcal disease in
the elderly: systematic
review and meta-analysis.
PLoS ONE 2017;12:e0169368
Pneumonia 19–64 years of age, no None
(PCV13 recommendation
[Prevnar]) $65 years of age, without an One dose 3 Matanock A, Lee G, Gierke R,
immunocompromising condition Kobayashi M, Leidner A,
(e.g., chronic renal failure), Pilishvili T. Use of 13-valent
cochlear implant, or cerebrospinal pneumococcal conjugate
fluid leak, have shared decision- vaccine and 23-valent
making discussion with doctor pneumococcal polysac-
charide vaccine among
adults aged $65 years:
updated recommendations
of the Advisory Committee
on Immunization Practices.
MMWR 2019;68:1069–1075
Continued on p. S48S48 Comprehensive Medical Evaluation and Assessment of Comorbidities Diabetes Care Volume 44, Supplement 1, January 2021
Table 4.5—Continued
GRADE evidence
Vaccination Age-group recommendations Frequency type* Reference
Tetanus, diphtheria, All adults; pregnant women Booster every 10 years 2 for Havers FP, Moro PL, Hunter P,
pertussis (TDAP) should have an extra dose effectiveness, Hariri S, Bernstein H. Use of
3 for safety tetanus toxoid, reduced
diphtheria toxoid, and
acellular pertussis vaccines:
updated recommendations
of the Advisory Committee
on Immunization
PracticesdUnited States,
2019. MMWR 2020;69:
77–83
Zoster $50 years of age Two-dose Shingrix, even if 1 Dooling KL, Guo A, Patel M,
previously vaccinated et al. Recommendations of
the Advisory Committee on
Immunization Practices for
use of herpes zoster
vaccines. MMWR
2018;67:103–108
GRADE, Grading of Recommendations Assessment, Development and Evaluation; PCV13, 13-valent pneumococcal conjugate vaccine; PPSV23,
23-valent pneumococcal polysaccharide vaccine. *Evidence type: 1 5 randomized controlled trials (RCTs), or overwhelming evidence from
observational studies; 2 5 RCTs with important limitations, or exceptionally strong evidence from observational studies; 3 5 observational studies, or
RCTs with notable limitations; and 4 5 clinical experience and observations, observational studies with important limitations, or RCTs with several major
limitations. For a comprehensive list, refer to the Centers for Disease Control and Prevention at https://www.cdc.gov/vaccines/.
outcomes are not known (55–57). which may disrupt the global architecture disease factors should be carefully con-
Treatment with other glucagon-like or physiology of the pancreas, often sidered when deciding the indications
peptide 1 receptor agonists and with resulting in both exocrine and endocrine and timing of this surgery. Surgeries
sodium–glucose cotransporter 2 inhib- dysfunction. Up to half of patients with should be performed in skilled facilities
itors has shown promise in preliminary diabetes may have some degree of im- that have demonstrated expertise in islet
studies, although benefits may be me- paired exocrine pancreas function (63). autotransplantation.
diated, at least in part, by weight loss People with diabetes are at an approx-
(57–59). imately twofold higher risk of developing Fractures
acute pancreatitis (64). Age-specific hip fracture risk is signifi-
Hepatitis C Infection Conversely, prediabetes and/or diabe- cantly increased in both people with
Infection with hepatitis C virus (HCV) is tes has been found to develop in ap- type 1 diabetes (relative risk 6.3) and
associated with a higher prevalence of proximately one-third of patients after those with type 2 diabetes (relative risk
type 2 diabetes, which is present in up an episode of acute pancreatitis (65); 1.7) in both sexes (75). Type 1 diabetes
to one-third of individuals with chronic thus, the relationship is likely bidirec- is associated with osteoporosis, but in
HCV infection. HCV may impair glucose tional. Postpancreatitis diabetes may in- type 2 diabetes, an increased risk of hip
metabolism by several mechanisms, in- clude either new-onset disease or previously fracture is seen despite higher bone
cluding directly via viral proteins and unrecognized diabetes (66). Studies of mineral density (BMD) (76). In three large
indirectly by altering proinflammatory patients treated with incretin-based ther- observational studies of older adults,
cytokine levels (60). The use of newer apies for diabetes have also reported that femoral neck BMD T-score and the World
direct-acting antiviral drugs produces a pancreatitis may occur more frequently Health Organization Fracture Risk Assess-
sustained virological response (cure) with these medications, but results have ment Tool (FRAX) score were associated
in nearly all cases and has been re- been mixed and causality has not been with hip and nonspine fractures. Fracture
ported to improve glucose metabo- established (67–69). risk was higher in participants with di-
lism in individuals with diabetes (61). Islet autotransplantation should be abetes compared with those without
A meta-analysis of mostly observa- considered for patients requiring total diabetes for a given T-score and age or
tional studies found a mean reduction pancreatectomy for medically refractory for a given FRAX score (77). Providers
in A1C levels of 0.45% (95% CI 20.60 chronic pancreatitis to prevent postsur- should assess fracture history and risk
to 20.30) and reduced requirement gical diabetes. Approximately one-third factors in older patients with diabetes
for glucose-lowering medication use of patients undergoing total pancreatec- and recommend measurement of BMD if
following successful eradication of tomy with islet autotransplantation are appropriate for the patient’s age and sex.
HCV infection (62). insulin free 1 year postoperatively, and Fracture prevention strategies for people
observational studies from different cen- with diabetes are the same as for the
Pancreatitis ters have demonstrated islet graft func- general population and may include vi-
Diabetes is linked to diseases of the tion up to a decade after the surgery in tamin D supplementation. For patients
exocrine pancreas such as pancreatitis, some patients (70–74). Both patient and with type 2 diabetes with fracture riskcare.diabetesjournals.org Comprehensive Medical Evaluation and Assessment of Comorbidities S49
factors, thiazolidinediones (78) and sodium– signs of low testosterone (hypogonad- Current evidence suggests that peri-
glucose cotransporter 2 inhibitors (79) ism), a morning total testosterone level odontal disease adversely affects diabe-
should be used with caution. should be measured using an accurate tes outcomes, although evidence for
and reliable assay (89). In men who treatment benefits remains controversial
Sensory Impairment have total testosterone levels close to (28,99). In a randomized clinical trial, in-
Hearing impairment, both in high-frequency the lower limit, it is reasonable to de- tensive periodontal treatment was associ-
and low- to midfrequency ranges, is termine free testosterone concentra- ated with better glycemic control (A1C
more common in people with diabetes tions either directly from equilibrium 8.3% vs. 7.8% in control subjects and the
than in those without, with stronger dialysis assays or by calculations that intensive-treatment group, respectively)
associations found in studies of younger use total testosterone, sex hormone and reduction in inflammatory markers
people (80). Proposed pathophysiologic binding globulin, and albumin concen- after 12 months of follow-up (100).
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