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    AACE Guidelines

    Yehuda Handelsman, MD, FACP, FACE, FNLA; Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU;

    Lawrence Blonde, MD, FACP, FACE; George Grunberger, MD, FACP, FACE;

    Zachary T. Bloomgarden, MD, FACE; George A. Bray, MD, MACP, MACE;

    Samuel Dagogo-Jack, MD, FACE; Jaime A. Davidson, MD, FACP, MACE

    Daniel Einhorn, MD, FACP, FACE; Om Ganda, MD, FACE;

    Alan J. Garber, MD, PhD, FACE; Irl B. Hirsch, MD; Edward S. Horton, MD, FACE;

    Faramarz Ismail-Beigi, MD, PhD; Paul S. Jellinger, MD, MACE; Kenneth L. Jones, MD;

    Lois Jovanovi, MD, MACE; Harold Lebovitz, MD, FACE; Philip Levy, MD, MACE;

    Etie S. Moghissi, MD, FACP, FACE; Eric A. Orzeck, MD, FACP, FACE;

    Aaron I. Vinik, MD, PhD, FACP, MACP; Kathleen L. Wyne, MD, PhD, FACE

    American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice are systematically

    of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied.

    rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use

    this information in conjunction with their best clinical judgment. The presented recommendations may not be appropri-

    ate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and

    individual patient circumstances.

    Copyright AACE 2011

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    AACE Task Force for Developing a Diabetes Comprehensive Care Plan

    Writing Committee

    Cochairpersons

    Yehuda Handelsman, MD, FACP, FACE, FNLA

    Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU

    Lawrence Blonde, MD, FACP, FACE

    George Grunberger, MD, FACP, FACE

    Task Force Members

    Zachary T. Bloomgarden, MD, FACE

    George A. Bray, MD, MACP, MACE

    Samuel Dagogo-Jack, MD, FACE

    Jaime A. Davidson, MD, FACP, MACEDaniel Einhorn, MD, FACP, FACE

    Om Ganda, MD, FACE

    Alan J. Garber, MD, PhD, FACE

    Irl B. Hirsch, MD

    Edward S. Horton, MD, FACE

    Faramarz Ismail-Beigi, MD, PhD

    Paul S. Jellinger, MD, MACE

    Kenneth L. Jones, MD

    Lois Jovanovi, MD, MACE

    Harold Lebovitz, MD, FACE

    Philip Levy, MD, MACE

    Etie S. Moghissi, MD, FACP, FACEEric A. Orzeck, MD, FACP, FACE

    Aaron I. Vinik, MD, PhD, FACP, MACP

    Kathleen L. Wyne, MD, PhD, FACE

    Reviewers

    Alan J. Garber, MD, PhD, FACE

    Daniel L. Hurley, MD

    Farhad Zangeneh, MD, FACP, FACE

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    Abbreviations:

    AACE = American Association of Clinical

    Endocrinologists; BEL = best evidence level; CDE =

    CGM

    monitoring; CPGCSII =

    CVD = car-

    DM DPP-4

    inhibitor = dipeptidyl-peptidase 4 inhibitor; EL = evi-

    dence level; FDA

    FPG GDM = gestational

    GFR

    GLP-1A1C = hemoglobin

    A1c

    ; HDL-C = high-density lipoprotein cholesterol;

    LDL-C = low-density lipoprotein cholesterol; MDI

    NPH

    Hagedorn; PPG Q = clinical

    R = recommendation; RCT = randomized

    controlled trial; SMBG-

    cose; T1DMT2DM = typeTZD = thiazolidinedione

    1. INTRODUCTION

    -

    glycemic control.

    -lished American Association of Clinical Endocrinologists

    -

    control. This comprehensive approach is based on the evi-

    -

    globin A1c

    -

    -

    recommendations.

    following:

    -

    prehensive care plan for clinical endocrinologists and

    -

    tronically in clinical practices to assist with decision-

    -

    cal implementation strategies in a more concise format than

    -

    -

    2. METHODS

    -

    -

    -

    review byEndocrine Practice.

    Comments may be appended to the recommendation grade

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    regarding -

    clinical management is based on what is in the best interest

    Fig. 1.

    -level review mechanism.

    Table 1

    2010 American Association of Clinical Endocrinologists Protocol for

    Production of Clinical Practice GuidelinesStep I: Evidence Ratinga

    Numerical

    descriptor

    (evidence level)b Semantic descriptor (reference methodology)

    1

    1

    2

    2

    2 2

    4

    a Adapted from reference 1:Endocr Practb

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    Table 2

    2010 American Association of Clinical Endocrinologists Protocol for

    Production of Clinical Practice GuidelinesStep II:

    Evidence Analysis and Subjective Factorsa

    Study design Data analysis Interpretation of results

    Intent-to-treat

    Appropriate statistics

    Selection bias Incompleteness

    Appropriate blinding

    aEndocr Pract

    Table 3

    2010 American Association of Clinical Endocrinologists Protocol for

    Production of Clinical Practice GuidelinesStep III:

    Grading of Recommendations; How Different Evidence Levels

    Can Be Mapped to the Same Recommendation Gradea,b

    Bestevidence

    level

    Subjectivefactorimpact

    Two-thirdsconsensus Mapping

    Recommendationgrade

    1 Yes Direct A

    2 Yes A

    2 Yes Direct B1 Yes B

    Yes B

    Yes Direct C

    2 Yes C

    4 Yes C

    4 Yes Direct D

    Yes D

    D

    a - -bEndocr Pract

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    6

    -

    3. EXECUTIVE SUMMARY

    3.Q1.1. Diagnosis of DM

    Grade A; BEL 1

    or

    load in the morning after an overnight fast of at

    or

    or

    -

    Grade D; BEL 4

    Grade D; BEL 4

    --

    Grade D; BEL

    4

    Grade D; BEL 4

    Grade D; BEL

    4

    Grade

    D; BEL 4

    Grade

    C; BEL 3

    Grade C; BEL 3

    -

    -ance test.

    - -

    Grade A; BEL 1

    -

    -

    creatic islet

    Grade A; BEL 1

    Grade A; BEL 1

    - -

    Grade C; BEL 3

    Table 4

    2010 American Association of

    Clinical Endocrinologists Protocol

    for Production of Clinical Practice Guidelines

    a

    Cost-effectiveness

    Evidence gaps

    aEndocr Pract

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    7

    -

    -

    Grade A; BEL 1

    -

    -

    Grade D; BEL 4

    Grade D; BEL 4

    Grade

    D; BEL 4

    -

    body weight if overweight or obese and participation

    Grade D; BEL 4-

    Grade A; BEL 1

    -

    Grade A;

    BEL 1

    -

    Grade A; BEL 1

    weight loss may be considered when lifestyle modi-

    m2Grade D; BEL 4

    laparoscopic-assisted gastric banding in patients with

    2

    2 to achieve at

    Grade A; BEL 1

    Grade D; BEL 4

    3.Q3. What is the Role of a DM Comprehensive Care

    Glucose Testing and Interpretation

    Test Result Diagnosis

    126

    test on a different day

    200

    test on a different day

    Hemoglobin A1c

    test on a different day

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    8

    -

    Grade A; BEL 4

    -

    -

    Grade D; BEL 4

    -

    Grade D; BEL 4

    [See Appendix for Q4: What is the Imperative for

    -

    -

    Grade A; BEL 1

    Grade D, BEL 4

    -

    Grade B,

    BEL 2

    Grade A;

    BEL 1

    Grade

    A; BEL 1

    Grade A; BEL 1

    -

    Grade A;

    BEL 1

    For most hospitalized persons with hyperglyce- -

    Grade D; BEL 4

    -

    Grade D; BEL 4

    Grade D; BEL 4

    -

    (Grade A; BEL 1)-

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    Grade D; BEL 4

    Treatment targets for dyslipidemia are based on

    -

    -

    Grade A; BEL 1

    -

    Grade C; BEL 3

    -

    -

    Grade D; BEL 4-

    in weight loss and weight maintenance programs.

    -

    -

    -

    Grade D; BEL 4

    Grade D; BEL 4

    -

    Grade A; BEL 1

    Antihyperglycemic agents may be broadly cat-

    -

    glargine and detemir are preferred over intermediate-

    Grade A;

    BEL 1

    -

    Grade A; BEL 1

    -

    have a more rapid onset and offset of action and are

    Grade A; BEL

    1

    Grade A; BEL 1

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    be considered for patients in whom adherence to a

    Grade D; BEL 4

    Grade B; BEL 3

    - -

    priate intervals when treatment goals are not achieved

    Grade D; BEL 4

    -

    Grade D; BEL 4

    Grade D; BEL 4

    Grade A; BEL 1

    -

    Grade A; BEL 1

    -

    -

    Grade D; BEL4

    Grade B;

    BEL 2

    Grade D;

    BEL 4 -

    Grade D; BEL

    4

    -

    Grade

    D; BEL 4

    -

    sidered when glycemic targets are not achievable

    Grade C; BEL 3). An

    -

    -

    Grade B; BEL 2

    treatment for postprandial hyperglycemia in pregnant

    Grade B; BEL 2

    -

    women.

    Grade D; BEL 4

    -

    Grade D; BEL 4-

    Grade D; BEL 4

    Grade D; BEL 4 -

    Grade D;

    BEL 4

    preferred for critically ill patients.

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    Grade D; BEL 4

    Grade D; BEL 4

    -

    Grade D; BEL 4

    the effects of their lifestyle and pharmacologic ther-

    Grade

    D; BEL 4

    Grade D; BEL 4

    -

    Grade D; BEL4 -

    cagon may be given by a trained family member or by

    Grade D; BEL 4

    Grade

    D; BEL 4

    Grade D; BEL

    4

    -

    Grade A; BEL 1

    become hypoglycemic and have been treated with

    an

    -

    Grade D; BEL 4

    3.Q10. How Should Microvascular and Neuropathic

    Disease Be Prevented, Diagnosed, and Treated

    improving glycemic control.

    Grade

    D; BEL 4

    -

    Grade A; BEL

    1

    -

    Grade A; BEL 1

    Being overweight or obese

    Sedentary lifestyle

    Hypertension

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    ComprehensiveDiabetesCareTreatmentGoals

    Parameter

    TreatmentGoal

    Reference(evidenceleveland

    studydesign)

    HemoglobinA1c

    110

    140

    140-180

    40inmen;

    80

    Aspirin

    a

    -

    a

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    -

    -

    Grade D; BEL 4

    Grade B; BEL 2

    Grade C; BEL 3

    -

    Grade D; BEL 4

    implemented to slow the progression of retinopathy

    Grade D; BEL 4

    -

    Grade D; BEL 4

    Grade

    A; BEL 1

    Grade C; BEL 3-

    -

    Grade

    A; BEL 1

    -

    ment; orthotics to treat and prevent foot deformities;-

    Grade A; BEL 1

    -

    -

    Grade A; BEL 1

    3.Q11. How Should Macrovascular Disease Be

    Prevented, Diagnosed, and Treated in Patients

    Grade A; BEL 1

    Grade D; BEL 4

    Grade A; BEL 1

    -

    agents are selected on the basis of their ability to

    -

    gression of nephropathy and retinopathy; angiotensin-

    converting enzyme inhibitors or angiotensin II recep-

    Grade D; BEL 4-

    -

    and newer-generation -

    Grade A; BEL 1

    -Grade A; BEL 1-

    Grade A; BEL 1-

    -

    target for therapy. Statins are the treatment of choicein the absence of contraindications. Combinations of

    Grade A; BEL 1

    -

    cases of statin-related adverse events or intolerance

    Grade A; BEL 2

    -

    -

    Grade A;

    BEL 1

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    Grade

    C; BEL 3

    Grade D; BEL 4

    3.Q12. How Should Other Common Comorbidities of

    Grade D; BEL 4

    Grade

    A; BEL 1

    -

    -

    Grade D; BEL 4

    3.Q12.2. Depression

    Grade A; BEL 1

    4. APPENDIX: EVIDENCE BASE

    4.Q1.1. Diagnosis of DM

    -

    -

    -

    -

    -

    -

    the pancreatic

    -

    -

    -

    -

    -

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    -

    cations are approved by the FDA for the management of

    -

    P

    -

    Obesity

    The cornerstone for controlling obesity in prediabe-

    -

    -

    -

    -

    perioperative complications were more common with gas-

    percentage of reversal is related to the degree of weight

    -

    -

    -

    4.Q3. What is the Role of a DM Comprehensive

    A.

    4.Q4. What is the Imperative for Education and

    different health care providers allows the patient to learn

    -

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    -

    tion to foot care. They often have more time than physi-

    their physician. Having a CDE credential indicates the

    in this area.

    to especially follow their prescribed meal plan and physi-

    cal activity program as an integral part of their therapy.

    -

    -

    tion administration is another important area that can be

    -

    -

    treatment plans and set goals that other team members will

    It is important that a patient has a primary care physi-cian. It is critical that a primary care physician addresses

    -

    patients might not be seen on a timely basis for medical

    -

    the appropriate specialist as part of their care.

    -

    -

    -

    -

    -

    -

    -

    -

    -

    trials achieving improved A1C levels and epidemiologic

    -

    target A1C-

    -

    -

    terminal illness.

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    -

    -

    -

    -

    therapy glycemic targets that were associated with a higher

    -

    -

    -

    -

    -

    -

    -

    -

    recommended.

    -

    -

    -

    -

    -

    -

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    -

    -

    -

    port when appropriate. The last category applies to those

    -

    -

    -

    vs foods that may promote disease or complications from

    -

    -

    American Association of Clinical Endocrinologists Healthful Eating Recommendations for

    Patients With Diabetes Mellitus

    Topic RecommendationReference (evidence level and

    study design)

    habits

    Carbohydrate

    negative health effects

    Fat trans

    Avoid or limit processed meats

    controlled trial.

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    -

    the physician or a registered dietician in all patients with

    -

    ommendations aimed at optimizing glycemic control and

    2

    adopting the principles given in Tables 7 and 8 are to per-

    -

    -

    Key recommendations address the need for consistency in

    -

    -

    physician.

    -

    ing the effects of increased physical activity alone from

    -

    a main component in weight loss and maintenance pro-

    -

    -

    -

    is to achieve clinical and biochemical targets with as few

    statement has important implications for the choice of

    -

    -

    -

    -

    -

    be associated with the development of vitamin B12

    -

    -

    effect not widely appreciated.

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    -

    -

    Colesevelam and -

    -

    systemic adverse effects.

    -

    -

    -

    -

    Bromocriptine is a potent agonist at dopamine D2

    receptors

    -

    -

    impairment.

    -

    -

    -

    Several years of clinical trials and treatment with -

    -

    postprandial hyperglycemia and is associated with minimal

    do not increase satiety. The administration of pharmaco-

    -

    -

    -

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    -

    -

    -

    has stated that patients on therapy do not need to be moni-

    -

    -

    prolonged lifestyle and oral agent efforts to achieve glyce-

    mic control has been revised in the last decade to incorpo-

    -

    -

    glargine and detemir are preferred over intermediate-

    -

    -

    control has been achieved in the absence of hypoglyce-

    -

    -

    -

    -

    -

    -

    -

    -

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    are consistently modest and mild weight loss is common.

    -

    resistance.

    -

    -

    -

    the largest meal once daily or at the 2 largest meals twice

    -

    -

    meal patternsAnother advantage

    -

    lin doses at each meal depending on the size of the meal

    -

    may vary considerably on the basis of body weight and

    -

    -

    -

    4.Q7.1.

    -

    -

    4.Q7.2.

    -

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    Table10

    Summ

    aryDataFromCost-effectivenessAnalysesComparingContinuousSubcutaneousInsulinInfusionWith

    MultipleDailyInjectionsinAdultsandChildrenWithType1D

    iabetesMellitus

    Reference

    Studyobjective,perspective,datasource

    QALYsgained

    Costper

    QALY(ICER)

    USthird-partypayerperspective

    CSII:$16

    ImprovedglycemiccontrolfromCSIIled

    Canadianpayerperspective

    CSII:Can$27

    inpregnancy

    CS

    II:80

    104

    Improvementsinglyc

    emiccontrolwith

    ofdiabetes-related

    complications

    standards

    -

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    -

    combination with metformin.

    -

    -

    By the time these offspring themselves reach childbearing

    is not simply a genetic predisposition is inferred from the

    -

    -

    not able to maintain normoglycemia with a carbohydrate-

    -

    -

    -

    -

    are not the only factors at play in the early stages of child-

    hood that can have lasting adverse effects on the offspring.

    -

    -

    4.Q7.5.

    -

    American Diabetes Association standards of medical care

    The management of hyperglycemia in the hospital

    -

    -

    -

    may be appropriate in terminally ill patients or in patients

    -

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    -

    -

    -

    -sition to oral agents in the day or two before discharge is

    often necessary.

    When and How Should Glucose

    -

    term assessment is most often by A1C.

    chain of hemoglobin.

    -

    -

    -

    -

    -

    -

    of A1C

    -

    hypoglycemia is typically recognized in association with

    -

    -

    Hypoglycemia is associated with more short-term disabil-

    ity and higher health care costs. Hypoglycemia manifests

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    awareness and response to hypoglycemia. Severe and pro-

    longed hypoglycemia may be associated with severe con-

    arrhythmia.

    -

    lin reserve and perhaps the drive for strict glycemic con-

    -

    -

    -

    by a period of intensive therapy that dampens glyce-

    -

    Hypoglycemia is an important consideration in the

    achievement of glycemic goals.

    -

    -

    4.Q10. How Should Microvascular and

    Neuropathic Disease Be Prevented,

    -

    after the onset of

    clinical manifestation of diabetic nephropathy in persons

    -

    -

    -

    -

    -

    -vention for diabetic nephropathy.

    -

    -

    2

    Stage Description

    Stage 1 Kidney damage with normal or

    Stage 2 Kidney damage with mildly

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    -

    -

    -

    -

    This property hasbeen demonstrated for the angiotensin-converting enzyme

    -

    demonstrated after renin-angiotensin-aldosterone sys-

    -

    -

    -

    -

    -

    -

    -

    nephrologist is cost-effective and delays the time to dialy-

    -

    -

    -

    -

    -

    -

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    by an ophthalmologist. This 2-step approach can be an

    -

    -

    -

    -

    strategies for primary prevention of diabetic retinopathy

    -

    -

    -

    -

    -

    -

    -

    -

    -

    -

    ther progression. It is vitally important to improve strength

    -

    density correlates inversely with

    -

    -

    with treatment.

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    -

    daily basis.

    adapted from one recently proposed by the International

    -

    ities in the peripheral somatosensory system in people with

    -

    -

    -

    -

    -

    -

    -

    -

    -

    -

    -

    -

    -

    -

    other physiological stresses; and as an indicator for more

    -

    -

    -

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    a relationship between hyperglycemia and the develop-

    -

    a greater

    -

    -

    4.Q11. How Should Macrovascular DiseaseBe Prevented, Diagnosed, and Treated in

    -

    -

    myocardial infarction at baseline and was almost 6-fold

    greater than the incidence of myocardial infarction in non-

    -

    -

    Fig. 2.

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    Table11

    Symptoms

    Tests

    Treatments

    Cardiac

    intolerance

    Gastrointestinal

    electrogastrogram

    Constipation

    Endoscop

    y

    Sexualdysfunction

    Bladderdysfunction

    sonograph

    y

    Sudomotordysfunction

    hyperhidrosis

    Pupillomotorandvisceraldysfunction

    Carewithdrivingatn

    ight

    Impairedvisceralsensation:silent

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    -

    -

    as well as in those with hyperglycemia. Early epidemio-

    -

    -

    in patients referred to a cardiologist for coronary artery

    -

    -

    -

    -

    als investigated the effect of intensive glycemic control

    vs ordinary glycemic control on the development of new

    -

    glycemic control.

    -

    -

    to correlate very well with the development of clinical car-

    -

    -

    controversial owing to recent data showing little to no

    -

    The data from the many clinical trials and observa-

    -

    reported that low-dosage aspirin was associated with a

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    -

    -

    -

    -

    4.Q11.3.

    -

    -

    with either an angiotensin-converting enzyme inhibitor

    -

    -

    strated a decrease in the progression of nephropathy and

    -

    -

    -

    -

    -

    --

    lowering has the greatest and most immediate impact on

    -

    -

    -

    and the average recorded.

    -

    -

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    -

    -

    ciated with increased long-term morbidity and mortality.

    -

    -

    -

    -

    -

    treatment regimen and avoid overtreatment.

    -

    -

    aged as aggressively and with the same agents as in overt

    -

    as vasodilating

    -

    -

    4.Q11.4.

    -

    hyperglycemia. -

    ized by increased levels of triglyceride-rich lipoproteins

    Table 12

    Suggested Priority of Initiating Blood PressureLowering Agents

    Therapy

    Reference (evidence level and

    study design)

    Evidence based

    Additional therapy

    Direct renin inhibitor

    Selective 1

    Central 2

    agonists

    Direct vasodilators

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    -

    the latter being responsible for transfer of triglycerides and

    cholesterol esters from very low-density lipoprotein and

    -

    level.

    associated phospholipase A2

    -

    if the

    -

    -

    -

    hypertriglyceridemia.

    In patients with fasting triglyceride concentrations of

    -

    -

    -

    -

    -

    -

    -

    erides with proliferator-activated receptor-

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    necessary to prevent pancreatitis. Use of gemfibrozil is

    -

    no randomized interventional trials of prediabetes with

    4.Q11.5.

    -

    -cation of glycemic control.

    The impression in the past was that diagnosing asymp-

    -

    -

    to identify those patients who will receive the most ben-

    4.Q12. How Should Other Common Comorbidities of

    DM Be Addressed

    4.Q12.1. S

    -

    -

    to a sleep specialist who may choose to do an overnight

    and physical.

    -

    -

    -

    -

    -

    appropriate.

    4.Q12.2. Depression

    recommended. Untreated comorbid depression can have

    -

    pressant medication is associated with an increased relative

    ACKNOWLEDGMENT

    -

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    FACE.

    DISCLOSURE

    Cochairpersons

    reports that he has received

    -

    reports that he has received

    reports that he has received

    for his role as investigator from Boehinger Ingelheim

    Dr. George Grunberger reports that he has

    -

    Inc.

    Task Force Members

    reports that he has

    reports that he does not have

    interests.

    Dr. Samuel Dagogo-Jackreports that he has received

    reports that he has received

    Company.

    reports that he has received shares

    -

    reports that he has received

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    reports that he has received con-

    reports that he has received

    -

    -

    reports that he has

    reports that he has received

    reports that he does not have

    interests.

    reports that she has received

    reports that he has received

    reports that she has received

    reports that he has received

    -

    and the American Diabetes Association.

    reports that she has received

    Reviewers

    reports that he has received

    reports that he does not have

    interests.

    reports that he has received

    Medical Writer reports that she does not have any

    interests.

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