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. 2018 Mar 26;9(3):657-697.
doi: 10.1111/jdi.12810. Online ahead of print.

Japanese Clinical Practice Guideline for Diabetes 2016

Masakazu Haneda  1 , Mitsuhiko Noda  2 , Hideki Origasa  3 , Hiroshi Noto  4 , Daisuke Yabe  5 , Yukihiro Fujita  1 , Atsushi Goto  6 , Tatsuya Kondo  7 , Eiichi Araki  7
Affiliations

Japanese Clinical Practice Guideline for Diabetes 2016

Masakazu Haneda et al. J Diabetes Investig. .

Erratum in

  • Eratum.
    [No authors listed] [No authors listed] J Diabetes Investig. 2019 Jan;10(1):190. doi: 10.1111/jdi.12979. Epub 2018 Dec 3. J Diabetes Investig. 2019. PMID: 30609323 Free PMC article. No abstract available.
  • Corrigendum.
    [No authors listed] [No authors listed] J Diabetes Investig. 2020 May;11(3):752. doi: 10.1111/jdi.13252. J Diabetes Investig. 2020. PMID: 32419345 Free PMC article. No abstract available.
No abstract available

Keywords: Diabetes; Diagnosis; Guideline; Treatment.

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Figures

Figure 1
Figure 1
Flow chart outlining the steps in the clinical diagnosis of diabetes mellitus. OGTT, Oral glucose tolerance test.
Figure 2
Figure 2
The categories of glycemia as indicated by fasting plasma glucose levels and 75 g OGTT results. *1 The impaired fasting glucose (IFG) category represents cases of fasting plasma glucose levels of 110–125 mg/dL (6.1–7.0 mmol/L) and 2‐h plasma glucose levels of <140 mg/dL (7.8 mmol/L) in a 75 g OGTT (WHO). However, in the ADA criteria, IFG is defined as a fasting plasma glucose levels of 100–125 mg/dL (5.6–7.0 mmol/L), and only FPG is used for the determination of IFG. *2 Fasting plasma glucose levels of 100–109 mg/dL (5.6–6.1 mmol/L) are within the normal limits, but are considered to be ‘high‐normal’. Because patients with a high‐normal glucose level are at risk of developing diabetes and include cases with various degrees of impaired glucose tolerance, the performance of an OGTT is desirable. *3 The category was adopted by the WHO in the diagnostic criteria for diabetes mellitus, and represents cases with fasting plasma glucose levels of <126 mg/dL and 2‐h plasma glucose levels of 140–199 mg/dL (7.8–11.1 mmol/L in a 75 g OGTT.
Figure 3
Figure 3
A schematic diagram of the relationship between the etiology (mechanism) and pathophysiological stages (states) of diabetes mellitus. Arrows pointing right represent the worsening of glucose metabolism disorders (including the onset of diabetes mellitus). Among the arrow lines, indicates the condition classified as ‘diabetes mellitus’. Arrows pointing left represent improvement in the glucose metabolism disorder. The broken lines indicate events of low frequency. For example, in type 2 diabetes mellitus, infection can lead to ketoacidosis and require temporary insulin treatment for survival. Also, once diabetes mellitus has developed, it is treated as diabetes mellitus regardless of the improvement in the glucose metabolism; thus, the arrow lines pointing left are filled in black. In such cases, a broken line is used, because complete normalization of the glucose metabolism is rare.
Figure 4
Figure 4
Treatment of patients in a non‐insulin‐dependent state. This provides a guide to the management of patients without acute metabolic disorder (i.e., those who had a casual blood glucose level of 250–300 mg/dL [13.9–16.7 mmol/L] or less than 250 to 300 mg/dL with a negative urinary ketone test). The glycemic goal should be determined individually depending on the disease condition or age of the patient but is generally set at HbA1c <7.0%. ‘Diet therapy’ and ‘exercise therapy’ are referred to as ‘medical nutrition therapy (MNT)’ and ‘physical activity/exercise’, respectively, elsewhere in this guideline.
Figure 5
Figure 5
Glycemic control targets. Control targets are established individually, in consideration of age, duration of disease, organ damage, risk of hypoglycemia, support structures, etc. *1 When targets can be attained by appropriate MNT or physical activity/exercise, or during pharmacotherapy without the occurrence of side effects such as hypoglycemia. *2 From the perspective of preventing complication, HbA1c target value is set at <7%. A fasting blood glucose level <130 mg/dL (7.2 mmol/L) and a 2‐h postprandial blood glucose level <180 mg/dL (10.0 mmol/L) can be used as an approximate guideline for the corresponding blood glucose levels. *3 When intensification of treatment is considered difficult due to side effects such as hypoglycemia or for other reasons. *4 All target values are for adults, not including pregnant women.
Figure 6
Figure 6
The treatment of hypertension complicating diabetes mellitus. Excerpt from: The Japanese Society of Hypertension, Guidelines for the Treatment of Hypertension, 2014, p. 78. *Care needs to be taken to closely monitor patients with coronary atherosclerosis, peripheral arterial disease, or older patients with diabetes, for decreased organ blood flow.
Figure 7
Figure 7
Glycemic targets (HbA1c values) for older patients with diabetes. For older patients, the glycemic target is to be determined for each patient by taking into account his/her age, duration of diabetes, risk of hypoglycemia, and any support available to the patient, as well as the patient's cognitive function, basic/instrumental activities of daily living (ADL), and comorbidities/functional impairments, while noting the potential risk of hypoglycemia that increases with age in each patient. (1) Refer to the Japan Geriatrics Society website1, 2, for the evaluation of the cognitive function, basic ADL (e.g., self‐care abilities such as dressing, transferring, bathing, and toileting), and instrumental ADL (e.g., the patient's ability to maintain an independent household by performing activities such as shopping, meal preparation, taking medication, and handling finances). In end‐of‐life care, priority is to be given to preventing significant hyperglycemia and subsequent dehydration and acute complications through appropriate therapeutic measures. (2) As in other age groups, the glycemic target for preventing diabetic complications in older patients with diabetes is set to <7.0%. However, this can be set to <6.0% for those who are thought to be likely to achieve glycemic control through MNT and/or physical activity/exercise alone or those who are likely to achieve glycemic control with drug therapy without adverse reactions, or 8.0% for those in whom intensifying therapy may prove difficult. In either case, no lower limit is specified for the glycemic target. A glycemic target of <8.5% may be allowed in patients who are thought to be in category III and therefore at risk of developing adverse reactions to multi‐drug combination therapy or in those with serious comorbidities or poor social support. (3) In patients in whom priority should be given to preventing the onset/progression of diabetic complications due to their duration of disease, the glycemic target or its lower limit may be set for each older patient with appropriate measures in place to prevent severe hypoglycemia. Current treatments are to be continued in those who are <65 years of age, even when their HbA1c values fall below their glycemic target or a lower limit while on therapy; however, care needs to be taken to monitor these patients for potential severe hypoglycemia. Glinides may be classified as drugs that are unlikely to be associated with severe hypoglycemia, as the onset of severe hypoglycemia varies depending on the type and amount of glinide used in a particular patient relative to the patient's glucose level.
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