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Review
. 2020 Jul 24;11(3):165-223.
doi: 10.1007/s13340-020-00439-5. eCollection 2020 Jul.

Japanese Clinical Practice Guideline for Diabetes 2019

Eiichi Araki  1 , Atsushi Goto  2 , Tatsuya Kondo  3 , Mitsuhiko Noda  4 , Hiroshi Noto  5 , Hideki Origasa  6 , Haruhiko Osawa  7 , Akihiko Taguchi  8 , Yukio Tanizawa  8 , Kazuyuki Tobe  9 , Narihito Yoshioka  10
Affiliations
Review

Japanese Clinical Practice Guideline for Diabetes 2019

Eiichi Araki et al. Diabetol Int. .
No abstract available

Keywords: Diabetes; Diagnosis; Guideline; Treatment.

PubMed Disclaimer

Figures

Fig. 1
Fig. 1
Flowchart outlining the steps in the clinical diagnosis of diabetes mellitus. OGTT oral glucose tolerance test [4]
Fig. 2
Fig. 2
Categories of glycemia as indicated by fasting plasma glucose levels and 75 g OGTT results. *1 The impaired fasting glucose (IFG) category refers to individuals with fasting plasma glucose (FPG) levels of 110–125 mg/dL and 2-hour plasma glucose (PG) levels of < 140 mg/dL in a 75 g OGTT (WHO), with the caveat, however, that IFG is defined as an FPG 100–125 mg/dL and only FPG is used in the diagnosis of IFG in the American Diabetes Association criteria. *2 Individuals with FPG 100–109 mg/dL are defined as the normal high FPG sub-category as part of the normal FPG category. It is advisable to perform OGTTs in this population who are shown to be quite heterogeneous in their susceptibility to diabetes or the severity of IGT confirmed at OGTT. *3 As one of the definitions included in the diagnostic criteria proposed by the WHO, IGT is diagnosed in individuals with FPG < 126 mg/dL or 2-hour 75 g OGTT PG ranging between 140 and 199 mg/dL
Fig. 3
Fig. 3
Schematic diagram showing the etiology (mechanisms of onset) and pathophysiological stages (phases) of diabetes mellitus [4]
Fig. 4
Fig. 4
Treatment of type 2 diabetes patients in 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 or less than 250–300 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
Fig. 5
Fig. 5
Glycemic control targets (see Fig. 8 for those for patients 65 years of age or older). The glycemic control target should be determined for each individual in light of his/her age, duration of diabetes, presence of organ damage, risk of hypoglycemia, and access to any support available. *1 Intended for individuals capable of achieving glycemic control with appropriate diet therapy (MNT) or exercise therapy or those capable of achieving glycemic control while on pharmacotherapy without developing hypoglycemia. *2 Defined as HbA1c < 7.0% for prevention of diabetic complications, which is assumed to correspond to fasting glucose < 130 mg/dL and postprandial 2-hour glucose < 180 mg/dL as measured glucose values. *3 Intended for individuals deemed less amenable to treatment intensification due to associated hypoglycemia or for some other reason. *4 All these targets are intended for use by adults except for pregnant women
Fig. 6
Fig. 6
Blood pressure measurement and procedure for hypertension diagnosis (Cited from Umemura, S., Arima, H., Arima, S. et al. The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019) Hypertens Res. 2019 Sep;42(9):1256. 10.1038/s41440-019-0284-9, with the permission of the JSH)
Fig. 7
Fig. 7
Treatment plan for hypertension complicated by diabetes mellitus (Cited from Umemura, S., Arima, H., Arima, S. et al. The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019) Hypertens Res. 2019 Sep;42(9):1356. 10.1038/s41440-019-0284-9, with the permission of the JSH)
Fig. 8
Fig. 8
Glycemic control targets (HbA1c values) for elderly patients with diabetes. The glycemic target is to be determined for each patient by taking into account his/her age, duration of diabetes, risk for hypoglycemia, and any support available to the patient, as well as the patient’s cognitive function, basic/instrumental ADL, and comorbidities/functional impairments, while noting the potential risk of hypoglycemia that increases with age in each patient. Note (1): Refer to the Japan Geriatrics Society website (https://www.jpn-geriat-soc.or.jp/tool/index.html), for the evaluation of the cognitive function, basic ADL (e.g. self-care abilities such as dressing, mobility, bathing, and toileting), and instrumental ADL (e.g. abilities to maintain an independent household 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. Note (2): As in other age groups, the glycemic target is set at < 7.0% in the elderly for preventing diabetic complications. However, this could be set at < 6.0% for those likely to achieve glycemic control through diet and exercise therapy alone or those 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 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. Note (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 control target or its lower limit may be set for each elderly patient with appropriate measures in order to prevent severe hypoglycemia. In patients in whom any of these agents was initiated before the age of 65 and whose HbA1c values are shown to fall below their glycemic control targets described above, current treatments are to be continued, with utmost care being taken to avoid potential severe hypoglycemia. Glinides may be classified as drugs 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 (Cited from Haneda, M., Inagaki, N., Suzuki, R. et al. Glycemic targets for elderly patients with diabetes. Diabetol Int 7, 331–333 (2016). 10.1007/s13340-016-0293-8)
See this image and copyright information in PMC

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8. Diabetic retinopathy

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9. Diabetic nephropathy

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12. Diabetic macroangiopathy

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13. Diabetes and periodontitis

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14. Diabetes complicated by obesity (including metabolic syndrome)

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15. Hypertension associated with diabetes

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16. Dyslipidemia associated with diabetes

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17. Impaired glucose metabolism in pregnancy

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18. Pediatric/adolescent diabetes

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20. Acute metabolic complications of diabetes, sick days, and infectious diseases

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21. Prevention of type 2 diabetes

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Appendix ① Diabetes and cancer

    1. Larsson SC, Orsini N, Wolk A. Diabetes mellitus and risk of colorectal cancer: a meta-analysis. J Natl Cancer Inst. 2005;97:1679–1687. - PubMed
    1. Larsson SC, Orsini N, Brismar K, et al. Diabetes mellitus and risk of bladder cancer: a meta-analysis. Diabetologia. 2006;49:2819–2823. - PubMed
    1. Giovannucci E, Harlan DM, Archer MC, et al. Diabetes and cancer: a consensus report. CA Cancer J Clin. 2010;60:207–221. - PubMed
    1. Kasuga M, Ueki K, Tajima N, et al. Report of the JDS/JCA Joint Committee on Diabetes and Cancer. Diabetol Int. 2013;2:81–96. - PMC - PubMed
    1. Goto A, Noto H, Noda M, et al. Report of the Japan Diabetes Society (JDS)/Japanese Cancer Association (JCA) Joint Committee on Diabetes and Cancer, Second Report. Diabetol Int. 2016;7:12–15. - PMC - PubMed

Appendix ② Diabetes and bone mineral metabolism

    1. Guidelines for Prevention and Treatment of Osteoporosis. Life Science publishing.
    1. Janghorbani M, Van Dam RM, Willett WC, et al. Systematic review of type 1 and type 2 diabetes mellitus and risk of fracture. Am J Epidemiol. 2007;166:495–505. - PubMed
    1. Vestergaard P. Discrepancies in bone mineral density and fracture risk in patients with type 1 and type 2 diabetes: a meta-analysis. Osteoporos Int. 2007;18:427–444. - PubMed
    1. Weber DR, Haynes K, Leonard MB, et al. Type 1 diabetes is associated with an increased risk of fracture across the life span: a population-based cohort study using The Health Improvement Network (THIN) Diabetes Care. 2015;38:1913–1920. - PMC - PubMed
    1. Hothersall EJ, Livingstone SJ, Looker HC, et al. Contemporary risk of hip fracture in type 1 and type 2 diabetes: a national registry study from Scotland. J Bone Miner Res. 2014;29:1054–1060. - PMC - PubMed

Appendix ③ Pancreas/islet transplantation

    1. Saito T, Gotoh M, Satomi S, et al. Islet transplantation using donors after cardiac death: report of the Japan Islet Transplantation Registry. Transplantation. 2010;90:740–747. - PubMed
    1. Hering BJ, Kandaswamy R, Ansite JD, et al. Single-donor, marginal-dose islet transplantation in patients with type 1 diabetes. JAMA. 2005;293:830–835. - PubMed

Appendix ④ Large-scale clinical trials in Japanese patients with diabetes

    1. Ueki K, Sasako T, Okazaki Y, et al. Effect of an intensified multifactorial intervention on cardiovascular outcomes and mortality in type 2 diabetes (J-DOIT3): an open-label, randomised controlled trial. Lancet Diabetes Endocrinol 2017 - PubMed

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