Objective: The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. Methods: The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. Results: This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. Conclusions: This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus. (c) 2022 AACE. Published by Elsevier Inc. All rights reserved.

Objective: We investigated sex and racial differences in insulin sensitivity, β-cell function and HbA1c, and the associations with selected phenotypic characteristics. Research Design and Methods: This is a cross-sectional analysis of baseline data from 3,108 GRADE participants. All had type 2 diabetes diagnosed <10 years and were on metformin monotherapy. Insulin sensitivity and β-cell function were evaluated using the homeostasis model assessment of insulin sensitivity (HOMA2-S) and estimates from oral glucose tolerance tests including the Matsuda index, insulinogenic index (IGI), C-peptide index (CPI) and oral disposition index (DI). Results: The cohort was 56.6±10 years of age (mean±SD), 63.8% male, with BMI 34.2±6.7 kg/m2, HbA1c 7.5±0.5% and type 2 diabetes duration 4.0±2.8 years. Women had higher DI than men but similar insulin sensitivity. DI was the highest in Black/African Americans, followed by American Indians/Alaska Natives, Asians and Whites in descending order. Compared to white, American Indian/Alaska Native had significantly higher HbA1c but Black/African Americans and Asians had lower HbA1c. However, when adjusted for glucose levels, Black/African Americans had higher HbA1c than whites. Insulin sensitivity correlated inversely with BMI, waist to hip ratio, triglyceride to HDL cholesterol ratio (TG/HDL- C) and the presence of metabolic syndrome; whereas DI was associated directly with age and inversely with BMI, HbA1c and TG/HDL-C. Conclusion: In the GRADE cohort, β-cell function differed by sex and race and was associated with the concurrent level of HbA1c. HbA1c also differed among the races, but not sex. Age, BMI and TG/HDL-C were associated with multiple measures of β-cell function and insulin sensitivity.

Source Citation Visser MM, Charleer S, Fieuws S, et al. Comparing real-time and intermittently scanned continuous glucose monitoring in adults with type 1 diabetes (ALERTT1): a 6-month, prospective, multicentre, randomised controlled trial. Lancet. 2021;397:2275-83. 34089660

Abstract Continuous glucose monitors (CGM) have demonstrated accuracy in outpatients and were accurate with pilot data using blinded systems in inpatients. Libre CGMs were approved and donated to hospitalsfor use during the COVID-19 to minimize exposure and PPE use. We made a prospective plan to assess accuracy of the Libre on inpatients admitted to COVID units during an initial “validation phase”. Fingerstick blood glucose (FSBG) was checked for the first three days after placing the sensor and compared to Libre values within the next 1–15 minutes. Patients were instructed to scan the sensor after each FSBG, and at other times as clinically warranted. FSBG values were recorded from the medical record (CPRS) and compared to Libre values downloaded to LibreView. The mean absolute relative difference (MARD) between FSBG and Libre was calculated for each patient for one to three days. The average MARD across all patients was calculated. Accuracy was further assessed using the Bland-Altman Plot and error grid analysis using web-based tool. Of the 21 patients assessed in the validation phase, 19 had at least one day of data and 11 had at least three days. The mean MARD was 11.2% after one day, and 12.5% after three days. Four patients after one day and three patients after three days had a MARD of 15–20% where use of the Libre was continued with confirmatory FSBG. In 15/19 (78%) patients with one day of data and 8/11 (73%) of patients with 3 days of data had a MARD <15% and continued using the Libre without further FSBG. One patient had a MARD >20% that did not improve with changing the sensor, and Libre was discontinued. In 16 of 19 patients, the Libre values were lower than FSBG. No adverse events relating to Libre use were identified. Error grid analysis showed that most patients had no values outside the A and B ranges, and very few values outside of the clinically accurate range, occurring in 2 of the 19 patients (9% of values in the “slight risk” zone in 9% in one and 6% in the other). The Libre was well-accepted by patient and nursing staff, but did not have measurable effect on glycemic control, hypoglycemic events, or hospitalization measures. The libre was deemed a useful intervention in inpatients, but it can be inaccurate or only moderately accurate compared to FSBG in enough patients to require checking accuracy for at least 1–3 days. Inaccurate Libre values were mostly lower than FSBG requiring confirmatory measures of low Libre values with FSBG in our experience.

Diabetic retinopathy (DR) is diagnosed clinically by directly viewing retinal vascular changes during ophthalmoscopy or through fundus photographs. However, electroretinography (ERG) studies in humans and rodents have revealed that retinal dysfunction is demonstrable prior to the development of visible vascular defects. Specifically, delays in dark-adapted ERG oscillatory potential (OP) implicit times in response to dim-flash stimuli (<−1.8 log cd · s/m2) occur prior to clinically recognized DR. Animal studies suggest that retinal dopamine deficiency underlies these early functional deficits. In this study, we randomized individuals with diabetes, without clinically detectable retinopathy, to treatment with either low- or high-dose Sinemet (levodopa plus carbidopa) for 2 weeks and compared their ERG findings with those of control subjects (no diabetes). We assessed dim-flash–stimulated OP delays using a novel handheld ERG system (RETeval) at baseline and 2 and 4 weeks. RETeval recordings identified significant OP implicit time delays in individuals with diabetes without retinopathy compared with age-matched control subjects (P < 0.001). After 2 weeks of Sinemet treatment, OP implicit times were restored to control values, and these improvements persisted even after a 2-week washout. We conclude that detection of dim-flash OP delays could provide early detection of DR and that Sinemet treatment may reverse retinal dysfunction.

Continuous glucose monitoring (CGM) has become a widely used tool in the ambulatory setting for monitoring glucose levels, as well as detecting uncontrolled hyperglycemia, hypoglycemia, and glycemic variability. The accuracy of some CGM systems has recently improved to the point of manufacture with factory calibration and Food and Drug Administration clearance for nonadjunctive use to dose insulin. In this commentary, we analyze the answers to six questions about what is needed to bring CGM into the hospital as a reliable, safe, and effective tool. The evidence to date indicates that CGM offers promise as an effective tool for monitoring hospitalized patients. During the current coronavirus disease 2019 crisis, we hope to provide guidance to healthcare professionals, who are seeking to reduce exposure to SARS-Cov-2, as well as preserve invaluable personal protective equipment. In this commentary, we address who, what, where, when, why, and how CGM can be adopted for inpatient use.

SOURCE CITATION:Pratley RE, Kanapka LG, Rickels MR, et al. Effect of continuous glucose monitoring on hypoglycemia in older adults with type 1 diabetes: a randomized clinical trial. JAMA. 2020;323:2397-406. 32543682.

Many type 2 diabetes patients require mealtime insulin to help maintain glycemic control, but this carries a risk of hypoglycemia. Since the glucose-lowering mechanism of SGLT2 inhibitors does not require beta-cell function, we asked if addition of the SGLT2 inhibitor canagliflozin (CANA) could “rescue” patients from the need for mealtime insulin. In a pilot study, after 2 week run-in, 26 pts requiring QID basal-bolus insulin with negative GAD antibodies were randomized, double-blind, to CANA or placebo (PLBO); dosage was 100 mg/d for 2 week, then 300 mg/d for 22 week. At baseline, the groups were similar: mean age 64 year, BMI 31.2, 100% male, 64% black, HbA1c 8.0%, insulin 107 units/day, CGM time in range (TIR, 70-180 mg/dl) 75.5%, hypoglycemia (<54 mg/dl) 0.41%, and hyperglycemia (>180 mg/dl) 22.8% (all p>0.05). Over 24 weeks, insulin was adjusted weekly in all pts to improve control but avoid hypoglycemia. One PLBO pt had a penile infection and d/c’d study drug, but other adverse events were similar, and there was no severe hypoglycemia. Among 13 CANA and 11 PLBO pts who followed the protocol for 24 week, during the last 12 week, despite a 27% reduction in insulin dosage to 78 units/day with CANA vs. a 7% increase to 112 units/day with PLBO (p=ns), 37% of CANA pts were able to d/c mealtime Rx entirely, and 4% to switch to glipizide, for >1 meal/day, vs. 32% and 8% with PLBO, respectively (p=ns); CGM metrics were better with CANA as well, TIR 79% vs. 74%, hypoglycemia 0.58% vs. 0.84%, and hyperglycemia 18.7% vs. 23.9% with CANA vs. PLBO, respectively, all p=ns, and HbA1c was 7.4% with CANA vs. 7.6% with PLBO (p=ns). Conclusions: Addition of canagliflozin to the regimens of patients using basal-bolus insulin, allows some patients to discontinue mealtime medication entirely, and others to switch from insulin to an oral agent, for at least one meal/day, with concomitant improvement in glycemic control, although differences from placebo were not statistically significant in this pilot study. Intensive management allows many patients to reduce their need for mealtime insulin. Disclosure L.S. Phillips: Advisory Panel; Self; Janssen Pharmaceuticals, Inc. Research Support; Self; AbbVie Inc., GlaxoSmithKline plc., Kowa Pharmaceutical Europe Co. Ltd., Novartis Pharmaceuticals Corporation, Novo Nordisk Inc., Pfizer Inc. Stock/Shareholder; Self; Diasyst Inc. Other Relationship; Self; Diasyst Inc., Janssen Pharmaceuticals, Inc. F. Morehead: None. L.P. Savoye: None. M.K. Rhee: None. D. Olson: None. E.H. Burgess: None. X. Cui: None. P. Calhoun: Stock/Shareholder; Self; Dexcom, Inc. R. Bailey: None. Funding U.S. Department of Veterans Affairs; National Institutes of Health

Background: The Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) study has enrolled a racially and ethnically diverse population with type 2 diabetes, performed extensive phenotyping, and randomly assigned the participants to one of four second-line diabetes medications. The continuous glucose monitoring (CGM) substudy has been added to determine whether there are racial/ethnic differences in the relationship between average glucose (AG) and hemoglobin A1c (HbA1c). CGM will also be used to compare time in target range, glucose variability, and the frequency and duration of hypoglycemia across study groups. Methods: The observational CGM substudy will enroll up to 1800 of the 5047 GRADE study participants from the four treatment groups, including as many as 450 participants from each of 4 racial/ethnic minority groups to be compared: Hispanic White, non-Hispanic White, non-Hispanic African American, and non-Hispanic Other. CGM will be performed for 2 weeks in proximity to a GRADE annual visit, during which an oral glucose tolerance test will be performed and HbA1c and glycated albumin measured. Indicators of interindividual variation in red blood cell turnover, based on specialized erythrocyte measurements, will also be measured to explore the potential causes of interindividual HbA1c variations. Conclusions: The GRADE CGM substudy will provide new insights into whether differences exist in the relationship between HbA1c and AG among different racial/ethnic groups and whether glycemic profiles differ among frequently used diabetes medications and their potential clinical implications. Understanding such differences is important for clinical care and adjustment of diabetes medications in patients of different races or ethnicities.

Primary prevention of type 2 diabetes (T2D) should be achievable through the implementation of early and sustainable measures. Several randomized control studies that found success in preventing the progression to T2D in high-risk populations have identified early and intensive intervention based on an individualized prevention model as the key factor for participant benefit. The global prevalence of both overweight and obesity has now been widely recognized as the major epidemic of the 21st century. Obesity is a major risk factor for the progression from normal glucose tolerance to prediabetes and then to T2D. However, not all obese individuals will develop prediabetes or progress to diabetes. Intensive, multicomponent behavioural interventions for overweight and obese adults can lead to weight loss. Diabetes medications, including metformin, GLP-1 agonists, glitazones, and acarbose, can be considered for selected high-risk patients with prediabetes when lifestyle-based programmes are proven unsuccessful. Nutrition education is the cornerstone of a healthy lifestyle. Also, physical activity is an integral part of the prediabetes management plan and one of the main pillars in the prevention of diabetes. Mobile phones, used extensively worldwide, can facilitate communication between health professionals and the general population, and have been shown to be helpful in the prevention of T2D. Universal screening is needed. Noninvasive risk scores should be used in all countries, but they should be locally validated in all ethnic populations focusing on cultural differences around the world. Lifestyle interventions reduce the progression to prediabetes and diabetes. Nevertheless, many questions still need to be answered.

Purpose: Electroretinograms (ERGs) are abnormal in diabetic retinas before the appearance of vascular lesions, providing a possible biomarker for diabetic vision loss. Previously, we reported that decreased retinal dopamine (DA) levels in diabetic rodents contributed to early visual and retinal dysfunction. In the current study, we examined whether oscillatory potentials (OPs) could serve as a potential marker for detecting early inner retinal dysfunction due to retinal DA deficiency. Methods: Retinal function was tested with dark-adapted ERGs, taken at 3, 4, and 5 weeks after diabetes induction with streptozotocin. Electrical responses were analyzed and correlations were made with previously reported retinal DA levels. The effect of restoring systemic DA levels or removing DA from the retina in diabetic mice on OPs was assessed using L-3,4-dihydroxyphenylalanine (L-DOPA) treatments and retina-specific tyrosine hydroxylase (Th) knockout mice (rTHKO), respectively. Results: Diabetic animals had significantly delayed OPs compared to control animals in response to dim, but not bright, flash stimuli. L-DOPA treatment preserved OP implicit time in diabetic mice. Diabetic rTHKO mice had further delayed OPs compared to diabetic mice with normal retinal Th, with L-DOPA treatment also providing benefit. Decreasing retinal DA levels significantly correlated with increasing OP delays mediated by rod pathways. Conclusions: Our data suggest that inner retinal dysfunction in early-stage diabetes is mediated by rod-pathway deficits and DA deficiencies. OP delays may be used to determine the earliest functional deficits in diabetic retinopathy and to establish an early treatment window for DA therapies that may prevent progressive vision loss.

BACKGROUND: Many individuals with diabetes remain undiagnosed, leading to delays in treatment and higher risk for subsequent diabetes complications. Despite recommendations for diabetes screening in high-risk groups, the optimal approach is not known. We evaluated the utility of inpatient glucose levels as an opportunistic screening tool for identifying patients at high risk for diabetes. METHODS: We retrospectively examined 462,421 patients in the US Department of Veterans Affairs health-care system, hospitalized on medical/surgical services in 2000-2010, for >= 3 days, with >= 2 inpatient random plasma glucose (RPG) measurements. All had continuity of care: >= 1 primary care visit and >= 1 glucose measurement within 2 years before hospitalization and yearly for >= 3 years after discharge. Glucose levels during hospitalization and incidence of diabetes within 3 years after discharge in patients without diabetes were evaluated. RESULTS: Patients had a mean age of 65.0 years, body mass index of 29.9 kg/m(2), and were 96% male, 71% white, and 18% black. Pre-existing diabetes was present in 39.4%, 1.3% were diagnosed during hospitalization, 8.1% were diagnosed 5 years after discharge, and 51.3% were never diagnosed (NonDM). The NonDM group had the lowest mean hospital RPG value (112 mg/dL [6.2 mmol/L]). Having at least 2 RPG values >140 mg/dL (>7.8 mmol/L), the 95th percentile of NonDM hospital glucose, provided 81% specificity for identifying incident diabetes within 3 years after discharge. CONCLUSIONS: Screening for diabetes could be considered in patients with at least 2 hospital glucose values at/above the 95th percentile of the nondiabetic range (141 mg/dL [7.8 mmol/L]). Published by Elsevier Inc.

BACKGROUND: Increasing use of nurse practitioners and physician assistants is a possible solution to the shortage of primary care providers in the United States, but the quality of care they provide is not well understood. METHODS: Because the scope of practice of the 3 provider types is similar in the Veterans Health Administration, we determined whether patients managed by primary care nurse practitioners, physician assistants, or physicians had similar hemoglobin A1c levels at comparable times in the natural history of diabetes. Our retrospective cohort study examined veterans with newly diagnosed diabetes in 2008, continuous primary care from 2008 to 2012, and more than 75% of primary care visits with nurse practitioner, physician assistant, or physician. RESULTS: Of the 19,238 patients, 95.3% were male, 77.7% were white, and they had a mean age 68.5 years; 14.7%, 7.1%, and 78.2% of patients were managed by nurse practitioners, physician assistants, and physicians, respectively. Median hemoglobin A1c was comparable at diagnosis (6.6%, 6.7%, 6.7%, P > .05) and after 4 years (all 6.5%, P > .5). Hemoglobin A1c levels at initiation of the first (7.5%-7.6%) and second (8.0%-8.2%) oral medications for patients of nurse practitioners and physician assistants compared with that of physicians was also similar after adjusting for patient characteristics (all P > .05). Nurse practitioners started insulin at a lower hemoglobin A1c (9.4%) than physicians (9.7%), which remained significant after adjustment (P <.05). CONCLUSIONS: At diagnosis and during 4 years of follow-up, diabetes management by nurse practitioners and physician assistants was comparable to management by physicians. The Veterans Health Administration model for roles of nurse practitioners and physician assistants may be broadly useful to help meet the demand for primary care providers in the United States. Published by Elsevier Inc.

OBJECTIVES:Safe and easily implemented treatment regimens are needed for the management of patients with type 2 diabetes mellitus (T2DM) in long-term care (LTC) and skilled nursing facilities. DESIGN:This 6-month open-label randomized controlled trial compared the efficacy and safety of a DPP4 inhibitor (linagliptin) and basal insulin (glargine) in LTC residents with T2DM. SETTINGS:Three LTC institutions affiliated with a community safety-net hospital, US Department of Veterans Affairs and Emory Healthcare System in Atlanta, Georgia. PARTICIPANTS:A total of 140 residents with T2DM treated with oral antidiabetic agents or low-dose insulin (≤0.1 U/kg/d), with fasting or premeal blood glucose (BG) > 180 mg/dL and/or HbA1c >7.5%. INTERVENTION:Baseline antidiabetic therapy, except metformin, was discontinued on trial entry. Residents were treated with linagliptin 5 mg/d (n = 67) or glargine at a starting dose of 0.1 U/kg/d (n = 73). Both groups received supplemental rapid-acting insulin before meals for BG > 200 mg/dL. MEASUREMENTS:Primary outcome was mean difference in daily BG between groups. Main secondary endpoints included differences in frequency of hypoglycemia, glycosylated hemoglobin (HbA1c), complications, emergency department visits, and hospital transfers. RESULTS:Treatment with linagliptin resulted in no significant differences in mean daily BG (146 ± 34 mg/dL vs. 157 ± 36 mg/dL, P = .07) compared to glargine. Linagliptin treatment resulted in fewer mild hypoglycemic events <70 mg/dL (3% vs. 37%, P < .001), but there were no differences in BG < 54 mg/dL (P = .06) or <40 mg/dL (P = .05) compared to glargine. There were no significant between-group differences in HbA1c, length of stay, complications, emergency department visits, or hospitalizations. CONCLUSION:Treatment with linagliptin resulted in noninferior glycemic control and in significantly lower risk of hypoglycemia compared to insulin glargine in long-term care and skilled nursing facility residents with type 2 diabetes.

Aims: Clinical trials show lifestyle change programs are beneficial, yet large-scale, successful translation of these programs is scarce. We investigated the association between participation in the largest U.S. lifestyle change program, MOVE!, and diabetes control outcomes.Methods: This longitudinal, retrospective cohort study used Veterans Health Administration databases of patients with diabetes who participated in MOVE! between 2005 and 2012, or met eligibility criteria (BMI >= 25 kg/m(2)) but did not participate. Main outcomes were diabetic eye disease, renal disease, and medication intensification.Results: There were 400,170 eligible patients with diabetes, including 87,366 (22%) MOVE! participants. Included patients were 96% male, 77% white, with mean age 58 years and BMI 34 kg/m(2). Controlling for baseline measurements and age, race, sex, BMI, and antidiabetes medications, MOVE! participants had lower body weight (-0.6 kg), random plasma glucose (-2.8 mg/dL), and HbA1 c (-0.1%) at 12 months compared to nonparticipants (each p < 0.001). In multivariable Cox models, MOVE! participants had lower incidence of eye disease (hazard ratio 0.80, 95% CI 0.75-0.84) and renal disease (HR 0.89, 95% CI 0.86-0.92) and reduced medication intensification (HR 0.82, 95% CI 0.80-0.84).Conclusions: If able to overcome participation challenges, lifestyle change programs in U.S. health systems may improve health among the growing patient population with diabetes. Published by Elsevier Inc.

Background Hepatic insulin gene therapy (HIGT) employing a glucose and insulin sensitive promoter to direct insulin transcription can lower blood sugars within 2 h of an intraperitoneal glucose challenge. However, post-challenge blood sugars frequently decline to below baseline. We hypothesize that this ` over-shoot' hypoglycemia results from sustained translation of longlived transgene message, and that reducing pro-insulin message half-life will ameliorate post-challenge hypoglycemia.Methods We compared pro-insulin message content and insulin secretion from primary rat hepatocytes expressing insulin from either a standard construct (2xfur), or a construct producing a destabilized pro-insulin message (InsTail), following exposure to stimulating or inhibitory conditions.Results Hepatocytes transduced with a 2xfur construct accumulated pro-insulin message, and exhibited increased insulin secretion, under conditions that both inhibit or stimulate transcription. By contrast, pro-insulin message content remained stable in InsTail expressing cells, and insulin secretion increased less than 2xfur during prolonged stimulation. During transitions from stimulatory to inhibitory conditions, or vice versa, amounts of pro-insulin message changed more rapidly in InsTail expressing cells than 2xfur expressing cells. Importantly, insulin secretion increased during the transition from stimulation to inhibition in 2xfur expressing cells, although it remained unchanged in InsTail expressing cells. Use of the InsTail destabilized insulin message tended to more rapidly reduce glucose induced glycemic excursions, and limit post-load hypoglycemia in STZ-diabetic mice in vivo.Conclusions The data obtained in the present study suggest that combining transcriptional and post-transcriptional regulatory strategies may reduce undesirable glycemic excursion in models of HIGT.

AimsTo test the hypothesis that a 50-g oral glucose challenge test with 1-h glucose measurement would have superior performance compared with other opportunistic screening methods.MethodsIn this prospective study in a Veterans Health Administration primary care clinic, the following test performances, measured by area under receiver-operating characteristic curves, were compared: 50-g oral glucose challenge test; random glucose; and HbA(1c) level, using a 75-g oral glucose tolerance test as the gold standard'.ResultsThe study population was comprised of 1535 people (mean age 56 years, BMI 30.3 kg/m(2), 94% men, 74% black). By oral glucose tolerance test criteria, diabetes was present in 10% and high-risk prediabetes was present in 22% of participants. The plasma glucose challenge test provided area under receiver-operating characteristic curves of 0.85 (95% CI 0.78-0.91) to detect diabetes and 0.76 (95% CI 0.72-0.80) to detect high-risk dysglycaemia (diabetes or high-risk prediabetes), while area under receiver-operating characteristic curves for the capillary glucose challenge test were 0.82 (95% CI 0.75-0.89) and 0.73 (95% CI 0.69-0.77) for diabetes and high-risk dysglycaemia, respectively. Random glucose performed less well [plasma: 0.76 (95% CI 0.69-0.82) and 0.66 (95% CI 0.62-0.71), respectively; capillary: 0.72 (95% CI 0.65-0.80) and 0.64 (95% CI 0.59-0.68), respectively], and HbA(1c) performed even less well [0.67 (95% CI 0.57-0.76) and 0.63 (95% CI 0.58-0.68), respectively]. The cost of identifying one case of high-risk dysglycaemia with a plasma glucose challenge test would be $42 from a Veterans Health Administration perspective, and $55 from a US Medicare perspective.ConclusionsGlucose challenge test screening, followed, if abnormal, by an oral glucose tolerance test, would be convenient and more accurate than other opportunistic tests. Use of glucose challenge test screening could improve management by permitting earlier therapy.