What are the guidelines for managing diabetes?

Guidelines for Managing Diabetes

The management of diabetes should begin with metformin plus lifestyle modifications, followed by the addition of SGLT-2 inhibitors or GLP-1 receptor agonists, especially in patients with cardiovascular or renal comorbidities. 1

Comprehensive Approach to Diabetes Management

Initial Evaluation and Diagnosis

• Complete medical evaluation to classify diabetes, detect complications, and formulate management plan 2
• Laboratory tests to evaluate glycemic control (HbA1c), renal function, lipid profile
• Screen for autoimmune diseases in type 1 diabetes (thyroid dysfunction, celiac disease) 2
• Assess for comorbidities including cardiovascular disease, hypertension, dyslipidemia, and obesity

Treatment Goals

• Target HbA1c <7% for most adults 1
• More stringent targets (<6.5%) for patients with short disease duration and long life expectancy
• Less stringent targets (<8%) for those with history of severe hypoglycemia or advanced complications
• Monitor HbA1c every 3-6 months to assess medication adherence and adjust therapy 1

Medication Management

First-Line Therapy

• Metformin is the preferred initial pharmacologic agent for type 2 diabetes 2, 1
• Start at diagnosis unless contraindicated
• Contraindications include eGFR <30 ml/min/1.73m², active liver disease, or risk of lactic acidosis

Second-Line Therapy (Based on Comorbidities)

• For patients with heart failure or chronic kidney disease: Add SGLT-2 inhibitors 1
• For patients with increased stroke risk or weight loss goals: Add GLP-1 receptor agonists 1
• When adding these medications results in adequate glycemic control, reduce or discontinue sulfonylureas or long-acting insulins to decrease hypoglycemia risk 1

Insulin Therapy

• Consider for patients with severe hyperglycemia (A1C ≥10-12%, blood glucose ≥300-350 mg/dL)
• Begin with basal insulin (0.1-0.2 units/kg/day) 1
• Adjust based on blood glucose monitoring results

Lifestyle Management

Nutrition Therapy

• Individualized medical nutrition therapy program, preferably provided by a registered dietitian 2
• Diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts 1
• Reduce intake of processed meats, refined carbohydrates, and sweetened beverages 1
• Protein intake of 0.8 g/kg/day for patients not on dialysis 1
• Sodium intake less than 2g per day 1
• Target initial weight loss of 7% of baseline weight 1

Physical Activity

• At least 150 minutes of moderate-intensity aerobic activity per week 2, 1
• Resistance training at least twice per week 2, 3
• Reduce sedentary time with frequent activity breaks 3
• Consider afternoon or post-meal exercise for better glycemic benefits 4

Self-Management Education

• All patients should participate in diabetes self-management education and support 2
• Focus on problem-solving skills for all aspects of diabetes management 2
• Structured educational program to empower patients 1

Special Considerations

Hypoglycemia Management

• Hypoglycemia (plasma glucose <70 mg/dL) is a major limiting factor in glycemic management 2
• Treat with 15-20g of rapid-acting glucose and confirm reversal with blood glucose monitoring after 15 minutes 2
• For patients with hypoglycemia unawareness, consider increasing glycemic targets temporarily 2
• Prescribe glucagon for patients at risk for severe hypoglycemia 2

Cardiovascular and Renal Protection

• Use ACE inhibitors or ARBs for patients with hypertension and albuminuria 1
• Statin therapy recommended for all patients with diabetes 1
• SGLT2 inhibitors provide kidney protection and should be prioritized 1
• Adjust medication doses based on eGFR and monitor renal function regularly 1

Team-Based Care

• Patients should receive care from a collaborative, interdisciplinary team 2
• Team may include physicians, nurse practitioners, physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals 2
• Use patient-centered communication that elicits patient preferences and assesses potential barriers to care 2

Common Pitfalls and How to Avoid Them

1. Therapeutic Inertia: Regularly assess treatment efficacy and intensify therapy when needed to avoid clinical inertia 2

2. Hypoglycemia Risk: When adding medications that improve glycemic control, reduce doses of sulfonylureas or insulin to prevent hypoglycemia 1

3. Medication Side Effects: Monitor for side effects of medications, particularly:

   • Metformin: GI side effects, vitamin B12 deficiency
   • SGLT-2 inhibitors: Genital infections, volume depletion, diabetic ketoacidosis
   • GLP-1 receptor agonists: Nausea, vomiting, pancreatitis

4. Overlooking Comorbidities: Regularly screen for and manage diabetes-related complications including retinopathy, nephropathy, neuropathy, and cardiovascular disease 2

5. Inadequate Self-Management Support: Ensure patients have the knowledge and tools needed for effective self-management, including blood glucose monitoring, medication administration, and recognition of hypo/hyperglycemia 2

By following these comprehensive guidelines, healthcare providers can optimize diabetes management, reduce complications, and improve quality of life for patients with diabetes.