What are the latest guidelines for managing diabetes?

Latest Diabetes Management Guidelines

Metformin should be used as first-line pharmacological therapy for most adults with type 2 diabetes, along with lifestyle interventions, with a starting dose of 500 mg daily gradually increased to a target maximum dose of 2000 mg daily in divided doses. 1

Diagnosis and Screening

• Fasting glucose should be measured in venous plasma when used to establish the diagnosis of diabetes, with a value >7.0 mmol/L (>126 mg/dL) diagnostic of diabetes 2
• Screening by HbA1c, fasting plasma glucose (FPG), or 2-h oral glucose tolerance test is recommended for individuals at high risk of diabetes 2
• To minimize glycolysis in blood samples, use tubes containing glycolytic inhibitors such as citrate buffer or place samples immediately in an ice-water slurry 2

Glycemic Monitoring and Targets

• HbA1c should be used to monitor glycemic control in patients with diabetes and chronic kidney disease (CKD) 2
• Monitor HbA1c twice per year for stable patients, and up to 4 times per year if glycemic targets aren't met or after changing therapy 2
• Note that HbA1c measurement accuracy declines with advanced CKD (G4-G5), particularly in dialysis patients 2
• For patients where HbA1c may be unreliable, continuous glucose monitoring (CGM) metrics such as glucose management indicator (GMI) can be used 2
• Individualize HbA1c targets based on risk of complications, comorbidities, life expectancy, and patient preferences, with a general target of <7% for most patients 1

Lifestyle Management

• Implement a structured self-management educational program for all patients with diabetes 2
• Engage in at least 150 minutes of moderate-intensity aerobic activity weekly, spread over at least 3 days 1
• Perform 2-3 sessions of resistance exercise per week on non-consecutive days 1
• Break up prolonged sitting every 30 minutes with brief activity 1
• For patients with diabetes and CKD, consume an individualized diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts; and lower in processed meats, refined carbohydrates, and sweetened beverages 2
• Maintain protein intake of 0.8 g protein/kg/day for those with diabetes and CKD not treated with dialysis 2
• For patients on hemodialysis or peritoneal dialysis, consume between 1.0 and 1.2 g protein/kg/day 2
• Limit sodium intake to <2 g per day (or <5 g sodium chloride) in patients with diabetes and CKD 2

Pharmacological Therapy Algorithm

First-Line Therapy

• Metformin is the first-line foundation therapy for most adults with T2DM 1, 2
  • Start with low dose (500 mg daily) and gradually increase by 500 mg every 1-2 weeks
  • Target maximum dose of 2000 mg daily in divided doses
  • Monitor for gastrointestinal side effects
  • Contraindicated in renal insufficiency (eGFR <45 mL/min/1.73m²), liver dysfunction, severe infection, hypoxia

Second-Line Therapy (if metformin alone is insufficient)

• For patients with established cardiovascular disease or high CV risk:

  • Add a GLP-1 receptor agonist or SGLT-2 inhibitor with proven cardiovascular benefit 2, 1

• For patients with heart failure or chronic kidney disease:

  • Add an SGLT-2 inhibitor with proven cardiorenal protection benefits 1

• For patients without specific comorbidities:

  • Consider GLP-1 receptor agonists (preferred over sulfonylureas due to cardiovascular benefits and weight reduction) 1
  • DPP-4 inhibitors if SGLT-2 inhibitors or GLP-1 receptor agonists are not appropriate (weight neutral with low hypoglycemia risk) 1
  • Sulfonylureas are effective but have increased hypoglycemia risk and weight gain 1

Insulin Therapy

• Initiate insulin when:
  • Random blood glucose ≥250 mg/dL
  • HbA1c >9%
  • Patient is ketotic or in diabetic ketoacidosis
  • Distinction between T1DM and T2DM is unclear 1
• Consider basal insulin if HbA1c remains >9% despite oral agents 1
• When adding insulin to patients on SGLT2 inhibitors, consider reducing insulin dose to prevent hypoglycemia 2

Cardiovascular Risk Management

• Patients with diabetes and hypertension should have a blood pressure treatment goal of <140/90 mm Hg 2
• Pharmacologic therapy for hypertension should include either an ACE inhibitor or an ARB (but not both) 2
• Use only one agent at a time to block the renin-angiotensin system (RAS) 2
• Statin therapy is recommended for most persons with diabetes aged 40 years or older 2
• Advise patients with diabetes and CKD who use tobacco to quit using tobacco products 2

Special Populations

Older Adults

• For end-of-life care, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate 2
• Intensity of lipid management can be relaxed in palliative care settings 2
• Primary goals for diabetes management at the end of life are overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity 2

Patients with CKD

• Reduce the dose or discontinue ACEi or ARB therapy in the setting of symptomatic hypotension, uncontrolled hyperkalemia, or to reduce uremic symptoms while treating kidney failure 2
• Mineralocorticoid receptor antagonists are effective for refractory hypertension but may cause hyperkalemia or reversible decline in GFR, particularly in patients with low eGFR 2

Monitoring and Follow-up

• Check HbA1c every 3 months and intensify treatment if glycemic targets not met 1
• Monitor finger-stick blood glucose in patients taking insulin or medications with hypoglycemia risk 1
• For patients on SGLT2 inhibitors, monitor for volume depletion, especially if also on diuretics 2
• Monitor renal function regularly, especially with SGLT2 inhibitors and metformin 1

Common Pitfalls and Caveats

• SGLT2 inhibitors may cause an initial modest reduction in eGFR that is hemodynamic and reversible; this is generally not a reason to discontinue therapy 2
• When using insulin, be aware of the risk of medication errors between different insulin products; always check the insulin label before each injection 3, 4
• Early warning symptoms of hypoglycemia may be different or less pronounced in patients with long duration of diabetes, diabetic nerve disease, or use of medications such as beta-blockers 5
• For patients with type 2 diabetes who choose not to do daily glycemic monitoring, antihyperglycemic agents with lower risk of hypoglycemia are preferred 2