What is the recommended protocol for managing diabetes?

Comprehensive Diabetes Management Protocol

The recommended protocol for managing diabetes requires a structured approach focusing on glycemic control, lifestyle modifications, medication management, and regular monitoring to reduce morbidity and mortality while improving quality of life.

Diagnosis and Classification

• Accurately diagnose diabetes type using the AABBCC approach: Age, Autoimmunity, Body habitus, Background, Control, and Comorbidities 1
• Perform initial laboratory evaluation including A1C, fasting lipid profile, microalbuminuria testing, serum creatinine, and TSH 2

Glycemic Targets

• Target A1C <7.0% for most patients 2
• Target preprandial plasma glucose: 90-130 mg/dl (5.0-7.2 mmol/l) 2
• Target postprandial plasma glucose: <180 mg/dl (<10.0 mmol/l) 2
• Individualize targets based on:
  • Risk of hypoglycemia
  • Disease duration
  • Life expectancy
  • Comorbidities
  • Patient preferences 1

Medication Management

Type 1 Diabetes

• Initiate insulin therapy immediately upon diagnosis 1
• Use multiple-dose insulin injections (≥3 injections per day) or continuous subcutaneous insulin infusion 2
• Use insulin analogues to reduce hypoglycemia risk 2
• Educate on matching prandial insulin doses to carbohydrate intake, preprandial glucose levels, and anticipated activity 2

Type 2 Diabetes

• Start with metformin as first-line therapy if not contraindicated 2, 3
• If glycemic targets not met after 3-6 months, add a second agent based on patient factors 1
• Consider GLP-1 receptor agonists or SGLT-2 inhibitors for patients with established cardiovascular disease 1
• For patients requiring insulin, begin with basal insulin and add prandial insulin as needed 1
• Monitor for medication side effects:
  • Metformin: GI side effects, vitamin B12 deficiency, lactic acidosis risk 3
  • Pioglitazone: fluid retention, heart failure risk, weight gain 4

Lifestyle Management

Medical Nutrition Therapy

• Provide individualized medical nutrition therapy by a registered dietitian 2
• No ideal percentage of calories from carbohydrates, protein, or fat exists 2
• Focus on:
  • Non-starchy vegetables
  • Whole fruits
  • Legumes
  • Whole grains
  • Nuts and seeds
  • Low-fat dairy products 2
• Minimize consumption of:
  • Red meat
  • Sugar-sweetened beverages
  • Sweets
  • Refined grains
  • Processed foods 2

Physical Activity

• Prescribe at least 150 minutes of moderate-intensity aerobic activity weekly, spread over at least 3 days with no more than 2 consecutive days without exercise 2
• Include resistance training at least twice per week 2
• Reduce sedentary time 2
• Adjust insulin or carbohydrate intake for exercise to prevent hypoglycemia 2

Monitoring

• Monitor A1C at least twice yearly for stable patients, quarterly for those not meeting glycemic targets or after therapy changes 2, 1
• Self-monitoring of blood glucose (SMBG) for patients on insulin or medications with hypoglycemia risk 2
• For type 1 diabetes, monitor at least 3 times daily 2
• For type 2 diabetes, frequency should be sufficient to help achieve glycemic goals 2
• Regular monitoring of blood pressure, lipids, weight, and kidney function 2

Hypoglycemia Management

• Treat hypoglycemia with 15-20g of glucose (preferred) or any form of carbohydrate containing glucose 2
• Recheck blood glucose after 15 minutes; repeat treatment if hypoglycemia persists 2
• Once blood glucose returns to normal, have the patient consume a meal or snack to prevent recurrence 2
• Prescribe glucagon for all individuals at significant risk of severe hypoglycemia 2
• For patients with hypoglycemia unawareness, raise glycemic targets temporarily to reverse the condition 2

Cardiovascular Risk Management

• Target blood pressure <130/80 mmHg 2
• Target LDL cholesterol <100 mg/dl 2
• Target triglycerides <150 mg/dl 2
• Target HDL >40 mg/dl (>50 mg/dl for women) 2
• Use ACE inhibitors or ARBs for hypertension management 1
• Prescribe statins for most persons with diabetes aged 40 years or older 1

Diabetes Self-Management Education

• Provide diabetes self-management education at diagnosis, annually, with changes in health status, and during transitions of care 1
• Focus on:
  • Medication management
  • Blood glucose monitoring
  • Meal planning
  • Physical activity
  • Hypoglycemia prevention and treatment
  • Sick day management 2

Complications Screening and Management

• Annual comprehensive foot examination
• Annual dilated eye examination
• Annual screening for albuminuria
• Regular assessment of cardiovascular risk factors
• Monitor for diabetes distress and depression 2

Special Considerations

• Adjust treatment regimen during illness or stress
• Modify approach for elderly patients or those with limited life expectancy
• Consider more intensive monitoring during pregnancy 1

By following this comprehensive protocol, healthcare providers can effectively manage diabetes, reduce the risk of complications, and improve patients' quality of life and long-term outcomes.