What are the guidelines for managing Diabetes Mellitus (DM)?

Guidelines for Managing Diabetes Mellitus

The management of Diabetes Mellitus (DM) should follow a comprehensive approach focusing on lifestyle modifications, glycemic control, cardiovascular risk reduction, and regular screening for complications to reduce morbidity and mortality and improve quality of life. 1, 2

Initial Assessment and Treatment Approach

• For newly diagnosed type 2 diabetes patients with high blood sugar levels or poor glucose control, initiate insulin therapy immediately 2
• For patients with ketosis, diabetic ketoacidosis, or when distinction between type 1 and type 2 diabetes is unclear, insulin therapy should be started immediately 2
• For most newly diagnosed type 2 diabetes patients, metformin should be started as first-line therapy alongside lifestyle modifications 2, 3
• Assess cardiovascular risk factors including hypertension, dyslipidemia, and microalbuminuria to guide comprehensive management 1, 2

Glycemic Control Targets

• Target HbA1c <7.0% (53 mmol/mol) to decrease microvascular complications in most patients with DM 1
• Individualize HbA1c targets according to:
  • Duration of diabetes
  • Age and comorbidities
  • Risk of hypoglycemia 1
• For older adults (>65 years), less stringent glycemic targets may be appropriate based on functional status and life expectancy 1
• Avoid hypoglycemia, especially in elderly patients or those with cardiovascular disease 1

Monitoring Protocol

• Monitor HbA1c every 3 months until target is reached, then at least twice yearly 2
• Recommend self-monitoring of blood glucose for patients on insulin, those at risk for hypoglycemia, or when treatment regimens are changing 1, 2
• Regularly assess technique if patients self-monitor blood glucose levels 1

Lifestyle Modifications

Physical Activity

• Prescribe at least 150 minutes per week of moderate-intensity aerobic physical activity, spread over at least 3 days per week with no more than 2 consecutive days without activity 1, 2
• Recommend a combination of aerobic and resistance exercise for optimal glycemic control 1, 4
• Reduce sedentary time by breaking up periods of sedentary activity with moderate-to-vigorous physical activity 1, 4

Nutrition

• Recommend reduced calorie intake for lowering excessive body weight in individuals with DM 1, 2
• Consider a Mediterranean diet pattern, which has been associated with an 11% decreased risk of developing T2DM with high adherence 5
• Individualize meal planning based on personal preferences, cultural practices, and comorbidities 1
• Commonly stated weight loss goal for obese patients with DM is 5% of baseline weight 1, 6

Other Lifestyle Factors

• Recommend smoking cessation with structured advice for all individuals with DM 1
• Evaluate sleep patterns and identify sleep disorders that may affect glycemic control 4
• Address stress management and promote social connections as part of comprehensive care 4

Cardiovascular Risk Management

Blood Pressure Control

• Target office BP to systolic BP (SBP) of 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg 1
• For older people (aged >65 years), target SBP to a range of 130-139 mmHg 1
• Target diastolic BP to <80 mmHg, but not <70 mmHg 1
• Recommend lifestyle changes (weight loss if overweight, physical activity, alcohol restriction, sodium restriction, increased consumption of fruits, vegetables, and low-fat dairy products) 1
• Initiate treatment with a RAAS blocker (ACEI or ARB) in combination with a calcium channel blocker or a thiazide/thiazide-like diuretic 1

Lipid Management

• For patients with T2DM at very high CV risk, target LDL-C <1.4 mmol/L (<55 mg/dL) and LDL-C reduction of at least 50% 1
• Statins are the first-choice lipid-lowering treatment in patients with DM and high LDL-C levels 1
• For patients with T2DM, a secondary goal of non-HDL-C target of <2.2 mmol/L (<85 mg/dL) in very high-CV risk patients and <2.6 mmol/L (<100 mg/dL) in high-CV risk patients is recommended 1

Screening for Complications

Nephropathy

• Perform routine assessment of microalbuminuria to identify patients at risk of developing renal dysfunction or at high risk of future CVD 1
• Test for the presence of albuminuria at diagnosis of type 2 DM and annually thereafter if previously negative 1

Retinopathy

• Conduct regular eye examinations, with frequency determined by risk factors and previous findings 1

Foot Care

• Perform careful foot examination at least annually to check skin integrity and determine whether there is loss of sensation or decreased perfusion 1
• Educate patients and caregivers about risk factors for foot ulcers and amputation 1

Treatment Intensification Algorithm

• If metformin monotherapy is insufficient, consider adding a second agent based on patient-specific factors 2
• For patients with established cardiovascular disease or risk factors, consider SGLT-2 inhibitors or GLP-1 receptor agonists as second-line therapy 2
• For patients requiring third-line therapy, add an agent from a different class 2
• Consider insulin therapy when oral medications fail to achieve glycemic targets 2, 6

Special Considerations for Older Adults

• Evaluate for depression during the initial evaluation period and if there is any unexplained decline in clinical status 1
• Provide education about medications, including purpose, administration, side effects, and important adverse reactions 1
• For older adults with DM who smoke, assess readiness to quit and offer counseling and pharmacologic interventions 1

Patient Education and Support

• Provide diabetes self-management education and support (DSME/S) to patients and, if appropriate, family members and caregivers 1
• Educate patients about their medications, including purpose, administration, side effects, and important adverse reactions 1
• Promote peer/familial support and social connections to improve adherence to lifestyle changes 4