What are the guidelines for managing diabetes?

Guidelines for Managing Diabetes

The management of diabetes requires a comprehensive, patient-centered approach that includes a multidisciplinary team, individualized glycemic targets, lifestyle modifications, appropriate pharmacologic therapy, and regular screening for complications to optimize morbidity, mortality, and quality of life outcomes. 1

Initial Evaluation and Assessment

• A complete medical evaluation should be performed at diagnosis to classify diabetes, detect complications, review previous treatment, and establish a management plan 1, 2
• Laboratory tests should include HbA1c, fasting glucose, lipid profile, kidney function tests, and urine albumin-to-creatinine ratio 1
• Screen for autoimmune conditions in type 1 diabetes (thyroid dysfunction, celiac disease) 2
• Assess for comorbidities including obesity, hypertension, dyslipidemia, and existing microvascular complications 1

Team-Based Care Approach

• Diabetes care should be managed by a multidisciplinary team including physicians, nurse practitioners, nurses, dietitians, pharmacists, and mental health professionals 1, 2
• The management plan should be written with input from the patient, family, physician, and other healthcare team members 2, 1
• Implement shared decision-making to improve treatment adherence, patient satisfaction, and clinical outcomes 2

Glycemic Targets and Monitoring

• Set individualized HbA1c targets based on patient's age, comorbidities, risk of hypoglycemia, and life expectancy 1
• The proportion of people with diabetes who achieve recommended A1C, blood pressure, and LDL cholesterol levels has fluctuated over the years, with only 23% meeting all three targets while avoiding smoking 2
• Regular HbA1c testing (typically every 3-6 months) is recommended to assess long-term glycemic control 1, 3

Lifestyle Management

Nutrition

• Implement medical nutrition therapy with individualized meal planning 1, 2
• No ideal percentage of calories from carbohydrate, protein, and fat exists for all people with diabetes; macronutrient distribution should be based on individualized assessment 2
• Various eating patterns can be effective, including Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate patterns 2

Physical Activity

• Encourage 30-60 minutes of moderate aerobic activity daily, at least 5 days per week 2
• Consider adding resistance training twice weekly 2
• Physical activity can reduce HbA1c by 0.4-1.0% and improve cardiovascular risk factors 4

Weight Management

• For overweight/obese patients, prescribe high-intensity diet, physical activity, and behavioral therapy designed to achieve ≥5% weight loss 1
• Recommend 500-750 kcal/day energy deficit to promote weight loss 1

Diabetes Self-Management Education and Support (DSMES)

• Provide DSMES to all patients at diagnosis and at critical points throughout their care 5
• Education should focus on helping patients make informed self-management choices rather than simply providing information 5
• Include essential content on hypoglycemia/hyperglycemia recognition and treatment, medication administration, blood glucose monitoring, and nutritional management 5

Pharmacologic Therapy

Initial Therapy

• Initiate pharmacologic therapy at diagnosis of type 2 diabetes, in addition to lifestyle therapy 1
• For metabolically stable patients (HbA1c <8.5% and asymptomatic), metformin is the initial treatment of choice if renal function is adequate (>30 ml/min/1.73 m²) 1, 6
• For patients with marked hyperglycemia (blood glucose ≥250 mg/dL, HbA1c ≥8.5%) who are symptomatic, consider initiating basal insulin while starting metformin 1

Medication Selection

• For patients with cardiovascular or kidney comorbidities or at high cardiovascular risk, consider early treatment with SGLT2 inhibitors and/or GLP-1 receptor agonists 4
• Thiazolidinediones like pioglitazone can be used as an adjunct to diet and exercise to improve glycemic control 3
• Adjust treatment based on clinical outcomes, patient preferences, and development of complications 1

Cardiovascular Risk Factor Management

• Blood pressure control is recommended (target <140/90 mmHg or <130/80 mmHg for individuals with chronic kidney disease or diabetes) 2
• Initiate blood pressure medication as tolerated, treating initially with beta blockers and/or ACE inhibitors 2
• Manage lipid abnormalities aggressively, particularly in patients with cardiovascular disease 2
• Recommend smoking cessation and avoidance of environmental tobacco smoke 2

Complication Screening and Prevention

• Conduct regular screening for microvascular complications, including annual comprehensive eye examination, screening for diabetic kidney disease, and comprehensive foot examination 1
• Screen for and treat modifiable cardiovascular risk factors 1
• Provide all age-appropriate vaccinations 1

Common Pitfalls and Considerations

• Patient adherence to complex regimens may be challenging; simplify when possible and address barriers to care 1
• Consider social determinants of health that may impact a patient's ability to follow treatment recommendations 1
• Metformin can cause an unpleasant metallic taste when starting the medication, but this typically resolves quickly 6
• Monitor for hypoglycemia, especially when using insulin or insulin secretagogues 6
• Monitor liver function before and periodically during treatment with thiazolidinediones like pioglitazone 3