What are the management strategies for diabetes based on recent findings?

Comprehensive Management Strategies for Diabetes Based on Recent Findings

Patient-centered care using evidence-based guidelines and a team-based approach is the cornerstone of effective diabetes management to reduce morbidity, mortality, and improve quality of life. 1

Core Management Principles

Patient-Centered Approach

• Implement a patient-centered communication style that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care 1
• Treatment decisions should be timely, evidence-based, and tailored to individual patient preferences, prognoses, and comorbidities 1
• Care should align with components of the Chronic Care Model to ensure productive interactions between a prepared proactive practice team and an informed activated patient 1

Team-Based Care

• Utilize a collaborative, integrated team with expertise in diabetes including physicians, nurse practitioners, physician assistants, nurses, dietitians, pharmacists, and mental health professionals 1
• When feasible, care systems should support team-based care, community involvement, patient registries, and decision support tools 1
• The Chronic Care Model has been shown to reduce cardiovascular disease risk by 56.6%, microvascular complications by 11.9%, and mortality by 66.1% 1

Diabetes Self-Management Education and Support

• All patients should participate in diabetes self-management education and support (DSME) 1
• DSME should include problem-solving skills for all aspects of diabetes management 1
• An individualized medical nutrition therapy program, preferably provided by a registered dietitian, is recommended for all persons with diabetes 1
• Physical activity recommendations include at least 150 minutes of moderate-intensity aerobic activity per week, reduced sedentary time, and resistance training at least twice per week 1

Pharmacological Management

Type 1 Diabetes

• Most patients with T1DM should be treated with multiple-dose insulin injections or continuous subcutaneous insulin injection 1
• Insulin analogues should be used to reduce hypoglycemia risk 1
• Continuous glucose monitoring systems significantly reduce severe hypoglycemia risk 1
• Insulin pump therapy with low glucose suspend features can reduce nocturnal hypoglycemia without increasing HbA1c levels 1

Type 2 Diabetes

• Initial therapy algorithm:

  1. Begin with lifestyle modifications (diet, physical activity, weight management) 1
  2. If lifestyle efforts are insufficient, metformin is the preferred initial pharmacologic agent if not contraindicated 1
  3. Metformin can be continued in patients with declining renal function down to a GFR of 30-45 mL/min (with dose reduction) 1

• Combination therapy algorithm:

  1. When monotherapy doesn't achieve HbA1c target over 3 months, add a second agent 1
  2. Consider combining metformin with one of: sulfonylureas, thiazolidinediones, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 agonists, or basal insulin 1
  3. Selection should consider efficacy, cost, side effects (including weight effects), comorbidities, hypoglycemia risk, and patient preferences 1

Special Populations - Children with Type 2 Diabetes

• Insulin therapy must be initiated for children with T2DM who are ketotic, in diabetic ketoacidosis, or when the distinction between type 1 and 2 diabetes is unclear 1
• Insulin should be initiated when random blood glucose ≥250 mg/dL or HbA1c >9% 1
• In all other cases, initiate lifestyle modification program and metformin as first-line therapy 1

Glycemic Monitoring and Targets

• Regular monitoring of HbA1c is essential for evaluating long-term glycemic control 2
• Continuous glucose monitoring and time in range metrics are increasingly important for comprehensive assessment 3
• Glycemic targets should be individualized based on:
  • Duration of diabetes
  • Age/life expectancy
  • Comorbid conditions
  • Known cardiovascular disease
  • Hypoglycemia unawareness
  • Individual patient considerations 1

Managing Complications and Comorbidities

• Regularly screen for diabetes complications including retinopathy, nephropathy, neuropathy, and cardiovascular disease 1
• Consider screening patients with type 1 diabetes for autoimmune diseases (thyroid dysfunction, celiac disease) 1
• Patients with diabetes should undergo recommended age- and sex-appropriate cancer screenings 1
• For hospitalized patients, blood glucose targets of 7.8-10 mmol/L (140-180 mg/dL) are recommended for most patients 1

Hypoglycemia Management

• Hypoglycemia may be reversed with 15-20g of rapid-acting glucose 1
• Blood glucose should be rechecked after 15 minutes; if hypoglycemia persists, repeat treatment 1
• For patients with hypoglycemia unawareness, glycemic targets should be temporarily increased to help reverse the condition 1
• Severe or frequent hypoglycemia is an absolute indication for modification of treatment regimens 1

Common Pitfalls and Caveats

• Avoid therapeutic inertia - prioritize timely and appropriate intensification of therapy when targets aren't met 1
• Avoid sole use of sliding-scale insulin in hospitalized patients - this approach is strongly discouraged 1
• Recognize that metformin rarely causes hypoglycemia by itself, but risk increases with alcohol consumption or when combined with other glucose-lowering medications 4
• Be vigilant about hypoglycemia in patients with advanced disease; don't aggressively pursue near-normal HbA1c levels in patients where such targets cannot be safely achieved 1
• When transitioning from intravenous to subcutaneous insulin in hospitalized patients, overlap timing is critical to prevent hyperglycemia 1