What are the recommended management strategies for diabetes?

Comprehensive Management Strategies for Diabetes

The management of diabetes requires a patient-centered, multidisciplinary team approach focusing on lifestyle modifications, pharmacological interventions, and regular monitoring to prevent complications and optimize quality of life. 1

Team-Based Care Approach

• Diabetes care should be managed by a multidisciplinary team including physicians, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals 2, 1
• Care should align with the Chronic Care Model to ensure productive interactions between a prepared proactive practice team and an informed activated patient 2
• Treatment decisions should be timely, evidence-based, and tailored to individual patient preferences, prognoses, and comorbidities 2

Initial Evaluation and Assessment

• A complete medical evaluation should classify diabetes type, detect complications, review previous treatment, and establish a management plan 1
• 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, such as thyroid dysfunction and celiac disease 1
• Assess for comorbidities including obesity, hypertension, dyslipidemia, and existing microvascular complications 1

Glycemic Targets and Monitoring

• Set individualized HbA1c targets based on patient's age, comorbidities, risk of hypoglycemia, and life expectancy 1
• Regular HbA1c testing (typically every 3-6 months) is recommended to assess long-term glycemic control 1
• Self-monitoring of blood glucose plays an essential role in the prevention and management of hypoglycemia 3
• Increased frequency of blood glucose monitoring is recommended for patients at higher risk for hypoglycemia and those with reduced symptomatic awareness 3

Lifestyle Management

Nutrition

• Implement medical nutrition therapy with individualized meal planning 1
• No ideal percentage of calories from carbohydrate, protein, and fat exists for all people with diabetes; macronutrient distribution should be based on individualized assessment 1
• Various eating patterns can be effective, including Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate patterns 1
• Focus on weight loss (if indicated) by reducing intake of saturated fat, trans fat, and cholesterol while increasing intake of ω-3 fatty acids, viscous fiber, and plant stanols or sterols 2

Physical Activity

• Encourage at least 150 minutes of moderate-intensity aerobic activity per week, reduced sedentary time, and resistance training at least twice weekly 2, 1
• Regular physical activity improves blood glucose control, reduces cardiovascular risk factors, contributes to weight loss, and improves well-being 4
• Exercise interventions should be tailored based on individual factors including residual β-cell functionality 5

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
• Lifestyle interventions focusing on weight loss have been shown to prevent or delay the onset of type 2 diabetes in high-risk individuals 4

Pharmacologic Therapy

Type 1 Diabetes

• Most patients with type 1 diabetes should be treated with multiple-dose insulin injections or continuous subcutaneous insulin injection 2
• Patients should use insulin analogues to reduce hypoglycemia risk 2
• Patients should be educated on matching prandial insulin doses to carbohydrate intake, preprandial blood glucose levels, and anticipated activity level 2

Type 2 Diabetes

• Initiate pharmacologic therapy at diagnosis of type 2 diabetes, in addition to lifestyle therapy 1
• Metformin is the preferred initial pharmacologic agent if renal function is adequate 2, 1
• When monotherapy with a noninsulin agent at maximum tolerated dose does not achieve or maintain the HbA1c target over 3 months, a second agent should be added 2
• Consider patient factors when selecting medications, including efficacy, cost, potential side effects, weight effects, comorbidities, and risk for hypoglycemia 2

Cardiovascular Risk Factor Management

Blood Pressure Control

• Patients with diabetes and hypertension should have a blood pressure treatment goal of less than 140/90 mm Hg 2
• Lifestyle therapy should consist of weight loss, reduced-sodium diet, moderate alcohol intake, and increased physical activity 2
• Pharmacologic therapy should include either an ACE inhibitor or ARB (but not both) 2

Lipid Management

• Statin use is recommended for most persons with diabetes aged 40 years or older 2
• Lifestyle modification should be recommended to improve the lipid profile 2
• In addition to intensive lifestyle therapy, statin intensity should be based on the patient's risk profile 2

Hypoglycemia Management

• Hypoglycemia is the most common adverse reaction of all insulins 3, 6
• Early warning symptoms of hypoglycemia may be different or less pronounced under certain conditions, such as long duration of diabetes, diabetic nerve disease, or use of medications like beta-blockers 6
• Hypoglycemia may be reversed with administration of rapid-acting glucose (15-20g) 2
• Patients should be educated on situations that increase their risk for hypoglycemia, such as fasting for tests or procedures, during or after exercise, and during sleep 2

Diabetes Self-Management Education and Support (DSMES)

• Provide DSMES to all patients at diagnosis and at critical points throughout their care 1
• Education should focus on helping patients make informed self-management choices rather than simply providing information 1
• Include essential content on hypoglycemia/hyperglycemia recognition and treatment, medication administration, blood glucose monitoring, and nutritional management 1
• A patient-centered communication style that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care should be used 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 Caveats

• Never share insulin pens, needles, or syringes between patients, even if the needle is changed, due to risk of blood-borne pathogen transmission 3
• Changes in insulin regimen (e.g., insulin strength, manufacturer, type, injection site, or method of administration) may affect glycemic control and predispose to hypoglycemia or hyperglycemia 3
• Repeated insulin injections into areas of lipodystrophy can result in hyperglycemia; sudden change in injection site to unaffected area may result in hypoglycemia 3
• Severe hypoglycemia can cause seizures, may lead to unconsciousness, and may be life-threatening 3
• Insulin requirements may change during intercurrent conditions such as illness, emotional disturbances, or other stresses 6