What are the guidelines for managing diabetes?

Guidelines for Managing Diabetes

The comprehensive management of diabetes requires a multidisciplinary team approach including physicians, nurses, dietitians, pharmacists, and mental health professionals, with individualized treatment plans based on patient factors and comorbidities. 1, 2

Initial Assessment and Evaluation

• Complete medical evaluation should classify diabetes type, detect complications, review previous treatment, and establish a management plan 1, 3
• Laboratory tests should include HbA1c, fasting glucose, lipid profile, kidney function tests, and urine albumin-to-creatinine ratio 1, 3
• Assess for comorbidities including obesity, hypertension, dyslipidemia, and existing microvascular complications 1, 2
• Screen for autoimmune conditions in type 1 diabetes, such as thyroid dysfunction and celiac disease 2, 3

Glycemic Targets and Monitoring

• Set individualized HbA1c targets based on patient's age, comorbidities, risk of hypoglycemia, and life expectancy 1, 2
• Regular HbA1c testing (typically every 3-6 months) to assess long-term glycemic control 1, 3
• Implement self-monitoring of blood glucose (SMBG) appropriate to medication regimen 1
• Only 23% of people with diabetes achieve recommended A1C, blood pressure, and LDL cholesterol levels while avoiding smoking 3

Lifestyle Management

Nutrition

• Implement medical nutrition therapy with individualized meal planning 1, 2, 3
• No single ideal macronutrient distribution exists for all people with diabetes; distribution should be based on individualized assessment 2, 3
• Various eating patterns can be effective, including Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate patterns 2, 3
• For weight loss, recommend 500-750 kcal/day energy deficit 1, 3

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, 4
• Physical activity produces multiple general and diabetes-specific health benefits, including improved insulin sensitivity and glycemic control 5
• Consider individual limitations and comorbidities when prescribing exercise regimens 6

Weight Management

• For overweight/obese patients, prescribe high-intensity diet, physical activity, and behavioral therapy designed to achieve ≥5% weight loss 1, 2, 3
• Implement long-term weight maintenance programs for patients who achieve short-term weight loss goals 1

Diabetes Self-Management Education and Support (DSMES)

• Provide DSMES to all patients at diagnosis and at critical points throughout their care 2, 3
• Education should focus on helping patients make informed self-management choices rather than simply providing information 2, 3
• Include essential content on hypoglycemia/hyperglycemia recognition and treatment, medication administration, blood glucose monitoring, and nutritional management 2, 3
• Use a patient-centered communication style that incorporates patient preferences and addresses cultural barriers to care 1, 2

Pharmacologic Therapy

Type 2 Diabetes

• Initiate pharmacologic therapy at diagnosis of type 2 diabetes, in addition to lifestyle therapy 1, 2, 3
• Metformin is the preferred initial pharmacologic agent if renal function is adequate (>30 ml/min/1.73 m²) 1, 7
• For metabolically stable patients (HbA1c <8.5% and asymptomatic), start with metformin 1
• For patients with marked hyperglycemia (blood glucose ≥250 mg/dL, HbA1c ≥8.5%) who are symptomatic, initiate basal insulin while starting metformin 1
• When monotherapy with a noninsulin agent at maximum tolerated dose does not achieve or maintain the blood glucose target over 3 months, add a second agent 2
• Consider patient factors when selecting medications, including efficacy, cost, potential side effects, weight effects, comorbidities, and risk for hypoglycemia 2

Type 1 Diabetes

• Most patients with type 1 diabetes should be treated with multiple-dose insulin injections or continuous subcutaneous insulin injection 2, 8
• Patients should use insulin analogues to reduce hypoglycemia risk 2, 8
• Patients should be educated on matching prandial insulin doses to carbohydrate intake, preprandial blood glucose levels, and anticipated activity level 2, 8

Cardiovascular Risk Factor Management

Blood Pressure Control

• Blood pressure target should be <140/90 mm Hg for most patients with diabetes 2, 3
• 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, 3

Complication Screening and Prevention

• Regular screening for microvascular complications, including annual comprehensive eye examination, screening for diabetic kidney disease, and comprehensive foot examination 1, 2, 3
• Screen for and treat modifiable cardiovascular risk factors 1, 2, 3
• Provide all age-appropriate vaccinations 1, 2, 3

Hypoglycemia Management

• Hypoglycemia may be reversed with administration of rapid-acting glucose (15-20g) 2, 8
• 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, 8
• 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 8

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
• Recognize that frequent, patient-performed blood glucose measurements are needed to achieve effective glycemic control 8
• Be aware that lifestyle interventions are the foundation of diabetes management and prevention 9, 10
• Understand that medication adjustments (including deprescribing) may be necessary as lifestyle changes take effect 9, 10