What is the recommended management plan for individuals with diabetes?

Recommended Management Plan for Diabetes

Diabetes management requires a multidisciplinary team approach with patient-centered care, combining comprehensive initial evaluation, individualized glycemic targets, lifestyle interventions (medical nutrition therapy and ≥150 minutes weekly of moderate-intensity exercise), pharmacologic therapy (metformin first-line for type 2 diabetes, multiple-dose insulin for type 1 diabetes), cardiovascular risk factor management, and regular complication screening. 1, 2, 3

Initial Comprehensive Medical Evaluation

At the initial visit, perform a complete medical evaluation to classify diabetes type, detect existing complications, review previous treatments, and establish a management plan. 1, 2, 3

Essential Components of Initial Assessment:

• Medical history: Document age and characteristics of diabetes onset (DKA, asymptomatic finding), eating patterns, physical activity habits, weight history, growth/development in children, presence of comorbidities, psychosocial problems, dental disease, and diabetes education history 1

• Treatment review: Assess previous regimens and response to therapy (A1C records), current medications and adherence barriers, meal plan, physical activity patterns, glucose monitoring results and patient's use of data 1

• Complication history: Evaluate DKA frequency/severity/cause, hypoglycemic episodes and awareness, severe hypoglycemia frequency/cause, and history of diabetes-related complications 1

• Microvascular complications: Screen for retinopathy, nephropathy, neuropathy (sensory including foot lesions; autonomic including sexual dysfunction and gastroparesis) 1

• Macrovascular complications: Assess for coronary heart disease, cerebrovascular disease, and peripheral arterial disease 1

Laboratory Testing:

• Obtain HbA1c, fasting glucose, lipid profile, kidney function tests, and urine albumin-to-creatinine ratio 3

• Screen for autoimmune conditions in type 1 diabetes: thyroid dysfunction and celiac disease 1, 2, 3

• Assess comorbidities: obesity, hypertension, dyslipidemia, and existing microvascular complications 2, 3

Team-Based Collaborative Care Model

Assemble a multidisciplinary team including physicians, nurse practitioners, physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals. 1, 2, 3

• The management plan must be written collaboratively with input from the patient, family, physician, and healthcare team members 1, 3

• Use patient-centered communication with person-centered and strength-based language, active listening, and assessment of patient preferences, beliefs, literacy, numeracy, and barriers to care 1

• Individualize treatment goals and plans based on patient's age, cognitive abilities, school/work schedule, health beliefs, support systems, eating patterns, physical activity, social situation, financial concerns, cultural factors, literacy/numeracy, diabetes complications and duration, comorbidities, health priorities, other medical conditions, preferences for care, and life expectancy 1

Glycemic Targets and Monitoring

• Set individualized HbA1c targets based on patient's age, comorbidities, risk of hypoglycemia, and life expectancy 2, 3

• Perform HbA1c testing every 3-6 months to assess long-term glycemic control 2, 3

• Regular blood glucose testing is essential for prevention and management of hypoglycemia 4

Lifestyle Management

Medical Nutrition Therapy:

• Implement individualized meal planning with no single ideal macronutrient distribution—tailor carbohydrate, protein, and fat percentages based on individual assessment 2, 3

• Effective eating patterns include Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate patterns 2, 3

• For weight loss (if indicated), reduce saturated fat, trans fat, and cholesterol while increasing ω-3 fatty acids, viscous fiber, and plant stanols/sterols 2

Physical Activity:

• Prescribe at least 150 minutes of moderate-intensity aerobic activity per week, reduced sedentary time, and resistance training at least twice weekly 2

• Alternative recommendation: 30-60 minutes of moderate aerobic activity daily, at least 5 days per week, with resistance training twice weekly 3

Weight Management:

• For overweight/obese patients, prescribe high-intensity diet, physical activity, and behavioral therapy designed to achieve ≥5% weight loss 2, 3

• Recommend 500-750 kcal/day energy deficit to promote weight loss 2, 3

Pharmacologic Therapy

Type 1 Diabetes:

• Treat most patients with multiple-dose insulin injections (3-4 injections daily) or continuous subcutaneous insulin infusion 2

• Use insulin analogues to reduce hypoglycemia risk 2

• Educate patients 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, in addition to lifestyle therapy 2, 3

• Metformin is the preferred initial pharmacologic agent if renal function is adequate 2, 3

• When monotherapy with a noninsulin agent at maximum tolerated dose does not achieve or maintain blood glucose target over 3 months, add a second agent 2

• Consider patient factors when selecting medications: efficacy, cost, potential side effects, weight effects, comorbidities, and hypoglycemia risk 2

Cardiovascular Risk Factor Management

Blood Pressure Control:

• Target blood pressure <140/90 mmHg (or <130/80 mmHg for individuals with chronic kidney disease or diabetes) 2, 3

• Lifestyle therapy: weight loss, reduced-sodium diet, moderate alcohol intake, and increased physical activity 2

• Pharmacologic therapy: include either an ACE inhibitor or ARB (but not both) 2

• For patients with cardiovascular disease, initiate blood pressure medication as tolerated, treating initially with beta blockers and/or ACE inhibitors 3

Lipid Management:

• Statin use is recommended for most persons with diabetes aged 40 years or older 2

• Recommend lifestyle modification to improve lipid profile 2

• Statin intensity should be based on patient's risk profile in addition to intensive lifestyle therapy 2

• Manage lipid abnormalities aggressively, particularly in patients with cardiovascular disease 3

Hypoglycemia Management and Prevention

• Reverse hypoglycemia with administration of 15-20g of rapid-acting glucose 2

• Educate patients on situations that increase hypoglycemia risk: fasting for tests/procedures, during or after exercise, and during sleep 2

• For patients at higher risk for hypoglycemia and those with reduced symptomatic awareness, increase frequency of blood glucose monitoring 4

• The long-acting effect of insulin glargine may delay recovery from hypoglycemia 4

• Risk factors for hypoglycemia include changes in meal pattern, changes in physical activity level, changes to concomitant drugs, renal or hepatic impairment 4

Medication Error Prevention:

• Instruct patients to always check the insulin label before each injection to avoid accidental mix-ups among insulin products 4

• Do not mix insulin detemir with other insulin preparations 5

• Do not mix or dilute insulin glargine with any other insulin preparations 4

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 various strategies and techniques to support patients' self-management efforts, including education on problem-solving skills for all aspects of diabetes management 1

• Use a nonjudgmental approach that normalizes periodic lapses in self-management to minimize patients' resistance to reporting problems 1

Complication Screening and Prevention

• Conduct annual comprehensive eye examination 2, 3

• Screen for diabetic kidney disease regularly 2, 3

• Perform comprehensive foot examination 2, 3

• Screen for and treat modifiable cardiovascular risk factors 2, 3

• Provide all age-appropriate vaccinations 2, 3

Special Considerations

Injection Site Management:

• Continuously rotate injection sites within a given area to reduce or prevent lipodystrophy and localized cutaneous amyloidosis 5

• Repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis can result in hyperglycemia; sudden change to unaffected area can result in hypoglycemia 4

Renal and Hepatic Impairment:

• Insulin requirements may need adjustment in patients with renal or hepatic impairment, who are at higher risk of hypoglycemia 4, 5

Concomitant PPAR-gamma Agonists:

• Observe patients treated with insulin and a PPAR-gamma agonist (thiazolidinediones) for signs and symptoms of heart failure due to dose-related fluid retention 4

• If heart failure develops, manage according to current standards and consider discontinuation or dose reduction of the PPAR-gamma agonist 4

Hypokalemia Monitoring:

• Monitor potassium levels in patients at risk for hypokalemia (e.g., patients using potassium-lowering medications, patients taking medications sensitive to serum potassium concentrations), as all insulins cause a shift in potassium from extracellular to intracellular space 4