What are the current recommendations for diabetic patient management?

Current Recommendations for Diabetic Patient Management

Diabetes management requires a multidisciplinary team approach with lifestyle management as the foundation, including diabetes self-management education and support (DSMES), medical nutrition therapy, physical activity, smoking cessation, and psychosocial care, initiated at diagnosis and continued throughout all follow-up evaluations. 1

Core Management Framework

Team-Based Care Structure

• Assemble an interdisciplinary team including physicians, nurse practitioners, physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals 1, 2
• Establish a patient-centered collaborative relationship where treatment plans are formulated jointly with patients based on their preferences, values, and goals 1
• Use neutral, nonjudgmental, strength-based language that is free from stigma and fosters collaboration (e.g., "person with diabetes" rather than "diabetic") 1

Initial Comprehensive Evaluation

At the initial visit, perform a complete medical evaluation to confirm diagnosis, classify diabetes type, evaluate for complications and comorbidities, review previous treatment, and begin patient engagement in care planning. 1

Key assessment components include: 2

• Laboratory tests: blood glucose, lipid profile, kidney function, urine tests
• Screen for autoimmune conditions in type 1 diabetes (thyroid dysfunction, celiac disease)
• Assess for comorbidities: obesity, hypertension, dyslipidemia, microvascular complications
• Measure HbA1c if unavailable from prior 3 months 1

Diabetes Self-Management Education and Support (DSMES)

All people with diabetes must participate in DSMES at four critical times: at diagnosis, annually, when complicating factors arise, and when transitions in care occur. 1

• Provide education on knowledge, skills, and abilities necessary for diabetes self-care 1
• Deliver DSMES in patient-centered formats (group, individual, or technology-based) 1
• Focus on informed decision-making, self-care behaviors, problem-solving, and active collaboration with the healthcare team 1
• Measure clinical outcomes, health status, and quality of life as part of routine care 1

Lifestyle Management

Medical Nutrition Therapy

No single ideal macronutrient distribution exists for all patients; individualize meal planning based on patient assessment. 2

• Various eating patterns are effective: Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate patterns 2
• 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
• Prescribe 500-750 kcal/day energy deficit for overweight/obese patients 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. 1, 2

Critical pre-exercise considerations: 1

• Perform careful cardiovascular history and assess risk factors
• Patients with diabetic autonomic neuropathy should undergo cardiac investigation before beginning intense physical activity
• Assess for conditions contraindicating certain exercises: uncontrolled hypertension, untreated proliferative retinopathy, autonomic neuropathy, peripheral neuropathy, history of foot ulcers or Charcot foot
• No specific exercise restrictions needed for diabetic kidney disease in general 1

Smoking Cessation

Include smoking cessation counseling and treatment as a routine component of diabetes care for all tobacco users. 1

• Advise all patients not to use cigarettes, other tobacco products, or e-cigarettes 1
• Combine brief counseling with pharmacologic therapy for patients motivated to quit 1
• E-cigarettes should not be recommended as no rigorous studies demonstrate they are healthier alternatives or facilitate cessation 1

Weight Management

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

• Men should maintain waist size ≤40 inches (102 cm); women ≤35 inches (88.9 cm) 1
• Weight gain after smoking cessation does not diminish substantial cardiovascular benefits 1

Glycemic Monitoring and Targets

Blood Glucose Monitoring

Self-monitoring of blood glucose (SMBG) is integral to comprehensive diabetes management and recommended for all patients. 1

Monitoring frequency: 1

• Hospitalized patients with poor control or severe conditions: 4-7 times daily
• Patients on lifestyle interventions: as needed to assess diet and exercise effects
• Type 1 diabetes: at least 3 times daily, plus before/after exercise, before driving, at bedtime 1
• Increase frequency for patients at higher risk for hypoglycemia or with reduced symptomatic awareness 3, 4

Glycemic Targets

• Set individualized blood glucose targets based on age, comorbidities, hypoglycemia risk, and life expectancy 2
• Regular testing every 3-6 months to assess long-term glycemic control 2
• Measure HbA1c periodically for monitoring long-term control 5

Pharmacologic Management

Type 1 Diabetes

Most patients with type 1 diabetes should be treated with multiple-dose insulin injections or continuous subcutaneous insulin injection using insulin analogues to reduce hypoglycemia risk. 2

• Use basal insulin plus mealtime insulin bolus to mimic normal physiologic insulin levels 1, 2
• Educate patients on matching prandial insulin doses to carbohydrate intake, preprandial blood glucose levels, and anticipated activity 2
• Initial insulin dosage ranges from 0.25 to 1.0 U/kg/day 6

Type 2 Diabetes

Initiate pharmacologic therapy at diagnosis in addition to lifestyle therapy, with metformin as the preferred initial agent if renal function is adequate. 2

• When monotherapy at maximum tolerated dose fails to achieve target over 3 months, add a second agent 2
• Consider patient factors when selecting medications: efficacy, cost, side effects, weight effects, comorbidities, and hypoglycemia risk 2
• Standard therapy begins with dietary modifications, exercise, and oral hypoglycemic agent if needed 6

Insulin Safety Considerations

Changes in insulin regimen (strength, manufacturer, type, injection site, or administration method) require close medical supervision with increased blood glucose monitoring frequency. 3, 4

Critical warnings: 3, 4, 5

• Hypoglycemia is the most common adverse reaction; can cause seizures, unconsciousness, or death
• Repeated injections into lipodystrophy or localized cutaneous amyloidosis areas cause hyperglycemia
• Sudden change to unaffected injection site can cause hypoglycemia
• Continuously rotate injection sites within given areas
• Long-acting insulin effect may delay hypoglycemia recovery 3
• Do NOT mix insulin detemir with other insulin preparations 5

Cardiovascular Risk Factor Management

Blood Pressure Control

Target blood pressure <140/90 mmHg for patients with diabetes and hypertension. 2

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

• Recommend lifestyle modification to improve lipid profile 2
• Base statin intensity on patient's risk profile in addition to intensive lifestyle therapy 2

Hypoglycemia Management

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

Patient education priorities: 2

• Recognize situations increasing hypoglycemia risk: fasting for tests/procedures, during/after exercise, during sleep
• Early warning symptoms may be less pronounced with long diabetes duration, diabetic neuropathy, beta-blocker use, or intensified control 5
• Symptomatic awareness may be reduced in patients with longstanding diabetes or recurrent hypoglycemia 3, 4

Complication Screening

Conduct regular screening for microvascular complications and cardiovascular risk factors. 2

• Annual comprehensive eye examination 2
• Annual screening for diabetic kidney disease 2
• Comprehensive foot examination 2
• Provide all age-appropriate vaccinations 1, 2

Special Populations and Situations

Renal or Hepatic Impairment

• Patients may be at higher risk of hypoglycemia; insulin requirements may need adjustment 3, 4, 5

Perioperative Care

Target blood glucose range in perioperative period: 80-180 mg/dL (4.4-10.0 mmol/L). 1

• Perform preoperative risk assessment for high-risk patients (ischemic heart disease, autonomic neuropathy, renal failure) 1
• Withhold metformin on surgery day 1
• Give half of NPH dose or 60-80% of long-acting analog/pump basal insulin 1
• Monitor blood glucose at least every 4-6 hours while NPO 1

Concomitant PPAR-gamma Agonist Use

Observe patients on insulin plus thiazolidinediones for signs/symptoms of heart failure due to dose-related fluid retention. 3, 4, 5

• If heart failure develops, manage per current standards and consider discontinuation or dose reduction of PPAR-gamma agonist 3, 4, 5

Discharge Planning

Implement a structured discharge plan tailored to the individual patient to reduce length of stay, readmission rates, and increase satisfaction. 1

• Schedule outpatient follow-up within 1 month of discharge for all patients with hyperglycemia 1
• If glycemic medications changed or glucose control suboptimal at discharge, schedule appointment in 1-2 weeks 1
• Perform medication reconciliation to ensure no chronic medications were stopped and new prescriptions are safe 1
• Provide clear communication with outpatient providers regarding hyperglycemia cause, complications, comorbidities, and recommended treatments 1