Management and Treatment of Diabetes
Diabetes management requires a team-based, person-centered approach with individualized glycemic targets, comprehensive lifestyle modification, early pharmacologic intervention, and systematic screening for complications to prevent morbidity and mortality. 1
Initial Evaluation and Risk Stratification
Perform a complete medical evaluation at diagnosis to classify diabetes type, detect existing complications, and establish baseline parameters 2, 3:
- Laboratory assessment: HbA1c, fasting glucose, comprehensive lipid panel (total cholesterol, HDL, LDL, triglycerides), serum creatinine, urine albumin-to-creatinine ratio, TSH (especially in type 1 diabetes), and urinalysis 1, 2
- Physical examination priorities: Blood pressure with orthostatic measurements, fundoscopic examination, comprehensive foot examination (pulses, sensation, skin integrity), cardiac examination, thyroid palpation, and skin examination for acanthosis nigricans or lipodystrophy at injection sites 1
- Comorbidity screening: Assess for obesity, hypertension, dyslipidemia, cardiovascular disease, chronic kidney disease, and existing microvascular complications 2, 3
Team-Based Care Structure
Assemble a multidisciplinary team including primary care physicians, endocrinologists, diabetes educators, registered dietitian nutritionists, pharmacists, mental health professionals, podiatrists, and ophthalmologists 1. The patient must assume an active role in collaborative decision-making, with treatment plans co-created based on individual preferences, values, and goals 1.
Critical communication approach: Use empowering, non-judgmental language that avoids terms like "noncompliance" or "nonadherence," recognizing that multiple factors impact glycemic management beyond patient effort 1. Employ active listening techniques including open-ended questions and reflective statements 1.
Glycemic Targets (Individualized)
Set HbA1c targets based on patient-specific factors 1, 2, 3:
- Standard target: HbA1c <7.0% for most adults to reduce microvascular complications 1
- More stringent target: HbA1c <6.0% may further reduce complications but increases hypoglycemia risk, particularly in type 1 diabetes 1
- Less stringent targets: Consider for patients with severe/frequent hypoglycemia, limited life expectancy, advanced complications, or extensive comorbidities 1
Glucose monitoring targets 1:
- Preprandial plasma glucose: 90-130 mg/dL (5.0-7.2 mmol/L)
- Postprandial plasma glucose (1-2 hours after meals): <180 mg/dL (<10.0 mmol/L)
Implement self-monitoring of blood glucose appropriate to the medication regimen, with HbA1c testing every 3-6 months 2, 3.
Lifestyle Management (Non-Negotiable Foundation)
Medical Nutrition Therapy
No single eating pattern works for all patients—individualize based on preferences, cultural factors, and metabolic goals 1, 2. Effective patterns include Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate approaches 3. Macronutrient distribution should be individualized rather than following rigid percentages 3.
Weight Management (For Overweight/Obese Patients)
Prescribe high-intensity combined intervention: 500-750 kcal/day energy deficit through diet, physical activity, and behavioral therapy designed to achieve and maintain ≥5% weight loss 2, 3. This degree of weight loss improves glycemic control and reduces cardiovascular risk factors 2.
Physical Activity
Recommend at least 150 minutes weekly of moderate aerobic activity (30-60 minutes daily, minimum 5 days/week) plus resistance training twice weekly 3.
Diabetes Self-Management Education and Support (DSMES)
Provide DSMES at diagnosis and at critical transition points, focusing on problem-solving skills rather than passive information delivery 2, 3. Essential content includes hypoglycemia/hyperglycemia recognition and treatment, medication administration, blood glucose monitoring, and nutritional management 3.
Pharmacologic Therapy
Type 2 Diabetes Initial Approach
Initiate pharmacologic therapy at diagnosis, concurrent with lifestyle modification 2, 3:
- For metabolically stable patients (HbA1c <8.5%, asymptomatic): Start metformin if renal function adequate (eGFR >30 mL/min/1.73 m²) 2
- For marked hyperglycemia (blood glucose ≥250 mg/dL, HbA1c ≥8.5%) with symptoms: Initiate basal insulin while starting metformin 2
Insulin Therapy Considerations
When insulin is required, options include long-acting analogs such as insulin glargine (duration of action up to 24 hours with relatively flat profile) 4 or insulin detemir 5. Critical safety point: Insulin requirements may need adjustment in renal or hepatic impairment, and geriatric patients require conservative dosing to avoid hypoglycemia 4, 5.
Hypoglycemia management: Mild episodes can be treated with oral carbohydrates; severe episodes with coma or seizure require glucagon or intravenous glucose, with continued observation after recovery to prevent recurrence 4.
Cardiovascular Risk Factor Management
Blood pressure target: <130/80 mmHg 1. Initiate antihypertensive therapy as tolerated, with beta-blockers and/or ACE inhibitors as initial agents, particularly in patients with cardiovascular disease 3.
Lipid targets 1:
- LDL cholesterol: <100 mg/dL (<2.6 mmol/L)
- Triglycerides: <150 mg/dL (<1.7 mmol/L)
- HDL cholesterol: >40 mg/dL (>1.1 mmol/L); consider >50 mg/dL for women
Manage lipid abnormalities aggressively, especially in patients with established cardiovascular disease 3.
Complication Screening and Prevention
Implement systematic annual screening 2, 3:
- Diabetic retinopathy: Comprehensive dilated eye examination annually
- Diabetic kidney disease: Annual urine albumin-to-creatinine ratio and serum creatinine; begin screening in type 1 diabetes after 5 years duration, at diagnosis in type 2 diabetes 1
- Diabetic neuropathy: Comprehensive foot examination annually including monofilament testing, vibration sensation, ankle reflexes, and visual inspection
- Cardiovascular disease: Screen for and treat all modifiable risk factors
- Immunizations: Provide all age-appropriate vaccinations, which are particularly important in diabetes 2, 3
Ongoing Management and Treatment Adjustment
Regular follow-up schedule: Assess glycemic control, medication effectiveness and adverse effects, adherence barriers, and complication progression 2, 3. When targets are not met despite reaching preprandial glucose goals, consider targeting postprandial glucose 1.
Referral indications 1:
- Failure to achieve glycemic targets despite optimization
- Frequent or severe hypoglycemia
- Rapid progression of complications
- Complex management scenarios requiring endocrinology consultation
- Need for specialized services (ophthalmology, podiatry, nephrology, behavioral health)
Critical Pitfalls to Avoid
Intercurrent illness: Insulin requirements may increase during illness, emotional stress, or other physiologic stressors—proactive dose adjustment is essential 5. Patients must understand how to manage sick days, including when to seek emergency care 5.
Injection site management: Continuous rotation within injection areas prevents lipodystrophy and ensures consistent absorption 5. Lipodystrophy at injection sites can significantly delay insulin absorption and worsen glycemic control 5.
Drug interactions: Multiple medications affect glucose metabolism 5. Corticosteroids, thiazide diuretics, and sympathomimetic agents may increase glucose; ACE inhibitors, fibrates, and sulfonamide antibiotics may increase hypoglycemia risk 5. Beta-blockers may mask hypoglycemia symptoms 5.
Social determinants of health: Financial constraints, health literacy, cultural factors, and access to care significantly impact treatment adherence and outcomes—these must be systematically assessed and addressed 1.
Insulin mixing: Insulin detemir should NOT be mixed or diluted with other insulin preparations, as this alters the pharmacokinetic profile 5. Similarly, mixing insulin glargine with rapid-acting analogs can reduce the rapid-acting component's effectiveness by approximately 40% 5.