What are the latest guidelines for managing diabetes?

Latest Guidelines for Diabetes Management

The 2018 ADA/EASD consensus and 2025 ADA Standards prioritize a patient-centered, team-based approach with metformin as first-line therapy, but for patients with established cardiovascular disease or chronic kidney disease, SGLT-2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefit should be initiated regardless of baseline HbA1c. 1, 2

Initial Assessment and Diagnosis

At diagnosis, perform a complete medical evaluation including: 2

• HbA1c, fasting glucose, comprehensive metabolic panel, lipid profile, and urine albumin-to-creatinine ratio 2
• Screen for autoimmune conditions in type 1 diabetes (thyroid dysfunction, celiac disease) 2
• Assess for obesity, hypertension, dyslipidemia, and existing microvascular complications 2

Team-Based Care Model

Diabetes management requires a multidisciplinary team including physicians, nurse practitioners, nurses, dietitians, pharmacists, and mental health professionals. 1, 2 The 2017 VA/DoD guideline strongly emphasizes shared decision-making at diagnosis, during management difficulties, and at care transitions. 1 This approach improves treatment adherence and patient satisfaction compared to traditional physician-directed care. 1

Glycemic Targets

Set individualized HbA1c targets based on age, comorbidities, hypoglycemia risk, and life expectancy rather than applying a universal target. 2, 3 Test HbA1c every 3-6 months to assess long-term glycemic control. 2 Currently, only 23% of patients achieve all three targets (HbA1c, blood pressure, and LDL cholesterol) while avoiding smoking, highlighting the need for comprehensive risk factor management. 2

Lifestyle Interventions as Foundation

Nutrition

No single macronutrient distribution is ideal for all patients; individualize based on patient assessment. 2 Effective eating patterns include Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate approaches. 2 For weight loss, prescribe a 500-750 kcal/day energy deficit. 2

Physical Activity

Prescribe 150 minutes per week of moderate aerobic activity (30-60 minutes daily, at least 5 days weekly) plus resistance training twice weekly. 2, 4, 5

Weight Management

For overweight/obese patients, prescribe high-intensity diet, physical activity, and behavioral therapy designed to achieve ≥5% weight loss. 2 This is critical as excess adiposity is the most important modifiable risk factor for type 2 diabetes. 6

Pharmacologic Therapy Algorithm

First-Line Therapy

Initiate metformin at diagnosis alongside lifestyle therapy for metabolically stable patients with adequate renal function. 2, 7, 4 Metformin decreases hepatic glucose output, sensitizes peripheral tissues to insulin, and has demonstrated mortality reduction in type 2 diabetes. 4

Cardiovascular Disease-Directed Therapy

This represents the most significant paradigm shift in recent guidelines:

• For patients with established cardiovascular disease: Add an SGLT-2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit, independent of HbA1c level or metformin use 1
• For patients with chronic kidney disease or heart failure with atherosclerotic cardiovascular disease: Prioritize an SGLT-2 inhibitor with proven benefit 1
• GLP-1 receptor agonists are the preferred first injectable medication over insulin 1

This cardiovascular-first approach supersedes the traditional glucose-centric stepwise escalation and reflects cardiovascular outcome trial data showing mortality and morbidity benefits beyond glycemic control. 1

Second-Line Oral Therapy

When adding a second oral agent to metformin, consider a DPP-4 inhibitor after discussing benefits, adverse effects, and costs with the patient. 1 Alternative options include sulfonylureas (with hypoglycemia risk) and thiazolidinediones (with fluid retention and heart failure concerns). 1, 8

Cardiovascular Risk Factor Management

Target blood pressure <140/90 mmHg (or <130/80 mmHg for patients with chronic kidney disease). 2, 3 Initiate beta blockers and/or ACE inhibitors as first-line agents. 2

Manage lipid abnormalities aggressively, particularly in patients with cardiovascular disease. 2, 3 Target LDL cholesterol <100 mg/dL. 3

Complication Screening

Conduct annual comprehensive eye examinations, screen for diabetic kidney disease, and perform comprehensive foot examinations. 2 Screen for and treat modifiable cardiovascular risk factors at each visit. 2 Provide all age-appropriate vaccinations. 2

Diabetes Self-Management Education and Support (DSMES)

Provide DSMES at diagnosis and at critical points throughout care, focusing on empowering informed self-management choices rather than passive information delivery. 2 Essential content includes hypoglycemia/hyperglycemia recognition and treatment, medication administration, blood glucose monitoring, and nutritional management. 2

Special Populations: Older Adults

For older adults receiving palliative or end-of-life care, overall comfort, prevention of distressing symptoms, and quality of life preservation are primary goals. 1 Strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. 1 Glucose targets should prevent both hypoglycemia and symptomatic hyperglycemia rather than achieving intensive control. 1

Monitoring and Follow-Up

Schedule follow-up appointments every 3 months to evaluate metabolic parameters and adjust treatment. 3 Evaluate microvascular complications (retinopathy, nephropathy, neuropathy) and global cardiovascular risk annually. 3

Common Pitfalls to Avoid

• Do not delay SGLT-2 inhibitor or GLP-1 receptor agonist initiation in patients with established cardiovascular disease while attempting to optimize HbA1c with traditional agents 1
• Do not initiate pioglitazone if clinical evidence of active liver disease or ALT >2.5 times upper limit of normal exists 8
• Do not prescribe restrictive therapeutic diets in older adults that may lead to unintentional weight loss and undernutrition 1
• Do not assume home glucose monitoring benefits all patients; tailor its use to individual needs, particularly questioning utility in well-controlled patients not on multiple insulin injections 4