What are the management and treatment recommendations for individuals with diabetes?

Diabetes Management and Treatment

Diabetes management requires a team-based approach with glycemic control as the cornerstone, targeting HbA1c <7% for most adults, combined with comprehensive cardiovascular risk reduction and regular complication screening. 1

Initial Evaluation and Baseline Assessment

Perform a complete medical evaluation at diagnosis to classify diabetes type, detect existing complications, and establish baseline metrics 2, 3:

Laboratory Testing:

• HbA1c, fasting glucose, and lipid panel (total cholesterol, HDL, LDL, triglycerides) 1, 2
• Serum creatinine and urine albumin-to-creatinine ratio for kidney function 1, 2
• TSH in all type 1 diabetes patients; in type 2 if clinically indicated 1
• Urinalysis for ketones, protein, and sediment 1

Physical Examination Focus:

• Blood pressure with orthostatic measurements when indicated 1
• Fundoscopic and comprehensive foot examination 1
• Cardiovascular examination including pulse palpation and auscultation 1
• Skin examination for acanthosis nigricans and insulin injection sites 1
• Neurological examination 1

Team-Based Care Structure

Assemble a multidisciplinary team including physicians, nurse practitioners, diabetes educators, registered dietitian nutritionists, pharmacists, and mental health professionals 1. The patient must assume an active role in their care, with treatment plans co-created based on individual preferences, values, and goals 1.

Communication Approach:

• Use empowering, non-judgmental language that avoids blame for suboptimal outcomes 1
• Employ active listening with open-ended questions and reflective statements 1
• Assess self-efficacy, as this correlates with improved self-management and outcomes 1

Glycemic Targets

Standard Targets for Most Adults: 1

• HbA1c: <7% (referenced to nondiabetic range 4.0-6.0%)
• Preprandial glucose: 90-130 mg/dL (5.0-7.2 mmol/L)
• Postprandial glucose: <180 mg/dL (<10.0 mmol/L), measured 1-2 hours after meal start

Target Individualization: 1, 2

• More stringent goals (HbA1c <6%) may reduce complications but increase hypoglycemia risk
• Less intensive goals appropriate for patients with severe/frequent hypoglycemia, limited life expectancy, or advanced complications
• Consider age, cognitive abilities, comorbidities, and hypoglycemia risk when setting targets

Monitoring Frequency:

• HbA1c testing every 3-6 months to assess long-term control 2, 3
• Self-monitoring of blood glucose appropriate to medication regimen 2

Pharmacologic Therapy

Initial Treatment Algorithm: 2, 3

For metabolically stable patients (HbA1c <8.5%, asymptomatic):

• Initiate metformin at diagnosis alongside lifestyle therapy if renal function adequate (eGFR >30 mL/min/1.73 m²) 2

For marked hyperglycemia (glucose ≥250 mg/dL, HbA1c ≥8.5%) with symptoms:

• Initiate basal insulin immediately while starting metformin 2

Insulin Considerations:

• Insulin glargine provides 24-hour duration of action with relatively flat profile 4
• Insulin detemir requires dose adjustment in renal or hepatic impairment 5
• Both require individualized dosing based on blood glucose monitoring 4, 5

Lifestyle Management

Medical Nutrition Therapy: 1, 2

• No single ideal macronutrient distribution exists; individualize based on patient assessment 3
• Effective patterns include Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate approaches 3

Weight Management for Overweight/Obese Patients: 2, 3

• Prescribe high-intensity diet, physical activity, and behavioral therapy targeting ≥5% weight loss
• Implement 500-750 kcal/day energy deficit
• Provide long-term weight maintenance programs after achieving short-term goals

Physical Activity: 3

• 30-60 minutes moderate aerobic activity daily, at least 5 days per week
• Add resistance training twice weekly

Diabetes Self-Management Education (DSME): 2, 3

• Provide at diagnosis and at critical care points
• Focus on problem-solving skills, not just information delivery
• Include hypoglycemia/hyperglycemia recognition, medication administration, glucose monitoring, and nutritional management

Cardiovascular Risk Factor Management

Blood Pressure Targets: 1, 3

• <130/80 mmHg for most patients with diabetes
• Initiate beta-blockers and/or ACE inhibitors as first-line agents 3

Lipid Management: 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); >50 mg/dL for women
• For triglycerides ≥200 mg/dL, target non-HDL cholesterol <130 mg/dL 1

Complication Screening Schedule

Annual Screening Requirements: 2, 3

• Comprehensive dilated eye examination
• Diabetic kidney disease screening (urine albumin-to-creatinine ratio, serum creatinine)
• Comprehensive foot examination with monofilament testing

Type 1 Diabetes Specific:

• Begin microalbuminuria screening after 5 years of diabetes duration 1
• Screen for autoimmune thyroid disease and celiac disease 3

Type 2 Diabetes:

• Begin microalbuminuria screening at diagnosis 1

Additional Screening:

• Age-appropriate vaccinations 2, 3
• Cardiovascular risk factor assessment at each visit 2, 3

Ongoing Management and Follow-Up

Regular Visit Components: 2, 3

• Assess glycemic control, medication effectiveness, and side effects
• Monitor for complication progression
• Adjust treatment based on clinical outcomes and patient preferences
• Reassess treatment goals as circumstances change across lifespan 1

Referral Indications: 1

• Endocrinologist when glycemic targets not met despite optimization
• Ophthalmologist for eye examination
• Podiatrist for foot complications
• Behavioral specialist for diabetes distress or mental health concerns
• Registered dietitian nutritionist for medical nutrition therapy

Critical Pitfalls to Avoid

Hypoglycemia Recognition: 1, 5

• Early warning symptoms may be blunted with long diabetes duration, autonomic neuropathy, or beta-blocker use
• Geriatric patients may have difficulty recognizing hypoglycemia; use conservative dosing 4
• Severe hypoglycemia more common in pediatric type 1 diabetes 4

Social Determinants of Health: 1, 2

• Address financial concerns, cultural factors, literacy/numeracy, and access barriers
• Simplify regimens when adherence is challenging
• Consider work/school schedules when timing medications

Medication Adjustments: 4, 5

• Insulin requirements change with intercurrent illness, stress, or emotional disturbances
• Renal impairment increases insulin levels; adjust doses accordingly
• Hepatic impairment may alter insulin requirements

Drug Interactions: 5

• Corticosteroids, diuretics, and sympathomimetics reduce insulin effectiveness
• ACE inhibitors, fibrates, and sulfonamides increase hypoglycemia risk
• Beta-blockers may mask hypoglycemia symptoms