What are the guidelines for managing diabetes, including lifestyle modifications, pharmacotherapy, and comorbidity management?

Comprehensive Diabetes Management: Guidelines, Pharmacotherapy, and Comorbidities

Initial Assessment and Glycemic Targets

For most adults with diabetes, target an HbA1c <7% to reduce microvascular complications, but individualize based on hypoglycemia risk, life expectancy, and comorbidities. 1 For patients with a history of severe hypoglycemia, limited life expectancy, advanced complications, or extensive comorbidities, less stringent targets (HbA1c 7-8%) are appropriate. 1 Blood pressure should be measured at every visit, with targets <130/80 mmHg for most patients with diabetes. 1

Lifestyle Modifications: The Foundation

All patients must begin with intensive lifestyle interventions regardless of pharmacotherapy plans. 1

Physical Activity Requirements

• Minimum 150 minutes of moderate-intensity aerobic activity per week (e.g., brisk walking), spread over at least 5 days, preferably 7 days. 1
• Add resistance training at least 2 days per week. 1
• Reduce sedentary time throughout the day with movement breaks. 1

Weight Management

• Target at least 5-10% body weight reduction for overweight/obese patients (BMI ≥25 kg/m²). 1
• Ideal BMI target: 18.5-24.9 kg/m². 1
• Waist circumference goals: <35 inches (89 cm) for women, <40 inches (102 cm) for men. 1
• When waist circumference exceeds these thresholds, intensify weight management interventions. 1

Medical Nutrition Therapy

• Refer all patients to a registered dietitian for individualized nutrition planning. 1
• Reduce saturated fat, trans fat, and cholesterol intake. 1
• Increase omega-3 fatty acids, viscous fiber, and plant stanols/sterols. 1

Diabetes Self-Management Education

• All patients must participate in diabetes self-management education and support programs. 1

Pharmacotherapy for Type 2 Diabetes

First-Line Therapy

Start metformin at or soon after diagnosis if lifestyle modifications are insufficient, unless contraindicated. 1 Metformin is the preferred initial agent because it is inexpensive, has established efficacy and safety, and may reduce cardiovascular events and death. 1

Key metformin considerations:

• Can be continued with declining renal function down to GFR 30-45 mL/min with dose reduction. 1
• For HbA1c ≥9% at diagnosis, initiate dual-therapy immediately (metformin plus second agent) to achieve rapid glycemic control. 1

Second-Line Therapy (When Metformin Monotherapy Fails)

When HbA1c remains above target after 3 months on maximum tolerated metformin, add a second agent. 1 Choose from these six options based on patient-specific factors:

1. Sulfonylureas - Low cost, but hypoglycemia risk 1
2. Thiazolidinediones - Avoid in heart failure 1
3. DPP-4 inhibitors - Weight neutral, low hypoglycemia risk 1
4. SGLT2 inhibitors - Weight loss, cardiovascular benefits 1
5. GLP-1 agonists - Weight loss, cardiovascular benefits 1
6. Basal insulin - Most effective for severe hyperglycemia 1

Selection criteria: Consider efficacy, cost, side effects (especially weight and hypoglycemia risk), comorbidities, and patient preferences. 1

Type 1 Diabetes Management

Treat with multiple daily insulin injections (≥3 injections/day) or continuous subcutaneous insulin infusion. 1 This intensive approach significantly reduces microvascular complications and cardiovascular disease compared to 1-2 injections daily. 1

Essential insulin management strategies:

• Use insulin analogues to reduce hypoglycemia risk. 1
• Educate patients on carbohydrate counting and matching prandial insulin to carbohydrate intake, preprandial glucose, and anticipated activity. 1
• Consider continuous glucose monitoring to reduce severe hypoglycemia risk. 1
• Insulin pump therapy with low glucose suspend features reduces nocturnal hypoglycemia. 1

Hypoglycemia Management

Hypoglycemia (glucose <70 mg/dL) is the major limiting factor in diabetes management. 1

Treatment Protocol

• Administer 15-20 grams of rapid-acting glucose (pure glucose preferred). 1
• Recheck blood glucose after 15 minutes; repeat if hypoglycemia persists. 1
• Prescribe glucagon for all patients at risk for severe hypoglycemia and train close contacts on administration. 1

Prevention Strategies

• Educate patients on high-risk situations: fasting for procedures, during/after exercise, and during sleep. 1
• For hypoglycemia unawareness, raise glycemic targets for several weeks to restore counterregulatory responses. 1
• Severe or frequent hypoglycemia mandates immediate treatment regimen modification. 1

Cardiovascular Risk Management

Blood Pressure Control

Target <130/80 mmHg for patients with diabetes. 1

Treatment algorithm:

• For BP 130-139/80-89 mmHg: Lifestyle therapy for up to 3 months, then add medication if target not achieved. 1
• For BP ≥140/90 mmHg: Immediate pharmacologic therapy plus lifestyle modifications. 1
• First-line agents: Beta-blockers and/or ACE inhibitors, add thiazides as needed. 1
• Monitor creatinine/eGFR and potassium at least annually in patients on ACE inhibitors, ARBs, or diuretics. 2

Lipid Management

Measure fasting lipid profile at least annually; every 2 years if low-risk values (LDL <100, HDL >50, triglycerides <150 mg/dL). 1

Statin therapy indications:

• All diabetic patients with overt CVD (regardless of baseline lipids). 1
• All diabetic patients >40 years with ≥1 additional CVD risk factor (regardless of baseline lipids). 1
• Consider for patients <40 years if LDL remains >100 mg/dL or multiple CVD risk factors present. 1

LDL targets:

• Primary prevention: <100 mg/dL 1
• Secondary prevention (with CVD): <70 mg/dL using high-dose statin 1
• Alternative goal: 30-40% LDL reduction from baseline if targets not achieved on maximum tolerated statin. 1

Antiplatelet Therapy

Aspirin 75-162 mg daily for all patients with coronary artery disease unless contraindicated. 1

• Clopidogrel 75 mg daily is the alternative for aspirin-intolerant patients. 1
• After ACS or PCI with stent: Dual antiplatelet therapy (aspirin plus P2Y12 inhibitor) for at least 12 months. 1

Smoking Cessation

Implement persistent smoking cessation counseling using the 5 A's approach: Ask, Advise, Assess, Assist, Arrange. 1 Offer referral to cessation programs and pharmacotherapy including nicotine replacement. 1

Immunizations

Annual influenza vaccine for all diabetic patients ≥6 months of age. 1 Pneumococcal polysaccharide vaccine for all diabetic patients ≥2 years. 1

• Revaccinate once if previously immunized when <65 years and vaccine given ≥5 years ago. 1

Hepatitis B vaccination per CDC recommendations. 1

Monitoring Schedule

• HbA1c every 3 months to assess treatment efficacy. 2
• Blood pressure at every visit. 1
• Fasting lipid profile annually (or every 2 years if low-risk). 1
• Renal function and potassium annually for patients on ACE inhibitors/ARBs/diuretics. 2
• Self-monitoring of blood glucose: Individualize frequency based on treatment regimen. 2

Special Populations

Pediatric Type 2 Diabetes

• Initial treatment depends on presentation severity and presence of ketoacidosis. 1
• For HbA1c ≥8.5% or glucose ≥250 mg/dL: Start insulin. 1
• For less severe presentations: Metformin plus intensive lifestyle modifications. 1
• Family-centered approach essential; involve multidisciplinary team. 1

Renal/Hepatic Impairment

• Increased hypoglycemia risk requires more frequent dose adjustments and glucose monitoring. 3

Critical Pitfalls to Avoid

• Never aggressively pursue near-normal HbA1c in patients with hypoglycemia unawareness, advanced disease, or limited life expectancy. 1
• Do not continue metformin without dose reduction when GFR falls below 45 mL/min. 1
• Avoid thiazolidinediones in patients with heart failure or at risk for heart failure. 1
• Never share insulin pens between patients, even with needle changes. 3
• Always verify insulin product before injection to prevent medication errors. 3