What are the guidelines for managing diabetes?

Management Guidelines for Diabetes

Diabetes management requires immediate initiation of both lifestyle interventions and pharmacologic therapy at diagnosis, centered around a multidisciplinary team approach with individualized glycemic targets and comprehensive complication screening. 1, 2, 3

Initial Evaluation at Diagnosis

Perform a complete medical evaluation to classify diabetes type, detect existing complications, and establish baseline parameters 1, 2, 3:

• Laboratory assessment must include: HbA1c, fasting glucose, complete lipid profile, kidney function tests (creatinine, eGFR), and urine albumin-to-creatinine ratio 1, 3
• Screen for autoimmune conditions in type 1 diabetes patients, specifically thyroid dysfunction and celiac disease 1, 2
• Assess comorbidities including obesity (calculate BMI), hypertension, dyslipidemia, and any existing microvascular complications 1, 3

Team-Based Care Structure

Assemble a multidisciplinary team including physicians, nurse practitioners, nurses, dietitians, pharmacists, and mental health professionals 1, 2, 3:

• Implement shared decision-making with written management plans developed collaboratively with the patient and family 1
• Use patient-centered communication that incorporates patient preferences, assesses health literacy and numeracy, and addresses cultural barriers 2, 3
• Only 23% of patients with diabetes meet all three targets (HbA1c, blood pressure, LDL cholesterol) while avoiding smoking, highlighting the need for comprehensive team support 1

Glycemic Targets and Monitoring

Set HbA1c targets based on: patient age, presence of comorbidities, hypoglycemia risk, and life expectancy 1, 2, 3:

• Test HbA1c every 3-6 months to assess long-term glycemic control 1, 2, 3
• Increase blood glucose monitoring frequency during any changes to the insulin regimen or when adjusting medications 1, 3
• Implement self-monitoring of blood glucose appropriate to the medication regimen 3

Pharmacologic Therapy

Type 2 Diabetes - Initial Treatment

Initiate pharmacologic therapy at diagnosis alongside lifestyle interventions 1, 2, 3:

• For metabolically stable patients (HbA1c <8.5%, asymptomatic): Start metformin if renal function is adequate (eGFR >30 mL/min/1.73 m²) 2, 3
• For marked hyperglycemia (blood glucose ≥250 mg/dL, HbA1c ≥8.5%) with symptoms: Initiate basal insulin while simultaneously starting metformin 3
• When monotherapy fails after 3 months at maximum tolerated dose, add a second agent 2
• Consider patient-specific factors when selecting medications: efficacy, cost, side effects, weight effects, comorbidities, and hypoglycemia risk 2

Type 1 Diabetes

Treat with multiple-dose insulin injections or continuous subcutaneous insulin infusion 2:

• Use insulin analogues to reduce hypoglycemia risk 2
• Educate patients on matching prandial insulin doses to carbohydrate intake, preprandial glucose levels, and anticipated activity 2

Insulin Administration (Rapid-Acting)

For rapid-acting insulin aspart products 4:

• Inject subcutaneously 5-10 minutes before meals into the abdominal area, thigh, buttocks, or upper arm 4
• Rotate injection sites within the same region to reduce lipodystrophy and localized cutaneous amyloidosis risk 4
• Never inject into areas of lipodystrophy or localized cutaneous amyloidosis; switching from affected to unaffected areas can cause hypoglycemia and requires close monitoring 4
• Do not mix with any other insulin 4
• Generally use with an intermediate- or long-acting insulin 4

Lifestyle Management

Medical Nutrition Therapy

Implement individualized meal planning with no single ideal macronutrient distribution for all patients 1, 2, 3:

• Effective eating patterns include: Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate diets 1, 2
• For weight loss: Prescribe 500-750 kcal/day energy deficit 1, 2, 3
• Focus on reducing saturated fat, trans fat, and cholesterol while increasing omega-3 fatty acids, viscous fiber, and plant stanols/sterols 2

Physical Activity

Prescribe at least 150 minutes of moderate-intensity aerobic activity per week 2:

• Add resistance training at least twice weekly 1, 2
• Reduce sedentary time throughout the day 2
• The American College of Lifestyle Medicine strongly recommends both aerobic and muscle strength physical activity as first-line management 5

Weight Management

For overweight/obese patients, prescribe high-intensity interventions targeting ≥5% weight loss 1, 2, 3:

• Combine diet, physical activity, and behavioral therapy 1, 2, 3
• Implement long-term weight maintenance programs after achieving short-term goals 3

Diabetes Self-Management Education and Support (DSMES)

Provide DSMES to all patients at diagnosis and at critical care transition points 1, 2, 3:

• Focus on informed self-management choices rather than passive information delivery 1, 2
• Essential content includes: hypoglycemia/hyperglycemia recognition and treatment, medication administration, blood glucose monitoring, and nutritional management 1, 2

Cardiovascular Risk Factor Management

Blood Pressure Control

Target blood pressure <140/90 mmHg (or <130/80 mmHg for patients with chronic kidney disease or diabetes) 1, 2:

• Lifestyle therapy: Weight loss, reduced-sodium diet, moderate alcohol intake, increased physical activity 2
• Pharmacologic therapy: Use either ACE inhibitor or ARB (but not both simultaneously) 2
• Initiate beta blockers and/or ACE inhibitors as tolerated 1

Lipid Management

Statin therapy is recommended for most patients with diabetes aged 40 years or older 2:

• Lifestyle modification should be recommended to improve lipid profile 2
• Statin intensity should be based on the patient's cardiovascular risk profile 2
• Manage lipid abnormalities aggressively, particularly in patients with existing cardiovascular disease 1

Complication Screening and Prevention

Conduct regular screening for microvascular complications 1, 2, 3:

• Annual comprehensive eye examination 1, 2, 3
• Annual screening for diabetic kidney disease (urine albumin-to-creatinine ratio, eGFR) 1, 2, 3
• Annual comprehensive foot examination 1, 2, 3
• Screen and treat modifiable cardiovascular risk factors 1, 2, 3
• Provide all age-appropriate vaccinations, which are especially important for people with diabetes 1, 2, 3

Hypoglycemia Management and Prevention

Hypoglycemia is the most common adverse reaction of all insulins and can be life-threatening 4:

• Reverse with 15-20g of rapid-acting glucose 2, 4
• Risk factors include: changes in meal patterns, increased physical activity, changes in concomitant medications, renal or hepatic impairment 4
• Increased monitoring frequency is essential for patients at higher risk and those with reduced symptomatic awareness 4
• Educate patients on situations increasing hypoglycemia risk: fasting for procedures, during/after exercise, and during sleep 2
• Patients with longstanding diabetes, diabetic neuropathy, or those taking beta-blockers may have reduced hypoglycemia awareness 4

Medication Safety

Always check insulin labels before each injection to avoid accidental mix-ups between insulin products 4:

• Never share insulin pens between patients, even with needle changes, due to blood-borne pathogen transmission risk 4
• Never share needles or syringes when using vials 4

Ongoing Care and Treatment Adjustments

Regular follow-up visits to assess glycemic control, medication effectiveness, side effects, and complication progression 3:

• Adjust treatment plans based on clinical outcomes, patient preferences, and development of complications 3
• Address social determinants of health that may impact treatment adherence 3
• Simplify regimens when possible to improve adherence, as complex regimens pose significant challenges 3
• Consider deprescribing pharmacologic therapy when lifestyle interventions achieve glycemic targets 5

Common Pitfalls to Avoid

• Repeated injections into lipodystrophy areas cause hyperglycemia; sudden site changes to unaffected areas can cause hypoglycemia requiring close monitoring 4
• Dosage adjustments are needed with changes in physical activity, meal patterns, renal/hepatic function, or during acute illness 4
• Patient adherence challenges are common with complex regimens; address barriers proactively and simplify when feasible 3
• Many patients, particularly regarding physical activity, do not perceive lifestyle changes as essential treatment components, requiring specific interventions to promote adherence 6