What are the recommended management strategies for diabetes?

Management of Diabetes

Diabetes management requires immediate initiation of both lifestyle modifications and pharmacologic therapy at diagnosis, with metformin as the first-line medication for type 2 diabetes alongside comprehensive self-management education. 1, 2

Team-Based Care Structure

• Assemble a multidisciplinary team including physicians, nurses, dietitians, exercise specialists, pharmacists, and mental health professionals to manage all aspects of diabetes care 1, 3
• Implement the Chronic Care Model to ensure productive interactions between a prepared practice team and an informed, activated patient 1
• Use shared decision-making to improve treatment adherence, patient satisfaction, and clinical outcomes 3

Initial Evaluation Requirements

Perform a complete medical evaluation at diagnosis that includes:

• HbA1c, fasting glucose, lipid profile, kidney function tests, and urine albumin-to-creatinine ratio 3
• Classification of diabetes type and detection of existing complications 1, 3
• Screening for autoimmune conditions in type 1 diabetes (thyroid dysfunction, celiac disease) 1, 3
• Assessment for comorbidities: obesity, hypertension, dyslipidemia, and microvascular complications 1, 3

Glycemic Targets

• Set HbA1c goal of <7% for most adults, with more stringent targets (<6.5%) for selected individuals without significant hypoglycemia risk 2
• Individualize targets based on age, comorbidities, hypoglycemia risk, and life expectancy 1, 3, 2
• Monitor HbA1c every 3 months until target is reached, then at least twice yearly 2

Lifestyle Management

Medical Nutrition Therapy

• Provide individualized meal planning with no single ideal macronutrient distribution—tailor carbohydrate, protein, and fat percentages to individual assessment 4, 3, 2
• Recommend effective eating patterns including Mediterranean-style, DASH, plant-based, lower-fat, or lower-carbohydrate diets 1, 3
• Focus on nutrient-dense, high-quality foods while decreasing calorie-dense, nutrient-poor foods 2
• Reduce intake of saturated fat, trans fat, and cholesterol while increasing ω-3 fatty acids, viscous fiber, and plant stanols or sterols 1

Physical Activity

• Prescribe at least 150 minutes of moderate-intensity aerobic activity per week, spread across at least 5 days 1, 2
• Add resistance training at least twice weekly 1, 2
• Reduce sedentary time throughout the day 1, 2

Weight Management

• For overweight/obese patients, prescribe high-intensity diet, physical activity, and behavioral therapy designed to achieve ≥5% weight loss 1, 3, 2
• Implement a 500-750 kcal/day energy deficit to promote weight loss 1, 3
• Recognize that modest weight loss (5-7% of starting weight) provides clinical benefits including improved glycemia, blood pressure, and lipids 2

Pharmacologic Therapy for Type 2 Diabetes

First-Line Treatment

• Initiate metformin at diagnosis alongside lifestyle therapy if renal function is adequate 1, 3, 2
• Start metformin at a low dose and increase gradually to an ideal maximum dose of 2000 mg daily in divided doses 2
• Metformin is preferred due to its efficacy, safety, low cost, and potential cardiovascular benefits 2

Exceptions Requiring Insulin First

Initiate insulin instead of metformin as first-line treatment when patients present with:

• Ketosis or diabetic ketoacidosis 2
• Random blood glucose ≥250 mg/dL 2
• HbA1c >8.5% 2
• Symptomatic diabetes with polyuria, polydipsia, and weight loss 2

Treatment Intensification

• Add a second agent when metformin at maximum tolerated dose fails to achieve or maintain HbA1c target over 3 months 1, 2
• Second-line options include SGLT-2 inhibitors, GLP-1 receptor agonists, thiazolidinediones, DPP-4 inhibitors, or basal insulin 2
• Consider patient factors when selecting medications: efficacy, cost, side effects, weight effects, comorbidities, and hypoglycemia risk 1

Pharmacologic Therapy for Type 1 Diabetes

• Treat most patients with multiple-dose insulin injections (≥3 injections per day) or continuous subcutaneous insulin infusion 1, 2
• Use insulin analogues to reduce hypoglycemia risk 1, 2
• Educate patients on matching prandial insulin doses to carbohydrate intake, preprandial blood glucose levels, and anticipated activity level 1, 2
• Consider continuous glucose monitoring systems to significantly reduce severe hypoglycemia risk 2

Diabetes Self-Management Education and Support (DSMES)

• Provide DSMES to all patients at diagnosis and at critical points throughout their care 1, 3, 2
• Focus education on helping patients make informed self-management choices rather than simply providing information 1, 3
• Include essential content on hypoglycemia/hyperglycemia recognition and treatment, medication administration, blood glucose monitoring, and nutritional management 1, 3
• Use a patient-centered communication style that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers 1

Cardiovascular Risk Factor Management

Blood Pressure Control

• Target blood pressure <140/90 mmHg for most patients with diabetes 1, 3
• Implement lifestyle therapy consisting of weight loss, reduced-sodium diet, moderate alcohol intake, and increased physical activity 1
• Initiate pharmacologic therapy with either an ACE inhibitor or ARB (but not both) for confirmed hypertension 1, 2

Lipid Management

• Prescribe statin therapy for most persons with diabetes aged 40 years or older 1
• Recommend lifestyle modification to improve the lipid profile 1
• Base statin intensity on the patient's risk profile in addition to intensive lifestyle therapy 1

Hypoglycemia Management

• Reverse hypoglycemia (plasma glucose <3.9 mmol/L) with 15-20g of rapid-acting glucose 1, 2
• Confirm blood glucose after 15 minutes and repeat treatment if hypoglycemia persists 2
• Educate patients about situations that increase hypoglycemia risk: fasting for tests or procedures, during or after exercise, and during sleep 1, 2
• Increase glycemic targets temporarily in patients with hypoglycemia unawareness to partially reverse this condition 2
• Modify treatment regimens for severe or frequent hypoglycemia 2

Complication Screening and Prevention

• Conduct annual comprehensive eye examination 1, 3
• Screen for diabetic kidney disease annually 1, 3
• Perform comprehensive foot examination regularly 1, 3
• Screen for and treat modifiable cardiovascular risk factors 1, 3
• Provide all age-appropriate vaccinations 1, 3

Critical Pitfalls to Avoid

• Never share insulin pens or needles between patients—this poses a risk for transmission of blood-borne pathogens 5
• Always instruct patients to check the insulin label before each injection to avoid medication errors between insulin products 5
• Avoid aggressively targeting near-normal HbA1c levels in patients with advanced disease where such targets cannot be safely reached 2
• Monitor for lipodystrophy or localized cutaneous amyloidosis at injection sites—repeated injections into these areas cause hyperglycemia, and sudden site changes can cause hypoglycemia 5
• Observe patients treated with insulin and PPAR-gamma agonists (thiazolidinediones) for signs of heart failure due to dose-related fluid retention 5
• Monitor potassium levels in at-risk patients, as all insulins can cause hypokalemia leading to respiratory paralysis, ventricular arrhythmia, and death 5