What are the primary recommendations for managing diabetes in a patient, including lifestyle modifications and medication options?

Diabetic Management: Evidence-Based Recommendations

Glycemic Control

For most nonpregnant adults with diabetes, target an HbA1c <7% to reduce microvascular complications and long-term macrovascular disease risk. 1

• More stringent targets (HbA1c <6.5%) are appropriate for patients with short diabetes duration, long life expectancy, and no significant cardiovascular disease, if achievable without significant hypoglycemia 1
• Less stringent targets (HbA1c <8%) are warranted for patients with severe hypoglycemia history, limited life expectancy, advanced complications, extensive comorbidities, or longstanding diabetes difficult to control despite optimal therapy 1
• Check HbA1c at least twice yearly in patients meeting treatment goals, and quarterly in those whose therapy has changed or who are not meeting goals 1

Pharmacologic Management

Type 1 Diabetes

Treat most patients with type 1 diabetes using multiple-dose insulin injections (≥3 injections daily) or continuous subcutaneous insulin infusion to reduce microvascular and cardiovascular complications. 1

• Integrate insulin therapy into the patient's dietary and physical activity patterns 1
• Patients using rapid-acting insulin should adjust meal and snack doses based on carbohydrate content 1
• Use insulin analogues rather than regular insulin to reduce hypoglycemia risk 1
• For patients on fixed insulin doses, maintain consistent carbohydrate intake regarding timing and amount 1

Type 2 Diabetes

Initiate metformin therapy at or soon after diagnosis, along with lifestyle interventions, unless contraindicated. 1

• Metformin is the preferred initial agent due to established efficacy, safety profile, potential cardiovascular benefits, and low cost 1
• Metformin can be continued with declining renal function down to GFR 30-45 mL/min with dose reduction 1
• For newly diagnosed patients with marked symptoms, elevated glucose, or HbA1c ≥9%, consider insulin therapy with or without additional agents from the outset 1

When monotherapy at maximum tolerated dose fails to achieve or maintain HbA1c target over 3 months, add a second agent. 1

• Combination options include: sulfonylureas, thiazolidinediones, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 agonists, or basal insulin 1
• Base drug selection on patient characteristics, disease factors, drug properties (including effects on weight and hypoglycemia risk), cost, and patient preferences 1
• For HbA1c ≥9%, initiate dual-regimen combination therapy to achieve glycemic control more rapidly 1

Lifestyle Modifications

Medical Nutrition Therapy

All patients with diabetes should receive individualized medical nutrition therapy, preferably from a registered dietitian. 1

• Target weight loss of 5-7% of body weight for overweight or obese patients through calorie restriction 2, 3
• Reduce total calorie intake by 500-1,000 calories daily from maintenance levels to achieve 1-2 pounds per week weight loss 2
• Focus on reducing saturated fat, trans fat, and cholesterol intake while increasing omega-3 fatty acids, viscous fiber, and plant stanols/sterols 1
• Emphasize nutrient-dense, minimally processed foods and eliminate sugar-sweetened beverages, refined grains, and ultraprocessed foods 2
• Restrict sodium intake to <2,300 mg/day 1
• Increase consumption of fruits and vegetables (8-10 servings daily) and low-fat dairy products (2-3 servings daily) 1

Physical Activity

Prescribe at least 150 minutes per week of moderate-intensity aerobic activity (50-70% maximum heart rate), spread over at least 3 days with no more than 2 consecutive days without exercise. 1, 2

• Include resistance training at least twice weekly for most adults with diabetes 1
• Reduce sedentary time throughout the day 4
• For planned exercise, adjust insulin doses; for unplanned exercise, provide extra carbohydrate 1

Diabetes Self-Management Education

Enroll patients in a CDC-recognized Diabetes Prevention Program or equivalent intensive behavioral counseling program with frequent follow-up. 2

• Provide diabetes self-management education at diagnosis and as needed thereafter 1
• Address psychosocial issues, as emotional well-being correlates with positive diabetes outcomes 1

Blood Pressure Management

For patients with confirmed office-based blood pressure ≥140/90 mmHg, initiate pharmacologic therapy promptly in addition to lifestyle modifications. 1

• Target blood pressure <130/80 mmHg for most patients with diabetes 1
• For blood pressure ≥160/100 mmHg, initiate two antihypertensive medications or a single-pill combination immediately 1
• For blood pressure 140-159/90-99 mmHg, begin with a single agent 1

Antihypertensive Drug Selection

Use drug classes proven to reduce cardiovascular events in diabetes: ACE inhibitors, ARBs, thiazide-like diuretics (chlorthalidone or indapamide preferred), or dihydropyridine calcium channel blockers. 1, 5

• For patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), initiate treatment with an ACE inhibitor or ARB at maximum tolerated dose 1
• If one class is not tolerated, substitute the other 1
• Multiple-drug therapy is generally required to achieve blood pressure targets 1
• Never combine ACE inhibitors with ARBs, or either with direct renin inhibitors 1
• Monitor serum creatinine/eGFR and potassium levels at least annually when using ACE inhibitors, ARBs, or diuretics 1

Lifestyle Interventions for Blood Pressure

For blood pressure >120/80 mmHg, implement lifestyle modifications including DASH-style dietary pattern, sodium reduction, potassium increase, alcohol moderation, and increased physical activity. 1, 5

Lipid Management

Screening

Measure fasting lipid profile at least annually in most adult patients. 1

• In adults with low-risk values (LDL <100 mg/dL, HDL >50 mg/dL, triglycerides <150 mg/dL), repeat lipid assessments every 2 years 1

Statin Therapy

Initiate high-intensity statin therapy immediately for diabetic patients aged 40-75 years with LDL >130 mg/dL and multiple cardiovascular risk factors to achieve at least 50% LDL reduction. 5

• Add statin therapy to lifestyle modifications regardless of baseline lipid levels for patients with overt cardiovascular disease 1
• For patients over age 40 without overt cardiovascular disease but with one or more cardiovascular risk factors, add statin therapy 1
• Primary LDL goal is <100 mg/dL for individuals without overt cardiovascular disease 1
• For patients with overt cardiovascular disease, consider LDL goal <70 mg/dL using high-dose statin 1
• Major cardiovascular risk factors include: smoking, hypertension (BP ≥140/90 mmHg or on antihypertensive medication), low HDL (<40 mg/dL), and family history of premature coronary heart disease 1

Triglyceride and HDL Management

Target triglycerides <150 mg/dL and HDL >40 mg/dL (>50 mg/dL for women). 1

• For triglycerides 200-499 mg/dL, achieve non-HDL cholesterol goal of <130 mg/dL 1
• For triglycerides ≥500 mg/dL, consider fibrate or niacin before LDL-lowering therapy 1

Nephropathy Screening and Management

Perform annual testing to quantitate urine albumin excretion in type 1 diabetic patients with diabetes duration ≥5 years and in all type 2 diabetic patients starting at diagnosis. 1

• Optimize glucose control to reduce risk or slow progression of nephropathy 1
• Optimize blood pressure control to reduce risk or slow progression of nephropathy 1
• For patients with chronic kidney disease, reduce protein intake to 0.8-1.0 g/kg body weight/day in earlier stages and to 0.8 g/kg body weight/day in later stages 1

Retinopathy Screening

Adults with type 1 diabetes should have initial dilated comprehensive eye examination within 5 years after diabetes onset. 1

Patients with type 2 diabetes should have initial dilated comprehensive eye examination shortly after diagnosis. 1

• If no retinopathy is present for one or more exams, consider exams every 2 years 1

Antiplatelet Therapy

Consider aspirin therapy (75-162 mg/day) for primary prevention in patients with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk >10%). 1

• This includes most men aged >50 years or women aged >60 years with at least one additional major cardiovascular risk factor (family history of cardiovascular disease, hypertension, smoking, dyslipidemia, or albuminuria) 1
• In patients with prior myocardial infarction, continue beta-blockers for at least 2 years after the event 1

Heart Failure Considerations

Avoid thiazolidinedione treatment in patients with symptomatic heart failure. 1, 6

• Metformin may be used in patients with stable congestive heart failure if renal function is normal, but avoid in unstable or hospitalized patients with heart failure 1
• When using thiazolidinediones, observe for signs and symptoms of heart failure; consider dosage reduction or discontinuation if heart failure occurs 6

Alcohol Consumption

If adults with diabetes choose to use alcohol, limit daily intake to one drink or less for women and two drinks or less for men. 1

• Consume alcohol with food to reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin secretagogues 1

Immunizations

Provide annual influenza vaccine to all diabetic patients ≥6 months of age. 1

Administer pneumococcal polysaccharide vaccine to all diabetic patients ≥2 years of age. 1

• One-time revaccination is recommended for individuals <64 years previously immunized when they were <65 years if vaccine was administered ≥5 years ago 1
• Administer hepatitis B vaccination per CDC recommendations 1

Monitoring and Follow-Up

Recheck blood pressure in 2-4 weeks after initiating antihypertensive therapy to assess response, and titrate medications to maximum tolerated doses if target is not achieved. 5

Recheck HbA1c in 3 months after initiating diabetes therapy. 5

Monitor serum creatinine/eGFR and potassium at least annually once on ACE inhibitor/ARB therapy. 5