What are the best practices for managing diabetes?

Diabetes Management: Easy-to-Read Format

Core Treatment Goals

Aim for an A1C of <7% with preprandial glucose 90-130 mg/dL and peak postprandial glucose <180 mg/dL 1. These targets prevent microvascular and macrovascular complications while maintaining quality of life 1.

Key Glycemic Targets 1

• A1C: <7.0%
• Preprandial glucose: 90-130 mg/dL (5.0-7.2 mmol/L)
• Peak postprandial glucose: <180 mg/dL (10.0 mmol/L)
• Blood pressure: <130/80 mmHg
• LDL cholesterol: <100 mg/dL
• Triglycerides: <150 mg/dL
• HDL cholesterol: >40 mg/dL (>50 mg/dL for women)

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Glucose Monitoring Strategy

Perform self-monitoring of blood glucose (SMBG) at frequencies matched to treatment intensity 1. For insulin users, test at least 3 times daily; for oral medication users, test frequently enough to achieve glycemic targets 1.

Monitoring Schedule 1, 2

• Type 1 diabetes or multiple daily insulin injections: ≥3 times daily
• Type 2 diabetes on oral agents: Frequency sufficient to reach goals (typically fasting and 2-hour postprandial)
• Stable patients: Can reduce to twice daily or every 3 days 1
• Continuous glucose monitoring (CGM): Standard of care for type 1 diabetes and type 2 diabetes on prandial insulin, targeting time in range (70-180 mg/dL) ≥70% 3

A1C Testing Frequency 1

• Stable patients meeting goals: Every 6 months (twice yearly)
• Therapy changes or not meeting goals: Every 3 months (quarterly)

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Medication Management

First-Line Therapy for Type 2 Diabetes

Start metformin immediately at diagnosis alongside lifestyle modifications 1. Metformin is the preferred initial pharmacologic agent due to efficacy, safety profile, and low hypoglycemia risk 1.

Metformin Dosing 4

• Initiate at 500-850 mg once or twice daily with meals
• Titrate gradually to minimize gastrointestinal side effects
• Maximum dose: 2,000-2,550 mg daily in divided doses
• Key warning: Rarely causes hypoglycemia alone but risk increases with alcohol or inadequate food intake 4

Insulin Therapy

For type 1 diabetes, use multiple daily injections (≥3 injections/day) or continuous subcutaneous insulin infusion 1. For type 2 diabetes, add insulin when oral agents fail to achieve A1C targets 5.

Insulin Initiation Strategy 6, 5

• Basal insulin: Start with bedtime long-acting insulin (e.g., insulin glargine) at 10 units or 0.1-0.2 units/kg
• Combination with oral agents: Continue metformin when adding insulin 6
• Hypoglycemia management: Reduce insulin dose by 10-25% if glucose <100 mg/dL or hypoglycemia occurs 6
• Timing with meals: Match insulin injection timing to meal schedule; eliminate delay if premeal hypoglycemia present 1

Insulin Analog Advantages 1

• Use rapid-acting analogs (lispro, aspart) to reduce hypoglycemia risk
• Long-acting analogs (glargine) improve nocturnal hypoglycemia control 5

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Lifestyle Management

Nutrition Therapy

Implement medical nutrition therapy (MNT) immediately, ideally with a registered dietitian 1. Meals should occur at consistent times daily, especially for insulin users 1.

Nutritional Priorities 1

• Carbohydrate consistency: Match insulin doses to carbohydrate intake 1
• Whole foods emphasis: Include whole grains, fruits, vegetables, and low-fat dairy 1
• Individualized approach: Adapt to cultural preferences, work schedules, and personal goals 1
• Avoid restrictive diets: Therapeutic diets in older adults may cause unintentional weight loss 1

Physical Activity

Prescribe at least 150 minutes of moderate-intensity aerobic activity weekly plus resistance training twice weekly 1. Exercise should occur at approximately the same time daily to minimize hypoglycemia risk 1.

Exercise Precautions 1

• Understand immediate and delayed hypoglycemia risks
• Modify diabetes regimen before exercise if needed
• Monitor glucose before and after activity

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Special Populations

Older Adults

Relax glycemic targets in older adults with limited life expectancy, cognitive impairment, or high hypoglycemia risk 1. Preventing hypoglycemia takes priority over tight glucose control 1.

Simplified Regimens for Older Adults 1

• Stable patients: Continue previous regimen, focus on preventing hypoglycemia and hyperglycemia-related dehydration 1
• Organ failure: Allow glucose in upper target range; reduce hypoglycemia-causing agents 1
• Avoid complex regimens: Prefer oral agents over multiple daily insulin injections 1
• Reduce monitoring: Capillary glucose testing can decrease to twice daily or every 3 days 1

End-of-Life Care

Prioritize comfort, symptom control, and quality of life over strict glycemic control 1. Discontinue statins and relax blood pressure targets 1.

End-of-Life Glucose Management 1

1. Stable patients: Continue previous regimen; prevent hypoglycemia and keep glucose below renal threshold; no role for A1C monitoring 1
2. Organ failure: Prevent hypoglycemia and dehydration; reduce insulin in type 1 diabetes as oral intake decreases; reduce hypoglycemia-causing agents in type 2 diabetes 1
3. Dying patients: Discontinue all medications in type 2 diabetes; consider small basal insulin dose in type 1 diabetes to prevent acute complications 1

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Hypoglycemia Management

Treat hypoglycemia (<70 mg/dL) immediately with 15-20 grams of rapid-acting glucose 1. Recheck glucose in 15 minutes and repeat treatment if needed 1.

Hypoglycemia Prevention 1

• Prescribe glucagon for patients at risk for severe hypoglycemia
• Train family members on glucagon administration
• Increase glycemic targets for several weeks in patients with hypoglycemia unawareness
• Avoid aggressive A1C targets in patients with frequent hypoglycemia

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Complication Screening

Annual Assessments 1

• Urine albumin: Screen annually for nephropathy (microalbumin test required) 1
• Dilated retinal exam: Annually by ophthalmologist or optometrist experienced in diabetic retinopathy 1
• Foot examination: Check for neuropathy, vascular disease, and skin integrity 1
• Lipid panel: Monitor cardiovascular risk 1

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Team-Based Care

Diabetes management requires a physician-coordinated interdisciplinary team including nurses, dietitians, pharmacists, and diabetes educators 1. The patient must assume an active role in self-management 1.

Patient Engagement 1

• Use nonjudgmental, empowering language
• Avoid terms like "noncompliance" or "diabetic"
• Normalize periodic lapses in self-management
• Develop collaborative treatment plans based on patient preferences, values, and goals
• Provide diabetes self-management education at diagnosis 1