Latest Diabetes Management Guidelines
Type 1 Diabetes Management
Most adults with type 1 diabetes must receive continuous subcutaneous insulin infusion or multiple daily injections (≥3 injections daily) of prandial and basal insulin analogs, combined with continuous glucose monitoring and automated insulin delivery systems to prevent microvascular complications and reduce mortality. 1
Insulin Delivery
- Insulin analogs (or inhaled insulin) are mandatory over injectable human insulins because they significantly reduce hypoglycemia risk 1
- Automated insulin delivery systems should be offered to all adults with type 1 diabetes as they improve glycemic outcomes and quality of life 1
- Continuous glucose monitoring must be initiated early in all adults with type 1 diabetes to improve outcomes, enhance quality of life, and minimize hypoglycemia 1
Patient Education Requirements
- All patients require education on matching mealtime insulin doses to carbohydrate intake, fat, and protein content 1
- Teach patients to modify insulin doses based on concurrent glycemia, glycemic trends, sick-day management, and anticipated physical activity 1
- Reassess insulin treatment plans and insulin-taking behavior every 3-6 months and adjust accordingly 1
Hypoglycemia Prevention
- Prescribe glucagon to all individuals taking insulin or at high risk for hypoglycemia 1
- Family members, caregivers, and close contacts must know glucagon location and administration technique 1
- Use glucagon preparations that do not require reconstitution as they are preferred for ease of emergency use 1
Type 2 Diabetes Management
Metformin is the mandatory first-line pharmacologic agent at or soon after diagnosis (if tolerated and not contraindicated) because it reduces cardiovascular events and death, and must be combined with lifestyle modifications including diabetes self-management education, medical nutrition therapy, and physical activity. 2, 3
Metformin Initiation
- Start metformin 500 mg twice daily with meals, increasing to 1000 mg twice daily over 2-4 weeks to minimize gastrointestinal side effects 2
- Continue metformin unless contraindicated by renal impairment or intolerance 2, 3
Second-Line Therapy Selection
- When metformin monotherapy fails to achieve HbA1c target over 3 months, immediately add a second agent to prevent progression of complications 2
- For patients with established cardiovascular disease, heart failure, or chronic kidney disease, add an SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit, independent of HbA1c level or metformin use 3
- For patients without established cardiovascular disease, choose from sulfonylureas, thiazolidinediones, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 agonists, or basal insulin based on patient-specific factors including hypoglycemia risk, weight, cost, and patient preference 2
- GLP-1 receptor agonists are the preferred first injectable medication over insulin for patients with cardiovascular disease 4
Lifestyle Interventions
- Medical nutrition therapy delivered by a registered dietitian is mandatory for all persons with diabetes to achieve glycemic targets and prevent cardiovascular events 2
- Physical activity must include at least 150 minutes of moderate-intensity aerobic exercise weekly, plus resistance training at least twice weekly to improve insulin sensitivity and reduce cardiovascular risk 2
- Overweight or obese patients must be counseled to lose at least 5% of body weight through lifestyle modifications before or concurrent with pharmacotherapy 2
Glycemic Targets and Monitoring
Target HbA1c <7% for most patients with diabetes and no established cardiovascular disease complications with reasonable life expectancy to reduce microvascular complications. 2, 3
Target Individualization
- Consider more stringent targets (6.0-6.5%) for patients with short disease duration, long life expectancy, and no significant cardiovascular disease 3
- Do not aggressively pursue near-normal HbA1c levels in patients with advanced disease, limited life expectancy, or hypoglycemia unawareness as this increases mortality risk without benefit 2
Monitoring Frequency
- Check HbA1c every 3 months until target is achieved, then every 6 months for ongoing monitoring 2, 3
- Patients on intensive insulin regimens must self-monitor blood glucose before meals and snacks, at bedtime, and occasionally after meals 1
Cardiovascular Risk Management
Initiate at least moderate-intensity statin therapy for most patients with diabetes aged 40 years or older to reduce cardiovascular mortality. 2, 3
Blood Pressure Management
- Target blood pressure <140/90 mmHg for most patients with diabetes and hypertension to reduce cardiovascular mortality 2, 3
- Consider <130/80 mmHg for patients with chronic kidney disease 4, 3
- Initiate pharmacologic therapy with an ACE inhibitor or ARB (but not both) as first-line antihypertensive therapy for renal protection 2, 3
- Never aggressively lower blood pressure below 130/70 mmHg in older adults due to increased mortality risk 2
Lipid Management
- For patients with diabetes and atherosclerotic cardiovascular disease, use high-intensity statin therapy in addition to lifestyle therapy 1
- For patients aged 40-75 years without atherosclerotic cardiovascular disease, use moderate-intensity statin in addition to lifestyle therapy 1, 3
- If LDL cholesterol is >70 mg/dL on maximally tolerated statin dose in patients with atherosclerotic cardiovascular disease, consider adding ezetimibe or PCSK9 inhibitor 1
- Obtain lipid profile at diagnosis, at initial medical evaluation, and every 5 years thereafter if under age 40 years 1
Hypoglycemia Management
Treat hypoglycemia (glucose <70 mg/dL) with 15-20 grams of rapid-acting glucose, preferably pure glucose to reverse symptoms quickly. 2, 3
- Confirm blood glucose reversal with self-monitoring after 15 minutes; if hypoglycemia persists, repeat treatment until glucose normalizes 2, 3
- Prescribe glucagon to all patients at risk for severe hypoglycemia and train close contacts on administration to prevent mortality 2, 3
- Never continue aggressive glycemic targets in patients experiencing severe or frequent hypoglycemia as this is an absolute indication for regimen modification 2
Screening for Complications
Arrange annual comprehensive dilated eye examination by an ophthalmologist or optometrist starting immediately at diagnosis to detect diabetic retinopathy early. 2, 3
- Assess cardiovascular risk factors annually for all patients with diabetes to guide preventive interventions 2, 4
- Screen for neuropathy at diagnosis and annually thereafter 3
- Monitor urine albumin-to-creatinine ratio annually to detect diabetic nephropathy 4
Chronic Kidney Disease Management
For all patients with diabetes and chronic kidney disease, initiate comprehensive organ-protective therapy including SGLT2 inhibitors, metformin (if eGFR permits), RAS inhibitors, and moderate- or high-intensity statins. 3
Critical Pitfalls to Avoid
- Never delay cardiovascular risk factor management (statins, ACE inhibitors/ARBs, blood pressure control) as diabetes itself confers high cardiovascular risk 2
- Never initiate pioglitazone if the patient exhibits clinical evidence of active liver disease or ALT greater than 2.5 times the upper limit of normal 5
- Never mix LEVEMIR (insulin detemir) with other insulin preparations as this alters the pharmacokinetic profile and reduces efficacy 6
- Avoid intramuscular insulin injections, especially with long-acting insulins, because severe hypoglycemia may result; use the shortest needles (4-mm pen and 6-mm syringe needles) as first-line choice 1
- Never inject insulin into areas of lipohypertrophy as this distorts insulin absorption; rotate injection sites continuously within a given area 1, 6
Multidisciplinary Team Approach
Diabetes management requires a multidisciplinary team including physicians, nurse practitioners, dietitians, pharmacists, and mental health professionals, with shared decision-making and regular risk factor reassessment. 4, 3