Diabetes Mellitus-Management

Management

 

Glycemic Goals

HbA1c

  • American Diabetes Association (ADA) recommendations for HbA1c in adults with diabetes1
    • HbA1c targets in nonpregnant adults
      • HbA1c < 7% (53 mmol/mol) is a reasonable goal for many nonpregnant adults without significant hypoglycemia (ADA Grade A), but goal should be individualized based on
        • duration of diabetes
        • age and life expectancy
        • important comorbidities
        • presence of known cardiovascular disease or advanced microvascular complications
        • risks associated with hypoglycemia and other adverse drug effects
        • other individual considerations (such as patient preference and abilities, resources, and support system)
      • more stringent target, such as HbA1c < 6.5% (48 mmol/mol), may be reasonable if it can be achieved without significant hypoglycemia or other adverse effects of treatment (such as polypharmacy) for selected patients (ADA Grade C), such as those with
        • the short duration of diabetes
        • long life expectancy
        • no significant cardiovascular disease
      • less stringent target, such as HbA1c < 8% (64 mmol/mol), may be appropriate for patients with (ADA Grade B)
        • history of severe hypoglycemia
        • limited life expectancy
        • harms of treatment likely to outweigh the benefits
    • HbA1c monitoring
      • assess glycemic status using either HbA1c or another glycemic measurement at least twice/year in patients who have stable glycemic control and who are meeting treatment goals (ADA Grade E)
      • assess glycemic status as needed and at least every 3 months (quarterly) in patients not meeting treatment goals or if therapy changes (ADA Grade E)
      • point-of-care HbA1c testing may offer the opportunity for more timely therapy changes
  • see also
    • Management of Type 2 Diabetes in Adults
    • Glycemic Goals in Type 2 Diabetes

Glucose

  • glucose targets in nonpregnant adults1
    • preprandial plasma glucose 80-130 mg/dL (4.4-7.2 mmol/L)
    • peak postprandial plasma glucose < 180 mg/dL (< 10 mmol/L) 1-2 hours after beginning of meal
    • more or less stringent glucose targets may be appropriate based on same individual patient characteristics considered in setting HbA1c goals
  • American Diabetes Association (ADA) recommendations for monitoring of glucose targets includes1
    • self-monitoring of blood glucose (SMBG)
      • when prescribing SMBG, consider (ADA Grade E)
        • providing initial and ongoing instruction
        • confirming patient’s ability to use data to adjust therapy
        • providing routine follow-up of SMBG technique
      • SMBG may be useful to guide treatment decisions and/or self-management for patients using less frequent insulin injections (ADA Grade B)
      • SMBG might be helpful in patients using noninsulin therapies (particularly those associated with hypoglycemia) when altering medications and/or diet or exercise (ADA Grade E)
      • when to advise performing SMBG
        • advise patients using multiple daily insulin injections or insulin pump therapy to perform SMBG before meals and snacks, and at bedtime (ADA Grade B)
          • before exercise (ADA Grade B)
          • if low blood glucose suspected (ADA Grade B)
          • after treating low blood glucose, until normoglycemic (ADA Grade B)
          • prior to and during critical tasks, such as driving (ADA Grade B)
          • occasionally postprandially
        • additional glycemic monitoring might be useful for patients with type 2 diabetes not using insulin during periods of intercurrent illness (including trauma or surgery)
        • increased daily frequency of SMBG reported being associated with lower HbA1c and fewer acute complications in patients with type 1 diabetes
      • insufficient evidence for when to prescribe SMBG and how often SMBG needed for patients not using intensive insulin regimens
      • assessment of fasting glucose with SMBG in patients using basal insulin only reported being associated with lower HbA1c
      • some real-time continuous glucose monitoring (CGM) systems require SMBG confirmation for treatment decisions or user calibration
      • healthcare providers should be aware of differences in meter accuracy, and only use FDA-approved meters with unexpired strips, purchased from a pharmacy or licensed distributor (ADA Grade E)
      • consider that medications and other factors (such as high-dose vitamin C and hypoxemia) may interfere with the accuracy of glucose meters (ADA Grade E)
      • other factors that may interfere with accuracy of glucose meters include
        • high oxygen tension (such as use of arterial blood and oxygen therapy)
        • low oxygen tension (such as high altitude, hypoxia, or use of venous blood)
        • temperature
        • substances such as uric acid, galactose, xylose, acetaminophen, levodopa, and ascorbic acid with glucose oxidase monitors (or icodextrin, used in peritoneal dialysis, with glucose dehydrogenase monitors)
    • continuous glucose monitoring (CGM)
      • CGM measures interstitial glucose, which is reported to correlate well with plasma glucose
      • CGM devices can be adjunctive (requiring self-monitoring of blood glucose confirmation [SMBG]) or nonadjunctive (not requiring SMBG confirmation)
      • use of professional CGM and/or intermittent real-time or intermittently scanned CGM can help identify and correct patterns of hyper- and hypoglycemia and improve HbA1C levels in patients with diabetes on noninsulin or basal insulin regimens (ADA Grade C)
      • real-time CGM
        • real-time CGM in conjunction with multiple daily insulin injections and continuous subcutaneous insulin infusion (ADA Grade A) and other types of insulin therapy (ADA Grade C) is useful to lower HbA1C in adults and youth with diabetes
        • use real-time CGM as close to daily as possible for max benefit (ADA Grade A)
      • intermittently scanned CGM
        • intermittently scanned CGM in conjunction with multiple daily insulin injections and continuous subcutaneous insulin infusion (ADA Grade B) and other types of insulin therapy (ADA Grade C) may be useful to lower HbA1c and/or reduce hypoglycemia in adults and youth with diabetes to replace self-monitoring of blood glucose
        • intermittently scanned CGM devices should be scanned frequently, at minimum once every 8 hours
      • considerations for prescribing CGM
        • ensure patients have access to robust diabetes education, training, and support, and that they are able to perform self-monitoring of blood glucose to calibrate monitor and/or verify readings if discordant with symptoms (ADA Grade B)
        • patients successfully using CGM should continue to have access across third-party payers (ADA Grade E)
  • see also
    • Management of Type 2 Diabetes in Adults
    • Glycemic Goals in Type 2 Diabetes

Lifestyle Modifications

  • diet
    • variety of eating patterns are acceptable for the management of type 2 diabetes, including1
      • Dietary Approaches to Stop Hypertension (DASH) diet
      • Mediterranean diet
      • high-fiber diet
      • low-fat diet
      • vegetarian and vegan diets
      • low-carbohydrate diet
    • American Diabetes Association (ADA) nutrition recommendations for patients with type 2 diabetes1
      • individualize macronutrient intake (carbohydrate, protein, fat) considering total calorie and metabolic goals, since there is no one ideal dietary distribution of calories among macronutrients for patients with diabetes (ADA Grade E)
      • emphasize consumption of
        • A mediterranean-style diet rich in monounsaturated and polyunsaturated fats to improve glucose metabolism and reduce cardiovascular disease risk (ADA Grade B)
        • foods rich in omega-3 fatty acids such as fatty fish, nuts, and seeds to prevent or treat cardiovascular disease (ADA Grade B)
      • replace consumption of sugar-sweetened beverages (including fruit juices) with water in order to control glycemia and weight and reduce the risk for cardiovascular disease and fatty liver (ADA Grade B)
    • Academy of Nutrition and Dietetics (AND) recommends foods high in fiber (such as fruits, vegetables, whole grains, and legumes) in all patients with diabetes (AND Fair recommendation, Imperative statement) (AND 2015)
    • see also
      • Management of Type 2 Diabetes in Adults
      • Dietary Considerations for Patients With Type 2 Diabetes
  • physical activity
    • ADA recommendations for physical activity1
      • in adults with diabetes
        • perform moderate to vigorous-intensity physical activity ≥ 150 minutes/week (ADA Grade B)
          • exercise at least 3 days/week with no more than 2 consecutive days without exercise
          • shorter duration (minimum 75 minutes/week) of vigorous-intensity or interval training may be sufficient for younger and more physically fit individuals
        • perform resistance training at least 2-3 days/week on nonconsecutive days (unless contraindicated) (ADA Grade B)
      • in older adults with diabetes
        • encourage regular exercise, including aerobic activity, weight-bearing exercise, and/or resistance training, in all older adults who can safely participate in such activities (ADA Grade B)
        • flexibility and balance training recommended 2-3 times/week (ADA Grade C)
        • yoga and tai chi may increase flexibility, muscular strength, and balance (ADA Grade C)
    • American College of Sports Medicine (ACSM) recommendations for physical activity
      • perform moderate to vigorous-intensity physical activity ≥ 150 minutes/week; exercise at least 3 days/week with no more than 2 consecutive days without exercise (ACSM/ADA Grade B)
      • perform moderate to vigorous resistance training at least 2-3 days/week (ACSM/ADA Grade B)
      • Reference – Diabetes Care 2010 Dec;33(12):e147full-text
    • see also
      • Management of Type 2 Diabetes in Adults
      • Physical Activity for Type 2 Diabetes

Medications

Glucose-lowering Medications

  • American Diabetes Association (ADA) recommendations for glucose-lowering medications in adults with type 2 diabetes1
    • general recommendations
      • use a patient-centered approach to guide the choice of pharmacologic agents, considering factors such as cardiovascular and renal risk, hypoglycemia risk, effect on weight, cost, risk for adverse events, and patient preferences (ADA Grade E)
      • evaluate medication regimen every 3-6 months and adjust as needed to account for new patient factors (ADA Grade E) and glycemic control; for patients with diabetes, HbA1c is standard biomarker for glycemic control
      • do not delay intensification of treatment if patient is not achieving glycemic goals (ADA Grade A)
    • metformin is the preferred initial pharmacologic therapy for most patients with type 2 diabetes (ADA Grade A)
      • metformin should be continued as long as tolerated and not contraindicated (ADA Grade A)
      • for patients with stable heart failure, metformin may be used if estimated glomerular filtration rate > 30 mL/minute/1.73m2 but avoid in unstable or hospitalized patients with heart failure (ADA Grade B)
      • consider periodic assessment of vitamin B12 levels in patients treated with metformin (especially if anemia or peripheral neuropathy) since long-term metformin use may be associated with vitamin B12 deficiency (ADA Grade B)
      • if metformin is contraindicated or intolerable, a select initial drug from another class
    • for patients at high risk of or with known atherosclerotic cardiovascular disease (or indicators of high atherosclerotic cardiovascular disease risk), heart failure, or established kidney disease, add as a second-line agent either glucagon-like peptide 1 (GLP-1) receptor agonist or sodium-glucose cotransporter-2 (SGLT-2) inhibitor (if adequate estimated glomerular filtration rate) demonstrated to reduce cardiovascular disease events, independent of HbA1c and in consideration of patient-specific factors (ADA Grade A)
      • for patients with established atherosclerotic cardiovascular disease or multiple risk factors for atherosclerotic cardiovascular disease
        • an SGLT-2 inhibitor and/or GLP-1 receptor agonist with demonstrated cardiovascular benefit is recommended (ADA Grade A)
          • for patients on an SGLT-2 inhibitor who require further intensification of therapy, consider adding a GLP-1 receptor agonist with demonstrated cardiovascular disease benefit
          • for patients on a GLP-1 receptor agonist who require further intensification of therapy, consider adding an SGLT-2 inhibitor with demonstrated cardiovascular disease benefit
        • if HbA1c is above target with second-line agent or the patient is unable to tolerate either GLP-1 receptor agonist or SGLT-2 inhibitor, consider adding 1 of the following cardiovascular neutral agents
          • basal insulin
          • dipeptidyl peptidase 4 inhibitors if not on GLP-1 receptor agonist
          • thiazolidinedione – – low dose is not well studied for cardiovascular disease effects, but might be better tolerated
          • sulfonylurea – later generations suggested due to lower risk of hypoglycemia (glimepiride may have similar cardiovascular safety as dipeptidyl peptidase 4 [DPP-4] inhibitor)
      • for patients with heart failure
        • for patients with stable heart failure, metformin may be continued for glucose lowering if estimated glomerular filtration rate > 30 mL/minute/1.73m2, but should be avoided in those who are hospitalized or become otherwise unstable (ADA Grade B)
        • an SGLT-2 inhibitor with proven benefit for this population is recommended to reduce worsening heart failure risk and cardiovascular death (ADA Grade A); (empagliflozin, canagliflozin, and dapagliflozin have demonstrated reduction in heart failure)
        • thiazolidinediones not recommended in patients with symptomatic heart failure due to association with increased risk of heart failure
      • for patients with diabetic kidney disease
        • for patients with estimated glomerular filtration rate ≥ 30 mL/min1.73m2and urinary albumin > 300 mg/g creatinine, offer an SGLT-2 inhibitor to decrease risk or progression of chronic kidney and to reduce risk for cardiovascular events (ADA Grade A)
          • CLINICIANS’ PRACTICE POINT

             
            Different SGLT-2 inhibitors have different official estimated glomerular filtration rate cut-points for SGLT-2 inhibitor use, though some studies have supported use at estimated glomerular filtration rate cutoffs below the official cut-points.
        • for patients with increased risk for cardiovascular events, offer GLP-1 receptor agonist to reduce albuminuria (as a renal endpoint), progression of albuminuria, and cardiovascular events (ADA Grade A)
      • for patients with no diabetic kidney disease or albuminuria but with increased risk of cardiovascular events, options include either GLP-1 receptor agonist or SGLT-2 inhibitor with proven cardiovascular disease benefit
      • for patients without atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease and HbA1c above target, add an additional antihyperglycemic medication based on drug-specific and patient factors; options include (in no particular order)
        • sulfonylurea (or rapid-acting secretagogues [meglitinides] in patients with irregular meal schedules who develop late postprandial hypoglycemia on sulfonylureas)
        • thiazolidinedione
        • dipeptidyl peptidase IV (DPP-4) inhibitor
        • SGLT2 inhibitor
        • GLP-1 receptor agonist
    • additional medications for adults
      • many patients with type 2 diabetes and HbA1c ≥ 1.5% above glycemic target will require dual therapy (metformin + additional agent) and some patients may require triple therapy (metformin + additional agents) to achieve the glycemic target
        • in adults with type 2 diabetes and HbA1c ≥ 1.5%-2% above glycemic target, consider early combination therapy at treatment initiation to prolong the time to treatment failure (ADA Grade A)
        • continue to use metformin in combination with other medications (including insulin) if tolerated and not contraindicated (ADA Grade A)
        • timing of combination therapy initiation
          • stepwise addition of agents currently recommended
          • some evidence supports initial combination therapy
        • choice of additional medication based on presence of comorbidities, risk of adverse drug effects, safety, tolerability, and cost
        • for patients without atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, add an additional antihyperglycemic medication based on drug-specific and patient factors; options include (in no particular order)
          • sulfonylurea (or rapid-acting secretagogues [meglitinides] in patients with irregular meal schedules who develop late postprandial hypoglycemia on sulfonylureas)
          • thiazolidinedione
          • dipeptidyl peptidase IV (DPP-4) inhibitor
          • SGLT-2 inhibitor
          • GLP-1 receptor agonist
        • in patients with overweight or obesity, consider the effect on weight when choosing glucose-lowering medications (ADA Grade B)
      • in patients on dual/triple therapy with HbA1c above target, consider injectable therapy
        • in patients who require greater glucose-lowering than can be achieved with oral agents alone, GLP-1 receptor agonists are preferred over insulin when possible due to their favorable effects on weight and hypoglycemia risk (ADA Grade A)
          • consider HbA1c, patient preferences, frequency of injection, weight-lowering effect, and if patient has cardiovascular disease
          • for patients with cardiovascular disease, consider GLP-1 receptor agonist with proven cardiovascular disease benefit
          • consider starting the lowest dose and then gradually titrating to maintenance dose, which varies within class, to limit side effects
        • consider early introduction of insulin (at diagnosis or as the first injectable therapy) in patients with any of the following
          • weight loss or other evidence of ongoing catabolism (ADA Grade E)
          • symptomatic hyperglycemia (such as polyuria or polydipsia) (ADA Grade E)
          • HbA1c > 10% (86 mmol/mol) or blood glucose levels ≥ 300 mg/dL (16.7 mmol/L) (ADA Grade E)
    • considerations in older adults
      • lower glycemic goals, such as HbA1c < 7%-7.5% (53-58 mmol/mol), should be used for older adults who are otherwise healthy and have few coexisting chronic illnesses and intact cognitive and functional status (ADA Grade C)
      • less stringent glycemic goals, such as HbA1c < 8%-8.5% (64-69 mmol/mol), should be used for older adults with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence (ADA Grade C)
      • glycemic goals for some older adults may be relaxed as part of individualized care, but avoid hyperglycemia leading to symptoms and risk of acute hyperglycemia complications (ADA Grade C)
      • consider the assessment of functional (self-management abilities), medical, psychological, and social geriatric domains in older adults to help determine targets and therapeutic approaches for diabetes management (ADA Grade B)
  • see also
    • Management of Type 2 Diabetes in Adults
    • Glucose-lowering Medications for Type 2 Diabetes
    • Insulin Management

Weight Loss Medications

  • American Diabetes Association (ADA) recommendations for weight loss medications in patients with diabetes1
    • in selected patients with type 2 diabetes and body mass index (BMI) ≥ 27 kg/m2, weight loss medications may be effective as adjuncts to diet, physical activity, and behavioral counseling; possible benefits should be weighed against possible medication risks (ADA Grade A)
    • if a patient taking weight loss medication has an insufficient response (defined as < 5% weight loss after 3 months), or if the patient has tolerability or significant safety issues at any time, discontinue medication and consider alternative medication or approach to treatment (ADA Grade A)
  • see also
    • Management of Type 2 Diabetes in Adults
    • Medications for Weight Loss in Patients With Diabetes

Management of Comorbidities

Cardiovascular Disease Risk Factors

Dyslipidemia
  • monitoring for dyslipidemia1
    • in adults < 40 years old who are not taking statins or other lipid-lowering therapy, consider measuring lipid levels at time of diabetes diagnosis, at initial medical evaluation, and at 5-year intervals, or more frequently if indicated (ADA Grade E); more frequent lipid profiles may be reasonable if longer duration of diabetes
    • to monitor response and adherence to therapy, measure lipid levels at start of statin therapy or other lipid-lowering therapy, 4-12 weeks after starting therapy or changing dose, and once annually thereafter (ADA Grade E)
  • lipid goals for adults with diabetes
    • some guideline organizations recommend lipid goals for adults with diabetes while others make recommendations based on atherosclerotic cardiovascular disease (ASCVD) risk
      • American Association of Clinical Endocrinologists/American Collage of Endocrinology (AACE/ACE) and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) each recommend goal lipid targets based on patient’s ASCVD risk status
      • American Diabetes Association (ADA) and multisociety guideline from American Heart Association (AHA) and others recommend initiation of statin therapy and dose intensification based primarily on ASCVD risk status rather than lipid targets
    • see Lipid Management in Diabetes for additional information
  • management options for dyslipidemia
    • lifestyle modifications recommended to improve lipid profile in adults with diabetes include1
      • losing weight if appropriate (ADA Grade A)
      • use of Mediterranean style or Dietary Approaches to Stop Hypertension (DASH) eating pattern (ADA Grade A)
      • reducing intake of saturated fat, trans fat, and cholesterol (ADA Grade A)
      • increasing intake of omega-3 fatty acids, fiber, and plant stanols/sterols (ADA Grade A)
      • increasing physical activity (ADA Grade A)
    • medications
      • lipid-lowering drug therapy is effective for primary and secondary prevention of major coronary events in patients with diabetes 
        DynaMed Level1
      • statins recommended for primary prevention of cardiovascular disease and LDL-C lowering in most adults (especially those ≥ 40 years old) and some children with diabetes1
        • prescribe a moderate-intensity statin (in addition to lifestyle therapy) for most adults aged 40-75 years with diabetes and without atherosclerotic cardiovascular disease (ADA Grade A)
        • consider prescribing a statin (in addition to lifestyle therapy) in patients aged 20-39 years with cardiovascular risk factors (ADA Grade C)
      • other lipid-lowering drugs
        • alternative drug therapy and combination therapy with statins generally not recommended in absence of atherosclerotic cardiovascular disease, but may be considered if statins contraindicated, not tolerated, or not achieving treatment targets1
        • addition of another drug should be considered for lowering LDL-C in adults with diabetes and atherosclerotic cardiovascular disease if LDL-C targets not met on maximally tolerated statin dose; options include1
          • ezetimibe (ADA Grade A), which may be preferred due to lower cost
          • proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors (ADA Grade A)
        • drugs for management of hypertriglyceridemia (triglycerides > 500 mg/dL [5.65 mmol/L]) in adults
          • evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce risk of pancreatitis (ADA Grade C)1
          • fibrates for triglycerides > 500 mg/dL (5.65 mmol/L) (AACE/ACE Grade A, Level 1) (Endocr Pract 2017 Apr;23(Suppl 2):1)
        • bile acid sequestrants may be considered for reducing LDL-C and apolipoprotein B and modestly increasing high-density lipoprotein cholesterol (HDL-C), but may increase triglycerides (AACE/ACE Grade A, Level 1) (Endocr Pract 2017 Apr;23(Suppl 2):1)
        • niacin not recommended in patients aggressively treated with statins due to
          • lack of additional benefits if LDL-C is well-controlled (AACE/ACE Grade A, Level 1) (Endocr Pract 2017 Apr;23(Suppl 2):1)
          • risk for stroke and additional side effects (ADA Grade A)1
        • fibrates with evidence showing efficacy for primary and secondary prevention of cardiovascular events in adults with diabetes include gemfibrozil 
          DynaMed Level2

           and fenofibrate 

          DynaMed Level2
        • treatments with evidence showing efficacy for improving lipid levels in adults with diabetes include colesevelam (a bile acid sequestrant), ezetimibe/statin combination therapy, and niacin 
          DynaMed Level3
Hypertension
  • monitoring for hypertension1
    • measure blood pressure at every routine visit (ADA Grade B)
    • confirm elevated blood pressure (≥ 140/90 mm Hg) with multiple readings on a separate day before diagnosing hypertension (ADA Grade B)
    • advise all patients with hypertension and diabetes to monitor their blood pressure at home (ADA Grade B)
  • blood pressure goals in adults with diabetes and hypertension1
    • individualize blood pressure targets through a shared decision-making process that incorporates cardiovascular risk, potential adverse effects of antihypertensive medications, and patient preferences (ADA Grade C)
    • for adults with low risk of cardiovascular disease (10-year atherosclerotic cardiovascular risk < 15%), blood pressure targets are
      • systolic blood pressure < 140 mm Hg (ADA Grade A)
      • diastolic blood pressure < 90 mm Hg (ADA Grade A)
    • for adults with a high risk of atherosclerotic cardiovascular disease (10-year atherosclerotic cardiovascular risk ≥ 15%), lower blood pressure targets may be appropriate if they can be safely achieved, such as
      • systolic blood pressure < 130 mm Hg (ADA Grade C)
      • diastolic blood pressure < 80 mm Hg (ADA Grade C)
  • management options for hypertension
    • lifestyle interventions are recommended for patients with systolic blood pressure > 120 mm Hg or diastolic blood pressure > 80 mm Hg, including (ADA Grade A)1
      • weight loss in those with overweight or obesity
      • Dietary Approaches to Stop Hypertension (DASH)-style eating pattern (including reducing sodium intake and increasing potassium)
      • moderation of alcohol intake
      • increased physical activity
    • pharmacologic approaches (in addition to lifestyle management)
      • in patients with confirmed office-based blood pressure ≥ 140/90 mm Hg, prompt initiation and timely titration of pharmacology therapy is recommended in addition to lifestyle interventions (ADA Grade A)1
      • American Diabetes Association (ADA) recommends antihypertensive therapy that includes drug classes demonstrated to reduce cardiovascular events in patients with diabetes (ADA Grade A); options include1
        • angiotensin-converting enzyme (ACE) inhibitor
          • for patients with urinary albumin to creatinine ratio ≥ 300 mg/g creatinine and/or estimated glomerular filtration rate < 60 mL/minute/1.73 m2 (ADA Grade A)
          • for patients with urinary albumin to creatinine ratio 30-299 mg/g creatinine (ADA Grade B)
        • angiotensin receptor blocker (ARB)
          • for patients with urinary albumin to creatinine ratio ≥ 300 mg/g creatinine and/or estimated glomerular filtration rate < 60 mL/minute/1.73 m2 (ADA Grade A)
          • for patients with urinary albumin to creatinine ratio 30-299 mg/g creatinine (ADA Grade B)
        • alternative classes of antihypertensive therapy, such as
          • dihydropyridine calcium channel blocker
          • thiazide-like diuretic
      • in patients with confirmed office-based blood pressure ≥ 160/100 mm Hg, prompt initiation and timely titration of 2 antihypertensive agents or a single-pill combination of drugs (with evidence for reduced cardiovascular events in patients with diabetes) is recommended in addition to lifestyle interventions (ADA Grade A)1
      • multiple drug therapy is usually necessary to achieve blood pressure targets; however, combinations that should not be used include ACE inhibitors with ARBs, and ACE inhibitors or ARBs with direct renin inhibitors (ADA Grade A)1
      • consider additional therapy with mineralocorticoid receptor antagonist in patients with resistant hypertension who are not meeting blood pressure targets on 3 classes of antihypertensive therapy (including a diuretic) (ADA Grade B)1
      • monitor serum creatinine estimated glomerular filtration rate (GFR), and serum potassium levels at least annually in patients treated with ACE inhibitors, ARBs, or diuretics (ADA Grade B)1
  • see for details
    • Management of Type 2 Diabetes in Adults
    • Hypertension Treatment in Patients With Diabetes.
 
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Cardiovascular Disease

  • monitoring for cardiovascular disease1
    • routine screening for coronary artery disease is not recommended in asymptomatic patients as it does not appear to improve outcomes assuming atherosclerotic cardiovascular risk factors are treated (ADA Grade A)
    • consider evaluating for coronary artery disease in patients with any of (ADA Grade E)
      • atypical cardiac symptoms (for example, unexplained dyspnea or chest discomfort)
      • symptoms or signs associated with vascular disease, including carotid bruits, transient ischemic attack, stroke, claudication, or peripheral arterial disease
      • abnormal electrocardiogram (for example, Q waves)
  • management of patients with known atherosclerotic cardiovascular disease1
    • use angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy in patients with known atherosclerotic cardiovascular disease (especially coronary artery disease) to reduce risk of cardiovascular events (ADA Grade A)
    • statins
      • high-intensity statins in addition to lifestyle therapy are recommended for all patients with diabetes and atherosclerotic cardiovascular disease, regardless of age (ADA Grade A)
      • considerations in patients > 75 years old
        • for patients on statin therapy, consider continuing therapy (ADA Grade B)
        • for patients not on statin therapy, consider initiating statin therapy after discussing potential risks and benefits (ADA Grade C)
    • antiplatelet therapy
      • primary prevention of cardiovascular disease
        • consider aspirin 75-162 mg/day orally in patients with diabetes (type 1 or type 2) and increased cardiovascular risk, but only after a comprehensive discussion with the patient and if benefits are deemed to outweigh the risk of bleeding (ADA Grade A)
        • aspirin is not recommended for adults with diabetes who are at low risk for atherosclerotic cardiovascular disease, including men or women < 50 years old with no other major cardiovascular risk factors
      • secondary prevention of cardiovascular disease
        • aspirin 75-162 mg/day orally is recommended in patients with diabetes and a history of atherosclerotic cardiovascular disease (ADA Grade A)
        • clopidogrel 75 mg/day orally is an alternative to aspirin for patients with a documented aspirin allergy (ADA Grade B)
        • dual antiplatelet therapy (low-dose aspirin plus P2Y12 inhibitor) can be used for up to 1 year after acute coronary syndrome and may be beneficial beyond 1 year (ADA Grade A)
        • consider long-term treatment with dual antiplatelet therapy for patients with prior coronary intervention, high ischemic risk, and low risk of bleeding to prevent major cardiovascular adverse events (ADA Grade A)
        • consider combination therapy with aspirin plus low-dose rivaroxaban for patients with stable coronary and/or peripheral artery disease and low risk of bleeding to prevent major limb and cardiovascular adverse events (ADA Grade A)
  • see Management of Type 2 Diabetes in Adults for additional information

Overweight or Obesity

  • American Diabetes Association (ADA) management strategies for patients with type 2 diabetes with overweight or obesity1
    • calculate body mass index (BMI) at annual visits (or more frequently) (ADA Grade E)
    • prescribe diet, physical activity, and behavioral therapy aimed at achieving and maintaining ≥ 5% weight loss (ADA Grade B)
    • medications
      • consider effect on weight when choosing glucose-lowering medications (ADA Grade B)
      • if possible, minimize medications associated with weight gain that have been prescribed for comorbid conditions (ADA Grade E)
      • in patients with BMI ≥ 27 kg/m2, weight-loss medications may be effective as adjuncts to diet, physical activity, and behavioral counseling, taking into account potential benefits and risks of use (ADA Grade A)
      • if patient taking weight-loss medication has insufficient response (defined as < 5% weight loss after 3 months) or if patient has tolerability or significant safety issues at any time, discontinue medication and consider alternative medication or approach to treatment (ADA Grade A)
    • bariatric (metabolic) surgery
      • ADA uses the term metabolic surgery rather than bariatric surgery to reinforce the role of surgery in treatment of type 2 diabetes
      • indications for metabolic surgery for adults with type 2 diabetes mellitus
        • metabolic surgery recommended if 1 of the following
          • BMI is ≥ 40 kg/m2 (≥ 37.5 kg/m2 if Asian descent), regardless of complexity of glucose-lowering regimens and level of glycemic control (ADA Grade A)
          • BMI is 35-39.9 kg/m2 (32.5-37.4 kg/m2 if Asian descent) and hyperglycemia is inadequately controlled despite lifestyle changes and optimal medical therapy (ADA Grade A)
        • consider metabolic surgery when BMI is 30-34.9 kg/m2 (27.5-32.4 kg/m2 if Asian descent), if unable to achieve durable weight loss, and if hyperglycemia is inadequately controlled despite lifestyle changes and optimal medical therapy (ADA Grade A)
      • prior to metabolic surgery, evaluate patient for comorbid psychological conditions and social circumstances that may potentially interfere with outcomes of surgery (ADA Grade B)
      • perform metabolic surgery in high-volume center with multidisciplinary team that understands and has experience in managing diabetes and gastrointestinal surgery (ADA Grade E)
      • follow-up after surgery
        • provide long-term lifestyle support and routine monitoring of micronutrient and nutritional status (ADA Grade C)
        • assess need for ongoing mental health services to help patients adjust to medical and psychosocial changes (ADA Grade C)
  • see Management of Type 2 Diabetes in Adults for additional information

Diabetic Retinopathy

  • American Diabetes Association (ADA) recommendations for monitoring for diabetic retinopathy1
    • patients with type 2 diabetes should have an initial dilated and comprehensive eye exam performed by an ophthalmologist or optometrist at the time of diabetes diagnosis (ADA Grade B)
    • follow-up exams
      • subsequent exams by ophthalmologist or optometrist recommended at least annually in patients with diabetic retinopathy (ADA Grade B)
      • if no evidence of retinopathy at ≥ 1 annual eye exam in patients with well-controlled glycemia consider screening every 1-2 years (ADA Grade B)
      • if retinopathy is progressive or sight-threatening, perform more frequent eye exams (ADA Grade B)
  • ADA recommendations for management of diabetic retinopathy1
    • optimize glycemic control, blood pressure, and serum lipid levels to reduce risk or slow progression of diabetic retinopathy (ADA Grade A)
    • for patients with macular edema, severe nonproliferative diabetic retinopathy (a precursor of proliferative diabetic retinopathy) or proliferative diabetic retinopathy, immediately refer patient to ophthalmologist with experience in the management of diabetic retinopathy (ADA Grade A)
    • for patients with high-risk proliferative diabetic retinopathy (or in some cases, severe nonproliferative diabetic retinopathy)
      • panretinal laser photocoagulation therapy is recommended to reduce risk of vision loss (ADA Grade A)
      • alternatively, intravitreal injections of antivascular endothelial growth factor ranibizumab (reported to not be inferior to panretinal laser photocoagulation therapy) is recommended to reduce risk of vision loss (ADA Grade A)
    • for patients with central-involved diabetic macular edema (occurs below foveal center and may affect reading vision), intravitreal injections of antivascular endothelial growth factor is recommended (ADA Grade A)
    • for patients with retinopathy, aspirin therapy for cardioprotection is not contraindicated since aspirin does not increase risk of retinal hemorrhage (ADA Grade A)
  • see Management of Type 2 Diabetes in Adults for additional information
  • see also Diabetic Retinopathy

Diabetic Kidney Disease

  • American Diabetes Association (ADA) recommendations for monitoring for diabetic kidney disease 1
    • at least annually, assess urinary albumin (such as spot urinary albumin to creatinine ratio) and estimated glomerular filtration rate (GFR) in all patients with type 2 diabetes regardless of treatment (ADA Grade B)
    • monitor twice annually to guide therapy in patients with urinary albumin > 300 mg/g creatinine and/or estimated GFR 30-60 mL/minute/1.73 m2 (ADA Grade B)
    • if ACE inhibitors, ARBs, or diuretics are used, periodically assess serum creatinine and potassium levels to assess for increased creatinine or changes in potassium (ADA Grade B)
  • ADA recommendations for management of diabetic kidney disease 1
    • promptly refer to nephrologist if evidence of progressive kidney disease (such as loss of kidney function and worsening albuminuria), uncertainty of etiology of kidney disease, or difficult management issues (ADA Grade A)
    • optimize glucose control and blood pressure control to reduce risk for or slow progression of chronic kidney disease (CKD) (ADA Grade A)
    • in patients with type 2 diabetes and diabetic kidney disease with estimated GFR ≥ 30 mL/minute/1.73 m2 and/or urinary albumin to creatinine ratio > 300 mg/g, offer sodium-glucose cotransporter (SGLT-2) inhibitors to reduce risk of progression of CKD and/or cardiovascular events (ADA Grade A)
    • in patients with chronic kidney disease and increased risk of cardiovascular events, offer glucagon-like peptide 1 (GLP-1) receptor agonist to reduce risk of progression of albuminuria and/or cardiovascular events (ADA Grade A)
    • in the absence of volume depletion, do not discontinue renin-angiotensin system blockade for minor (< 30%) increases in serum creatinine (ADA Grade A)
    • dietary protein restriction
      • recommended daily protein allowance 0.8 g/kg/day for patients with nondialysis-dependent nephropathy (ADA Grade A )
      • consider higher protein intake for patients on dialysis (ADA Grade B)
    • preventative angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs)
      • in nonpregnant patients with hypertension
        • use an ACE inhibitor or ARB if urinary albumin to creatinine ratio ≥ 300 mg/g creatinine and/or estimated GFR < 60 mL/minute1.73 m2 (ADA Grade A)
        • consider an ACE inhibitor or ARB if modestly elevated urinary albumin to creatinine ratio (30-299 mg/g creatinine) (ADA Grade B)
      • do not use ACE inhibitors or ARBs in normotensive patients with normal albumin to creatinine ratio (< 30 mg/g), and normal estimated GFR (ADA Grade A)
    • refer to a nephrologist for evaluation for potential need for renal replacement therapy if estimated GFR < 30 mL/minute/1.73 m2 (ADA Grade A)
  • see Diabetic Kidney Disease for additional information

Diabetic Neuropathy

  • American Diabetes Association (ADA) recommendations for monitoring for diabetic neuropathy1
    • screen all patients for diabetic peripheral neuropathy at least annually starting at diagnosis of type 2 diabetes (ADA Grade B)
    • screening for distal symmetric polyneuropathy should include careful history and assessment of (ADA Grade B)
      • temperature discrimination or pinprick sensation (for small-fiber function)
      • vibration sensation using a 128 hertz (Hz) tuning fork (for large-fiber function)
      • light touch perception with 10 g monofilament testing to identify risk of ulceration and amputation
    • in patients with microvascular complications, screen for signs and symptoms of autonomic neuropathy (ADA Grade E)
    • electrophysiological testing or referral to neurologist is rarely needed, unless patient has atypical clinical features or diagnosis is unclear
  • ADA recommendations for management of diabetic neuropathy1
    • optimize glucose control to prevent or delay development of neuropathy (ADA Grade A)
    • assess and treat patients to reduce
      • pain related to diabetic peripheral neuropathy (ADA Grade B)
      • symptoms of autonomic neuropathy and to improve quality of life (ADA Grade E)
    • for initial treatment of neuropathic pain in patients with diabetes, recommend pregabalin, duloxetine, or gabapentin (ADA Grade A)
  • see Diabetic Peripheral Neuropathy for additional information

Psychosocial Management

  • American Diabetes Association (ADA) recommendations for psychosocial assessment and care of adults with diabetes1
    • psychosocial care should be collaborative with a patient-centered approach with a goal of optimizing health outcomes and health-related quality of life for patients with diabetes (ADA Grade A)
    • psychosocial screening and follow-up may include (but are not limited to) (ADA Grade E)
      • attitudes about illness
      • expectations for medical management and outcomes
      • affect/mood
      • general and diabetes-related quality of life
      • resources (financial, social, and emotional)
      • psychiatric history
    • perform routine screening for psychosocial problems (such as depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment) at initial visit, periodic intervals, and if change in disease, treatment, or life circumstances (ADA Grade B)
      • use patient-appropriate standardized and validated tools
      • include caregivers and family members in screening process
    • consider screening adults ≥ 65 years old for cognitive impairment and depression (ADA Grade B)
    • for men with diabetes and symptoms or signs of hypogonadism (such as decreased sexual desire or activity or erectile dysfunction), consider screening with morning serum testosterone level (ADA Grade B)
  • see Management of Type 2 Diabetes in Adults for additional information

Management of Hypoglycemia

  • American Diabetes Association (ADA) recommendations for acute treatment of hypoglycemia (at alert value of ≤ 70 mg/dL [3.9 mmol/L]) in patients with diabetes1
    • if conscious (ADA Grade B)
      • glucose 15-20 g orally is preferred (for example, glucose tablets) for any individual with blood glucose < 70 mg/dL (3.9 mmol/L), but any glucose-containing carbohydrate is acceptable
      • check blood glucose after 15 minutes and repeat treatment if hypoglycemia persists
      • individual should consume meal or snack once blood glucose normalizes to prevent hypoglycemia recurrence
    • avoid use of protein-rich carbohydrate sources for treating or preventing hypoglycemia because ingested protein may increase insulin response without increasing plasma glucose (ADA Grade B)
    • added fat content to carbohydrate source may slow glucose absorption and prolong time to glycemic recovery
    • if unconscious, unable, or unwilling to take glucose orally, glucagon is indicated
  • prescribe glucagon to all patients at risk for level 2 or level 3 hypoglycemia (defined as blood glucose < 54 mg/dL [3 mmol/L]) and instruct caregivers, school personnel, or family members on its use (ADA Grade E)1
  • see Hypoglycemia in Diabetes for additional information

Hospitalized Patients

  • American Diabetes Association (ADA) recommendations for critically ill patients1
    • consult with a specialized diabetes or glucose management team when possible when caring for hospitalized patients with diabetes (ADA Grade C)
    • measure HbA1c levels in patients with diabetes or hyperglycemia (blood glucose > 140 mg/dL [7.8 mmol/L]) admitted to hospital if not performed in previous 3 months (ADA Grade B)
    • insulin therapy
      • continuous IV insulin is preferred route of insulin in intensive care unit; frequent glucose monitoring (every 30 minutes to 2 hours) is required while using IV insulin
      • insulin therapy is recommended for persistent hyperglycemia starting at threshold ≥ 180 mg/dL (≥ 10 mmol/L) (ADA Grade A)
      • use validated written or computerized IV insulin protocols that allow for predefined infusion rate adjustments based on glycemic fluctuations and insulin dosage (ADA Grade B)
      • do not use sliding-scale insulin as sole regimen in hospitalized patients (ADA Grade A)
    • target glucose range
      • after starting insulin, target glucose range 140-180 mg/dL (7.8-10 mmol/L) recommended for most critically ill patients (ADA Grade A)
      • more stringent target glucose range, such as 110-140 mg/dL (6.1-7.8 mmol/L), may be considered for select patients if significant hypoglycemia can be avoided (ADA Grade C)
    • establish plan for prevention and treatment of hypoglycemia for each patient, including documentation of hypoglycemia episodes (ADA Grade E)
    • review treatment regimen if blood glucose ≤ 70 mg/dL (< 3.9 mmol/L) and change if necessary to prevent further hypoglycemia (ADA Grade C)
    • establish a structured discharge plan that is tailored to individual patient (ADA Grade B)
  • ADA recommendations for noncritically ill patients1
    • consult with a specialized diabetes or glucose management team when possible when caring for hospitalized patients with diabetes (ADA Grade C)
    • measure HbA1c levels in patients with diabetes or hyperglycemia (blood glucose > 140 mg/dL [7.8 mmol/L]) admitted to hospital if not performed in previous 3 months (ADA Grade B)
    • insulin therapy is recommended for persistent hyperglycemia starting at threshold ≥ 180 mg/dL (≥ 10 mmol/L) (ADA Grade A)
    • if intensive glucose control necessitates insulin, use validated written or computerized IV insulin protocols that allow for predefined infusion rate adjustments based on glycemic fluctuations and insulin dosage (ADA Grade B)
    • do not use sliding-scale insulin as sole regimen in hospitalized patients (ADA Grade A)
    • target glucose range
      • after starting insulin, target glucose range 140-180 mg/dL (7.8-10 mmol/L) recommended for most noncritically ill patients (ADA Grade A)
      • more stringent target glucose range, such as 110-140 mg/dL (6.1-7.8 mmol/L), may be considered for select patients if significant hypoglycemia can be avoided (ADA Grade C)
    • insulin regimen with basal, prandial, and correction components preferred method for glucose control in noncritically ill patients who have good nutritional intake (ADA Grade A)
    • use basal insulin or basal plus bolus correction insulin for those who are taking nothing by mouth or have a limited oral intake (ADA Grade A)
    • establish plan for prevention and treatment of hypoglycemia for each patient, including documentation of hypoglycemia episodes (ADA Grade E)
    • review treatment regimen if blood glucose ≤ 70 mg/dL (< 3.9 mmol/L) and change if necessary to prevent further hypoglycemia (ADA Grade C)
    • establish a structured discharge plan that is tailored to the individual patient (ADA Grade B)