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–Lifestyle optimization is essential for all patients with diabetes but should not delay starting pharmacotherapy.
–Weight loss: reduced-calorie meal plan, physical activity, behavioral intervention, consider weight-loss medication.
–HbA1c target ≤6.5% is optimal, but higher targets may be appropriate for patients who are older and with other serious illness.
–Minimize the risk of hypoglycemia; individualize both fasting and post-prandial glucose targets.
–Control lipids and blood pressure.
–Metformin is first-line medication but combination therapy is usually necessary—choose agents with complementary mechanisms of action.
–Monitor therapy Q 3 mo until stable (HbA1c, SMBG records, weight, BP, lipids).
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–Self-monitoring blood glucose ≥3 times daily in all patients using multiple insulin injections or an insulin pump.
–Recommends HgbA1c every 3 mo if therapy has changed or if blood glucose control is inadequate.
–Provide diabetes self-management education, including education about hypoglycemia management and adjustments during illness.
–Provide family planning for women of reproductive age.
–Provide medical nutrition therapy.
–Weight loss is recommended for all overweight or obese diabetic patients.
–Keep saturated fat intake <7% of total calories.
–Reduction of protein intake to 0.8–1.0 g/kg/d for early stages of CKD and 0.8 g/kg/d for later stages of CKD.
–Recommends at least 150 min/wk of moderate physical activity.
–The glucose range for critically ill patients is 140–180 mg/dL.
–The glucose range for noncritically ill patients in the hospital is <140 mg/dL premeal (<7.8 mmol/L) and random blood glucose <180 mg/dL (<10 mmol/L).
–Recommends the following:
Immunizations
Annual influenza vaccination if age ≥6 mo.
Pneumococcal polysaccharide vaccine if age >2 y.
Revaccinate with pneumococcal polysaccharide vaccine when age ≥65 y and > 5 y since first dose.
Hepatitis B vaccination if unvaccinated and age 19–59 y.
Target BP <130/80 mm Hg.
Statin therapy if:
Overt CVD present.
Age >40 y and ≥1 CV risk factor.
LDL >100 mg/dL despite lifestyle modification.
LDL >70 mg/dL if DM2 and overt CVD.
ASA 75–162 mg/d if:
Check annually:
Urine albumin-to-creatinine ratio.
Serum creatinine.
Fasting lipid profile.
Dilated funduscopic exam.
Monofilament screening for diabetic neuropathy.
Comprehensive foot exam.
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Glycemic control recommendations:
Preprandial glucose: 70–130 mg/dL.
Postprandial glucose: <180 mg/dL (1–2 h postmeals).
HgbA1c <7%.
Consider bariatric surgery if BMI ≥40 kg/m2 (≥37.5 kg/m2 in Asian Americans), or ≥35 kg/m2 and diabetes is difficult to control with lifestyle modification and medications.
ACEIs or ARBs are first-line antihypertensives.
Second-line antihypertensives are a calcium channel blocker, or thiazide diuretic if GFR ≥30 mL/min/1.73 m2 or a loop diuretic if GFR <30 mL/min/1.73 m2.
Clopidogrel 75 mg/d is an alternative for persons ASA intolerant.
Nephrology referral indicated if GFR <60 mL/min/1.73 m2, or if heavy proteinuria or structural kidney disease present.
Consider a serum TSH in women age >50 y.
Consider assessing patients for the following comorbidities that are increased with DM:
Hearing impairment.
Obstructive sleep apnea.
Fatty liver disease.
Low testosterone in men.
Periodontal disease.
Cognitive impairment.
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International Diabetes Federation 2017
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–General target for HbA1c in Type 2 diabetes (T2D) is <7%; up to 8% may be appropriate in patients with <10 y life expectancy.
–SMBG is mandatory for patients using insulin, and useful when adjusting medications, during acute illness, as an education tool for self-care.
–Patient education is a cornerstone to diabetes management and should, at a minimum, involve the PCP, a trained diabetic educator, and a structured education program.
–Lifestyle recommendations include: weight loss, exercise (150 min/wk), a high-fiber, low-glycemic index foods diet and smoking cessation.
–Consider anti-obesity drugs in T2D patients with BMI ≥ 27 kg/m2.
–Encourage smoking cessation and limiting alcohol intake.
–Consider referral to bariatric surgery in T2D patients with BMI ≥35 kg/m2, or BMI 30–35 kg/m2 who have not responded to regular treatment.
–Pharmacotherapy:
–BP goal is 130–140/80; SBP of 130 is recommended in younger patients and those with CV risk or microvascular disease.
–Prescribe a high-intensity statin for patients with:
–Start low-dose aspirin (75–350 mg/d) in patients with T2D and CVD (secondary prevention).
–Additional recommendations:
Screen for depression (eg, PHQ-2).
Retina screening every 1–2 y with retinal photography.
Annual urine microalbumin-to-creatinine ratio.
Annual monofilament foot exam for peripheral neuropathy.
Frequent foot exams at office visits.
Screen for peripheral vascular disease by checking foot pulses and/or calculating the ankle/brachial index.
Routine screening for CAD is not recommended for asymptomatic patients.
T2D patients who observe Ramadan should interrupt their fast if SMBG is <70 or >300. High-risk patients are advised not to fast at all.
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aTitrate metformin from 500 to 2000 mg/d to minimize GI side effects.
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b When starting an SU, the patient must learn how to prevent, recognize, and treat hypoglycemia.
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c SGLT2 inhibitors reduce major cardiovascular events in patients with T2D and are preferred in patients with CVD.
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d GLP1 RA can be used if weight loss is a priority and the drug is affordable.
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–Avoid intensive insulin therapy in hospitalized patients (even if in SICU/MICU).
–Recommends a target blood glucose level of 140–180 mg/dL if insulin therapy is used in hospitalized patients, especially those who are critically ill.
–Either basal insulin or basal plus bolus correctional insulin may be used in the treatment of hospitalized patients; sliding scale regimens are no longer recommended.
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Intensive insulin therapy in SICU/MICU patients does not improve mortality, but has a 5-fold increased risk of hypoglycemia.
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–Insulin therapy should be initiated for children with:
–Diet, exercise, and metformin are initial therapy for other situations.
–Recommend moderate-to-vigorous exercise for 60 min daily.
–Limit nonacademic screen time to <2 h/d.
–Monitor HbA1c every 3 mo.
–Desire HbA1c <7%.
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–Prolonged metformin use can lead to vitamin B12 deficiency. SGLT-2 inhibitors are favored over sulfonylureas as an add-on to metformin in terms of cardiovascular mortality.
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