Diabetes Management Guidelines

Initial Management: Lifestyle Modifications

The American Diabetes Association recommends that all patients with diabetes receive comprehensive diabetes self-management education focusing on healthy eating patterns and physical activity 1
Physical activity recommendations include at least 150 minutes of moderate-intensity aerobic activity per week, reduced sedentary time, and resistance training at least twice per week 1, 2
Nutrition therapy should emphasize nutrient-dense, high-quality foods while decreasing calorie-dense, nutrient-poor foods 1, 3
For overweight or obese adults with type 2 diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss 3
Modest weight loss (5-7% of starting weight) can provide clinical benefits including improved glycemia, blood pressure, and lipids 1

The American College of Physicians recommends metformin as the first-line medication for type 2 diabetes when not contraindicated, starting at a low dose and increasing gradually to an ideal maximum dose of 2000 mg daily in divided doses 1, 2
Metformin is preferred as initial pharmacologic therapy due to its efficacy, safety, low cost, and potential cardiovascular benefits 2

Insulin therapy should be initiated instead of metformin as first-line treatment in patients with ketosis or diabetic ketoacidosis, random blood glucose ≥250 mg/dL, HbA1c >8.5%, or symptomatic diabetes with polyuria, polydipsia, and weight loss 1, 4

When monotherapy with metformin at maximum tolerated dose does not achieve or maintain the HbA1c target over 3 months, a second agent should be added, with options including SGLT-2 inhibitors, GLP-1 receptor agonists, thiazolidinediones, DPP-4 inhibitors, and basal insulin 1, 2, 4

Most patients with type 1 diabetes should be treated with multiple-dose insulin injections (≥3 injections per day) or continuous subcutaneous insulin infusion, with insulin analogs used to reduce hypoglycemia risk 2
Patients should be educated on matching prandial insulin doses to carbohydrate intake, preprandial blood glucose levels, and anticipated activity level 2
Continuous glucose monitoring systems can significantly reduce severe hypoglycemia risk 2

A reasonable HbA1c goal for most adults with diabetes is <7%, with more stringent targets (such as <6.5%) for selected individuals, and HbA1c should be monitored every 3 months until target is reached, then at least twice yearly 1
Treatment goals should be individualized based on patient factors including age, comorbidities, and risk of hypoglycemia 1, 2

Hypoglycemia (plasma glucose level <3.9 mmol/L) can be reversed with 15-20g of rapid-acting glucose, with blood glucose confirmed after 15 minutes, and the process repeated if hypoglycemia persists 2
Patients should be educated about situations that increase hypoglycemia risk, such as fasting, exercise, and sleep 1, 2
Severe or frequent hypoglycemia requires modification of treatment regimens 2

Initial management should include lifestyle modifications and diabetes education, with metformin recommended as initial therapy for A1C <8.5% without acidosis or ketosis 4
For A1C ≥8.5% or with ketosis, insulin therapy should be initiated until acidosis resolves, and metabolic surgery may be considered for adolescents with type 2 diabetes who have severe obesity and elevated A1C despite lifestyle and pharmacologic intervention 4

Treatment of elevated blood pressure should focus on lifestyle modification including healthy nutrition, physical activity, sleep, and weight management, with ACE inhibitors or angiotensin receptor blockers started for confirmed hypertension 4

Patients with hypoglycemia unawareness should increase their glycemic targets temporarily to partially reverse this condition and reduce future risk 2
Providers should avoid aggressively targeting near-normal HbA1c levels in patients with advanced disease where such targets cannot be safely reached 2