Comprehensive Management Strategies for Diabetes

Core Management Principles

The American Diabetes Association recommends a patient-centered communication style that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care 1
Treatment decisions should be timely, evidence-based, and tailored to individual patient preferences, prognoses, and comorbidities 1
Care should align with components of the Chronic Care Model to ensure productive interactions between a prepared proactive practice team and an informed activated patient 2
The Chronic Care Model has been shown to reduce cardiovascular disease risk by 56.6%, microvascular complications by 11.9%, and mortality by 66.1% 2
Utilize a collaborative, integrated team with expertise in diabetes including physicians, nurse practitioners, physician assistants, nurses, dietitians, pharmacists, and mental health professionals 3
When feasible, care systems should support team-based care, community involvement, patient registries, and decision support tools 1

All patients should participate in diabetes self-management education and support (DSME) 4, 5
DSME should include problem-solving skills for all aspects of diabetes management 3
An individualized medical nutrition therapy program, preferably provided by a registered dietitian, is recommended for all persons with diabetes 4
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 4

Most patients with T1DM should be treated with multiple-dose insulin injections or continuous subcutaneous insulin injection 4
Insulin analogues should be used to reduce hypoglycemia risk 4
Continuous glucose monitoring systems significantly reduce severe hypoglycemia risk 4
Insulin pump therapy with low glucose suspend features can reduce nocturnal hypoglycemia without increasing HbA1c levels 4
Initial therapy algorithm for T2DM: begin with lifestyle modifications, then metformin if not contraindicated 4, 5
Combination therapy algorithm for T2DM: add a second agent when monotherapy doesn't achieve HbA1c target over 3 months, considering efficacy, cost, side effects, comorbidities, hypoglycemia risk, and patient preferences 4

Insulin therapy must be initiated for children with T2DM who are ketotic, in diabetic ketoacidosis, or when the distinction between type 1 and 2 diabetes is unclear 6
Insulin should be initiated when random blood glucose ≥250 mg/dL or HbA1c >9% 6
In all other cases, initiate lifestyle modification program and metformin as first-line therapy 6

Glycemic targets should be individualized based on duration of diabetes 4, age/life expectancy 2, known cardiovascular disease 4, hypoglycemia unawareness 4, and individual patient considerations 4

Regularly screen for diabetes complications including retinopathy, nephropathy, neuropathy, and cardiovascular disease 3
Consider screening patients with type 1 diabetes for autoimmune diseases (thyroid dysfunction, celiac disease) 3
Patients with diabetes should undergo recommended age- and sex-appropriate cancer screenings 3
For hospitalized patients, blood glucose targets of 7.8-10 mmol/L (140-180 mg/dL) are recommended for most patients 7

Hypoglycemia may be reversed with 15-20g of rapid-acting glucose 4
Blood glucose should be rechecked after 15 minutes; if hypoglycemia persists, repeat treatment 4
For patients with hypoglycemia unawareness, glycemic targets should be temporarily increased to help reverse the condition 4
Severe or frequent hypoglycemia is an absolute indication for modification of treatment regimens 4

Avoid therapeutic inertia - prioritize timely and appropriate intensification of therapy when targets aren't met 2
Avoid sole use of sliding-scale insulin in hospitalized patients - this approach is strongly discouraged 7
Be vigilant about hypoglycemia in patients with advanced disease; don't aggressively pursue near-normal HbA1c levels in patients where such targets cannot be safely achieved 4
When transitioning from intravenous to subcutaneous insulin in hospitalized patients, overlap timing is critical to prevent hyperglycemia 7