Management of Type 2 Diabetes Mellitus

Guidelines for Clinical Care Ambulatory

Quality Department

Management of Type 2 Diabetes Mellitus

Diabetes Mellitus Guideline Team Team Leaders Connie J Standiford, MD General Internal Medicine Sandeep Vijan, MD General Internal Medicine Team Members

Patient population. Adults Objectives. To reduce morbidity and mortality by improving adherence to important recommendations for preventing, detecting, and managing diabetic complications.

Key points

Prevention. In individuals at risk for type 2 diabetes (see Table 1), type 2 diabetes can be delayed or prevented through diet, exercise, and pharmacologic interventions [IA] . R Van Harrison, PhD Screening. Although little evidence is available on screening for diabetes, screening should be considered Medical Education every 3 years beginning at age 45 or annually at any age if BMI ≥ 25 kg/m2 [evidence: IID], history of Caroline R Richardson, MD hypertension [IIB] , gestational diabetes [IC] , or other risk factors. Family Medicine Diagnosis. An A1c of 6.5% or greater, confirmed by second test, is diagnostic of diabetes. Alternatively, Jennifer A Wyckoff, MD Metabolism, Endocrinology diabetes can be diagnosed by two separate fasting glucoses ≥ 126 mg/dL; with symptoms, a glucose ≥ & Diabetes 200 mg/dL confirmed on a separate day by a fasting glucose ≥ 126 mg/dL; or 2-hour postload glucose ≥ Consultants 200 mg/dl during an oral glucose tolerance test [B]. (See Table 1. See Table 2 for differential diagnosis.) Hae Mi Choe, PharmD College of Pharmacy

Martha M Funnell, MS, RN, CDE Diabetes Research and Training Center

Treatment. Essential components of the treatment for diabetes include diabetes self-management education and support, lifestyle interventions, and goal setting (see Table 3); glycemic management (see Tables 410); and pharmacologic management of hypertension (see Table 11) and hyperlipidemia.

William H Herman, MD Metabolism, Endocrine & Diabetes

Screening for comorbidities and complications. Routine screening and prompt treatment for cardiovascular risk factors (hypertension, hyperlipidemia, tobacco use) and for microvascular disease (retinopathy, nephropathy, neuropathy) are recommended in the time frames below. Initial Release Treatment of comorbidities and complications. Management of risk factors and complications is May, 1996 summarized in Table 12. Diet, exercise, and pharmacologic interventions should be initiated for: Most Recent Major Update Hypertension [IA] Cardiovascular risk reduction [IA] September, 2012 Hyperlipidemia [IA] Diabetes complications as indicated Substantive Revisions May, 2014 Interim/Minor Revisions September, 2015, June, 2017

Each regular diabetes visit

Annually

• Blood pressure measured and controlled

• Dilated retinal examination by eye care specialist: if good blood sugar and blood pressure control and previous eye exam was normal, every 2 years; if diabetic changes, annually or more frequently per eye care provider [IB]. Treat retinopathy [IA].

[IA].

Ambulatory Clinical Guidelines Oversight Grant Greenberg, MD, MA, MHSA R. Van Harrison, PhD

• Check HbA1c every 3 months if on insulin; every 6 months if on oral agents or diet only and wellcontrolled. [II]. Optimize glycemic control [IA].

Literature search service Taubman Health Sciences Library

• Review and reinforce diet and physical activity [IID]. • Check weight, calculate BMI [IID].

For more information 734-936-9771 © Regents of the University of Michigan These guidelines should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific clinical procedure or treatment must be made by the physician in light of the circumstances presented by the patient.

• Feet should be inspected at each visit if neuropathy present. Otherwise visual foot exam and neuropathy evaluation annually [IA].

• Screen for microalbuminuria if not already on an ACE inhibitor or ARB [IB]. Prescribe an ACE inhibitor (or ARB, if ACE contraindicated) for microalbuminuria or proteinuria [IA]. • Serum creatinine and estimated glomerular filtration rate (eGFR) [ID].

• Monofilament testing of feet (see Table 13) [IA]. • Prescribe moderate dose statin; measure lipids for adherence.

• Smoking cessation counseling provided for patients with tobacco dependence

• Smoking status assessed [IB]. • All self-management goals reviewed and reinforced. [IB]. (See Table 3). • Review and reinforce key self• Influenza vaccination (annual) and confirm or give management goals (See Table 3) [IA]. pneumococcal and hepatitis B vaccinations. Special considerations: Pregnancy. Preconception counseling and glycemic control targeting a normal A1c in women with diabetes mellitus reduces the risk of congenital malformations and results in optimal maternal and fetal outcomes [IB]. * Strength of recommendation: I = generally should be performed; II = may be reasonable to perform; III = generally should not be performed. Level of evidence supporting a diagnostic method or an intervention: A=randomized controlled trials; B=controlled trials, no randomization; C=observational trials; D=opinion of expert panel.

Table 1. Diagnosis of Diabetes: Diagnostic Tests and Glucose Values Diagnostic Test Hemoglobin A1c (A1c) a Fasting plasma glucose

a

Random plasma glucose

b

Oral glucose tolerance test (OGTT) 2hrs after a 75 gm oral glucose load a b

Normal

Pre-diabetes

Diabetes