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Guidelines

Guidelines Summary

ADA guidelines on managing hypertension

Guidelines published in 2017 by the American Diabetes Association (ADA) on managing hypertension in patients with diabetes state the following^{[401, 402]}:

Blood pressure should be measured at every routine clinical care visit; patients found to have an elevated blood pressure (≥140/90 mm Hg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension; in the ADA’s Standards of Care in Diabetes—2023, hypertension was redefined as a blood pressure ≥130/80 mm Hg ^{[352, 353]}
All hypertensive patients with diabetes should have home blood pressure monitored to identify white-coat hypertension
Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed
These guidelines state that most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of < 140 mm Hg and a diastolic blood pressure goal of < 90 mm Hg; however, in the ADA’s Standards of Care in Diabetes—2023, it was advised that the target blood pressure for people with diabetes be below 130/80 mm Hg, if it can be safely achieved ^{[352, 353]}
For patients with systolic blood pressure >120 mm Hg or diastolic blood pressure >80 mm Hg, lifestyle intervention consists of weight loss if the patients are overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)–style dietary pattern, including reduced sodium and increased potassium intake, increased fruit and vegetable consumption, moderation of alcohol intake, and increased physical activity
Patients with confirmed office-based blood pressure ≥160/100 mm Hg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes
Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes: angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), thiazide-like diuretics, or dihydropyridine calcium channel blockers; multiple-drug therapy is generally required to achieve blood pressure targets (but not a combination of ACE inhibitors and ARBs)
An ACE inhibitor or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and a urine albumin-to-creatinine ratio of ≥300 mg/g creatinine or 30–299 mg/g creatinine; if one class is not tolerated, the other should be substituted
For patients treated with an ACE inhibitor, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored
Pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with systolic blood pressure < 160 mm Hg, diastolic blood pressure < 105 mm Hg, and no evidence of end-organ damage do not need to be treated with pharmacologic antihypertensive therapy
In pregnant patients with diabetes and preexisting hypertension who are treated with antihypertensive therapy, systolic or diastolic blood pressure targets of 120-160/80-105 mm Hg are suggested in the interest of optimizing long-term maternal health and fetal growth

ADA Standards of Medical Care in Diabetes

The 2022 edition of the ADA’s Standards of Medical Care in Diabetes features several important changes with regard to diabetes screening and management, including the following^{[4, 5]}:

The recommended age at which people should be screened for prediabetes and type 2 diabetes, regardless of the presence or absence of risk factors, has been lowered from age 45 years to age 35 years
It is recommended that all women, regardless of risk factors, be tested for undiagnosed diabetes at the time they are planning to become pregnant or else at their first prenatal visit; gestational diabetes screening should be carried out at 24-28 weeks “in pregnant women not previously found to have diabetes or high-risk abnormal glucose metabolism detected earlier in the current pregnancy”
In persons being screened for diabetes via oral glucose tolerance testing, at least 150 g/day of carbohydrate intake should be assured for 3 days prior to the screen
It is recommended that, in a research study setting or perhaps in first-degree family members of a proband with type 1 diabetes, screening tests that detect autoantibodies to insulin, glutamic acid decarboxylase (GAD), islet antigen 2, or zinc transporter 8 be used to screen for presymptomatic type 1 diabetes
A risk factor for clinical diabetes, the development and persistence of multiple islet autoantibodies may indicate the need “for intervention in the setting of a clinical trial or screening for stage 2 type 1 diabetes”
Persons with prediabetes should be monitored at least annually for the development of type 2 diabetes, with modifications made according to individual risk/benefit assessment
Care goals for adults with overweight/obesity for whom the risk of type 2 diabetes is high “should include weight loss or prevention of weight gain, minimizing progression of hyperglycemia, and attention to cardiovascular risk and associated” comorbidities
If insulin is used in adults with type 2 diabetes, it is recommended that, for better efficacy and durability of treatment effect, combination therapy be employed using a glucagon-like peptide 1 receptor agonist
Consideration may be given to combined therapy employing a sodium–glucose cotransporter 2 inhibitor and a glucagon-like peptide 1 receptor agonist, both with demonstrated cardiovascular benefit, “for additive reduction in the risk of adverse cardiovascular and kidney events” in patients “with type 2 diabetes and established atherosclerotic cardiovascular disease or multiple risk factors for atherosclerotic cardiovascular disease”
If they are capable of using a continuous glucose monitoring (CGM) device safely (either alone or with the aid of a caregiver), youth with type 2 diabetes who are on multiple daily injections or continuous subcutaneous insulin infusion should be offered the option of real-time or intermittently scanned CGM for diabetes management; the patient’s circumstances, desires, and needs should govern the choice of device

ADA guidelines for youth-onset type 2 diabetes

In November 2018, the ADA released a position statement the evaluation and management of youth-onset type 2 diabetes. It includes the following points^[403]:

Severe peripheral and hepatic insulin resistance occurs when type 2 diabetes develops in adolescents with obesity, with peripheral insulin sensitivity being about 50% below that of adolescents who have obesity without diabetes; the disposition index (the mathematically described product of insulin sensitivity and β-cell function) in youth with both obesity and type 2 diabetes is about 85% lower
Risk-based screening should be considered in overweight and obese children over age 10 years or who have commenced puberty
Risk factors for type 2 diabetes in youth should be taken into account, including whether the child’s mother has a history of diabetes or experienced gestational diabetes while pregnant with the child, as well as whether close family members have a history of type 2 diabetes; other risk factors to consider include signs of insulin resistance, as well as the youth’s ethnicity (ie, whether he or she is from a non-Caucasian background, such as African American or Latino)
As part of diagnosis, a panel of pancreatic autoantibodies should be employed to exclude the presence of autoimmune type 1 diabetes
Adherence to medication therapy and the impact of treatment on weight should be taken into account when glucose-lowering agents and other medications are being chosen for patients who are overweight or obese
A chronic approach to lifestyle management should be employed, with education, weight management, exercise, nutrition, and psychological factors emphasized
Education and lifestyle management programs need to be culturally and contextually sensitive
If their BMI is greater than 35 kg/m ², uncontrolled glycemia and/or serious comorbidities are present, and lifestyle and pharmacologic approaches have failed, adolescents with type 2 diabetes may be considered for metabolic surgery (but only by an experienced surgeon and only in tandem with input from a multidisciplinary team that also includes an endocrinologist, a nutritionist, a behavioral health specialist, and a nurse)
A transfer to adult care should be arranged only when the patient and provider deem it appropriate

ADA/EASD recommendations on hyperglycemia management

In October 2018, in an update to previous position statements, the ADA and the European Association for the Study of Diabetes (EASD) released new recommendations regarding adults with type 2 diabetes. The guidelines, on the management of hyperglycemia, include the following^[404]:

Providers and health-care systems should prioritize the delivery of patient-centered care
All people with type 2 diabetes should be offered access to ongoing diabetes self-management education and support (DSMES) programs
Facilitating medication adherence should be specifically considered when selecting glucose-lowering medications
Among patients with type 2 diabetes who have established atherosclerotic cardiovascular disease (ASCVD), sodium-glucose cotransporter–2 (SGLT2) inhibitors or glucacon-like peptide 1 (GLP-1) receptor agonists with proven cardiovascular benefit are recommended as part of glycemic management
Among patients with ASCVD in whom heart failure coexists or is of special concern, SGLT2 inhibitors are recommended
For patients with type 2 diabetes and chronic kidney disease (CKD), with or without CVD, consider the use of an SGLT2 inhibitor shown to reduce CKD progression or, if contraindicated or not preferred, a GLP-1 receptor agonist shown to reduce CKD progression
An individualized program of medical nutrition therapy (MNT) should be offered to all patients
All overweight and obese patients with diabetes should be advised of the health benefits of weight loss and encouraged to engage in a program of intensive lifestyle management, which may include food substitution
Increased physical activity improves glycemic control and should be encouraged in all people with type 2 diabetes
Metabolic surgery is a recommended treatment option for adults with type 2 diabetes and 1) a body mass index (BMI) of 40.0 kg/m ² or higher (BMI of 37.5 kg/m ² or higher in people of Asian ancestry) or 2) a BMI of 35.0-39.9 kg/m ² (32.5-37.4 kg/m ²in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities with reasonable nonsurgical methods
Metformin is the preferred initial glucose-lowering medication for most people with type 2 diabetes
The stepwise addition of glucose-lowering medication is generally preferred to initial combination therapy
The selection of medication added to metformin is based on patient preference and clinical characteristics; important clinical characteristics include the presence of established ASCVD and other comorbidities such as heart failure or CKD; the risk for specific adverse medication effects, particularly hypoglycemia and weight gain; and safety, tolerability, and cost
Intensification of treatment beyond dual therapy to maintain glycemic targets requires consideration of the impact of medication side effects on comorbidities, as well as the burden of treatment and cost
In patients who need the greater glucose-lowering effect of an injectable medication, GLP-1 receptor agonists are the preferred choice to insulin; for patients with extreme and symptomatic hyperglycemia, insulin is recommended
Patients who are unable to maintain glycemic targets on basal insulin in combination with oral medications can have treatment intensified with GLP-1 receptor agonists, SGLT2 inhibitors, or prandial insulin
Access, treatment cost, and insurance coverage should all be considered when selecting glucose-lowering medications

Diabetes Canada guidelines for family physicians

The following clinical practice guidelines for family physicians caring for patients with type 2 diabetes mellitus were released in 2018 by Diabetes Canada^[405]:

Patients without clinical cardiovascular disease (CVD) who fail to achieve glycemic targets with existing antihyperglycemic drug therapy and in whom reduced risk of hypoglycemia and weight gain are priorities should be considered for add-on treatment with incretin agents (dipeptidyl peptidase IV [DPP-4] inhibitors or glucagonlike peptide–1 [GLP-1] agonists) or selective sodium-glucose transporter–2 (SGLT-2) inhibitors, as alternatives to insulin secretagogues, insulin, and thiazolidinediones (TZDs)
Patients without clinical cardiovascular disease (CVD) who fail to achieve glycemic targets with existing antihyperglycemic drug therapy should additionally receive an antihyperglycemic agent with demonstrated cardiovascular (CV) outcome benefit (such as empagliflozin or liraglutide) to decrease the likelihood of major CV events
In patients who fail to achieve glycemic targets with existing noninsulin antihyperglycemic drug therapy, consider adding a once-daily basal insulin regimen as an alternative to premixed insulin or bolus-only regimens, as a means of reducing weight gain and hypoglycemia
To decrease the likelihood of nocturnal and symptomatic hypoglycemia, long-acting insulin analogues should be considered as an alternative to neutral protamine Hagedorn (NPH) insulin
Patients receiving insulin who fail to achieve glycemic targets should undergo dose adjustment or the administration of additional antihyperglycemic medication (noninsulin or bolus insulin), with the following kept in mind: (1) to achieve better glycemic control with weight loss and a lower hypoglycemia risk than with single- or multiple-bolus insulin injections, consider administering a GLP-1 agonist as add-on treatment prior to initiating bolus insulin or intensifying insulin therapy; (2) consider add-on therapy with an SGLT-2 inhibitor as a means of improving glycemic control with weight loss and reducing the likelihood of hypoglycemia, compared with the administration of additional insulin; (3) consider add-on therapy with a DPP-4 inhibitor as a means of improving glycemic control without weight gain or greater likelihood of hypoglycemia, compared with the administration of additional insulin
All persons with diabetes should engage in a comprehensive, multifaceted approach to CV risk reduction, including the following: (1) hemoglobin A1c (HbA1c) target of ≤7.0% instigated early in the course of diabetes; (2) systolic and diastolic blood pressure (BP) of < 130 mm Hg and < 80 mm Hg, respectively; (3) additional vascular protective medications in most adults with diabetes; (4) reaching and maintaining a healthy weight; (5) engaging in healthy nutrition; (6) regular physical activity; (7) smoking cessation
To lower the CV risk in adults with type 1 or type 2 diabetes, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should be employed at vascular-protective doses when any of the following exist (note: among women with childbearing potential, ACE inhibitors, ARBs, or statins should be used only in the presence of reliable contraception): (1) clinical CVD, (2) age >55 y with an additional CV risk factor or end organ damage (albuminuria, retinopathy, left ventricular hypertrophy), (3) microvascular complications
To prevent CV events in patients with established CVD, employ low-dose acetylsalicylic acid (ASA) therapy (81-162 mg)
The failure of existing antihyperglycemic drug therapy to achieve glycemic targets In adults with type 2 diabetes with clinical CVD should prompt the addition of an antihyperglycemic agent with demonstrated CV outcome benefit (such as empagliflozin or liraglutide) to lower the risk of major CV events
The failure of existing antihyperglycemic drug therapy to achieve glycemic targets in older people with type 2 diabetes who have no other complex comorbidities (but who do have clinical CVD) can prompt the addition of an antihyperglycemic agent with demonstrated CV outcome benefit (such as empagliflozin or liraglutide) to lower the risk of major CV events
Interprofessional teams should provide collaborative care for individuals with diabetes and depression to improve the following: (1) depressive symptoms, (2) adherence to the use of antidepressant and noninsulin antihyperglycemic medications, (3) glycemic control
Psychosocial interventions, including the following, should be woven into diabetes care plans: (1) motivational interventions, (2) stress management strategies, (3) coping skills training, (4) family therapy, (5) case management
To achieve better glycemic control and lower the risk of CVD and overall mortality, patients with diabetes should, over the course of at least 3 days per week, engage in a minimum of 150 minutes of moderate- to vigorous-intensity aerobic exercise, with no more than 2 consecutive nonexercise days; glycemic control can also be aided, though to a lesser extent, by 90-140 minutes per week of exercise or planned physical activity
In patients with type 2 diabetes who are able to perform interval training, this form of physical activity (in which short periods of vigorous exercise are alternated with short recovery periods employing low to moderate intensity or rest) can be recommended to aid cardiorespiratory fitness
Resistance exercise should be performed by patients with diabetes, including elderly ones, two or (preferably) three times per week
As a means of increasing physical activity and improving HbA1c levels, a patient with diabetes and his/her health-care provider should collaborate on setting exercise goals, resolving potential barriers to exercise, and determining where and when the patient should exercise, with self-monitoring performed
Timely education aimed at improving self-care practices and behavior should be offered to patients with diabetes
Self-management aimed at improving glycemic control can be technologically supported, including with Internet-based computer programs and glucose-monitoring systems, brief text messages, and mobile applications

Endocrine Society guidelines on diabetes management in older adults

In 2019, the Endocrine Society released the following clinical practice guidelines on the diagnosis and management of diabetes and its comorbidities in older adults^{[406, 407]}:

Screening for diabetes or prediabetes with the fasting plasma glucose test or HbA1c analysis is recommended for patients aged 65 years or older without known diabetes
A 2-hour glucose post–oral glucose tolerance test is suggested for patients aged 65 years or older without known diabetes in whom results from fasting plasma glucose or HbA1c analysis have indicated that prediabetes is present
To delay the onset of diabetes, it is recommended that patients aged 65 years or older with prediabetes adopt a lifestyle in line with that presented in the Diabetes Prevention Program
It is recommended that patients aged 65 years or older with diabetes participate in outpatient regimens specifically conceived to minimize hypoglycemia
Lifestyle modification is recommended as the first-line treatment for hyperglycemia in ambulatory individuals aged 65 years or older with diabetes
Nutritional status assessment for the detection and management of malnutrition is recommended in patients aged 65 years or older with diabetes
It is recommended that along with lifestyle changes, patients aged 65 years or older with diabetes undergo initial oral drug treatment with metformin, for glycemic management; significant kidney function impairment (estimated glomerular filtration rate < 30 mL/min/1.73 m ²) or gastrointestinal intolerance should preclude implementation of this recommendation
If metformin therapy and lifestyle changes have not led a patient aged 65 years or older with diabetes to achieve his/her glycemic target, it is recommended that metformin treatment be combined with therapy employing other oral or injectable agents and/or insulin
To reduce the risk of cardiovascular disease outcomes, stroke, and progressive chronic kidney disease, it is recommended that the target blood pressure in patients aged 65-85 years with diabetes be 140/90 mm Hg
It is recommended that an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker be administered as first-line therapy in patients aged 65 years or older with diabetes and hypertension
Statin therapy and an annual lipid profile are recommended in patients aged 65 years or older with diabetes to reduce absolute cardiovascular disease events and all-cause mortality
For detection of retinal disease, annual comprehensive eye examinations are recommended for patients aged 65 years or older with diabetes
It is recommended that patients aged 65 years or older with diabetes who are not on dialysis be screened annually for chronic kidney disease, with determination of the estimated glomerular filtration rate and urine albumin-to-creatinine ratio

ESC guidelines on CVD management and prevention

In September 2019, the European Society of Cardiology (ESC), in collaboration with the European Association for the Study of Diabetes (EASD), released updated guidelines aimed at managing and preventing cardiovascular disease (CVD) in patients with diabetes or prediabetes. Patient CV risk is classified in the guidelines as follows^[408]:

Medium CV risk - Young patients without other CV risk factors who have had diabetes for less than 10 years
High CV risk - Patients who lack target-organ damage but have had diabetes for over 10 years and in whom at least one other risk factor exists
Very high CV risk - Patients with CVD or target-organ damage or in whom type 1 diabetes has been present for more than 20 years

The recommendations include the following^[408]:

In drug-naïve patients with type 2 diabetes and established CVD, administration of a sodium-glucose cotransporter–2 (SGLT-2) inhibitor or glucagonlike peptide-1 (GLP-1) receptor agonist should be immediately initiated or added to existing metformin treatment
Based on a cardiovascular outcome trial (CVOT), it is recommended that aspirin be used in high- and very high–risk patients (on an individual basis) but not in moderate-risk patients
Very high–risk patients in whom low-density lipoprotein (LDL) cholesterol levels are persistently high even with maximal statin and ezetimibe therapy or who have statin intolerance should undergo proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitor treatment
An HbA1c level of under 7% is advised, particularly in young adults who have had diabetes for only a short time
In patients with medium, high, and very high CV risk, lipid targets of 2.5 mmol/L, 1.8 mmol/L, and below 1.4 mmol/L, respectively, are recommended

Expert panel: management of diabetes in patients with coronavirus disease 2019 (COVID-19)

Recommendations for the management of diabetes in patients with COVID-19 were published on April 23, 2020, by an international panel of diabetes experts.^{[409, 410]}

Regarding infection prevention and outpatient care:

Patients with diabetes, particularly those with type I diabetes mellitus, should be sensitized to the importance of optimal metabolic control
Current therapy should, if appropriate, be optimized
Telemedicine and connected health models should be used, if possible, to maintain maximal self-containment

All patients hospitalized with COVID-19 should be monitored for new-onset diabetes.

Regarding management in the intensive care unit (ICU) of infected patients with diabetes:

Plasma glucose monitoring, electrolytes, pH, blood ketones, or β-hydroxybutyrate
There is liberal indication for early intravenous insulin therapy in severe disease courses (acute respiratory distress syndrome, hyperinflammation) for exact titration, with variable subcutaneous resorption avoided, and management of commonly encountered very high insulin consumption

Therapeutic goals include the following:

Plasma glucose concentration: 4-8 mmol/L (72-144 mg/dL) for outpatients or 4-10 mmol/L (72-180 mg/dL) for inpatients/intensive care, with, for frail individuals, the lower value possibly adjusted upward to 5 mmol/L (90 mg/dL)
A1c < 53 mmol/mol (7%)
Continuous glucose monitoring/flash glucose monitoring targets: Time-in-range (3.9-10 mmol/L) >70% of time (or >50% in frail and older patients)
Hypoglycemia < 3.9 mmol/L (< 70 mg/dL): < 4% (< 1% in frail and older patients)

The panel advises stopping administration of metformin and sodium-glucose cotransporter–2 (SGLT2) inhibitors in patients with COVID-19 and type 2 diabetes in order to lower the risk of acute metabolic decompensation.

Fluid balance requires considerable care, “as there is a risk that excess fluid can exacerbate pulmonary edema in the severely inflamed lung.”

Potassium balance requires careful consideration in the context of insulin treatment, “as hypokalemia is a common feature in COVID-19,” with initiation of insulin possibly exacerbating it.

The panel recommends screening for hyperinflammation, owing to the possibility of increased risk for cytokine storm and severe COVID-19 in patients with type 2 diabetes and fatty liver disease.

ADA guidelines on pharmacologic means of glycemic therapy in type 2 diabetes

In September 2020, the ADA published clinical guidelines on pharmacologic means of glycemic therapy in type 2 diabetes. They include the following:

Metformin therapy is the preferred initial pharmacologic treatment for type 2 diabetes
To extend the time to treatment failure, early combination therapy can, in some patients, be considered at treatment initiation
If evidence of ongoing catabolism exists (weight loss), if symptoms of hyperglycemia are present, or when HbA1c or blood glucose levels are very high (HbA1c >10% [86 mmol/mol], blood glucose ≥16.7 mmol/L [300 mg/dL]), consider early introduction of insulin
Employ a patient-centered approach to guide the choice of pharmacologic agents, with factors such as cardiovascular comorbid conditions, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences taken into account
It is recommended that a sodium-glucose cotransporter–2 (SGLT2) inhibitor or glucagonlike peptide-1 receptor agonist (GLP-1 RA) with demonstrated cardiovascular disease benefit be administered to patients with type 2 diabetes who have established atherosclerotic cardiovascular disease (ASCVD), indicators of high ASCVD risk, established kidney disease, or heart failure
The use of GLP-1 RAs, when possible, is preferred over insulin therapy in the treatment of patients with type 2 diabetes who need greater glucose reduction than oral agents can provide
Reevaluate the patient’s medication regimen and medication-taking behavior every 3 to 6 months, adjusting them as needed to incorporate specific factors that affect treatment choice

AACE guidelines for use of advanced technology

In May 2021, the American Association of Clinical Endocrinology (AACE) released guidelines on the use of advanced technologies in diabetes management. The following recommendations are among those published.^{[411, 412]}

The percentage of time in range (%TIR) and below range (%TBR) should serve as a starting point for the evaluation of the quality of glycemic control and form the basis for therapy adjustment.

For all persons with diabetes who are undergoing intensive insulin therapy (ie, three or more injections of insulin per day or treatment with an insulin pump), continuous glucose monitoring (CGM) is strongly recommended. For individuals on insulin therapy for whom success with CGM has been limited (or for those who are unable or unwilling to use CGM), structured self-monitoring of blood glucose (SMBG) is recommended. CGM is recommended for all individuals with problematic hypoglycemia (frequent/severe hypoglycemia, nocturnal hypoglycemia, hypoglycemia unawareness), for children/adolescents with type 1 diabetes; for pregnant women with type 1 or type 2 diabetes treated with intensive insulin therapy, and for women with gestational diabetes mellitus (GDM) on insulin therapy. CGM may be recommended for women with GDM who are not undergoing insulin treatment and for individuals with type 2 diabetes who are undergoing less intensive insulin therapy.

For persons with diabetes who have problematic hypoglycemia (frequent/severe hypoglycemia, nocturnal hypoglycemia, hypoglycemia unawareness) and need predictive alarms/alerts, real-time CGM (rtCGM) should be recommended over intermittently scanned CGM (isCGM). Consideration should also be given, however, to a patient’s lifestyle and to other factors.

The management of persons with diabetes who meet one or more of the following criteria should entail the use of diagnostic/professional CGM:

Newly diagnosed with diabetes mellitus
Not using CGM
No access to personal CGM, despite having problematic hypoglycemia
Persons with type 2 diabetes who, although undergoing non-insulin therapy, would derive educational benefit from episodic use of CGM
Persons who, before committing to daily use of CGM, wish to know more about it

Importantly, continued adjunctive use of SMBG must be employed by patients who are using “masked” or “blinded” diagnostic/professional CGM, to assist in daily diabetes self-care.

Persons with diabetes in whom glycemic targets are being reached with minimal TBR, infrequent episodes of symptomatic hypoglycemia are being reported, and SMBG is being used on a regular basis (at least 4 times daily for persons with type 1 diabetes) could employ an insulin pump without CGM.

In all persons with diabetes who are undergoing intensive insulin management but who prefer to forgo the use of automated insulin suspension/dosing systems or have no access to them, use of an insulin pump with CGM or a sensor-augmented pump (SAP) is recommended.

To reduce hypoglycemia’s severity and duration in persons with type 1 diabetes, low-glucose suspend (LGS) is strongly recommended; for mitigation of hypoglycemia in these patients, predictive low-glucose suspend (PLGS) is strongly recommended.

It is strongly recommended that all persons with type 1 diabetes use automated insulin dosing (AID) systems; these have been shown to raise the TIR, especially in the overnight period, without increasing the hypoglycemia risk.

In persons with diabetes who are hospitalized but are suffering no cognitive impairment, consideration should be given to the continuation of CGM and/or continuous subcutaneous insulin injection (CSII) (insulin pump, SAP, LGS/PLGS). The presence of a family member who is knowledgeable and educated in the use of these devices or the availability of a specialized inpatient diabetes team for advice and support is ideal in such situations.

To enable persons aged 65 years or older with insulin-requiring diabetes to improve glycemic control, reduce episodes of severe hypoglycemia, and improve quality of life, use of rtCGM is recommended. Owing, however, to this population’s increased comorbidities and lowered capacity to detect and counter-regulate against severe hypoglycemia, glycemic goals should be individualized.

As a means of tracking glucose before, during, and after exercise in persons with diabetes; monitoring the glycemic response to exercise; and helping to direct insulin and carbohydrate consumption to prevent the development of hypoglycemia and hyperglycemia, clinicians should prescribe CGM.

It is strongly recommended that telemedicine be used in the treatment of diabetes, provision of diabetes education, remote monitoring of glucose and/or insulin data, and improvement of diabetes-related outcomes/control.

As a means of teaching/reinforcing diabetes self-management skills, encouraging engagement, and supporting/encouraging desired health behaviors, clinically validated smartphone applications should be recommended to persons with diabetes.

Comprehensive training in the proper use and care of insulin delivery technology should be provided to all persons with diabetes using that equipment.

It is strongly recommended that, in the absence of pump therapy, FDA-cleared and clinically validated smartphone bolus calculators be used to reduce the frequency of hypoglycemia or severe postprandial hyperglycemia.

SID/AMD treatment guidelines

Clinical guidelines on the treatment of type 2 diabetes mellitus were published in March 2022 by the Società Italiana di Diabetologia (SID) and the Associazione Medici Diabetologi (AMD). They include the following^[413]:

In patients with type 2 diabetes who are undergoing treatment with drugs that can induce hypoglycemia, it is recommended that the target hemoglobin A1c (HbA1c) level be between 49 mmol/mol (6.6%) and 58 mmol/mol (7.5%)
In patients with type 2 diabetes who are undergoing treatment with drugs that cannot induce hypoglycemia, it is recommended that the target HbA1c level be below 53 mmol/mol (7%)
It is suggested that structured medical nutrition therapy (made up of nutritional assessment, diagnosis, intervention, and monitoring) be employed in type 2 diabetes treatment
Regular physical exercise is suggested for type 2 diabetes treatment
Combined (aerobic and resistance) training, rather than aerobic training alone, is suggested for type 2 diabetes treatment
In patients with type 2 diabetes who have not had previous cardiovascular events, metformin is recommended as a first-line, long-term treatment; as second-line agents, sodium-glucose cotransporter-2 (SGLT-2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists are recommended, while as third-line treatments, consideration should be given to pioglitazone, dipeptidyl peptidase 4 (DPP-4) inhibitors, acarbose, and insulin
In patients with type 2 diabetes with previous cardiovascular events but without heart failure, the use of metformin, SGLT-2 inhibitors, or GLP-1 receptor agonists is recommended as first-line, long-term treatment; as second-line treatments, consideration should be given to DPP-4 inhibitors, pioglitazone, acarbose, and insulin
In patients with type 2 diabetes who have suffered previous heart failure, SGLT-2 inhibitors are recommended for first-line, long-term treatment; consideration should be given to GLP-1 receptor agonists and metformin as second-line treatments, and to DPP-4 inhibitors, acarbose, and insulin as third-line treatments
It is recommended that all patients with type 2 diabetes who require treatment with basal insulin receive basal insulin analogues rather than neutral protamine Hagedorn (NPH) insulin
It is not suggested that in patients with type 2 diabetes who are on basal-bolus insulin therapy, continuous glucose monitoring (continuous or on demand) instead of self-monitoring of blood glucose be practiced

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Media Gallery

Simplified scheme for the pathophysiology of type 2 diabetes mellitus.
Prevalence of type 2 diabetes mellitus in various racial and ethnic groups in the United States (2007-2009 data).
Prevalence of diabetes mellitus type 2 by age in the United States (2007 estimates).
Possible physical examination findings in patients with type 2 diabetes mellitus.
Diagnostic criteria (American Diabetes Association) for diabetes mellitus type 2.
Major findings from the primary glucose study in the United Kingdom Prospective Diabetes Study (UKPDS).
Results from metformin substudy in the United Kingdom Prospective Diabetes Study (UKPDS).
Findings from the blood pressure substudy in the United Kingdom Prospective Diabetes Study (UKPDS).
Laboratory monitoring guidelines for patients with type 2 diabetes mellitus.
American Diabetes Association guidelines for low-density lipoprotein cholesterol in diabetes mellitus type 2.
Treatment of type 2 diabetes mellitus.
Types of insulin. Premixed insulins can be assumed to have a combination of the onset, peak, and duration of the individual components.
Simplified scheme for using insulin in treating patients with type 2 diabetes mellitus.
Simplified scheme of idealized blood glucose values and multiple dose insulin therapy in type 2 diabetes mellitus.

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Author

Romesh Khardori, MD, PhD, FACP (Retired) Professor, Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for Physician Leadership, American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society, International Society for Clinical Densitometry, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgements

Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians