Type 2 Diabetes Mellitus Guidelines

Updated: Jul 17, 2019
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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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 [326, 327] :

  • 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
  • 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
  • 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
  • Lower systolic and diastolic blood pressure targets, such as < 130/80 mm Hg, may be appropriate for individuals at high risk for cardiovascular disease if they can be achieved without undue treatment burden
  • 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 ≥140/90 mm Hg should, in addition to lifestyle therapy, have timely titration of pharmacologic therapy to achieve blood pressure goals
  • 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 2018 edition of the ADA’s Standards of Medical Care in Diabetes recommends that a glucose-lowering medication with proven cardiovascular and/or mortality-reducing benefit be used to treat patients with type 2 diabetes who have established atherosclerotic cardiovascular disease and in whom lifestyle modification and metformin use have failed to achieve glycemic targets. [328, 329, 330, 331, 332, 333, 334, 335, 336, 337, 338, 339, 340, 341, 342, 343, 344]

It is also recommended that children and adolescents who, along with being overweight or obese, have at least one additional diabetes risk factor be screened for prediabetes and type 2 diabetes.

Another recommendation urges pregnant women with preexisting type 1 or type 2 diabetes to consider taking a low daily aspirin dose beginning at the end of the first trimester in order to lower their preeclampsia risk.

The recommendations continue to define hypertension in diabetes as 140/90 mm Hg or greater rather than considering a value of 130/80 mm Hg to represent stage 1 hypertension, as organizations such as the American College of Cardiology and the American Heart Association now do.

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 [345] :

  • 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 [346] :

  • 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 2 in 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 [347] :

  • 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 [348, 349] :

  • 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