Management of Type 2 Diabetes Mellitus

Quality Department

Guidelines for Clinical Care Ambulatory

Diabetes Mellitus Guideline Team

Management of Type 2 Diabetes Mellitus

Team Leaders

Connie J Standiford, MD General Internal Medicine

Sandeep Vijan, MD General Internal Medicine

Patient population. Adults

Objectives. To reduce morbidity and mortality by improving adherence to important

recommendations for preventing, detecting, and managing diabetic complications.

Team Members

Hae Mi Choe, PharmD College of Pharmacy

Key points

Prevention. In individuals at risk for type 2 diabetes (see Table 1), type 2 diabetes can be delayed or

R Van Harrison, PhD Learning Health Sciences

Caroline R Richardson, MD Family Medicine

Jennifer A Wyckoff, MD Metabolism, Endocrinology

& Diabetes

prevented through diet, exercise, and pharmacologic interventions. [IA]

Screening. Although little evidence is available on screening for diabetes, screening should be considered every 3 years beginning at age 45 or annually at any age if BMI 25 kg/m2 [IID], history of hypertension [IIB], gestational diabetes [IC], or other risk factors.

Diagnosis. An A1c of 6.5% or greater, confirmed by second test, is diagnostic of diabetes. Alternatively, diabetes can be diagnosed by two separate fasting glucoses 126 mg/dL; with symptoms, a glucose

Consultants

200 mg/dL confirmed on a separate day by a fasting glucose 126 mg/dL; or 2-hour postload glucose

Martha M Funnell, MS, RN, 200 mg/dl during an oral glucose tolerance test. [B] (See Table 1. See Table 2 for differential diagnosis.)

CDE Diabetes Research and

Treatment. Essential components of the treatment for diabetes include diabetes self-management education

Training Center

and support, lifestyle interventions, and goal setting (see Table 3); glycemic management (see Tables 4-

William H Herman, MD Metabolism, Endocrine &

Diabetes

10); and pharmacologic management of hypertension (see Table 11) and hyperlipidemia.

Screening for comorbidities and complications. Routine screening and prompt treatment for cardiovascular risk factors (hypertension, hyperlipidemia, tobacco use) and for microvascular disease

Initial Release

(retinopathy, nephropathy, neuropathy) are recommended in the time frames below.

May, 1996 Most Recent Major Update

September, 2012

Treatment of comorbidities and complications. Management of risk factors and complications summarized in Table 12. Diet, exercise, and pharmacologic interventions should be initiated for:

is

Substantive Revisions

Hypertension [IA]

Cardiovascular risk reduction [IA]

May, 2014

Hyperlipidemia [IA]

Diabetes complications as indicated

Interim/Minor Revisions September, 2015,

Each regular diabetes visit

Annually

June, 2017, July 2019

? Blood pressure measured and controlled. [IA]

? Dilated retinal examination by eye care specialist: if good blood sugar and blood pressure control and

Ambulatory Clinical Guidelines Oversight Karl T Rew, MD

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

previous eye exam was normal, every 2 years; if diabetic changes, annually or more frequently per eye care provider. [IB] Treat retinopathy. [IA]

? Screen for microalbuminuria if not already on an ACE

Literature search service Taubman Health Sciences

Library

control. [IA]

? Review and reinforce diet and physical activity. [IID]

inhibitor or ARB. [IB] Prescribe an ACE inhibitor (or ARB, if ACE contraindicated) for microalbuminuria or proteinuria. [IA]

For more information 734-936-9771

vider/clinical-care-guidelines

? Check weight, calculate BMI. [IID]

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

? 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.

? Smoking cessation counseling provided ? Smoking status assessed. [IB]

for patients with tobacco dependence ? 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.

1

UMHS Management of Type 2 Diabetes Mellitus July 2019

Table 1. Diagnosis of Diabetes: Diagnostic Tests and Glucose Values

Diagnostic Test

Normal

Pre-diabetes

Diabetes

Hemoglobin A1c (A1c) a Fasting plasma glucose a Random plasma glucose b

Oral glucose tolerance test (OGTT) 2 hours after a 75 gm oral glucose loa

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