Note from the National Guideline Clearinghouse (NGC): The following key points summarize the content of the guideline. Refer to the full text for additional information, including dosing and cost considerations for oral agents for the management of type 2 diabetes and self-management topics. The levels of evidence [A–D] are defined at the end of the "Major Recommendations" field.
Screening
Although little evidence is available on screening for diabetes, one may consider beginning screening at age 45 at 3–year intervals, earlier particularly if body mass index (BMI) >25 kg/m2 [D].
Prevention
In individuals at risk for diabetes (see Table 1 in original guideline document), diet, exercise, and pharmacologic interventions can delay or prevent type 2 diabetes [A].
Diagnosis
Either two separate fasting glucoses >126 mg/dL, or if symptoms, a glucose >200 mg/dL confirmed on a separate day by a fasting glucose >126 mg/dL, or 2-hour postload glucose > 200 mg/dL during an oral glucose tolerance test [B]. (See Table 1 in the original guideline document.) Glycated hemoglobin (HbA1c) has low sensitivity, but high specificity, for the diagnosis of diabetes, and most experts feel that it should not be used as a primary diagnostic test.
Treatment
Diet, exercise, and pharmacologic interventions should be initiated for:
- Hypertension control [A]
- Glycemic control [A]
- Lipid control [A]
- Cardiovascular risk reduction [A]
Ongoing Screening and Management
Routine screening and prevention efforts for cardiovascular risk factors (hypertension, hyperlipidemia, tobacco use) and for microvascular disease (retinopathy, nephropathy, neuropathy) are recommended to be performed in the following time frames. (See the original guideline document for management of risk factors, complications, and glycemia.)
| Each Regular Diabetes Visit |
Every 3 to 6 Months |
Annually (see Table 2 in the original guideline document) |
- Diabetes visit every 3 months for patients on insulin; every 6 months for patients on oral agents or diet only [D]
- Blood pressure measured and controlled [A] (see Table 2 in the original guideline document)
- Weight checked [D]
- Inspect feet each visit if presence of neuropathy; otherwise annually [A] (see Tables 2 and 8 in the original guideline document)
- Smoking cessation counseling provided for patients with tobacco dependence [B] (see Table 2 in the original guideline document)
- Very important self-management goals reviewed and reinforced [A] (see Table 8 in the original guideline document)
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- Check HbA1c and optimize glycemic control [A] (see Table 4 in the original guideline document)
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- Dilated retinal examination by an eye care specialist [B] and treatment of retinopathy [A] (Biannually if previous eye exam was normal, see Table 2 in the original guideline document)
- Screen for microalbuminuria if not on an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor antagonist (ARB) [B]. Prescribe an ACE-1 or ARB for microalbuminuria or proteinuria [A]
- Serum creatinine and estimated glomerular filtration rate (eGRF) [D].
- Monofilament testing of feet [A] (see Table 9 in the original guideline document)
- Lipids measured [B] and treated [A] (see Table 2 in the original guideline document)
- Smoking status assessed
- Other important self-management goals reviewed and reinforced (see Table 8 in the original guideline document)
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Special considerations: Pregnancy. Preconception counseling and glycemic control in women with diabetes mellitus results in optimal maternal and fetal outcomes [B].
Definitions:
Levels of Evidence
- Randomized controlled trials
- Controlled trials, no randomization
- Observational trials
- Opinion of expert panel
