The following is an outline of practice guidelines for management of type 2 diabetes mellitus. A detailed management plan and accompanying DecisionPaths can be found in the original guidelines:
Screening
Screen all patients every 3 years starting at age 45; if risk factors present, start earlier and screen annually.
Risk Factors
- Family history of type 2 diabetes (especially first-degree relatives)
- Body mass index >25 kg/m2 (especially waist-to-hip ratio >1)
- Age (risk increases with age)
- Hypertension (>140/90 mm Hg)
- Dyslipidemia (high-density lipoprotein <35 mg/dL and/or triglyceride >250 mg/dL)
- Previous impaired fasting glucose with fasting plasma glucose 110 to 125 mg/dL
- Previous impaired glucose tolerance with oral glucose tolerance test 2 hour glucose value 140 to 199 mg/dL
- Previous gestational diabetes: macrosomic or large-for-gestational age infant (>9lbs.)
- Acanthosis nigricans/polycystic ovary syndrome (PCOS)
- History of vascular disease
- American Indian or Alaska Native, African American, Hispanic, Asian, Pacific Islander
Diagnosis
Plasma Glucose
Casual >200 mg/dL plus symptoms, fasting >126 mg/dL, or 75 g Oral Glucose Tolerance Test 2 hour glucose value >200 mg/dL; if positive, confirm diagnosis with casual or fasting plasma glucose on subsequent day within one week.
Symptoms
Often none
Common: Blurred vision, urinary tract infection, yeast infection, dry/itchy skin, numbness or tingling in extremities, fatigue
Occasional: Increased urination, thirst, and appetite; nocturia; weight loss
Urine Ketones
Usually negative
Treatment Options
Medical nutrition therapy and activity, oral agent monotherapy, combination therapy (oral agents or oral agent-insulin), insulin stages 2, 3, 4 (see Type 2 Master DecisionPath in the original guideline document)
Targets
Self-Monitored Blood Glucose
- More than 50% of self-monitored blood glucose values within target range
- Pre-meal: 70 to140 mg/dL
- Post-meal (2 hr after start of meal): <160 mg/dL
- Bedtime: 100 to 160 mg/dL
- No severe (assisted) or nocturnal hypoglycemia
Adjust pre-meal target upwards (e.g. 100 to 160 mg/dL) if frail elderly, cognitive disorders, or other medical concerns (cardiac disease, stroke, hypoglycemia unawareness, end-stage renal disease)
Hemoglobin A1c
- Within 1.0% point of upper limit of normal (e.g. normal 6.0%; target <7.0%)
- Frequency: every 3 to 4 months
- Use hemoglobin A1c to verify self-monitored blood glucose data
Blood Pressure
<130/80 mm Hg
Lipids
Low-density lipoprotein <100 mg/dL; high-density lipoprotein >40 mg/dL; triglyceride <150 mg/dL
Monitoring
Self-Monitored Blood Glucose
2 to 4 times/day (e.g., before breakfast, before main meal, 2 hrs after main meal); if on insulin, check 3 a.m. self-monitored blood glucose as needed; self-monitored blood glucose may be modified due to cost, technical ability, or availability of meters.
Method
Meter with memory that is downloadable and log book
Follow Up
Monthly
Office visit during Adjust Phase (weekly phone contact may be necessary)
Every 3 Months
Hypoglycemia, medications, weight or body mass index, blood pressure, self-monitored blood glucose data (download and check meter), hemoglobin A1c, eye and foot screen, medical nutrition therapy, preconception planning for women of childbearing age, smoking cessation counseling, aspirin therapy
Yearly
In addition to the 3 month follow-up, complete the following: history and physical, fasting lipid profile, albuminuria screen, dilated eye examination, dental examination, neurologic assessment, complete foot examination (pulses, sensation, and inspection), referral for diabetes and nutrition education, adult immunizations
Complications Surveillance
Cardiovascular, renal, retinal, neurological, foot, oral, and dermatological
