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Diabetes mellitus type 2

Key sources
The following summarized guidelines for the evaluation and management of diabetes mellitus type 2 are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2024), the American Academy of Family Physicians (AAFP 2024), the Canadian Cardiovascular Society (CCS/CAIC 2024), the European Society of Cardiology (ESC 2023), the European Society of Hypertension (ESH 2023), the European Association of Urology (EAU 2023), the United Kingdom Kidney Association (UKKA 2023), the National Lipid Association (NLA/PCNA/ASPC/ACC/AHA/ACCP 2023), the Endocrine Society (ES 2022; 2020; 2018; 2016), the U.S. Preventive Services Task Force (USPSTF 2022; 2021), the Canadian Cardiovascular Society (CCS 2022), the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2022), the American College of Gastroenterology (ACG 2022), the Italian Society of Endocrinology (SIE/SIAMS 2022), the American Heart Association (AHA/ASA 2021), the Hypertension Canada (HC 2020), the European Academy of Andrology (EAA 2020), the Society for Vascular Medicine (SVM/SVS/APMA 2016), the Community Preventive Services Task Force (CPSTF 2015), and the Joint National Committee (JNC 2014).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per ADA 2024 guidelines, obtain screening for prediabetes and T2DM with an assessment of risk factors or a validated risk calculator in asymptomatic adults.
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  • Diagnosis

2.Classification and risk stratification

Diabetes classification: classify patients with hyperglycemia into appropriate diagnostic categories to aid in personalized management.
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  • Cardiovascular risk assessment

3.Diagnostic investigations

General principles: ensure a person-centered communication style using person-centered, culturally sensitive, and strength-based language and active listening, eliciting individual preferences and beliefs, and assessing literacy, numeracy, and potential barriers to care in order to optimize health outcomes and health-related QoL.
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  • HbA1c

  • Screening for obesity

  • Screening for hypertension

  • Screening for CVD

  • Screening for PAD

  • Screening for dyslipidemia

  • Screening for NAFLD

  • Screening for diabetic nephropathy

  • Screening for diabetic retinopathy

  • Screening for diabetic neuropathy

  • Screening for diabetic foot

  • Screening for osteoporosis

  • Screening for disability

  • Screening for anxiety and depression

  • Screening for sleep disorders

  • Screening for cognitive impairment

  • Screening for serious mental illnesses

  • Screening for disordered eating behavior

  • Screening for male hypogonadism

4.Medical management

General principles: identify and treat risk factors and comorbidities early.
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  • Glycemic targets

  • Initial therapy

  • Insulin therapy (indications)

  • Insulin therapy (choice of agent)

  • Insulin therapy (delivery systems)

  • Insulin therapy (monitoring)

  • Management of hypoglycemia

  • Management of obesity

  • Management of hypertension (BP targets)

  • Management of hypertension (lifestyle modifications)

  • Management of hypertension (pharmacotherapy)

  • Management of hypertension (monitoring)

  • Prevention of CVD (glucose-lowering medications)

  • Prevention of CVD (antiplatelet therapy)

  • Management of CVD (glucose-lowering medications)

  • Management of CVD (antihypertensives)

  • Management of CVD (revascularization)

  • Management of dyslipidemia (lipid targets)

  • Management of dyslipidemia (lifestyle modifications)

  • Management of dyslipidemia (statin therapy)

  • Management of dyslipidemia (non-statin lipid-lowering therapy)

  • Management of dyslipidemia (hypertriglyceridemia)

  • Management of dyslipidemia (lipid profile monitoring)

  • Management of NAFLD (cardiovascular assessment)

  • Management of NAFLD (lifestyle changes)

  • Management of NAFLD (glucose-lowering medications)

  • Management of NAFLD (insulin therapy)

  • Management of NAFLD (statin therapy)

  • Management of NAFLD (bariatric surgery)

  • Management of diabetic nephropathy (general principles)

  • Management of diabetic nephropathy (smoking cessation)

  • Management of diabetic nephropathy (metformin)

  • Management of diabetic nephropathy (GLP-1 receptor agonists)

  • Management of diabetic nephropathy (SGLT-2 inhibitors)

  • Management of diabetic nephropathy (RAAS blockade)

  • Management of diabetic retinopathy

  • Management of diabetic neuropathy

  • Management of diabetic foot

  • Management of osteoporosis

  • Management of gastroparesis

5.Inpatient care

Management of hospitalized patients, general principles, ADA: ensure that institutions implement protocols using validated written or computerized provider order entry sets for the management of dysglycemia in the hospital (including emergency department, ICU and non-ICU wards, gynecology-obstetrics/delivery units, dialysis suites, and behavioral health units) allowing for a personalized approach, including glucose monitoring, insulin and/or noninsulin therapy, hypoglycemia management, diabetes self-management education, nutrition recommendations, and transitions of care.
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  • Management of hospitalized patients (HbA1C testing)

  • Management of hospitalized patients (glucose monitoring)

  • Management of hospitalized patients (insulin therapy)

  • Management of hospitalized patients (non-insulin therapy)

  • Management of hospitalized patients (treatment targets)

  • Management of hospitalized patients (prevention of hypoglycemia)

  • Management of hospitalized patients (oral carbohydrate fluids)

6.Nonpharmacologic interventions

Smoking cessation
As per ADA 2024 guidelines:
Advise all patients with diabetes not to use cigarettes and other tobacco products or e-cigarettes.
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Ask patients with diabetes about the use of cigarettes or other tobacco products as a routine component of diabetes care and education. Offer and refer for combination treatment consisting of both tobacco/smoking cessation counseling and pharmacological therapy if identified.
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  • Weight loss

  • Physical activity

  • Dietary modifications (general principles)

  • Dietary modifications (eating patterns)

  • Dietary modifications (carbohydrates)

  • Dietary modifications (protein)

  • Dietary modifications (fat)

  • Dietary modifications (nonnutritive sweeteners)

  • Dietary modifications (sodium)

  • Dietary modifications (micronutrients and supplements)

  • Dietary modifications (alcohol)

  • Psychosocial care

7.Surgical interventions

Bariatric surgery: consider offering metabolic surgery as a weight and glycemic management approach in patients with diabetes with BMI ≥ 30.0 kg/m² (or ≥ 27.5 kg/m² in Asian Americans) otherwise being good surgical candidates.
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8.Specific circumstances

Elderly patients, screening for comorbidities: consider assessing medical, psychological, functional (self-management abilities), and social domains in older adults to provide a framework to determine goals and therapeutic approaches for diabetes management.
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  • Elderly patients (screening for hypoglycemia)

  • Elderly patients (treatment goals)

  • Elderly patients (lifestyle modifications)

  • Elderly patients (pharmacotherapy)

  • Elderly patients (residing in nursing facilities)

  • Elderly patients (end-of-life care)

  • Pediatric patients (screening and diagnosis)

  • Pediatric patients (screening for hypertension)

  • Pediatric patients (screening for CVD)

  • Pediatric patients (screening for dyslipidemia)

  • Pediatric patients (screening for NAFLD)

  • Pediatric patients (screening for nephropathy)

  • Pediatric patients (screening for retinopathy)

  • Pediatric patients (screening for neuropathy)

  • Pediatric patients (screening for obstructive sleep apnea)

  • Pediatric patients (screening for PCOS)

  • Pediatric patients (screening for psychosocial factors)

  • Pediatric patients (lifestyle modifications)

  • Pediatric patients (glycemic targets)

  • Pediatric patients (pharmacotherapy)

  • Pediatric patients (management of obesity)

  • Pediatric patients (management of hypertension)

  • Pediatric patients (management of dyslipidemia)

  • Pediatric patients (management of nephropathy)

  • Pediatric patients (transition to adult care)

  • Pregnant patients (screening)

  • Pregnant patients (preconception counseling and care)

  • Pregnant patients (nutrition)

  • Pregnant patients (glycemic targets)

  • Pregnant patients (management of gestational diabetes)

  • Pregnant patients (management of preexisting diabetes)

  • Pregnant patients (prevention of preeclampsia)

  • Pregnant patients (BP targets)

  • Pregnant patients (postpartum care)

  • Patients with CKD

  • Patients with AF

  • Patients with acute coronary syndrome (glycemic control)

  • Patients with acute coronary syndrome (revascularization)

  • Patients with acute coronary syndrome (antithrombotic therapy)

  • Patients with chronic coronary syndrome (pharmacotherapy)

  • Patients with chronic coronary syndrome (revascularization)

  • Patients with chronic coronary syndrome (antithrombotic therapy)

  • Patients with HF (general principles)

  • Patients with HF (asymptomatic)

  • Patients with HF (HFmrEF, HFpEF)

  • Patients with HF (HFrEF)

  • Patients with stroke

  • Patients with PAD

  • Patients with other vascular diseases

  • Patients with male hypogonadism

  • Patients with COVID-19 infection

9.Patient education

Self-management counseling: as per ADA 2024 guidelines, encourage strongly all patients with diabetes to participate in diabetes self-management education and support to facilitate informed decision-making, self-care behaviors, problem-solving, and active collaboration with the healthcare team.
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10.Preventative measures

Primary prevention, lifestyle modifications, ADA: refer adult patients with overweight or obesity at high risk of T2DM, as seen in the Diabetes Prevention Program, to an intensive lifestyle behavior change program to achieve and maintain a weight reduction of at least 7% of initial body weight through healthy reduced-calorie diet and ≥ 150 minute/week of moderate-intensity physical activity.
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  • Primary prevention (metformin)

  • Routine immunizations

11.Follow-up and surveillance

Treatment monitoring: include most components of the initial comprehensive medical evaluation in the follow-up visit.
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  • Monitoring of glycemic status

  • Continuous glucose monitoring

12.Quality improvement

Health promotion: ensure that treatment decisions are timely, rely on evidence-based guidelines, capture key elements within the social determinants of health, and are made collaboratively with patients and their care partners based on individual preferences, prognoses, comorbidities, and informed financial considerations.
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  • Use of diabetes technology