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Last Updated: 10/3/2014  

Diabetes Mellitus, Type 2

Prevention
  • Recommend healthy lifestyle changes in patients who have pre-diabetes or are at high risk for type 2 diabetes based on obesity, the presence of polycystic ovarian disease, metabolic syndrome, or a strong family history.

  • Consider treatment with metformin in addition to lifestyle changes in the prevention of diabetes in certain high-risk populations.

Screening
  • Obtain a fasting plasma glucose level, oral glucose tolerance test, or HbA1C level to screen for type 2 diabetes in patients with risk factors for type 2 diabetes, including obesity, gestational diabetes, polycystic ovarian syndrome, membership in a high-risk ethnic group, hyperlipidemia, hypertension, or a history of cardiovascular disease and family history of diabetes.

Diagnosis
  • Establish the diagnosis of diabetes using a glucose tolerance test (2-hour plasma glucose level of ≥200 mg/dL), a fasting plasma glucose level ≥126 mg/dL, or an HbA1c level 6.5% or greater).

  • Establish the diagnosis in patients with symptoms of hyperglycemia with a random plasma glucose level ≥200 mg/dL. Note that repeat testing is needed to confirm the diagnosis in patients without classic symptoms for hyperglycemia.

  • Confirm the diagnosis of type 2 diabetes in any patient with a random plasma glucose level above the normal range, symptoms of hyperglycemia, or possible complications of diabetes.

  • Perform a careful history and physical exam in all patients with hyperglycemia, and evaluate for possible complications of diabetes.

  • Order lab tests to establish baselines and to screen for complications of diabetes, checking HbA1c, urine microalbumin, lipid profile, creatinine and electrolyte levels.

Therapy
  • Individualize the glycemic control goal based on the patient's life expectancy, comorbid conditions, and risk for complications from hypoglycemia.

  • Target glucose control to achieve an HbA1c level less than 7% in most patients; consider a lower goal in select motivated patients who are low risk for hypoglycemia and a higher goal (8%) in some elderly patients.

  • Recommend diet and exercise programs as the cornerstones of therapy for diabetes.

  • Begin oral hypoglycemic agents in patients in whom diet and exercise do not adequately control diabetes, and adjust as needed to achieve the target level of glycemic control. Use metformin as the first-line oral agent in most patients with diabetes.

  • Consider using a combination of insulin, glucagon-like peptide-1 analogs, and non-insulin agents if non-insulin agents do not achieve the desired level of glycemic control, with individual therapies based on patient preference, side-effect profiles, costs, and patient comorbid conditions.

  • Treat hypertension preferentially with an ACE inhibitor or ARB, to reduce the risk for adverse microvascular (e.g., retinopathy, nephropathy) and macrovascular (e.g., MI, stroke) outcomes, with a goal blood pressure <140/90 mm Hg.

  • Treat hyperlipidemia with moderate- or high-intensity statin therapy to reduce the risk for macrovascular complications.

  • Use aspirin for secondary prevention of cardiovascular disease in patients with diabetes, and consider its use for primary prevention in select patients.

  • Treat diabetic nephropathy, preferentially with ACE inhibitors, to reduce the risk for progression to end-stage renal failure.

  • Institute foot-care strategies to prevent ulceration and amputation in patients with documented diabetic neuropathy.

  • Consider treating painful neuropathy preferentially with pregabalin or tricyclic antidepressants.

  • Provide pneumococcal vaccination and annual influenza vaccination.

  • Encourage smoking cessation.

DOI: 10.7326/d296
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Disclosures:
Sandeep Vijan, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Norra Kwong, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Rajesh K. Garg, MD has received a research grant from AstraZeneca Company.
The following editors of ACP Smart Medicine have nothing to disclose: Deborah Korenstein, MD, FACP, Editor in Chief; Richard B. Lynn, MD, FACP, Editor; and Davoren Chick, MD, Editor.
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