Current diagnostic criteria for diabetes
HbA1C ≥ 6.5%. or Fasting blood glucose (FPG) ≥ 7.0 mmol/L. Fasting is defined as no caloric intake for at least 8 hours. OR OGTT 2h blood glucose ≥ 11.1 mmol/L. The test should be performed according to the World Health Organization (WHO) criteria, using the equivalent of 75 g of anhydrous glucose dissolved in water as the sugar load. OR In patients with typical symptoms of hyperglycemia or hyperglycemic crisis, random blood glucose ≥ 11.1 mmol/L.
If there is no definite hyperglycemia, the results should be confirmed by repeat testing.
Screening for diabetes in asymptomatic patients
In asymptomatic adults who are overweight or obese (BMI ≥25 kg/m2) and have more than one other risk factor for diabetes, screening for diabetes and assessment of risk for future diabetes should begin at any age. For those without these risk factors, screening should begin at age 45 years.
If the test results are normal, the screening should be repeated at least every 3 years.
To screen for diabetes or assess the risk of future diabetes, A1C, FPG or 2h 75g OGTT are available.
For those who are already at a clear increased risk of future diabetes, other cardiovascular disease (CVD) risk factors should be further evaluated and treated.
Prevention/Delay of Type 2 Diabetes
Patients with abnormal glucose tolerance (IGT), impaired fasting glucose (IFG), or A1C between 5.7 and 6.4% should be referred to a unit with an effective ongoing support program to lose 7% of body weight, increase physical activity, and perform at least 150 minutes of moderate intensity (e.g., walking) physical activity per week.
Regular follow-up counseling is important for success.
Treatment with metformin for the prevention of type 2 diabetes may be considered for women with IGT, IFG, or A1C between 5.7 and 6.4%, especially those with a BMI >35 kg/m2, age <60< span=""> years, and previous GDM.
It is recommended that patients with prediabetes should be tested annually to watch for progression to diabetes.
Blood glucose monitoring
Patients treated with multiple daily insulin injections or insulin pumps should perform self-monitoring of blood glucose (SMBG) three or more times daily.
For patients with few insulin injections, non-insulin therapy, or medical nutrition therapy (MNT) only, SMBG may be helpful in guiding therapy.
Ambulatory glucose monitoring (CGM) in combination with intensive insulin therapy for patients with type 1 diabetes aged 25 years or older is an effective way to lower A1C.
Although the evidence for A1C reduction with CGM is not strong in pediatric, adolescent, and young adult patients, CGM may have something to offer to this population. Success is correlated with the continued use of this instrument.
In patients with asymptomatic hypoglycemia and/or frequent hypoglycemia, CGM may be used as an adjunct to SMBG.
A1C
A1C testing should be performed at least twice a year in patients who are on treatment (stable glycemic control).
For patients who change their treatment regimen or whose glycemic control is not up to standard, A1C testing should be performed four times a year.
The application of instant A1C testing helps to change the treatment plan in time.
Glucose control goals for adults
Reducing A1C to about 7% or less has been shown to reduce diabetic microvascular complications and, if treated immediately after diagnosis of diabetes, to reduce distant macrovascular disease. Therefore, a reasonable A1C control goal in many non-pregnant adults is <7%.
It may also be reasonable to recommend a more stringent A1C goal (e.g., <6.5%) if certain patients do not have significant hypoglycemia or other treatment side effects. These patients might include those with a shorter duration of diabetes, a longer life expectancy, and no significant cardiovascular complications.
For patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, more co-morbidities, and a longer duration of diabetes, a more lenient A1C goal (e.g., <8%) may be reasonable despite diabetes self-management education, reasonable blood glucose testing, and multiple effective doses of glucose-lowering medications, including insulin, but still having difficulty achieving the goal.
Energy balance, overweight and obesity
Weight loss is recommended for all individuals with diabetes who are overweight or obese or at risk for diabetes.
For weight loss, a low-carbohydrate diet, a low-fat calorie-restricted diet, or a Mediterranean diet may be effective in the short term (at least 2 years).
For patients on a low-carbohydrate diet, monitor their lipids, renal function and protein intake (in patients with renal disease) and adjust their glucose-lowering regimen in a timely manner.
Physical activity and behavior modification are important components of weight control and also most helpful in maintaining weight loss
Recommendations for primary prevention of diabetes
In individuals at risk for type 2 diabetes, prevention measures should emphasize lifestyle changes, including moderate weight loss (7% of body weight) and regular physical activity (150 minutes per week), and dietary controls such as reduced caloric intake and low-fat diets can reduce the risk of developing type 2 diabetes.
Individuals at risk for type 2 diabetes should be encouraged to consume fiber-rich (14 g fiber/1000 kcal) meals and whole grains (half of the grains).
Individuals at risk for type 2 diabetes should be encouraged to limit the intake of sugary beverages.
Nutrients in diabetes treatment
The optimal ratio of carbohydrate, protein and fat should probably be adjusted to meet the metabolic goals and personal preferences of the person with diabetes.
Monitoring carbohydrate intake using calculations, food exchange portions, or empirical estimates remains key to meeting glycemic control targets.
Saturated fat intake should be less than 7 percent of total calories.
Reducing trans fat intake can lower LDL cholesterol and increase HDL cholesterol, so trans fat intake should be minimized.
Other nutritional recommendations
Adults with diabetes who wish to consume alcohol should limit their daily intake to moderate amounts (≤1 drink per day for adult women and ≤2 drinks per day for adult men).
Routine supplementation with antioxidants such as vitamins E, C and carotenoids is not recommended because of the lack of evidence of effectiveness and long-term safety.
It is recommended that individualized diet plans should include optimized food choices to meet the Recommended Daily Allowance (RDA)/Dietary Reference Intake (DRI) for all micronutrients.
Physical activity
Patients with diabetes should engage in moderate intensity aerobic physical activity (50% to 70% of maximum heart rate) for at least 150 minutes per week, at least 3 days per week, and no more than 2 consecutive days without physical activity.
Patients with type 2 diabetes without contraindications are encouraged to perform endurance exercise at least 2 times per week.
Psychological assessment and treatment
An assessment that includes psychological and social status should always be part of the treatment of diabetes.
Psychological screening and follow-up should include, but not be limited to: attitudes toward the disease, expectations regarding treatment and prognosis, affective/emotional status, general and diabetes-related quality of life, sources of livelihood (financial, social, and emotional), and psychiatric history.
When self-management is poor, consider screening for depression and diabetes-related depression, anxiety, eating disorders, and psychological problems such as cognitive impairment.
Hypoglycemia
Glucose (15-20 g) is preferred for treatment of hypoglycemia in patients without impaired consciousness, or any carbohydrate containing glucose may be used. If the SMBG remains hypoglycemic after 15 minutes of treatment, it should be given again. after the SMBG blood glucose is normalized, the patient should continue an additional normal diet or snack to prevent the recurrence of hypoglycemia.
For asymptomatic hypoglycemia or diabetic patients who have experienced one or more severe hypoglycemia, glycemic control goals should be lowered and reoccurrence of hypoglycemia in recent weeks should be strictly avoided to reduce asymptomatic hypoglycemia and decrease the risk of hypoglycemia.
Bariatric surgery
Patients with type 2 diabetes with BMI ≥ 35 kg/m2, especially those whose diabetes or related comorbidities are difficult to control by lifestyle and medication, may be considered for bariatric surgery treatment.
Patients with type 2 diabetes who have undergone bariatric surgery should receive long-term lifestyle counseling and medical monitoring.
Although small studies have shown that patients with type 2 diabetes with a BMI between 30 and 35 kg/m2 also have better glycemic control when they undergo bariatric surgery, there is insufficient evidence-based medical evidence to recommend surgery for patients with a BMI <35 kg/m2 other than in studies.
The long-term benefits, cost-benefit ratio, and risks of bariatric surgery in patients with type 2 diabetes should be studied in well-designed randomized controlled trials in comparison with appropriate medications and lifestyle treatments.
Immunizations
Annual influenza vaccination is required for patients with diabetes aged ≥6 months.
Pneumococcal vaccine is required for all diabetic patients over 2 years of age, and patients >64 years of age who were previously vaccinated before age 65 need to be revaccinated if they were vaccinated 5 years ago. Indications for revaccination also include those with nephrotic syndrome, chronic kidney disease and other immune compromise such as after organ transplantation.
Hepatitis B vaccination in adults with diabetes should be done according to the recommendations of the Centers for Disease Control.
Hypertension/blood pressure control goals
Screening and diagnosis
Blood pressure should be measured at each follow-up visit for diabetic patients. Patients with a systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg should have a repeat measurement on another day. A second measurement of systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg confirms the diagnosis of hypertension.
Targets
A systolic blood pressure control goal of <130 mmHg is appropriate in most patients with diabetes.
Slightly higher or lower systolic blood pressure targets may be appropriate based on patient characteristics and response to therapy.
Diabetic patients should have diastolic blood pressure control of <80 mmHg.
Screening for dyslipidemia
Most adults with diabetes should be tested for fasting lipids at least once a year. Adults at low risk for dyslipidemia (LDL-C < 2.6 mmol/L, HDL-C > 1.3 mmol/L, TG < 1.7 mmol/L) may have their lipids assessed every 2 years.
Treatment recommendations and goals
Lifestyle interventions for diabetic patients mainly include: reducing the intake of saturated fatty acids, trans fatty acids and cholesterol; increasing the intake of n-3 fatty acids, viscous fiber, and plant sterols/sterols; reducing weight (if necessary); and increasing physical activity to improve blood lipids.
All of the following diabetic patients, regardless of lipid levels, should use statins in addition to lifestyle interventions.
Have definite CVD.
Those who do not have CVD but are older than 40 years and have one or more risk factors for CVD.
In low-risk groups (e.g., those without definite CVD and those under 40 years of age), it is recommended that statin therapy be considered on the basis of lifestyle interventions if the patient has LDL-C > 2.6 mmol/L or has multiple CVD risk factors.
In diabetic patients without CVD, the primary target value is LDL-C < 2.6 mmol/L.
Patients with diabetes mellitus with CVD should be treated with a high-dose statin to achieve LDL-C <1.8 mmol/L.
If the above treatment goal is not achieved with the maximum tolerated dose of statin, an approximately 30-40% reduction in LDL cholesterol from baseline is another alternative goal.
Other targets for treatment are TG<1.7 mmol/L, HDL-C>1.0 mmol/L in men and HDL-C>1.3 mmol/L in women. however, statin control of LDL-C attainment remains the primary choice.
If the maximum tolerated dose of statin is not achieved, a combination of statin and other lipid-lowering drugs may be considered to bring the lipids to standard, but no studies have been done to evaluate their CVD outcomes and safety. (E)
Statin therapy is contraindicated during pregnancy.
Antiplatelet agents
Consider aspirin primary prophylaxis (dose 75-162 mg/day) in patients with type 1 and type 2 diabetes mellitus with increased cardiovascular risk factors (10-year risk >10%). This includes most men >50 years of age or women >60 years of age with a combination of at least one other major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or proteinuria).
CVD prophylaxis with aspirin should not be recommended in adults with diabetes at low risk for CVD (10-year CVD risk <5%, e.g., men <50 years or women <60 years and no other major risk factors) because the potential side effects of bleeding may outweigh its potential benefits.
Patients in this age group with multiple risk factors (e.g., 10-year risk of 5-10%) require clinical judgment.
Diabetic patients with a history of CVD are treated with aspirin (dose 75 to 162 mg/day) as secondary prevention.
Diabetic patients with CVD and allergy to aspirin should be treated with clopidogrel (dose 75 mg/day).
After the occurrence of acute coronary syndrome, aspirin (dose 75-162 mg/day) combined with clopidogrel (dose 75 mg/day) for one year is reasonable.
Smoking cessation
All patients are advised not to smoke.
Smoking cessation counseling and other forms of treatment are an integral part of routine diabetes management.
Screening for coronary artery disease
Routine screening for coronary heart disease is not recommended for asymptomatic patients because treatment is given whenever cardiovascular risk factors are present, and routine screening for coronary heart disease has not been shown to improve outcomes.
Screening for renal disease
Overall recommendations
● To reduce and or delay the risk of progression of renal disease, optimize glycemic control.
● To reduce and or delay the risk of progression of renal disease, optimize blood pressure control.
Screening
● Urinary albumin excretion rates should be assessed annually from diagnosis for all patients with type 1 diabetes of 5 years or more duration and all patients with type 2 diabetes.
● For all adults with diabetes regardless of their urinary albumin excretion rate, serum creatinine should be measured at least annually. Serum creatinine should be used to assess glomerular filtration rate (GFR) and to stage chronic kidney disease (if CKD is present).
Screening for retinopathy
Overall recommendations
To reduce the risk and slow the progression of diabetic retinopathy, optimize glycemic control.
To reduce the risk of diabetic retinopathy and delay its progression, optimize blood pressure control.
Screening
Adult patients with type 1 diabetes or children over 10 years of age should receive a comprehensive eye examination by an ophthalmologist or optometrist after dilated pupils within 5 years of the onset of diabetes.
Patients with type 2 diabetes should receive a comprehensive ophthalmologic examination by an ophthalmologist or optometrist with dilated pupils as soon as possible after diagnosis.
Thereafter, patients with type 1 diabetes and type 2 diabetes should be reviewed annually by an ophthalmologist or optometrist. Those with normal examination results can be examined every 2 to 3 years. Those with progressive retinopathy should be examined more frequently.
High-quality fundus photography can detect most diabetic retinopathy with clinical signs. The films should be reviewed by an experienced ophthalmologist. Although retinal photography can be used as a screening tool for retinopathy, it is not a substitute for a comprehensive ophthalmologic examination. A comprehensive ophthalmologic examination and follow-up should be performed by an ophthalmologist at the time of diabetes diagnosis.
Women of childbearing age with diabetes who are planning to become pregnant or are already pregnant should undergo a comprehensive ophthalmologic examination for a comprehensive evaluation of the risk of developing or/and progression of diabetic retinopathy. Ophthalmic examinations should be performed early in pregnancy and followed closely throughout pregnancy and for 1 year after delivery.
Neuropathy screening and treatment
All type 2 diabetes should be screened for distal symmetric polyneuropathy (DPN) using a simple clinical test at diagnosis and 5 years after type 1 diabetes diagnosis, and at least annually thereafter.
Electrophysiologic testing is rarely needed unless clinical features are atypical.
Signs and symptoms of cardiovascular autonomic neuropathy should be screened for at the time of type 2 diabetes diagnosis and 5 years after type 1 diabetes diagnosis. Rarely is it necessary to go to special tests, and special tests guide treatment and assessment of prognosis.
Application of medications to reduce specific symptoms of painful DPN and autonomic neuropathy is recommended to improve the patient’s quality of life.
Foot Clinic
A comprehensive annual foot examination is performed in all diabetic patients to identify risk factors for foot ulceration and amputation. Foot examination should include visual examination, foot artery pulsation, and loss of protective sensation (LOPS) examination (10-g single nylon wire + any of the following: 128-Hz tuning fork to check vibrometry, pinprick sensation, ankle reflex, and vibrometry threshold). (B)
Education on self-protection of the diabetic foot should be given to all diabetic patients.
Multidisciplinary consultation should be performed for patients with foot ulcers and high-risk feet, especially those with a history of foot ulcers and amputations.
Those who smoke, have LOPS, deformities, or previous lower extremity complications should be referred to a diabetic foot specialist for preventive treatment and lifelong monitoring.
Initial screening for peripheral arterial disease (PAD) should include a history of claudication and assessment of dorsalis pedis artery pulsation. An ankle-brachial index (ABI) should be calculated, as many patients with peripheral arterial disease are asymptomatic.
Those with significant claudication or an abnormal ankle-brachial index should undergo further vascular evaluation and consider options for exercise, medication, and surgical treatment.
Older adults
For patients who are mobile, have no cognitive impairment, and have a long life expectancy, younger age-specific adult diabetes treatment goals should be established.
Older patients with diabetes who have difficulty achieving these goals for glycemic control should have their goals relaxed and individualized criteria set. However, all patients should avoid clinical signs of hyperglycemia or acute hyperglycemic complications.
Other cardiovascular risk factors in elderly patients should be considered for treatment based on the patient’s actual condition and the pros and cons of management. Hypertension should be treated aggressively in all patients. Lipid regulation and aspirin therapy may be beneficial in patients with a longer life expectancy than in the primary and secondary prevention trials.
Screening for complications of diabetes in older patients should be individualized, but special attention should be paid to those complications that cause functional impairment.
Treatment of Hospitalized Diabetic Patients
All hospitalized diabetic patients should be clearly documented in their medical record files.
All hospitalized diabetic patients should be monitored for blood glucose and the results should be communicated to all members of the treatment team.
Blood glucose control goals.
Critically ill patients: Patients with blood glucose consistently above 10 mmol/L should initiate insulin therapy. Once insulin therapy is initiated, it is recommended that most critically ill patients control their blood glucose between 7.8 and 10.0 mmol/L.
Stricter targets such as 6.1 to 7.8 mmol/L may be appropriate for some patients, provided this can be achieved in the absence of significant hypoglycemia.
Critically ill patients require intravenous drip insulin, which has been shown to be safe and effective in lowering blood glucose control to the target range without increasing the risk of severe hypoglycemia.
Non-critical patients: There is no clear evidence for glycemic control goals. If treated with insulin, pre-meal glucose targets should generally be <7.8 mmol/L and random blood glucose <10.0 mmol/L range, which should be safely met. Patients with previously tightly controlled stable blood glucose may have more stringent glycemic control goals. Patients with severe co-morbidities should have relaxed glycemic targets.
All diabetic patients who have not had their A1C values tested 2 to 3 months prior to admission should have their A1C checked during hospitalization.
Patients with undiagnosed diabetes mellitus who are found to have elevated blood glucose during hospitalization should be discharged with an appropriate follow-up testing and treatment plan.
HbA1C ≥ 6.5%. OR Fasting glucose (FPG) ≥ 7.0 mmol/L. Fasting is defined as no caloric intake for at least 8 hours. OR OGTT 2h blood glucose ≥ 11.1 mmol/L. The test should be performed according to World Health Organization (WHO) standards, using the equivalent of 75 g of anhydrous glucose dissolved in water as the sugar load. Or In patients with typical symptoms of hyperglycemia or hyperglycemic crisis, random blood glucose ≥ 11.1 mmol/L. Xiao Jianpeng, Department of Rheumatology and Endocrinology, Fuzhou General Hospital, Nanjing Military Region
If there is no definite hyperglycemia, the results should be confirmed by repeated testing.
Screening for diabetes in asymptomatic patients
In asymptomatic adults who are overweight or obese (BMI ≥ 25 kg/m2) and have more than one other risk factor for diabetes, screening for diabetes and assessment of risk for future diabetes should begin at any age. For those without these risk factors, screening should begin at age 45 years.
If the test results are normal, the screening should be repeated at least every 3 years.
To screen for diabetes or assess the risk of future diabetes, A1C, FPG or 2h 75g OGTT are available.
For those who are already at a clear increased risk of future diabetes, other cardiovascular disease (CVD) risk factors should be further evaluated and treated.
Prevention/Delay of Type 2 Diabetes
Patients with abnormal glucose tolerance (IGT), impaired fasting glucose (IFG), or A1C between 5.7 and 6.4% should be referred to a unit with an effective ongoing support program to lose 7% of body weight, increase physical activity, and perform at least 150 minutes of moderate intensity (e.g., walking) physical activity per week.
Regular follow-up counseling is important for success.
Treatment with metformin for the prevention of type 2 diabetes may be considered for women with IGT, IFG, or A1C between 5.7 and 6.4%, especially those with a BMI >35 kg/m2, age <60< span=""> years, and previous GDM.
It is recommended that patients with prediabetes should be tested annually to watch for progression to diabetes.
Blood glucose monitoring
Patients treated with multiple daily insulin injections or insulin pumps should perform self-monitoring of blood glucose (SMBG) three or more times daily.
For patients with few insulin injections, non-insulin therapy, or medical nutrition therapy (MNT) only, SMBG may be helpful in guiding therapy.
Ambulatory glucose monitoring (CGM) in combination with intensive insulin therapy for patients with type 1 diabetes aged 25 years or older is an effective way to lower A1C.
Although the evidence for A1C reduction with CGM is not strong in pediatric, adolescent, and young adult patients, CGM may have something to offer to this population. Success is correlated with the continued use of this instrument.
In patients with asymptomatic hypoglycemia and/or frequent hypoglycemia, CGM may be used as an adjunct to SMBG.
A1C
A1C testing should be performed at least twice a year in patients who are on treatment (stable glycemic control).
For patients who change their treatment regimen or whose glycemic control is not up to standard, A1C testing should be performed four times a year.
The application of instant A1C testing helps to change the treatment plan in time.
Glucose control goals for adults
Reducing A1C to about 7% or less has been shown to reduce diabetic microvascular complications and, if treated immediately after diagnosis of diabetes, to reduce distant macrovascular disease. Therefore, a reasonable A1C control goal in many non-pregnant adults is <7%.
It may also be reasonable to recommend a more stringent A1C goal (e.g., <6.5%) if certain patients do not have significant hypoglycemia or other treatment side effects. These patients might include those with a shorter duration of diabetes, a longer life expectancy, and no significant cardiovascular complications.
For patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, more co-morbidities, and a longer duration of diabetes, a more lenient A1C goal (e.g., <8%) may be reasonable despite diabetes self-management education, reasonable blood glucose testing, and multiple effective doses of glucose-lowering medications, including insulin, but still having difficulty achieving the goal.
Energy balance, overweight and obesity
Weight loss is recommended for all individuals with diabetes who are overweight or obese or at risk for diabetes.
For weight loss, a low-carbohydrate diet, a low-fat calorie-restricted diet, or a Mediterranean diet may be effective in the short term (at least 2 years).
For patients on a low-carbohydrate diet, monitor their lipids, renal function and protein intake (in patients with renal disease) and adjust their glucose-lowering regimen in a timely manner.
Physical activity and behavior modification are important components of weight control and also most helpful in maintaining weight loss
Recommendations for primary prevention of diabetes
In individuals at risk for type 2 diabetes, prevention measures should emphasize lifestyle changes, including moderate weight loss (7% of body weight) and regular physical activity (150 minutes per week), and dietary controls such as reduced caloric intake and low-fat diets can reduce the risk of developing type 2 diabetes.
Individuals at risk for type 2 diabetes should be encouraged to consume fiber-rich (14 g fiber/1000 kcal) meals and whole grains (half of the grains).
Individuals at risk for type 2 diabetes should be encouraged to limit the intake of sugary beverages.
Nutrients in diabetes treatment
The optimal ratio of carbohydrate, protein and fat should probably be adjusted to meet the metabolic goals and personal preferences of the person with diabetes.
Monitoring carbohydrate intake using calculations, food exchange portions, or empirical estimates remains key to meeting glycemic control targets.
Saturated fat intake should be less than 7 percent of total calories.
Reducing trans fat intake can lower LDL cholesterol and increase HDL cholesterol, so trans fat intake should be minimized.
Other nutritional recommendations
Adults with diabetes who wish to consume alcohol should limit their daily intake to moderate amounts (≤1 drink per day for adult women and ≤2 drinks per day for adult men).
Routine supplementation with antioxidants such as vitamins E, C and carotenoids is not recommended because of the lack of evidence of effectiveness and long-term safety.
It is recommended that individualized diet plans should include optimized food choices to meet the Recommended Daily Allowance (RDA)/Dietary Reference Intake (DRI) for all micronutrients.
Physical activity
Patients with diabetes should engage in moderate intensity aerobic physical activity (50% to 70% of maximum heart rate) for at least 150 minutes per week, at least 3 days per week, and no more than 2 consecutive days without physical activity.
Patients with type 2 diabetes without contraindications are encouraged to perform endurance exercise at least 2 times per week.
Psychological assessment and treatment
An assessment that includes psychological and social status should always be part of the treatment of diabetes.
Psychological screening and follow-up should include, but not be limited to: attitudes toward the disease, expectations regarding treatment and prognosis, affective/emotional status, general and diabetes-related quality of life, sources of livelihood (financial, social, and emotional), and psychiatric history.
When self-management is poor, consider screening for depression and diabetes-related depression, anxiety, eating disorders, and psychological problems such as cognitive impairment.
Hypoglycemia
Glucose (15-20 g) is preferred for treatment of hypoglycemia in patients without impaired consciousness, or any carbohydrate containing glucose may be used. If the SMBG remains hypoglycemic after 15 minutes of treatment, it should be given again. after the SMBG blood glucose is normalized, the patient should continue an additional normal diet or snack to prevent the recurrence of hypoglycemia.
For asymptomatic hypoglycemia or diabetic patients who have experienced one or more severe hypoglycemia, glycemic control goals should be lowered and reoccurrence of hypoglycemia in recent weeks should be strictly avoided to reduce asymptomatic hypoglycemia and decrease the risk of hypoglycemia.
Bariatric surgery
Patients with type 2 diabetes with BMI ≥ 35 kg/m2, especially those whose diabetes or related comorbidities are difficult to control by lifestyle and medication, may be considered for bariatric surgery treatment.
Patients with type 2 diabetes who have undergone bariatric surgery should receive long-term lifestyle counseling and medical monitoring.
Although small studies have shown that patients with type 2 diabetes with a BMI between 30 and 35 kg/m2 also have better glycemic control when they undergo bariatric surgery, there is insufficient evidence-based medical evidence to recommend surgery for patients with a BMI <35 kg/m2 other than in studies.
The long-term benefits, cost-benefit ratio, and risks of bariatric surgery in patients with type 2 diabetes should be studied in well-designed randomized controlled trials in comparison with appropriate medications and lifestyle treatments.
Immunizations
Annual influenza vaccination is required for patients with diabetes aged ≥6 months.
Pneumococcal vaccine is required for all diabetic patients over 2 years of age, and patients >64 years of age who were previously vaccinated before age 65 need to be revaccinated if they were vaccinated 5 years ago. Indications for revaccination also include those with nephrotic syndrome, chronic kidney disease and other immune compromise such as after organ transplantation.
Hepatitis B vaccination in adults with diabetes should be done according to the recommendations of the Centers for Disease Control.
Hypertension/blood pressure control goals
Screening and diagnosis
Blood pressure should be measured at each follow-up visit for diabetic patients. Patients with a systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg should have a repeat measurement on another day. A second measurement of systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg confirms the diagnosis of hypertension.
Targets
A systolic blood pressure control goal of <130 mmHg is appropriate in most patients with diabetes.
Slightly higher or lower systolic blood pressure targets may be appropriate based on patient characteristics and response to therapy.
Diabetic patients should have diastolic blood pressure control of <80 mmHg.
Screening for dyslipidemia
Most adults with diabetes should be tested for fasting lipids at least once a year. Adults at low risk for dyslipidemia (LDL-C < 2.6 mmol/L, HDL-C > 1.3 mmol/L, TG < 1.7 mmol/L) may have their lipids assessed every 2 years.
Treatment recommendations and goals
Lifestyle interventions for diabetic patients mainly include: reducing the intake of saturated fatty acids, trans fatty acids and cholesterol; increasing the intake of n-3 fatty acids, viscous fiber, and plant sterols/sterols; reducing weight (if necessary); and increasing physical activity to improve blood lipids.
All of the following diabetic patients, regardless of lipid levels, should use statins in addition to lifestyle interventions.
Have definite CVD.
Those who do not have CVD but are older than 40 years and have one or more risk factors for CVD.
In low-risk groups (e.g., those without definite CVD and those under 40 years of age), it is recommended that statin therapy be considered on the basis of lifestyle interventions if the patient has LDL-C > 2.6 mmol/L or has multiple CVD risk factors.
In diabetic patients without CVD, the primary target value is LDL-C < 2.6 mmol/L.
Patients with diabetes mellitus with CVD should be treated with a high-dose statin to achieve LDL-C <1.8 mmol/L.
If the above treatment goal is not achieved with the maximum tolerated dose of statin, an approximately 30-40% reduction in LDL cholesterol from baseline is another alternative goal.
Other targets for treatment are TG<1.7 mmol/L, HDL-C>1.0 mmol/L in men and HDL-C>1.3 mmol/L in women. however, statin control of LDL-C attainment remains the primary choice.
If the maximum tolerated dose of statin is not achieved, a combination of statin and other lipid-lowering drugs may be considered to bring the lipids to standard, but no studies have been done to evaluate their CVD outcomes and safety. (E)
Statin therapy is contraindicated during pregnancy.
Antiplatelet agents
Consider aspirin primary prophylaxis (dose 75-162 mg/day) in patients with type 1 and type 2 diabetes mellitus with increased cardiovascular risk factors (10-year risk >10%). This includes most men >50 years of age or women >60 years of age with a combination of at least one other major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or proteinuria).
CVD prophylaxis with aspirin should not be recommended in adults with diabetes at low risk for CVD (10-year CVD risk <5%, e.g., men <50 years or women <60 years and no other major risk factors) because the potential side effects of bleeding may outweigh its potential benefits.
Patients in this age group with multiple risk factors (e.g., 10-year risk of 5-10%) require clinical judgment.
Diabetic patients with a history of CVD are treated with aspirin (dose 75 to 162 mg/day) as secondary prevention.
Diabetic patients with CVD and allergy to aspirin should be treated with clopidogrel (dose 75 mg/day).
After the occurrence of acute coronary syndrome, aspirin (dose 75-162 mg/day) combined with clopidogrel (dose 75 mg/day) for one year is reasonable.
Smoking cessation
All patients are advised not to smoke.
Smoking cessation counseling and other forms of treatment are an integral part of routine diabetes management.
Screening for coronary artery disease
Routine screening for coronary heart disease is not recommended for asymptomatic patients because treatment is given whenever cardiovascular risk factors are present, and routine screening for coronary heart disease has not been shown to improve outcomes.
Screening for renal disease
Overall recommendations
To reduce and or delay the risk of progression of nephropathy, optimize glycemic control.
To reduce and or delay the risk of progression of renal disease, optimize blood pressure control.
Screening
Urinary albumin excretion rates should be evaluated annually from diagnosis for all patients with type 1 diabetes for more than 5 years and for all patients with type 2 diabetes.
For all adults with diabetes regardless of their urinary albumin excretion rate, serum creatinine should be measured at least annually. Serum creatinine should be used to assess glomerular filtration rate (GFR) and to stage chronic kidney disease (if CKD is present).
Screening for retinopathy
Overall recommendations
To reduce the risk of diabetic retinopathy and delay its progression, optimize glycemic control.
To reduce the risk of diabetic retinopathy and delay its progression, optimize blood pressure control.
Screening
Adult patients with type 1 diabetes or children over 10 years of age should receive a comprehensive eye examination by an ophthalmologist or optometrist after dilated pupils within 5 years of the onset of diabetes.
Patients with type 2 diabetes should receive a comprehensive ophthalmologic examination by an ophthalmologist or optometrist with dilated pupils as soon as possible after diagnosis.
Thereafter, patients with type 1 diabetes and type 2 diabetes should be reviewed annually by an ophthalmologist or optometrist. Those with normal examination results can be examined every 2 to 3 years. Those with progressive retinopathy should be examined more frequently.
High-quality fundus photography can detect most diabetic retinopathy with clinical signs. The films should be reviewed by an experienced ophthalmologist. Although retinal photography can be used as a screening tool for retinopathy, it is not a substitute for a comprehensive ophthalmologic examination. A comprehensive ophthalmologic examination and follow-up should be performed by an ophthalmologist at the time of diabetes diagnosis.
Women of childbearing age with diabetes who are planning to become pregnant or are already pregnant should undergo a comprehensive ophthalmologic examination for a comprehensive evaluation of the risk of developing or/and progression of diabetic retinopathy. Ophthalmic examinations should be performed early in pregnancy and followed closely throughout pregnancy and for 1 year after delivery.
Neuropathy screening and treatment
All type 2 diabetes should be screened for distal symmetric polyneuropathy (DPN) using a simple clinical test at diagnosis and 5 years after type 1 diabetes diagnosis, and at least annually thereafter.
Electrophysiologic testing is rarely needed unless clinical features are atypical.
Signs and symptoms of cardiovascular autonomic neuropathy should be screened for at the time of type 2 diabetes diagnosis and 5 years after type 1 diabetes diagnosis. Rarely is it necessary to go to special tests, and special tests guide treatment and assessment of prognosis.
Application of medications to reduce specific symptoms of painful DPN and autonomic neuropathy is recommended to improve the patient’s quality of life.
Foot Clinic
A comprehensive annual foot examination is performed in all diabetic patients to identify risk factors for foot ulceration and amputation. Foot examination should include visual examination, foot artery pulsation, and loss of protective sensation (LOPS) examination (10-g single nylon wire + any of the following: 128-Hz tuning fork to check vibrometry, pinprick sensation, ankle reflex, and vibrometry threshold). (B)
Education on self-protection of the diabetic foot should be given to all diabetic patients.
Multidisciplinary consultation should be performed for patients with foot ulcers and high-risk feet, especially those with a history of foot ulcers and amputations.
Those who smoke, have LOPS, deformities, or previous lower extremity complications should be referred to a diabetic foot specialist for preventive treatment and lifelong monitoring.
Initial screening for peripheral arterial disease (PAD) should include a history of claudication and assessment of dorsalis pedis artery pulsation. An ankle-brachial index (ABI) should be calculated, as many patients with peripheral arterial disease are asymptomatic.
Those with significant claudication or an abnormal ankle-brachial index should undergo further vascular evaluation and consider options for exercise, medication, and surgical treatment.
Older adults
For patients who are mobile, have no cognitive impairment, and have a long life expectancy, younger age-specific adult diabetes treatment goals should be established.
Older patients with diabetes who have difficulty achieving these goals for glycemic control should have their goals relaxed and individualized criteria set. However, all patients should avoid clinical signs of hyperglycemia or acute hyperglycemic complications.
Other cardiovascular risk factors in elderly patients should be considered for treatment based on the patient’s actual condition and the pros and cons of management. Hypertension should be treated aggressively in all patients. Lipid regulation and aspirin therapy may be beneficial in patients with a longer life expectancy than in the primary and secondary prevention trials.
Screening for complications of diabetes in older patients should be individualized, but special attention should be paid to those complications that cause functional impairment.
Treatment of Hospitalized Diabetic Patients
All hospitalized diabetic patients should be clearly documented in their medical record files.
All hospitalized diabetic patients should be monitored for blood glucose and the results should be communicated to all members of the treatment team.
Blood glucose control goals.
Critically ill patients: Patients with blood glucose consistently above 10 mmol/L should initiate insulin therapy. Once insulin therapy is initiated, it is recommended that most critically ill patients control their blood glucose between 7.8 and 10.0 mmol/L.
Stricter targets such as 6.1 to 7.8 mmol/L may be appropriate for some patients, provided this can be achieved in the absence of significant hypoglycemia.
Critically ill patients require intravenous drip insulin, which has been shown to be safe and effective in lowering blood glucose control to the target range without increasing the risk of severe hypoglycemia.
Non-critical patients: There is no clear evidence for glycemic control goals. If treated with insulin, pre-meal glucose targets should generally be <7.8 mmol/L and random blood glucose <10.0 mmol/L range, which should be safely met. Patients with previously tightly controlled stable blood glucose may have more stringent glycemic control goals. Patients with severe co-morbidities should have relaxed glycemic targets.
All diabetic patients who have not had their A1C values tested 2 to 3 months prior to admission should have their A1C checked during hospitalization.
Patients with undiagnosed diabetes mellitus who are found to have elevated blood glucose during hospitalization should be discharged with an appropriate follow-up testing and treatment plan.