Approach

For updates on diagnosis and management of coexisting conditions during the pandemic, see our topic 'Management of coexisting conditions in the context of COVID-19'.

The cornerstone of therapy for all patients with type 2 diabetes is a personalised management programme that includes pharmacotherapy and ongoing self-management education by a diabetes education nurse or nutritionist.[61][62][63] Diabetes self-management education promotes diabetes self-care and supports beneficial lifestyle changes on an ongoing basis.[2] This requires general nutrition and health lifestyle knowledge and an individualised nutrition and exercise plan based on an initial assessment and treatment goals. Interventions that enhance self-management can significantly reduce diabetes distress.[64]

About 80% of adults with type 2 diabetes have concurrent dyslipidaemias or hypertension, 70% are overweight or obese, and around 15% are current smokers.[9] On average, adults with type 2 diabetes are up to twice as likely to die of stroke or myocardial infarction (MI) compared with those without diabetes, and they are more than 40 times more likely to die of macrovascular than microvascular complications of diabetes.[65][66][67] However, data indicate that adults with type 2 diabetes who optimally manage glucose, blood pressure, lipids, smoking, and weight have a risk of major cardiovascular events that is not significantly above the risk of age and sex-matched non-diabetes peers.[68][69]

Therefore, care of adults with type 2 diabetes must include management of all major cardiovascular risk factors to individualised targets. In addition to glucose control, this includes smoking cessation, blood pressure control, lipid control, antiplatelet use for patients with known coronary heart disease, and ACE inhibitors or angiotensin-II receptor antagonists for patients with chronic kidney disease or proteinuria.[2][41][70] In addition, use of antihyperglycaemic agents that reduce cardiovascular or overall mortality or cardiovascular events may be especially beneficial in those who have type 2 diabetes and established cardiovascular disease.[2][41][71]

Diet

Nutrition therapy involves limiting caloric intake to achieve recommended weight, while offering a diversified and appealing menu of food choices.[72] Nutrition advice needs to be tailored to the needs of each individual patient, preferably by a nutritionist.[2][29] The optimal mix of carbohydrate, fats, and protein depends upon renal status, achieved lipid levels, body mass index (BMI), and level of glycaemic control, among other factors. Low-carbohydrate diets appear to be beneficial for glycaemic control in type 2 diabetes management.[73] Saturated fat should be limited to <10% of calories.[29] Reducing sugary beverage consumption (including milk, fizzy drinks, energy drinks, and fruit juice) is of benefit to many patients.[29] Weight loss management programmes with a healthy eating and physical activity plan resulting in an energy deficit have the potential for type 2 diabetes remission.[29][74][75] The Diabetes Remission Clinical Trial (DiRECT) of supported weight loss management for people diagnosed with type 2 diabetes within the previous 6 years, and a BMI of 27kg/m² to 45 kg/m², found that almost half of participants achieved remission to a non-diabetic state and off antidiabetic drugs at 12 months.[74] At 2 years, more than a third of people with type 2 diabetes had sustained remission.[76]

Exercise and sleep

  • To improve glycaemic control, assist with weight maintenance, and reduce cardiovascular risk, moderate physical activity is recommended as tolerated. The ACC/AHA has recommended that, in general, adults should engage in 3 to 4 sessions of aerobic physical activity per week, with each session lasting on average 40 minutes, and involving moderate- to vigorous-intensity physical activity.[77] Walking frequently in proper footwear is a recommended activity.[2]

  • In addition, gentle strength training that targets all major muscle groups may be beneficial if done for 20 minutes 2 to 3 times per week on non-consecutive days. Patients with severe or symptomatic heart disease may require evaluation before increasing levels of physical activity.[2]

  • People should be encouraged to limit the amount of time they spend being sedentary by avoiding extended amounts of time spent sitting.

  • Older adults may benefit from flexibility training and balance training 2-3 times/week (e.g., with yoga or tai chi).

  • An assessment of sleep duration and quality should be considered. Obesity, diabetes, hypertension, atrial fibrillation, and male sex are risk factors for sleep apnoea, and inadequate sleep may affect glycaemic control.[2]

Cardiovascular risk management

Blood pressure

Blood pressure guidelines differ regarding recommended targets for those with diabetes.

  • The 2017 American College of Cardiology/American Heart Association guideline for management of high blood pressure (BP) in adults recommends BP <130/80 mmHg for people with diabetes, and classifies BP using the following categories:[78]

    • normal (<120/80 mmHg)

    • elevated (120-129/<80 mmHg)

    • stage 1 (130-139/80-89 mmHg)

    • stage 2 hypertension (≥140/90 mmHg).

  • The American Diabetes Association Standards of Medical Care in Diabetes recommends goal BP <140/90 mmHg for people with diabetes, with consideration of a goal BP <130/80 mmHg for those with established hypertension and diabetes and who have established cardiovascular disease or 10-year cardiovascular risk greater than 15%.[2][79]

  • Regardless of specific blood pressure goal, initial treatment with an ACE inhibitor, an angiotensin-II receptor antagonist, a calcium-channel blocker, or a thiazide (or thiazide-like) diuretic is preferred. Black people may benefit most from a thiazide diuretic or a calcium-channel blocker.[79] ACE inhibitors may reduce mortality and cardiovascular events more than angiotensin-II receptor antagonists.[70] Combination drug therapy (with ACE inhibitor/angiotensin-II receptor antagonist, calcium-channel blocker, thiazide diuretic) is often required to reach blood pressure goals. Combined use of an ACE inhibitor and an angiotensin-II receptor antagonist is not recommended due to increased risk of adverse events.[80] However, most people with chronic kidney disease (CKD) should receive an ACE inhibitor or an angiotensin-II receptor antagonist as part of their antihypertensive regimen.[79] CKD is defined as (a) age <70 years with glomerular filtration rate (GFR) <60 mL/minute/1.73 m², or (b) people of any age with albuminuria >30 mg albumin/g of creatinine at any level of GFR.

  • Beta-blockers are not contraindicated in people with diabetes but are less-preferred antihypertensive agents[79] and may mask symptoms of hypoglycaemia. ACE inhibitors may increase risk for hypoglycaemia in conjunction with insulin or an insulin secretagogue (e.g., sulfonylurea or meglitinide).[81]

  • If blood pressure remains uncontrolled on first-line therapies, discontinue or minimise interfering substances such as non-steroidal anti-inflammatory drugs (NSAIDs), evaluate for secondary causes of hypertension (including obstructive sleep apnoea), and consider the addition of a mineralocorticoid receptor agonist,[82] and/or refer to a hypertension specialist.

  • Blood pressure goals and guidelines are evolving as more studies are carried out. The Systolic Blood Pressure Intervention Trial (SPRINT) was terminated early, as it found that a lower systolic target of 120 mmHg reduced cardiovascular complications and deaths in people aged over 50 years with high blood pressure and at least one additional risk factor for heart disease.[83] However, people with diabetes were excluded from this trial.

  • There is an increasing emphasis to incorporate the use of home blood pressure monitoring into the diagnosis and management of hypertension in adults, including those with diabetes.[84]

Lipids

  • The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend high-intensity statin therapy if tolerated in adults aged over 21 years if the patient has clinical atherosclerotic cardiovascular disease (ASCVD) or low-density lipoprotein (LDL)-cholesterol ≥4.9 mmol/L (≥190 mg/dL).[85] In those aged 40 to 75 years with diabetes but no ASCVD, moderate-intensity statin therapy should be considered. [ Cochrane Clinical Answers logo ] In those with diabetes and 10-year ACC/AHA cardiovascular risk greater than 20%, consider adding ezetimibe to maximally-tolerated statin therapy to reduce LDL by 50% or more.[85] In diabetes patients aged over 75 years, it is reasonable to consider and discuss with the patient advantages and disadvantages of initiation or continuation of statin therapy.[85] In those aged 20 to 39 years with diabetes, it may be reasonable to initiate statin therapy in the presence of albuminuria, estimated GFR <60 mL/minute/1.73 m², retinopathy, or neuropathy.[85] Statins are contraindicated in pregnancy.

  • The American Diabetes Association (ADA) recommends that management of lipid abnormalities is driven by risk status rather than LDL cholesterol level.[2] Risk factors for cardiovascular disease include LDL-cholesterol >2.6 mmol/L (>100 mg/dL), high blood pressure, smoking, and overweight and obesity. Lifestyle therapy is recommended for all people. For people with diabetes and overt cardiovascular disease, high-intensity statin therapy is added to lifestyle therapy, regardless of baseline lipid values. High-intensity statin therapy is also considered for those aged over 40 years without overt cardiovascular disease, but with one or more cardiovascular disease (CVD) risk factors. For people with diabetes aged over 40 years without additional CVD risk factors, moderate-intensity statin therapy is still considered. For some patients with diabetes and established coronary heart disease who have persistently elevated LDL despite maximally-tolerated statin therapy, addition of ezetimibe or a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor (e.g., alirocumab, evolocumab) may confer clinical benefit.[2][86][87][88]

Smoking cessation

  • Patients who smoke should be provided with smoking cessation resources, and be provided with smoking cessation assistance such as medications and counselling as appropriate. Varenicline combined with nicotine replacement therapy may be more effective than varenicline alone.[89] The ADA does not support e-cigarettes as an alternative to smoking or to facilitate smoking cessation.[2]

Antiplatelet therapy

  • Adults with cardiovascular disease should receive aspirin for secondary prevention. Clopidogrel is an alternative for patients with aspirin allergy or intolerance. Dual antiplatelet therapy is reasonable for up to 12 months after an acute coronary syndrome. The main adverse effect is an increased risk of gastrointestinal bleeding.[2][90]

  • The ADA recommends that aspirin therapy be considered for primary prevention in adults with type 2 diabetes aged 50 to 70 years who are at increased cardiovascular risk (family history of premature cardiovascular disease, hypertension, dyslipidaemias, smoking, chronic kidney disease/albuminuria), unless they are at high risk of serious bleeding.[2]

  • US Preventive Services Task Force (USPSTF) recommendations for primary prevention of heart attack or stroke in those aged 50 to 70 years are similar.[91]

Antihyperglycaemic pharmacotherapy: initial considerations

HbA1c goals should be individualised.[92][93] For many patients, the goal HbA1c <7% is appropriate. However, HbA1c 7.0% to 7.9% may be more appropriate in some patients, such as those with advanced age, limited life expectancy, known cardiovascular disease, high risk of severe hypoglycaemia, or difficulty achieving lower HbA1c goals despite use of multiple antihyperglycaemic medications and insulin.[2] Individualised HbA1c goals improve quality of life compared with uniform tight control.[93]

If HbA1c is above goal, pharmacotherapy is recommended to reduce risk of both microvascular (nephropathy, retinopathy, neuropathy) and macrovascular (myocardial infarction, stroke, peripheral vascular disease) complications.[94][95] Data suggest that preventing major cardiovascular events and renal complications of diabetes may be affected not only by HbA1c levels but also by strategic selection of specific antihyperglycaemic medications. Some specific antihyperglycaemic medications significantly reduce all-cause or cardiovascular mortality, or major cardiovascular events or renal complications in some patient subgroups, and for such patients, these agents may be preferred.[71] Among the antihyperglycaemic medications that reduce cardiovascular mortality in some patient subgroups are metformin,[96] empagliflozin, canagliflozin, and liraglutide.[71]

In older studies such as ACCORD, ADVANCE, and the Veterans Affairs Diabetes Trial (VADT), use of multiple drugs to achieve near-normal HbA1c was either not beneficial or increased mortality in type 2 diabetes patients with CVD or high CVD risk.[97][98][99][100][101] However, sodium-glucose co-transporter 2 (SGLT2) inhibitors were not available and glucagon-like peptide-1 (GLP-1) agonists were infrequently used in those studies.

Patients with type 2 diabetes using multiple daily insulin injections or an insulin pump should self-monitor blood glucose three or more times daily. For patients using less frequent insulin injections or non-insulin therapies, self-monitoring may be useful to guide therapy.[2]

Choice of agents should be individualised, taking into account patient values and preferences, the likelihood that an agent reduces all-cause or cardiovascular mortality, renal effects, adverse effects, costs, and other factors.

Metformin is the recommended first-choice therapy at diagnosis in the absence of contraindications because of its safety profile and likely cardiovascular benefit.[94][96] Metformin may be safely used in patients with reduced estimated glomerular filtration rates (eGFRs), but it is contraindicated if eGFR <30 mL/minute/1.73 m².[2][102] Metformin should not be initiated if the eGFR is <45 mL/minute/1.73 m², and, for patients taking metformin whose eGFR falls to within the 30-45 mL/minute/1.73 m² range, continued use can be considered with close monitoring of renal function and a dose reduction.[102][103] People who are unable to take metformin due to contraindications or intolerance can either use an alternative non-insulin agent or start insulin therapy. Basal-bolus insulin is used as initial treatment (without metformin) for those with type 2 diabetes and very high initial glucose levels (>16.6 mmol/L [>300 mg/dL]).

In patients with diabetes without diagnosed cardiovascular disease, if metformin is used as initial treatment and fails to achieve goals after 3 months, a second agent may be added based on individualised assessment of necessary clinical benefit, safety considerations, costs, and patient preference:[102]

  • Sodium-glucose co-transporter 2 (SGLT2) inhibitor: canagliflozin, dapagliflozin, empagliflozin, or ertugliflozin

  • Glucagon-like peptide-1 (GLP-1) agonist: liraglutide, exenatide, lixisenatide, semaglutide, or dulaglutide

  • Dipeptidyl peptidase-4 (DPP-4) inhibitor: sitagliptin, saxagliptin, linagliptin, or alogliptin

  • Sulfonylurea: glimepiride, gliclazide, or glipizide; meglitinides (e.g., repaglinide, nateglinide) are an alternative

  • Alpha-glucosidase inhibitor: acarbose or miglitol

  • Thiazolidinedione: pioglitazone

  • Insulin.

In patients with diabetes and with diagnosed cardiovascular disease, if metformin is used as initial treatment and fails to achieve goals after 3 months, a second agent may be added. Addition of a SGLT2 inhibitor or GLP-1 agonist is recommended in patients with long-standing sub-optimal glycaemic control plus established cardiovascular and/or renal disease.[2][102][104]

  • SGLT2 inhibitor: canagliflozin or empagliflozin may be preferred.

  • GLP-1 agonist: liraglutide may be preferred.

There are many appropriate 3-agent combinations of glucose-lowering therapy that do not involve insulin. Choice of second and third antihyperglycaemic medications may differ depending on cardiovascular comorbidities.[102] When 2- or 3-drug non-insulin regimens fail, basal insulin can be added. Bolus insulin can be subsequently added if needed to achieve or maintain adequate glucose control. To reduce the risk of hypoglycaemia, a sulfonylurea is usually tapered if insulin is started.

Clinical properties of specific oral antihyperglycaemic agents

Agents are often selected based on a discussion with the patient of the pros and cons of the agents. Agents that reduce all-cause or cardiovascular mortality may be preferred.[41]

  • Metformin can promote weight loss and may reduce cardiovascular events and mortality.[94][96]

  • SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) inhibit renal glucose reabsorption. The resulting increase in glycosuria improves glycaemic control, promotes weight loss, and has a diuretic effect that reduces blood pressure.[105] There is evidence that use of SGLT2 inhibitors prevents major kidney outcomes (dialysis, transplantation, or death due to kidney disease) in people with type 2 diabetes.[106] Empagliflozin and canagliflozin have been shown to reduce cardiovascular risk in people with CVD and type 2 diabetes, and may have renal benefits.[71][107][108][109][110] Empagliflozin and canagliflozin have been shown to significantly reduce cardiovascular or all-cause mortality in those with diabetes and established cardiovascular disease.[111][112][113] In one trial, treatment with dapaglifozin in patients with type 2 diabetes who had, or were at risk for, atherosclerotic cardiovascular disease did not result in a lower rate of major adverse cardiovascular events, but did report a lower rate of hospitalisation for heart failure.[114] Trials on the CVD benefits of ertugliflozin are ongoing.[115][116][117] Adverse effects for different agents have included a higher rate of genital infections, diabetic ketoacidosis, acute kidney injury, fracture, and/or amputation.[111][118][119] Notably, the US Food and Drug Administration (FDA) has confirmed an increased risk of leg and foot amputations with canagliflozin.[120] The European Medicines Agency (EMA) also warns of the potential increased risk of toe amputation with SGLT2 inhibitors.[121] For canagliflozin, the prescribing information will also list lower-limb amputation as an uncommon side effect.[122] The FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA) warn of cases of necrotising fasciitis of the perineum (also known as Fournier's gangrene) observed in post-marketing surveillance of SGLT2 inhibitors.[123][124] Thus, SGLT2 inhibitors should be avoided in patients with conditions that increase the risk for limb amputations, and in patients prone to urinary tract or genital infections.

  • GLP-1 agonists (liraglutide, exenatide, lixisenatide, semaglutide, dulaglutide) are suitable for obese patients without gastroparesis who desire weight loss, are willing to take injections, and can tolerate the common adverse effect of initial nausea.[125] In one review, GLP-1 agonist use led to loss of 1.4 kg versus placebo, and loss of 4.8 kg versus insulin.[126] As a class of drugs, GLP-1 agonist treatment has beneficial effects on cardiovascular, mortality, and kidney outcomes in patients with type 2 diabetes.[127] Liraglutide significantly reduced cardiovascular mortality and all-cause mortality in those with diabetes and cardiovascular disease or high CVD risk in one randomised trial.[128] Dulaglutide and semaglutide have both been shown to reduce major cardiovascular events, but not all-cause or cardiovascular mortality.[129][130][131] Exenatide and lixisenatide have both been shown not to reduce major cardiovascular events.[132] The MHRA warns of cases of diabetic ketoacidosis in patients with type 2 diabetes on a combination of a GLP-1 receptor agonist and insulin who had doses of concomitant insulin rapidly reduced or discontinued.[133]

  • DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin, alogliptin) are well tolerated, weight-neutral, but confer no mortality benefit.

  • Sulfonylureas (glipizide, glimepiride, glyburide) are the subject of long clinical experience and may reduce microvascular complications, but confer no mortality benefit and may cause weight gain and hypoglycaemia.[102] Along with metformin and human insulin, these are among the more affordable antihyperglycaemic medications.[134]

  • Alpha-glucosidase inhibitors (acarbose, miglitol) can be added to metformin in people with large postprandial glucose excursions, but increased flatus and gastrointestinal (GI) side effects are common. There is no strong evidence of a benefit on all-cause or cardiovascular mortality.

  • Thiazolidinediones (pioglitazone, rosiglitazone) lower blood sugar effectively but more than double the risk of congestive heart failure, often causing weight gain and oedema.[102] They may cause anaemia and increase fracture rates in both women and men. In addition, rosiglitazone raises LDL-cholesterol and mixed evidence suggests that rosiglitazone may increase the risk of cardiovascular events.[135] Rosiglitazone has been removed from the European market due to persistent safety concerns.[136] However, in 2013, the US Food and Drug Administration (FDA) lifted previous restrictions applied to rosiglitazone in the US, based on newer data.[137] As a result of an updated review, the FDA has concluded that use of pioglitazone may be linked to an increased risk of bladder cancer.[138]

  • Bromocriptine and colesevelam are oral agents approved for glucose-lowering in some countries. They have limited impact on blood glucose in many patients. Bromocriptine may cause GI side effects. Colesevelam, originally approved as a bile-acid sequestrant, requires multiple doses per day, and may bind other medications. Neither of these agents is widely used for glucose control at present.

Insulin therapy

Insulin therapy is required for severe hyperglycaemia and is an option when metformin monotherapy or multi-drug regimens are inadequate. Usually this is initiated with long-acting basal insulin at bedtime. Some patients' blood sugars can be well controlled with a combination of non-insulin therapy and one injection of basal insulin. However, some patients will need to use both a long-acting basal insulin (e.g., detemir, glargine, or degludec) injection once daily and rapid-acting insulin (e.g, lispro, aspart, or glulisine) injected before each meal. Intermediate (NPH) and short-acting (regular) insulins are other choices for basal-bolus regimens. For patients with type 2 diabetes, human insulins are as effective as analogue insulins for glucose control, serious hypoglycaemia risk, and mortality and cardiovascular events.[139] [ Cochrane Clinical Answers logo ] Human insulins are less expensive than analogue insulins. Pre-mixed insulin is available. Regimens should be individualised. Insulin delivery devices that can be programmed to administer set doses of insulin are now available and may be used by patients to help them achieve glycaemic control. As insulin doses increase, any sulfonylurea should be tapered, but metformin may be continued.

Insulin treatment should be considered at the time of diagnosis if glucose level is ≥16.6 mmol/L (≥300 mg/dL) or if HbA1c is ≥86 mmol/mol (≥10%). For these patients with marked hyperglycaemia, metformin can be used adjunctively, in the absence of nausea, vomiting, or volume depletion.

Exogenous insulin is a very effective way to lower serum glucose and lower HbA1c, but its use must be guided in most patients by regular self-monitored blood glucose testing. Hypoglycaemia (glucose ≤3.9 mmol/L [≤70 mg/dL]) is the most serious potential complication of insulin therapy. Another significant side effect is weight gain. Less common side effects may include hunger, nausea, diaphoresis, injection site irritation, or anaphylaxis.

Correction doses of insulin

When basal-bolus insulin is used by motivated and knowledgeable patients, the dose of rapid-acting insulin that is administered before each meal can be based on anticipated carbohydrate content of the upcoming meal and sometimes adjusted for anticipated physical activity. Correctional doses of rapid-acting insulin can also be applied based on pre-meal blood sugar readings (correctional algorithms). One acceptable method of determining a correction algorithm is to divide 1800 by the total daily dose of insulin to yield the expected blood sugar reduction per unit of insulin. For example, for a patient taking 60 units of insulin per day, the expected blood sugar lowering of 1 additional unit of insulin would be 1800/60=30 mg/dL (1.7 mmol/L).

Bariatric surgery for treatment of diabetes in patients with obesity

Randomised clinical trials have shown a benefit from bariatric surgery (also referred to as metabolic surgery) with regard to diabetes remission, glycaemic control, need for glucose-lowering medications, quality of life, and reduction in cardiovascular risk factor markers over the short term (e.g., 1-3 years) in people with type 2 diabetes as compared with medical therapy alone,[140][141][142][143][144] as well as for possible prevention of type 2 diabetes.[145] Cohort studies suggest that both Roux en Y bypass and sleeve gastrectomy procedures lead to diabetes remission that lasts a mean of about 5 years in more than half of patients, and significantly reduce mortality, stroke, myocardial infarction, and microvascular complications in those with type 2 diabetes.[146][147][148] Compared with sleeve gastrectomy, Roux en Y leads to somewhat greater weight loss and other benefits, but is a more technically challenging operation with higher re-operation and readmission rates. The benefits and risks of bariatric surgery also vary substantially across type 2 diabetes patient subgroups. In observational studies, average benefits appeared to be highest in those who are younger (age 40-50 years), those with more recent onset of type 2 diabetes, and those not on insulin therapy.[149]

Bariatric surgery may be considered for adults with BMI ≥40 kg/m² (≥37.5 kg/m² for people of Asian-family origin) with any level of glycaemic control/any complexity of glucose-lowering regimen.[2] Surgery may also be considered for adults with BMI 35.0 to 39.9 kg/m² (32.5 to 37.4 kg/m² for people of Asian-family origin) with hyperglycaemia inadequately controlled despite lifestyle and optimal medical management, and may be considered for those with BMI 30.0 to 34.9 kg/m² (27.5 to 32.4 kg/m² for people of Asian-family origin) with hyperglycaemia inadequately controlled despite optimal use of oral or injectable medications (including insulin).[2] Bariatric surgery is best done in a high-volume, specialised centre.[2]

Treatment of diabetes in pregnancy

Good glucose control with HbA1c as close to normal as is safely possible (ideally HbA1c <6.5% [48 mmol/mol]) before conception and during pregnancy optimises maternal and fetal health outcomes.[2][150] ADA guidelines recommend the following blood glucose targets in pregnant women with pre-existing type 2 diabetes (the same as for gestational diabetes): <5.3 mmol/L (<95 mg/dL) fasting, and either ≤7.8 mmol/L (≤140 mg/dL) 1-hour postprandially or ≤6.7 mmol/L (≤120 mg/dL) 2-hour postprandially, with HbA1c goal individualised between <42-48 mmol/mol (<6% to <6.5%) or up to <53 mmol/mol (<7%) as necessary to prevent hypoglycaemia.[2] Target blood glucose values in pregnant women according to guidelines from the UK National Institute for Health and Care Excellence are, if safely achievable, a preprandial glucose 5.3 mmol/L (95 mg/dL), at 1-hour postprandial glucose below 7.8 mmol/L (140 mg/dL), and at 2- hour postprandial glucose below 6.4 mmol/L (115 mg/dL).[151][Evidence C]

In clinical practice, insulin is usually used when nutrition therapy fails to achieve these goals. NPH insulin may be combined with human short-acting or analogue rapid-acting insulin. Long-acting analogue insulins (glargine, detemir, or degludec) are not approved in pregnancy. ACE inhibitors, angiotensin-II receptor antagonists, and beta-blockers are not recommended in pregnancy and should be avoided. Statins are contraindicated in pregnancy. Retinal exam in those with diabetes prior to pregnancy should be performed prior to, during, and after pregnancy. Women with diabetes who anticipate pregnancy or are pregnant benefit from care supervision by a specialised centre whenever possible.

Care delivery models

Diabetes care has, on average, dramatically improved in the past 20 years, with a 50% reduction in mortality rates, cardiovascular mortality rates, and cardiovascular event rates in adults with diabetes.[13] Many factors have contributed to diabetes care improvement and better clinical outcomes for patients.[152] The principal model used to frame these strategies is the Chronic Care Model.[153] The model includes 6 core elements: delivery system design, self-management support, decision support, clinical information systems, community resources and policies, and health systems.

Evidence is generally supportive of the following care improvement strategies.

  • A multidisciplinary team approach to patient care, including the involvement of trained diabetes self-management educators, pharmacists, and case managers[154][155]

  • Advanced and integrated electronic medical record clinical decision support beyond simple reminder systems and alerts[156][157]

  • Simulated case-based learning interventions for clinicians.[158][159][160]

Other re-designs to the care delivery system such as alternative reimbursement methods, public policy changes to support healthier lifestyles, the patient-centred medical home, and mobile health (mHealth) technology may provide additional opportunities to improve care and are currently being evaluated.[161][162] Diabetes management decisions should be timely, rely on evidence-based guidelines, and be made collaboratively with the patient.

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