Diabetes Treatment Guidelines

What is diabetes?

Diabetes is a chronic condition characterized by elevated blood glucose levels, commonly known as blood sugar. It occurs when the body either cannot produce enough insulin or cannot effectively use the insulin it makes. This leads to an imbalance in blood glucose levels, which, if left unmanaged, can result in serious health complications.

People with diabetes face an increased risk of developing various health issues, including chronic kidney disease and atherosclerotic cardiovascular disease. There are different types of diabetes, with type 2 diabetes being the most prevalent form. Additionally, gestational diabetes mellitus can occur during pregnancy, requiring careful monitoring and management.

Diabetes treatment typically involves monitoring blood glucose levels, adopting a healthy diet, regular exercise, and, when necessary, insulin therapy or other glucose-lowering medications. Management also involves controlling other risk factors, such as blood pressure, to reduce the likelihood of complications.

The American Diabetes Association provides comprehensive guidelines for diabetes management, including recommendations for continuous subcutaneous insulin infusion and continuous glucose monitoring, which are vital tools in maintaining optimal blood glucose control. By adhering to these guidelines and incorporating lifestyle changes, individuals with diabetes can lead fulfilling lives while minimizing the risk of complications.

Types

Diabetes encompasses several types, each with distinct characteristics and management strategies.

• Type 1 diabetes arises from the immune system attacking insulin-producing cells, necessitating lifelong insulin therapy.
• Type 2 diabetes, the most prevalent form, results from insulin resistance and inadequate insulin production, often managed with lifestyle changes and medications.
• Gestational diabetes mellitus occurs during pregnancy, increasing the risk of type 2 diabetes later in life.
• Prediabetes is a precursor to type 2 diabetes, marked by elevated blood glucose levels but not yet at diabetic levels. Lifestyle modifications can prevent or delay its progression to type 2 diabetes.

Understanding these distinctions is vital for effectively managing and preventing complications in individuals with diabetes or at risk of developing it.

Complications

Diabetes complications can affect various organs and systems, posing significant health risks to individuals, especially adults with type 2 diabetes. Diabetic kidney disease, a common complication, can lead to kidney failure if left untreated.

Undiagnosed diabetes raises the risk of complications, emphasizing the importance of regular blood glucose monitoring and early detection. Nonalcoholic fatty liver disease is more prevalent in those with diabetes, highlighting the need for comprehensive care. Established atherosclerotic cardiovascular disease is a grave concern, underscoring the importance of preventive measures like the Diabetes Prevention Program.

Additionally, complications may necessitate combination therapy to manage effectively. Monitoring fasting plasma glucose levels is crucial in preventing complications and maintaining optimal health outcomes for individuals with diabetes.

Diagnosing diabetes

Diagnosing diabetes requires a comprehensive approach considering various risk factors, especially in adults with diabetes or those with established cardiovascular disease. Screening involves assessing symptoms and risk factors like obesity or family history and conducting fasting plasma glucose or oral glucose tolerance tests.

Diabetes self-management education is pivotal for patients, emphasizing lifestyle modifications and hypoglycemia risk awareness. Additionally, evaluating microvascular complications and body weight provides valuable insights into disease progression and management strategies.

In some cases, basal insulin or GLP-1 receptor agonists may be prescribed, particularly for patients with type 2 diabetes and high hypoglycemia risk or weight concerns.

By addressing these aspects, healthcare providers can accurately diagnose diabetes and tailor treatment plans to optimize patient outcomes.

What is included in the treatment guidelines for diabetes?

Managing diabetes effectively involves a detailed understanding of current clinical recommendations. The American Diabetes Association's Standards of Medical Care in Diabetes (2023) provides an extensive framework for healthcare professionals to optimize diabetes care tailored to the latest research and clinical insights. These guidelines focus on individualized treatment and encompass various aspects of diabetes management.

• Emphasis on weight loss: The guidelines emphasize supporting higher weight loss (up to 15%) based on the efficacy of and access to newer medications when appropriate.
• Sleep health and physical activity: New recommendations include considerations for sleep health and physical activity in individuals with diabetes.
• Consideration of social determinants of health: The guidelines broaden the consideration of social determinants of health in guiding the design and delivery of care, acknowledging their impact on diabetes management.
• Hypertension diagnosis cut-offs: Hypertension is now defined as a systolic blood pressure ≥130 mmHg or a diastolic blood pressure ≥80 mmHg, reflecting updated diagnostic criteria.
• Expanded role of medications: The guidelines expand the role of certain medications, such as SGLT2 inhibitors in heart failure management and finerenone in individuals with diabetes and chronic kidney disease with albuminuria.
• New lipid management recommendations: Lower LDL goals are suggested for high-risk individuals, reflecting updated lipid management recommendations.
• Digital health and telehealth: Details on digital health, telehealth, and telemedicine are included, highlighting the benefits of these care delivery modalities.
• Point-of-care A1C testing: The guidelines discuss the utility of point-of-care A1C testing for diabetes screening and diagnosis.
• Nonalcoholic fatty liver disease (NAFLD): There is an expanded subsection on NAFLD, recognizing its importance in diabetes management.
• Food insecurity screening: Screening for food insecurity by any member of the diabetes healthcare team is recommended.
• Updates align with other guidelines: The guidelines align with other diabetes management guidelines, such as the Management of Hyperglycemia in Type 2 Diabetes, 2022.
• Technology use in older adults: The guidelines address the use of technology in older adults with diabetes.
• Person-first and inclusive language: There is a focus on using person-first and inclusive language in diabetes care.
• Vaccination and COVID-19 updates: Updates are provided regarding vaccination for people with diabetes and COVID-19 considerations.

These guidelines aim to provide evidence-based recommendations for the prevention, diagnosis, and treatment of diabetes. They take into account the latest scientific research and clinical trials while considering the diverse needs of individuals with diabetes.

How does the template work?

Healthcare providers should familiarize themselves with its contents and purpose to ensure accurate patient communication. This structured approach ensures that key updates and recommendations are highlighted clearly, providing healthcare professionals with a comprehensive overview of the latest developments in diabetes management.

Step 1: Overview

The template begins with an overview of the Standards of Care, highlighting its evidence-based nature and comprehensive coverage of diabetes prevention, diagnosis, and treatment.

Step 2: Notable updates

The template lists notable updates from the 2023 Standards of Care, including emphasis on weight loss, consideration of social determinants of health, and new recommendations for hypertension diagnosis and lipid management.

Step 3: Medication recommendations

It outlines expanded roles for medications such as SGLT2 inhibitors and finer enone, reflecting advancements in diabetes management.

Step 4: Lifestyle factors

The template discusses sleep health, physical activity, and food insecurity screening recommendations, emphasizing the importance of lifestyle factors in diabetes care.

Step 5: Technological integration

Details on digital health, telehealth, and the use of technology in older adults with diabetes are included, reflecting the integration of technology into diabetes management.

Step 6: Inclusive language

There's a focus on using person-first and inclusive language in diabetes care, promoting respectful and patient-centered communication.

Step 7: Vaccination and COVID-19 updates

The template addresses updates regarding vaccination for people with diabetes and considerations related to COVID-19, highlighting the importance of staying informed about emerging health threats.

Benefits of having treatment guidelines

Having treatment guidelines for diabetes offers numerous benefits to both healthcare providers and patients alike:

• Standardization of care: Guidelines provide a standardized approach to diabetes management, ensuring consistent and evidence-based care across healthcare settings.
• Optimized treatment: Healthcare providers can tailor treatment plans to individual patients, considering glycemic targets, estimated glomerular filtration rate, and demonstrated cardiovascular disease benefits.
• Improved patient outcomes: Following established guidelines makes patients more likely to achieve and maintain glycemic control, leading to better overall health and reduced risk of complications.
• Risk reduction: Guidelines help identify and address risk factors for diabetes-related complications, such as cardiovascular disease, through comprehensive evaluations and appropriate pharmacologic therapy.
• Education and empowerment: Patients benefit from education on lifestyle modifications, including carbohydrate intake and physical activity, empowering them to participate actively in their care.
• Early detection: Guidelines recommend regular screening tests, such as oral glucose tolerance tests, facilitating early detection of diabetes and enabling timely intervention.
• Medication management: Healthcare providers can make informed decisions regarding selecting and titrating diabetes medications based on established guidelines, ensuring optimal glycemic control while minimizing adverse effects.

Treatment options for diabetes

Effectively managing diabetes requires a diverse approach involving lifestyle changes, medications, and behavioral support. Each treatment method explicitly controls blood sugar, reduces complications, and enhances overall health. Here's a breakdown of these options:

• Lifestyle modifications: Adjusting diet, exercise, and weight helps control blood sugar, shed pounds, and lower heart risks. Patients are encouraged to eat healthily, stay active, and maintain a healthy weight.
• Oral medications: Pills like metformin and sulfonylureas help lower blood sugar by boosting insulin effectiveness or reducing glucose absorption. They're often the first choice for type 2 diabetes, combined with lifestyle changes.
• Insulin therapy: Essential for type 1 diabetes and sometimes needed for type 2, insulin injections or pumps regulate blood sugar by replacing or adding to natural insulin. Regular monitoring ensures proper dosage adjustments.
• Metabolic surgery: For severe obesity and uncontrolled diabetes, surgeries like gastric bypass reshape the digestive system, aiding weight loss and insulin sensitivity. Research shows significant improvements in blood sugar control and even remission.
• Behavioral health support: Addressing stress, smoking, and mental health is vital for diabetes care. Patients work with therapists to develop coping strategies, quit smoking, and maintain healthy habits, boosting overall well-being and treatment success.

Reference

American Diabetes Association Professional Practice Committee. (2023). Introduction and Methodology: Standards of Care in Diabetes—2024. Diabetes Care, 47(Supplement_1), S1–S4.b https://doi.org/10.2337/dc24-sint