Last updated March 15, 2022

Diabetes Mellitus in Primary Care

Recommendations

General Approach to T2DM Care

We recommend shared decision-making to enhance patient knowledge and satisfaction. (Strong for)
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We recommend that all patients with diabetes should be offered ongoing individualized diabetes self-management education via various modalities tailored to their preferences, learning needs and abilities based on available resources. (Strong for)
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We suggest offering one or more types of bidirectional telehealth interventions (typically health communication via computer, telephone or other electronic means) involving licensed independent practitioners to patients selected by their primary care provider as an adjunct to usual patient care. (Weak for)
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Glycemic Control Targets and Monitoring

We recommend developing an individualized glycemic management plan, based on the provider’s appraisal of the risk-benefit ratio and patient preferences. (Strong for)
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We recommend an individualized target range for HbA1c taking into account individual preferences, presence or absence of microvascular complications, and presence or severity of comorbid conditions. (Strong for)
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We suggest a target HbA1c range of 6.0-7.0% for patients with a life expectancy greater than 10-15 years and absent or mild microvascular complications, if it can be safely achieved. (Weak for)
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We recommend assessing patient characteristics such as race, ethnicity, chronic kidney disease, and non-glycemic factors (e.g., laboratory methodology and assay variability) when interpreting HbA1c, fructosamine and other glycemic biomarker results. (Strong for)
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We recommend setting an HbA1c target range based on absolute risk reduction of significant microvascular complications, life expectancy, patient preferences and social determinants of health. (Strong for)
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We recommend that in patients with type 2 diabetes, a range of HbA1c 7.0-8.5% is appropriate for most individuals with established microvascular or macrovascular disease, comorbid conditions, or 5-10 years life expectancy, if it can be safely achieved. (Strong for)
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We suggest a target HbA1c range of 8.0-9.0% for patients with type 2 diabetes with life expectancy <5 years, significant comorbid conditions, advanced complications of diabetes, or difficulties in self-management attributable to e.g., mental status, disability or other factors such as food insecurity and insufficient social support. (Weak for)
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We suggest that providers be aware that HbA1c variability is a risk factor for microvascular and macrovascular outcomes. (Weak for)
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Non-pharmacological Treatments

We recommend offering therapeutic lifestyle changes counseling that includes nutrition, physical activity, cessation of smoking and excessive use of alcohol, and weight control to patients with diabetes (See VA/DoD CPGs for obesity, substance use disorders, and tobacco use cessation). (Strong for)
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We recommend a Mediterranean diet if aligned to patient’s values and preferences. (Strong for)
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We recommend a nutrition intervention strategy reducing percent of energy from carbohydrate to 14-45% per day and/or foods with lower glycemic index in patients with type 2 diabetes who do not choose the Mediterranean diet. (Strong for)
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Inpatient Care

We recommend against targeting blood glucose levels <110 mg/dL for all hospitalized patients with type 2 diabetes receiving insulin. (Strong against)
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We recommend insulin be adjusted to maintain a blood glucose level between 110 and 180 mg/dL for patients with type 2 diabetes in critically ill patients or those with acute myocardial infarction. (Strong for)
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We recommend against the use of split mixed insulin regimen for all hospitalized patients with type 2 diabetes. (Strong against)
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We suggest a regimen including basal insulin and short-acting meal time or basal insulin and correction insulin for non-critically ill hospitalized patients with type 2 diabetes. (Weak for)
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We suggest providing medication education and diabetes survival skills to patients before hospital discharge. (Weak for)
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Selected Complications and Conditions

We recommend performing a comprehensive foot risk assessment annually. (Strong for)
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We recommend referring patients with limb-threatening conditions to the appropriate level of care for evaluation and treatment. (Strong for)
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We recommend a retinal examination (e.g., dilated fundus examination by an eye care professional or retinal imaging with interpretation by a qualified, experienced reader) be used to detect retinopathy. (Strong for)
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We suggest screening for retinopathy at least every other year (biennial screening) for patients who have had no retinopathy on all previous examinations. More frequent retinal examinations in such patients should be considered when risk factors associated with an increased rate of progression of retinopathy are present. Patients with existing retinopathy should be managed in conjunction with an eye care professional and examined at intervals deemed appropriate for the level of retinopathy. (Weak for)
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We recommend that all females with pre-existing diabetes or personal history of diabetes and who are of reproductive potential be provided contraceptive options education and education on the benefit of optimizing their glycemic control prior to attempting to conceive. (Strong for)
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We recommend that all females with pre-existing diabetes or personal history of diabetes who are planning pregnancy be educated about the safest options of diabetes management during the pregnancy and referred to a maternal fetal medicine provider (when available) before, or as early as possible, once pregnancy is confirmed. (Strong for)
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Recommendation Grading

Overview

Title

Management of Type 2 Diabetes Mellitus in Primary Care

Authoring Organization

Endorsing Organizations

Publication Month/Year

January 1, 2017

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Long term care, Outpatient

Intended Users

Social worker, physician, nurse, nurse practitioner, physician assistant

Scope

Assessment and screening, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D003924 - Diabetes Mellitus, Type 2

Keywords

type 2 diabetes mellitus, Diabetes Self-Management Education and Support (DSMES), Sodium glucose inhibitors

Methodology

Number of Source Documents
178
Literature Search Start Date
January 1, 2009
Literature Search End Date
March 1, 2016