Screening for Type 2 Diabetes in Adults

Type 2 diabetes is often asymptomatic and can cause microvascular and macrovascular damage before symptoms appear, and early detection and interventions can delay or prevent the onset of type 2 diabetes.

Lifestyle interventions and medications.

It may prevent or reduce the progression of microvascular disease and macrovascular cardiovascular disease (CVD).

The American Diabetes Association (ADA) and the U.S. Preventive Services Task Force (USPSTF).

No, screening for type 1 diabetes in the general population is not yet recommended.

To detect presymptomatic type 1 diabetes and potentially delay clinical diabetes development with therapy.

Hemoglobin A1c, fasting plasma glucose, and oral glucose tolerance test (OGTT)

Destruction of insulin-producing β cells in the pancreas

5% to 10%

Glutamic acid decarboxylase (GAD65), tyrosine phosphatases IA-2 and IA-2β, islet cells, insulin, and zinc transporter

It indicates little to no insulin secretion

It decreases toxicity associated with extreme hyperglycemia, allowing the β cells to regain some ability to produce insulin

Autoantibody development leading to β-cell destruction and ultimately to insulin deficiency

Measuring autoantibodies glutamic acid decarboxylase and tyrosine phosphatase IA-2 at initial diagnosis

Variable insulin deficiency due to β-cell destruction in the absence of autoantibodies

It is diagnostic of diabetes and does not require further confirmatory testing

7% over 6 months

Diet rich in monounsaturated fat, whole grains, vegetables, whole fruits, and nuts

Metformin

Persons with prediabetes, particularly those aged 25 to 59 years with a BMI of 35 or greater, higher fasting plasma glucose (≥110 mg/dL [6.11 mmol/L]), and hemoglobin A1c values of 6% or greater

A type of diabetes that presents with episodic diabetic ketoacidosis (DKA) resulting from insulin deficiency, but has variable periods of insulin dependence and independence

To resolve DKA and allow β cells to produce sufficient amounts of insulin to suppress lipolysis

Autoantibody status and β-cell function

Hyperglycemia during the second or third trimester in patients without a prepregnancy diagnosis of type 1 or type 2 diabetes

To identify women at risk for adverse maternal and neonatal outcomes related to diabetes

To identify women with preexisting and undiagnosed diabetes that is first noticed during pregnancy

Ineffective use of insulin by the peripheral cells to process glucose and fatty acids

Hyperglycemia

Every 3 years

A constellation of risk factors for development of type 2 diabetes and CVD

To identify patients at high risk of developing CVD

Multifactorial, with influence from both genetic and environmental factors

Adults, although the incidence is increasing among children and adolescents

Typically associated with insulin resistance

Weight loss and reduction of insulin resistance, as well as mitigation of cardiovascular risk factors

58%

Patient circumstances, preferences, and treatment

To identify undetected hyperglycemia when preprandial blood glucose values are at the target goal but hemoglobin A1c is above goal

To measure treatment efficacy

When altering nutrition plans, exercise, and/or medications

To improve diabetes care by lowering hemoglobin A1c and avoiding hypoglycemia

50%

As close to daily as possible

10 to 20 grams of carbohydrates

Because they are more likely to have serious morbidity and mortality from COVID-19

To cover meal-time glucose excursions

Diet and physical activity

Before 15 weeks of gestation

Individualized diabetes-specific education to promote healthy diet choices and reductions in hemoglobin A1c

1 unit of regular or analogue insulin for every 50 mg/dL above the target glucose value

Hyperglycemia identified during the first trimester is classified as type 2 diabetes, while hyperglycemia identified later is classified as gestational diabetes.

Improved glycemic control

Combination of intermediate- or long-acting basal insulin and rapid- or short-acting insulin in fixed concentrations

One-step OGTT involving blood glucose measurements at baseline, 1 hour, and 2 hours after a 75-g oral glucose load.

Twice daily

To confirm resolution of hyperglycemia after pregnancy.

Autosomal dominant monogenetic defect on different chromosomal loci with at least 14 known gene mutations.

A patient-centered approach with individualized goals and treatment plans compatible with patient preferences, lifestyle requirements, comorbidities, safety, and social determinants of health.

The knowledge and skills for patients to perform diabetes-related self-care and develop effective problem-solving strategies.

At the time of diagnosis, annually, when treatment targets are unmet, when complicating circumstances develop, and at times of life and care transitions.

Improved outcomes such as hemoglobin A1c and quality of life, as well as reduced costs by decreasing use of acute care and inpatient facilities for diabetes management.

Digital coaching and digital self-management.

Nutrient-dense carbohydrate sources that are high in fiber (≥14 g fiber/1000 kcal) and minimally processed

At least 5% weight loss

Moderate- to vigorous-intensity aerobic activity for 150 minutes/week, vigorous-intensity aerobic activity for 75 minutes/week, or a combination of both

Two to three times per week

Interrupting sedentary behavior with light activity or standing at 30-minute intervals

In patients with BMI of 40 or greater (≥37.5 in Asian Americans) and in patients with BMI of 35.0 to 39.9 (32.5-37.4 in Asian Americans) for whom medical interventions are unsuccessful

Smoking is a significant risk factor for cardiovascular disease and other complications in patients with diabetes

Age, health status, weight, pathophysiology of hyperglycemia, specific risks and benefits of a potential therapeutic agent, medication cost, lifestyle, and personal treatment goals

Between 7% and 8%

Based on individualized goals and the potential for harms to outweigh benefits in this population

Significantly reduces the incidence and progression of microvascular complications.

A significant reduction in CVD and mortality.

No change in cardiovascular or overall mortality.

Reduces the composite outcome of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, and hospitalization for heart failure.

Favorable outcomes, including decreased risk of kidney disease progression and mortality.

Reduces the primary composite outcome of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, and all-cause mortality.

Life-long insulin therapy with an intensive insulin regimen, including multiple daily doses of insulin to mimic the physiologic action of the pancreas.

To maintain glycemic control while fasting and between meals.

Reduces major adverse cardiovascular events, all-cause mortality, hospitalization for heart failure, and a composite of various kidney outcomes.

Most clinical practice guidelines recommend target hemoglobin A1c thresholds.

Type 2 diabetes is often preceded by a prolonged asymptomatic hyperglycemic period, lifestyle interventions and medications can delay or prevent onset, and early intensive glucose control can prevent or reduce microvascular and macrovascular disease.

It allows for referral to a specialized center for consideration of therapy to potentially delay clinical diabetes development.

To prevent or reduce the progression of microvascular and macrovascular disease.

It may delay the onset of symptomatic type 1 diabetes.

It is not yet recommended because it is not yet indicated.

The American Diabetes Association (ADA) and the U.S. Preventive Services Task Force (USPSTF).

Hemoglobin A1c, fasting plasma glucose, and oral glucose tolerance test (OGTT)

5% to 10%

Glutamic acid decarboxylase (GAD65), tyrosine phosphatases IA-2 and IA-2β, islet cells, insulin, and zinc transporter

It indicates little to no insulin secretion.

Autoantibody development leading to β-cell destruction and ultimately to insulin deficiency.

Measuring autoantibodies glutamic acid decarboxylase and tyrosine phosphatase IA-2 at initial diagnosis.

Variable insulin deficiency because of β-cell destruction in the absence of autoantibodies.

It is diagnostic of diabetes and does not require further confirmatory testing.

It decreases toxicity associated with extreme hyperglycemia, allowing the β cells to regain some ability to produce insulin.

GAD65 and IA-2 autoantibodies

Effective diabetes management is best achieved through a patient-centered approach with patients and their caregivers developing individualized goals and treatment plans compatible with patient preferences, lifestyle requirements, comorbidities, safety, and social determinants of health.

β-Cell destruction may occur from diseases affecting the pancreas or from the effect of drugs or infections.

The two types of OGTT methods are the 'one-step' OGTT and the 'two-step' OGTT.

The ineffective use of insulin by the peripheral cells to process glucose and fatty acids.

MODY is characterized as an autosomal dominant monogenetic defect on different chromosomal loci, with at least 14 known gene mutations.

Obesity

Before 15 weeks of gestation and considering testing all patients at the initial prenatal visit.

A constellation of risk factors for development of type 2 diabetes and CVD.

DSMES provides the knowledge and skills for patients to perform diabetes-related self-care and develop effective problem-solving strategies.

To confirm resolution of hyperglycemia.

Multifactorial, with influence from both genetic and environmental factors.

Gradual onset, with most affected persons remaining asymptomatic for several years.

Patient education has been shown to improve outcomes, such as hemoglobin A1c and quality of life, and reduce costs by decreasing use of acute care and inpatient facilities for diabetes management.

Acanthosis nigricans is typically associated with insulin resistance.

Most patients with gestational diabetes have glucose normalization after pregnancy, but they are at an increased risk for development of recurrent gestational diabetes and type 2 diabetes.

Weight loss and the reduction of insulin resistance.

Genetic counseling and testing are recommended to identify the specific gene mutation and guide treatment.

Lifestyle modifications reduced the incidence of type 2 diabetes in persons with prediabetes by 58%.

At least every 3 years.

Acquired β-cell destruction may occur from diseases affecting the pancreas or from the effect of drugs or infections.

A constellation of risk factors for development of type 2 diabetes and CVD.

To identify undetected hyperglycemia in patients with target preprandial blood glucose values but high hemoglobin A1c levels.

To measure treatment efficacy and correlate average 3-month blood glucose levels with hemoglobin A1c levels.

When altering nutrition plans, exercise, and/or medications.

To improve diabetes care by lowering hemoglobin A1c and avoiding hypoglycemia.

To maximize the benefit of CGM in improving glycemic control and avoiding hypoglycemia.

To provide individualized diabetes-specific education to promote healthy diet choices and achieve glycemic and weight management goals.

Because patients with diabetes are more likely to have serious morbidity and mortality from COVID-19.

Diet and physical activity, which should be individualized to promote healthy choices and achieve glycemic and weight management goals.

Hemoglobin A1c generally correlates with average 3-month blood glucose levels.

Patient circumstances, preferences, and treatment, including insulin regimen and individualized monitoring needs.

Nutrient-dense carbohydrate sources that are high in fiber (≥14 g fiber/1000 kcal) and minimally processed, such as nonstarchy vegetables, fruits, and whole grains.

At least 5% weight loss, although weight loss of 10% or more may be necessary to achieve the desired results.

Moderate- to vigorous-intensity aerobic activity for 150 minutes/week, vigorous-intensity aerobic activity for 75 minutes/week, or a combination of both.

Two or more times per week.

Individualized based on the patient's age, health status, weight, pathophysiology of hyperglycemia, specific risks and benefits of a potential therapeutic agent, medication cost, lifestyle, and personal treatment goals.

Between 7% and 8%.

Assessment and management.

Interrupting prolonged sedentary behavior at 30-minute intervals with light activity or standing.

Considering metabolic surgery in patients with BMI of 40 or greater, and in patients with BMI of 35.0 to 39.9 who have not achieved weight loss goals and improvement in comorbidities with medical interventions.

One of the most important aspects of treatment.

Weight loss of at least 7% and moderate-intensity exercise of at least 150 minutes per week

Metformin

variable periods of insulin dependence and independence

Hyperglycemia during the second or third trimester in patients without a prepregnancy diagnosis of type 1 or type 2 diabetes

Reduces the risk of diabetes complications

To identify women at risk for GDM and prevent adverse maternal and neonatal outcomes

At least 7% weight loss over 6 months

A diet rich in monounsaturated fat, whole grains, vegetables, whole fruits, and nuts

Persons with prediabetes, particularly those aged 25 to 59 years with a BMI of 35 or greater, higher fasting plasma glucose (≥110 mg/dL [6.11 mmol/L]), and hemoglobin A1c values of 6% or greater, as well as patients with a history of gestational diabetes

Reduces the incidence of type 2 diabetes mellitus in persons with prediabetes

50%

Give an additional 1 unit of regular or analogue insulin at the time of the premeal measurement for every 50 mg/dL (2.8 mmol/L) above the target glucose value.

1 unit of insulin covers 10 to 20 g of carbohydrates consumed

Adjust the dose by 50% based on the portion of food consumed

To cover the remaining 50% of the total daily dose of insulin not covered by basal insulin

Twice daily

Significant reduction in the incidence and progression of microvascular complications

Significant reduction in CVD and mortality

Reduction in the composite outcome of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, as well as hospitalization for heart failure, and all-cause mortality

Significant reduction in the primary composite outcome of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, as well as all-cause mortality

The target hemoglobin A1c threshold should be based on a patient's health status

To mimic the physiologic action of the pancreas

To maintain glycemic control while fasting and between meals

Favorable outcomes for kidney function, including decreased risk of kidney disease progression and incidence of end-stage kidney disease

Improvement in nonglycemic effects such as weight loss, especially visceral fat, and reduction in triglycerides

To achieve tight glycemic control and reduce the risk of long-term complications

Glycemic control

Metformin, due to its known effectiveness and inability to cause hypoglycemia

Comorbidities such as atherosclerotic CVD, ASCVD risk factors, established kidney disease, heart failure, and overweight and obesity, as well as hypoglycemia risk, adverse effects, cost, and patient preference

Reducing gastrointestinal adverse effects

To consider individual patient needs, preferences, and comorbidities

Weight management, physical activity, and smoking cessation, when applicable

Intravenous insulin therapy

To maintain a glucose level between 140 and 180 mg/dL (7.8-10.0 mmol/L) for most patients

Because it is a reactive, nonphysiologic approach that leads to large glucose fluctuations

Basal insulin and prandial insulin therapy

Greater than 45 mL/min/1.73 m2

In noncritically ill hospitalized adults with insulin-treated diabetes who are at high risk for hypoglycemia, if CGM is available

Insulin therapy

Metformin

Annually

To detect undetected hypoglycemia

Continuation of outpatient CSII therapy may be appropriate for noncritically ill patients who have an intact level of consciousness and can appropriately adjust pump settings in hospitals with personnel who have expertise in insulin pump therapy

Every 3 months

SGLT2 inhibitors and/or GLP-1 RAs

Because organ function has returned to baseline

Monitoring for glucose abnormalities

SGLT2 inhibitors

SGLT2 inhibitors (preferred) and/or GLP-1 RAs

In patients with symptomatic hyperglycemia, ongoing catabolism, hemoglobin A1c > 10%, or glucose level > 300 mg/dL (16.7 mmol/L)

Insulin with a GLP-1 RA

To achieve glycemic targets and reduce the risk of cardiovascular complications

Intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF).

Monthly injections for at least 12 months followed by intermittent injections.

Measurement of eGFR and screening for the presence of albuminuria, as well as urinary albumin excretion determined from a random urine collection as the urine albumin-to-creatinine ratio (UACR).

An eGFR less than 30 mL/min/1.73 m2.

Uncontrolled hypertension and hyperglycemia.

An ACE inhibitor or an ARB.

It is indicative of glucose abnormalities before hospitalization, and these patients require follow-up for diagnosis of possible diabetes.

Infection, myocardial infarction, nonadherence to diabetes therapy, stress, trauma, and confounding medications (e.g., atypical antipsychotics, glucocorticoids, and SGLT2 inhibitors).

DKA typically occurs in individuals with type 1 diabetes younger than 65 years, while HHS typically occurs in individuals with type 2 diabetes who are older than 65 years.

DKA is a relative or absolute insulin deficiency state resulting in unsuppressed lipolysis, whereas HHS is a partial insulin deficiency that is able to suppress lipolysis and prevent ketone body production.

Symptoms may include abdominal pain, nausea, vomiting, polyuria, polydipsia, weight loss, or shortness of breath, and typically occur within 24 hours of onset in DKA, whereas symptoms from HHS may not appear for several days.

DKA is characterized by an increased anion gap metabolic acidosis, while HHS typically does not develop significant ketoacidosis.

Early recognition and treatment are crucial to prevent life-threatening consequences from dehydration and electrolyte abnormalities.

Euglycemic DKA is a condition described in patients taking SGLT2 inhibitors, and requires a high level of suspicion during initial evaluation.

They are initiated as a consequence of severe hyperglycemia and impair efficient glucose use.

HHS is associated with a higher mortality rate compared with DKA, and is typically seen in older individuals with type 2 diabetes.

DKA and HHS are life-threatening conditions that require early recognition and aggressive treatment to avoid severe consequences.

A basal-bolus insulin regimen with prandial insulin before two or more meals.

A prolonged action profile (>24 hours), peakless insulin delivery, and decreased variability in action between and within individuals.

Patients with type 2 diabetes not at glycemic goal despite adherence to glucose monitoring and multiple treatment modalities.

Patient-centered considerations, including comorbidities such as atherosclerotic cardiovascular disease and associated risk factors, kidney disease, heart failure, and overweight or obesity.

130/80 mm Hg or lower

Metformin.

Glucagon-like peptide 1 receptor agonists and/or sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy.

Moderate-intensity statin

In DKA, pH is profoundly low, whereas in HHS, it is typically greater than 7.3.

Aspirin (75-162 mg/d)

Every 3 months with subsequent adjustments to therapeutic agents until the glycemic target is achieved, and every 6 months if at goal.

Diabetic Retinopathy

It indicates severe dehydration.

Insulin.

To both monitor and modify insulin delivery via sensor-augmented, algorithm-derived insulin delivery.

Neovascularization caused by chronic ischemia

To identify potential depletion of body stores and avoid cardiac arrhythmias.

To correct hyperglycemia, replete electrolytes, and identify and treat inciting factors.

Complications from severe hypoglycemia and hyperglycemia, such as electrolyte abnormalities and dehydration.

To treat high-risk proliferative diabetic retinopathy and severe nonproliferative retinopathy

75-162 mg/d

Cardiovascular disease (CVD).

Below 130/80 mm Hg, if possible to achieve safely.

To prevent and delay the progression of retinopathy

Reduced risk of adverse cardiovascular and kidney events.

130/80 mm Hg or lower

To allow for treatment interventions to prevent vision loss

To prevent recurrence and improve patient outcomes.

To guide repletion and adjust insulin therapy.

Due to the complexity of care required.

An eGFR greater than 45 mL/min/1.73 m2

Comprehensive lifestyle modification, including weight management, physical activity, and smoking cessation, is first-line therapy. Clinicians should also consider comorbidities, hypoglycemia risk, adverse effects, cost, and patient preference when selecting medications.

Metformin

Metformin is the recommended first-line oral agent. Gastrointestinal adverse effects are common, which can be reduced by slow titration of doses, administration with food, or use of an extended-release formulation.

Up to 30%

Clinicians should consider comorbidities such as atherosclerotic CVD, ASCVD risk factors, established kidney disease, heart failure, and overweight and obesity, as well as hypoglycemia risk, adverse effects, cost, and patient preference.

Every 6 months

Comprehensive lifestyle modification, including weight management, physical activity, and smoking cessation, is an essential part of managing type 2 diabetes and can help obtain glycemic control.

Pharmacotherapy should be started at the time of type 2 diabetes diagnosis unless contraindications are present, and may be combined with lifestyle modifications to obtain glycemic control.

SGLT2 inhibitors and/or GLP-1 RAs

SGLT2 inhibitors (preferred) and/or GLP-1 RAs with proven benefit in this population

A basal-bolus insulin regimen with prandial insulin before two or more meals.

Clinicians should consider comorbidities, hypoglycemia risk, adverse effects, cost, and patient preference when selecting medications for patients with type 2 diabetes.

Ultralong-acting basal analogue insulins have a prolonged action profile (>24 hours), peakless insulin delivery, and decreased variability in action between and within individuals.

A stepwise approach, considering the clinical characteristics of the patient

When glycemic targets are not met, and other agents are not effective or tolerated

Glucagon-like peptide 1 receptor agonists and/or sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy.

Combination therapy with a GLP-1 RA

Every 3 months with subsequent adjustments to therapeutic agents until the glycemic target is achieved, and every 6 months if at goal.

Insulin therapy.

Combination injectable therapy initially, with a basal insulin dose and prandial insulin added before the largest meal if hyperglycemia persists

They both monitor and modify insulin delivery via sensor-augmented, algorithm-derived insulin delivery.

Blood glucose levels.

To avoid complications from severe hypoglycemia and hyperglycemia, such as electrolyte abnormalities and dehydration.

A hemoglobin A1c test should be performed if not done within the past 3 months.

Altered mental status, fasting (expected or unexpected), illness, insulin–meal timing mismatch, poor oral intake, and alterations in hyperglycemia-inducing therapies.

Between 140 and 180 mg/dL (7.8-10.0 mmol/L)

Critically ill patients with type 1 and type 2 diabetes

To avoid development of DKA (diabetic ketoacidosis)

Because it is a reactive, nonphysiologic approach that leads to large glucose fluctuations

Noncritically ill hospitalized adults with insulin-treated diabetes who are at high risk for hypoglycemia

Basal-bolus regimen with prandial coverage and correction boluses for premeal hyperglycemia

To detect undetected hypoglycemia

Continuous insulin therapy with basal insulin and prandial insulin coverage

To provide coverage for premeal hyperglycemia

Because it provides a continuous supply of insulin and can be adjusted in response to changing glucose levels

Insufficient insulin levels coupled with an increase in counterregulatory hormones, which impairs efficient glucose use and initiates glycogenolysis and gluconeogenesis.

DKA is a relative or absolute insulin deficiency state, whereas HHS is a partial insulin deficiency that can suppress lipolysis but cannot correct hyperglycemia or prevent dehydration and electrolyte abnormalities.

Infection, myocardial infarction, nonadherence to diabetes therapy, stress, trauma, and confounding medications such as atypical antipsychotics, glucocorticoids, and SGLT2 inhibitors.

A high level of suspicion is necessary during initial evaluation, as patients may present with normal or near-normal blood glucose levels.

Abdominal pain, nausea, vomiting, polyuria, polydipsia, weight loss, or shortness of breath, which can progress to lethargy, obtundation, and death if left untreated.

Measurement of serum glucose level, serum electrolytes, serum ketones, blood urea nitrogen, serum creatinine, plasma osmolality, complete blood count, arterial blood gases, urinalysis, and urine ketones, as well as an ECG and cultures of blood, sputum, and urine if an infection is suspected.

An increased anion gap metabolic acidosis secondary to the production of acetoacetic acid and β-hydroxybutyrate.

DKA typically presents with a moderate to severe reduction in serum bicarbonate levels, whereas HHS may have normal or mildly reduced levels (>20 mEq/L).

DKA or HHS may be the initial presentation of a person with undiagnosed diabetes, and prompt recognition can lead to timely diagnosis and treatment.

To avoid life-threatening consequences from dehydration and electrolyte abnormalities, as well as to reduce mortality rates.

Anti-VEGF intravitreal injections

For early detection of kidney disease

An ACE inhibitor or an ARB

It warrants a referral to a nephrologist

To decrease the risk of vision loss

Annual measurements, with more frequent assessments as necessary

Typically, the serum pH is less than 7.3 in DKA, but greater than 7.3 in HHS. Hypertonic hyponatremia occurs due to extreme hyperglycemia and osmotic shifts of water from intracellular to extracellular compartments.

Key components include intravenous hydration, electrolyte repletion, and correction of hyperglycemia with insulin. Frequent electrolyte measurements are necessary to guide repletion as hydration and insulin therapy continue.

Cardiovascular disease (CVD) is a major cause of morbidity and mortality. Simultaneous management of CVD risk factors, including hypertension, dyslipidemia, and albuminuria, is recommended to decrease morbidity and mortality.

The recommended target is below 130/80 mm Hg, if possible to achieve safely. The American Diabetes Association (ADA), American Association of Clinical Endocrinology/American College of Endocrinology, and the American College of Cardiology/American Heart Association advocate for this target.

SGLT2 inhibitors and/or GLP-1 RAs with proven CVD benefit are recommended to decrease morbidity and mortality.

Combined therapy can provide additive reduction of the risk for adverse cardiovascular and kidney events.

The ADA recommends receiving an SGLT2 inhibitor with proven cardiovascular benefit to reduce the risk for worsening heart failure, heart failure hospitalizations, and cardiovascular death.

Inciting factors, such as infection and myocardial infarction, must be identified and treated to prevent recurrence and improve outcomes.

Correcting hyperglycemia, preferably with intravenous insulin, is essential to prevent life-threatening consequences from dehydration and electrolyte abnormalities.

Repletion of electrolyte deficits, particularly potassium, is necessary to prevent cardiac arrhythmias and other complications.

130/80 mm Hg or lower

Moderate-intensity statin, with high-intensity statin reasonable if one or more atherosclerotic cardiovascular disease risk factors are present

Nonproliferative (occurs within the retina) or proliferative (occurs in the vitreous or retinal inner surface)

To treat high-risk proliferative diabetic retinopathy and severe nonproliferative retinopathy

Aspirin (75-162 mg/day)

Diabetic retinopathy

Duration of diabetes, degree of hyperglycemia, hypertension, albuminuria, and dyslipidemia

To allow for early detection of asymptomatic abnormalities and treatment interventions to prevent vision loss

To prevent and delay the progression of retinopathy

Not universally recommended; individualized decision-making is recommended

Type 2 diabetes is often preceded by a prolonged asymptomatic hyperglycemic period, lifestyle interventions and medications can delay or prevent its onset, and early intensive glucose control can prevent or reduce microvascular and macrovascular disease.

To identify individuals at high risk and prevent or delay the onset of type 2 diabetes and its associated complications.

It can identify individuals with presymptomatic type 1 diabetes who may benefit from therapy to delay clinical diabetes development.

It can prevent or reduce the progression of microvascular disease and macrovascular cardiovascular disease.

There is no effective therapy to prevent or delay the onset of type 1 diabetes in the general population.

It can delay the onset of symptomatic type 1 diabetes in selected individuals.

The presence of autoantibodies in type 1A diabetes, whereas type 1B diabetes is characterized by variable insulin deficiency in the absence of autoantibodies.

In the setting of symptomatic hyperglycemia, a single random plasma glucose value of 200 mg/dL or greater is diagnostic of diabetes.

GAD65 autoantibodies have a high prevalence (70%) at the time of diagnosis and may remain detectable for years.

Initiating insulin at the time of diagnosis may decrease toxicity associated with extreme hyperglycemia, allowing the β cells to regain some ability to produce insulin.

Latent autoimmune diabetes in adults is characterized by autoantibody development leading to β-cell destruction and ultimately to insulin deficiency, typically without initial insulin dependence.

The result is a state of insulin deficiency, which is characteristic of type 1 diabetes.

A low or undetectable serum C-peptide level is evidence of little to no insulin secretion, indicating a complete destruction of the insulin-producing β cells.

Patients with type 1A diabetes have an increased risk for other autoimmune disorders, including celiac disease, thyroid disorders, vitiligo, and autoimmune primary adrenal gland failure.

GAD65 and IA-2 autoantibodies are recommended as initial testing for type 1A diabetes in newly diagnosed disease.

The goal of insulin therapy is to replace the missing insulin and maintain near-normal blood glucose levels, reducing the risk of long-term complications.

Type 1B diabetes is characterized by β-cell destruction, which may occur from diseases affecting the pancreas or from the effect of drugs or infections, and has a strong family history of type 2 diabetes.

Insulin resistance leads to normal blood glucose levels as long as the β cells can increase insulin production, whereas insulin deficiency results in hyperglycemia.

Metabolic syndrome is a constellation of risk factors for the development of type 2 diabetes and cardiovascular disease.

The extent of β-cell dysfunction determines the degree of hyperglycemia, which may worsen over time with progressive decrease in insulin production.

The recommended screening interval is every 3 years, and the parameters to be measured include fasting plasma glucose, fasting lipid panel, blood pressure, and waist circumference.

A diet rich in monounsaturated fat, whole grains, vegetables, whole fruits, and nuts, and achieving at least 150 min/week of moderate-intensity exercise, with a goal of 7% weight loss over 6 months.

Acanthosis nigricans is typically associated with insulin resistance, and its presence should prompt screening for diabetes and, if of acute onset, screening for malignancy.

The goal is weight loss and the reduction of insulin resistance, with mitigation of cardiovascular risk factors.

Metformin

The DPP showed that lifestyle modifications reduced the incidence of type 2 diabetes in persons with prediabetes by 58%.

Episodic diabetic ketoacidosis (DKA) resulting from insulin deficiency, with variable periods of insulin dependence and independence.

Type 2 diabetes typically presents in adults, with a gradual onset, and most affected persons remain asymptomatic for several years.

Individuals with preserved β-cell function (A+β+ and A−β+) are more likely to discontinue insulin, whereas those without β-cell reserve (A+β− and A−β−) are more likely to have poor glycemic control and develop long-term insulin dependence.

Macrosomia, labor and delivery complications, preeclampsia, neonatal hypoglycemia, spontaneous abortion, and intrauterine fetal demise.

The pathogenesis of type 2 diabetes is multifactorial, with influence from both genetic and environmental factors.

Universal screening for all women between 24 and 28 weeks of gestation, or earlier if risk factors are present.

Reducing the risk of long-term complications, such as cardiovascular disease and microvascular disease.

They are effective tools for delivering DPP-based interventions and improving patient outcomes.

Values of 6% or greater are associated with an increased risk of developing type 2 diabetes.

To reduce the incidence of type 2 diabetes in high-risk individuals.

before 15 weeks of gestation

type 2 diabetes

at 24 weeks or after

to diagnose gestational diabetes

an autosomal dominant monogenetic defect on different chromosomal loci

at least every 3 years

to provide the knowledge and skills for patients to perform diabetes-related self-care and develop effective problem-solving strategies

Patient circumstances, preferences, and treatment.

improved outcomes, such as hemoglobin A1c and quality of life

at the time of diagnosis, annually and/or when treatment targets are unmet, when complicating circumstances develop, and at times of life and care transitions

When altering nutrition plans, exercise, and/or medications.

To measure treatment efficacy.

4 to 12 weeks postpartum

To improve diabetes care by lowering hemoglobin A1c and avoiding hypoglycemia.

As close to daily as possible.

Because patients with diabetes are more likely to have serious morbidity and mortality from COVID-19.

To provide individualized diabetes-specific education to promote healthy diet choices.

Diet and physical activity.

To identify undetected hyperglycemia.

Reductions in hemoglobin A1c.

Tight glycemic control significantly reduces the incidence and progression of microvascular complications.

It reduces the risk of CVD and mortality, particularly in patients early in the course of diabetes.

They reduce the risk of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, and hospitalization for heart failure.

They reduce the risk of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, and all-cause mortality.

The target threshold should be based on a patient's health status.

An intensive insulin regimen that includes multiple daily doses of insulin to mimic the physiologic action of the pancreas.

To provide continuous subcutaneous insulin infusions (CSII) for basal coverage and prandial coverage.

They decrease the risk of kidney disease progression, incidence of end-stage kidney disease, and mortality in patients with chronic kidney disease.

They improve weight loss, especially visceral fat, and reduce triglycerides.

To mimic the physiologic action of the pancreas and provide basal coverage, prandial coverage, and supplemental insulin for correction of hyperglycemia.

≥14 g fiber/1000 kcal

at least 5% weight loss

150 minutes/week of moderate- to vigorous-intensity aerobic activity

two or more times per week

interrupting prolonged sedentary behavior at 30-minute intervals with light activity or standing

BMI of 40 or greater (≥37.5 in Asian Americans)

smoking discontinuation

between 7% and 8%

based on individualized goals

based on the patient's age, health status, weight, pathophysiology of hyperglycemia, specific risks and benefits of a potential therapeutic agent, medication cost, lifestyle, and personal treatment goals

0.4 to 1.0 U/kg/day

50%

10 to 20 g

To correct hyperglycemia

1 unit for every 50 mg/dL above the target glucose value

To combine intermediate- or long-acting basal insulin and rapid- or short-acting insulin in fixed concentrations