Management of diabetes needs to be individualized. For most patients goal should be A1C(3 month average of blood glucose) < 7%. For others at risk of hypoglycaemia, advanced age or difficulty reaching the goal A1C of 7.0%-8.0% is appropriate. The importance of lifestyle changes (diet, exercise, weight management, tobacco cessation) needs to be emphasized. Referring new diagnosed patients for diabetic education is recommended. Screening for Retinopathy and foot exam to be done annually. Urine albumin/creatinine ratio to be done annually. Blood chemistry and renal function at least every 6 months. A1C testing every 3-6 months. Check lipids at diagnosis and every few years.
Cardiovascular risk assessment is important because most diabetics die of heart disease. Risk factors include: duration of diabetes, age(men>45, women>55), family history(1st degree relative CAD men<55, women<65), men, smoking, HTN, dyslipidemia.
Cardiovascular disease risk estimator can be used to estimate patients 10 year risk of heart disease or stroke. For patients at risk for heart disease a resting ECG is recommended as an initial diagnostic test and should be repeated every 3-5 years. Depending on the ECG findings and risk factors stress test should be considered. All diabetics 40-75 years old should be put on moderate-intensity statin. For 75 years and older moderate intensity can be considered.
Baby aspirin for diabetics between 50-70 years who are at increased risk of CVD, who do not have contraindication is recommended. BP of < 130/80 is recommended. ACE inhibitors(eg. Ramipril, Lisinopril) are preferred as first line as it may reduce mortality and recommended for patients with Chronic Kidney Disease and microalbuminuria(protein in urine).
Metformin remains the first line treatment in most cases. Start off with 500mg once a day and in 1-2 weeks increase to optimal dose of 1000 twice a day. Patient with eGFR(renal function) of 30-45 are not recommended to be started on Metformin but if already on it maybe be continued with caution, frequent testing and 50% dose reduction. eGFR of 45-60 require frequent renal function testing.
Recent studies has shown patients with type 2 diabetes and heart failure benefit from SGLT2 drugs(eg. Inovakan, Jardiance) and is preferred first line agent. SGLT2s increase risk of UTIs and genital yeast infections. GLP-1(Victoza, Trulicity) Agonists (Intramuscular injection) good A1C reducing agent and helps with weight loss, contraindicated if family history of thyroid cancer. DPP-4 Inhibitors(eg. Januvia, Tradjenta) are well tolerated, help with weight loss. Sulfonylureas(eg. Glipazide, Glyburide) are inexpensive but can cause hypoglycaemia, can cause weight gain and unknown affect on mortality.
Patients with marked hyperglycaemia A1C > 11% at the time of diagnosis should be started on Metformin and long acting insulin 0.1-0.2 units/kg/day and dose slowly adjusted (increase of 2-3 unit increase every 2 days). In some newly diagnosed patients 2 oral anti diabetes drugs plus lifestyle changes may bring their A1C to target without the need for insulin. Typically if a patient is not controlled with 2 oral drugs then insulin should be considered.