DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

Version 4.0
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
J. Initiate/Adjust Therapy
OBJECTIVE
Achieve glycemic target goals by the most cost-effective and least invasive means.
BACKGROUND
Long-term outcomes of treatment of DM (i.e., microvascular complications) are related to the degree of glycemic
control but not to the means used to achieve it (i.e., diet/exercise versus oral hypoglycemic agent versus insulin, or
any known combination therapy). Based on this principle, therapy should be tailored to individual preferences,
needs, and pragmatic considerations, such as cost and ease of compliance.
RECOMMENDATIONS
1. Individual treatment goals must be established with the patient based on the extent of the disease, comorbid
conditions, and patient preferences.
2. Institution of dietary modification and exercise alone is usually the appropriate initial management in
patients with new onset type 2 diabetes, depending upon severity of symptoms, psychosocial evaluation,
patient motivation, and overall health status. Encourage diet and exercise and lifestyle modifications.
3. Use various approaches (e.g., individual or group, counseling, coaching, motivational interviewing) to
promote healthful behaviors, such as healthful diet, adequate physical activity, and smoking cessation.
4. If treatment goals are not achieved with diet and exercise alone, drug therapy should be initiated while
encouraging lifestyle modifications.
The concept of sequential treatment is commonly employed in clinical management of chronic diseases. The
sequential steps for glycemic control therapy are summarized in Figure G1.
DISCUSSION
Non-Pharmacologic Therapy
Each patient with newly diagnosed type 2 DM without markedly elevated HbA 1 c or symptomatic hyperglycemia
should be offered trial of non-pharamcological therapy with diet and lifestyle modification prior to the use of
medications. Lifestyle changes include diet (see Module M, Self-management and Education), exercise for at least
30 minutes per day on most days of the week (as appropriate, after a detailed medical examination), weight loss if
indicated, and smoking cessation. Limit alcohol to no more than 2 drinks per day for men and 1 drink per day for
women (1 drink=12 ounces of beer, 5 ounces of wine, or 1.5 ounces of distilled spirits). Dietary modicficaion and
exercise should be given at least a 3 month trial before drug therapy is started, unless fasting glucose >250 mg/dL or