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

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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
Version 4.0 Figure G1. Sequential Treatment of Type 2 Diabetes VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus Establish A1C goals Nonpharmacologic Therapy -Diet -Exercise Very symptomatic Severe hyperglycemia Ketosis Unrecognized type 1 DM Glycemic goals not achieved Recommended Monotherapy -Biguanide -Sulfonylurea -Insulin Alternative Agents*‡ -Alpha-glucosidase inhibitors -DPP-4 inhibitors -GLP-1 agonist -Meglitinides -Thiazolidinediones Oral agent not tolerable or A1c > 2% above target Insulin† -Basal insulin -Basal + bolus insulin -Bolus insulin Basal insulin= NPH or longacting analog Bolus insulin= Regular or rapid-acting analog †+/- oral hypoglycemic agents for type 2 diabetes Glycemic goals not achieved Recommended Combination Therapy -Biguanide+ Sulfonylurea -Biguanide + Insulin -Sulfonylurea + Insulin Alternative Combination Therapy*‡ -Alpha-glucosidase inhibitors -DPP-4 inhibitors -GLP-1 agonists -Meglitinides -Thiazolidinediones Glycemic goals not achieved *Listed alphabetically; not in order of preference ‡If applicable, refer to VA www.pbm.va.gov or http://vaww.pbm.va.gov or DoD guidance/ criteria for further recommendations on use of these agents Module G: Glycemic Control Page 54
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