Establish diagnosis and classify type of diabetes mellitus (DM).
The oral glucose tolerance test (OGTT) is not recommended for routine clinical use because of its higher cost, time requirement, and limited reproducibility.
Initiate diabetes education classes to learn blood glucose monitoring and diabetes medications; to learn signs, symptoms, and complications; and to learn how to manage sick days.
Place patient on ADA diet with appropriate caloric, sodium, and lipid restrictions.
Establish cardiac risk factors, kidney function (serum creatinine, urine for microalbuminuria).
If neuropathy is present, refer to a neurologist.
Establish extent of fundoscopic lesion (refer to ophthalmologist as needed).
Check feet and toenails at least once a year and refer to a foot specialist.
Use finger-stick blood glucose for daily diabetic control.
Follow chronic glycemic control by HgA1c every 2 to 3 months in the office.
Initial general health evaluation should consist of a complete history and physical examination and the following laboratory tests: CBC with differential, chemistry profile, lipid profile, urinalysis, thyroid function tests, urine for microalbuminuria, and ECG (baseline at age 40 or older, repeat yearly).
Oral hypoglycemic agents like the sulfonylureas may be considered if fasting blood glucose does not decline or increase and if the patient has diabetes for fewer than 10 years, does not have severe hepatic or renal disease, and is not pregnant or allergic to sulfa drugs.
While on oral hypoglycemic agents, check the HgA1C every 3 months and at least two times a year if stable.
If the HgA1C is <7% or the postprandial glucose is <200 mg/dL, omit the oral hypoglycemic agents, place on diet alone, and follow every 3 months.
If the fasting serum glucose is >200 mg/dL consistently or the HgA1C is more than 10%, consider starting insulin and referring the patient to an internist.
Administer the ﬂu vaccine every fall and the pneumococcal vaccine every 6 years.
ADA, American Diabetic Association; HgA1c, hemoglobin A1C; CBC, complete blood count; ECG, electrocardiogram. Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2000;23:S4–S42.
Table 9.11 Patient Guidelines for Treatment of Type 2 Diabetes
Initiate an ADA reducing diet (50% CHO, 30% fat, 20% protein, high fiber) with three meals a day.
Maintain ideal body weight or to reduce weight by 5% to 15% in 3 months if obese.
Modify risk factors (smoking, exercise, fat intake).
Check fasting blood glucose by finger stick daily for 2 months. If FBS declines, no other therapy is needed. If FBG does not decline or increases, use of an oral hypoglycemic agent may be considered.
ADA, American Diabetic Association; CHO, carbohydrate; FBS, fasting blood glucose. Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2000;23:S4–S42.
medicines (i.e., metformin, a biguanide), insulin therapy should be initiated and referral should be considered because of the increased rate of complications.