Show 5 more Elderly patients (lifestyle modifications): ensure optimal nutrition and protein intake in older patients. B Show 2 more Elderly patients (pharmacotherapy): prefer medication classes with a low risk of hypoglycemia in older patients with T2DM at increased risk of hypoglycemia. B Show 4 more Elderly patients (residing in nursing facilities): obtain careful assessment in patients with diabetes residing in long-term care facilities to establish individualized glycemic goals and to make appropriate choices of glucose-lowering agents based on their clinical and functional status. B Show 2 more Elderly patients (end-of-life care): Initiate conversations regarding the goals and intensity of care when palliative care is required in older patients with diabetes. Avoid strict glucose and BP control. B Consider simplifying regimens. Consider relaxing the intensity of lipid management or withdrawing lipid-lowering therapy. A Set overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity as primary goals for diabetes management at the end of life. B Pediatric patients (screening and diagnosis): Consider obtaining risk-based screening for prediabetes and/or T2DM after the onset of puberty or 10 years of age, whichever occurs earlier, in young patients with overweight with BMI 85th percentile or obesity with BMI 95th percentile and having 1 additional risk factors for diabetes: Situation Guidance Diabetes or gestational diabetes during the child's gestation Maternal history T2DM in first- or second-degree relative Family history Native American, African American, Latino, Asian American, Pacific Islander B Race/ethnicity Acanthosis nigricans, hypertension, dyslipidemia, PCOS, or small-for- gestational-age birth weight. C Signs of or conditions associated with insulin resistance Show 3 more https://web.pathway.md/diseases/recNW2vC0lM724J79 13/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway Pediatric patients (screening for hypertension): measure BP in young patients with T2DM at every visit. Consider obtaining ambulatory BP monitoring in young patients with high BP (BP 90th percentile for age, gender, and height or, in adolescents aged 13 years, 120/80 mmHg) on 3 separate measurements. B Pediatric patients (screening for cardiovascular diseases): do not obtain routine screening for heart disease with electrocardiography, echocardiography, or stress testing in asymptomatic young patients with T2DM. D Pediatric patients (screening for dyslipidemia): obtain lipid profile screening initially after optimizing glycemia and annually thereafter. B Pediatric patients (screening for nonalcoholic fatty liver disease): Screen for nonalcoholic fatty liver disease by measuring AST and ALT at diagnosis and annually thereafter in pediatric patients with T1DM. B Consider referring to gastroenterology for persistently elevated or worsening transaminases. C Pediatric patients (screening for nephropathy): advise protein intake at the recommended daily allowance of 0.8 g/kg/day. B Show 5 more Pediatric patients (screening for retinopathy): obtain screening for retinopathy by dilated fundoscopy at or soon after diagnosis and annually thereafter. B Show 3 more Pediatric patients (screening for neuropathy): Screen for diabetic neuropathy by foot examination (including foot inspection, assessment of foot pulses, pinprick and 10-g monofilament sensation tests, testing of vibration sensation using a 128-Hz tuning fork, and ankle reflex tests) at diagnosis and annually thereafter in young patients with T2DM. B Focus on achieving glycemic targets for the prevention of diabetic neuropathy. B Pediatric patients (screening for obstructive sleep apnea): screen for symptoms of sleep apnea at each visit, and refer to a pediatric sleep specialist for evaluation and a polysomnogram, if indicated. Treat obstructive sleep apnea when documented. B Pediatric patients (screening for polycystic ovary syndrome): screen for PCOS in female adolescent patients with T2DM, including laboratory studies when indicated. B Show 2 more Pediatric patients (screening for psychosocial factors): screen for food security, housing stability/homelessness, health literacy, financial barriers, and social/community support and apply that information to treatment decisions. B Show 4 more Pediatric patients (lifestyle modifications): offer intensive lifestyle interventions focusing on weight loss, dyslipidemia, hypertension, and dysglycemia to prevent overt macrovascular disease in early adulthood. B Show 5 more Pediatric patients (glycemic targets): individualize blood glucose monitoring taking into consideration the pharmacologic treatment of the patient. B https://web.pathway.md/diseases/recNW2vC0lM724J79 14/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway Show 5 more Pediatric patients (pharmacotherapy): initiate pharmacotherapy, in addition to behavioral counseling for healthful nutrition and physical activity changes, at diagnosis of T2DM. A Show 8 more Pediatric patients (management of obesity): Consider offering metabolic surgery for the treatment of adolescent patients with T2DM with severe obesity (BMI > 35 kg/m ) and having elevated HbA1c and/or serious comorbidities despite lifestyle and pharmacologic interventions. B Perform metabolic surgery only by an experienced surgeon working as part of a well- organized and engaged multidisciplinary team, including a surgeon, endocrinologist, dietitian nutritionist, behavioral health specialist, and nurse. A Pediatric patients (management of hypertension): offer lifestyle modifications focused on healthy nutrition, physical activity, sleep, and, if appropriate, weight management for the treatment of elevated BP (defined as 90th to < 95th percentile for age, gender, and height or, in adolescents aged 13 years, 120-129/< 80 mmHg) in young patients with T2DM. B Show 2 more Pediatric patients (management of dyslipidemia): Set the following optimal goals: Situation Guidance < 100 mg/dL (2.6 mmol/L) LDL cholesterol > 35 mg/dL (0.91 mmol/L) HDL cholesterol < 150 mg/dL (1.7 mmol/L). B Triglycerides Show 3 more Pediatric patients (transition to adult care): begin to prepare young patients for transition to adult healthcare in early adolescence and, at the latest, at least 1 year before the transition. B Show 2 more Pregnant patients (screening): obtain screening for undiagnosed diabetes in individuals with risk factors planning pregnancy. B Consider testing all individuals of childbearing potential for undiagnosed diabetes. B Show 4 more Pregnant patients (preconception counseling and care): incorporate preconception counseling into routine diabetes care starting at puberty and continuing in all patients with diabetes and reproductive potential. A Show 6 more Pregnant patients (nutrition): encourage a balanced intake of macronutrients including nutrient-dense fruits, vegetables, legumes, whole grains, and healthy fats with omega-3 fatty acids (including nuts, seeds, and fish) in the eating pattern. B Pregnant patients (glycemic targets): obtain fasting and postprandial blood glucose monitoring in both gestational diabetes mellitus and preexisting diabetes in pregnancy, to achieve optimal glucose levels. Set the following glucose targets: fasting plasma glucose < 95 https://web.pathway.md/diseases/recNW2vC0lM724J79 15/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway mg/dL (5.3 mmol/L) and either 1-hour postprandial glucose < 140 mg/dL (7.8 mmol/L) or 2- hour postprandial glucose < 120 mg/dL (6.7 mmol/L). Obtain blood glucose preprandially in some patients with preexisting diabetes. B Show 4 more Pregnant patients (management of gestational diabetes): offer lifestyle behavior changes for the management of gestational diabetes mellitus. Add insulin if needed to achieve glycemic targets. A Show 5 more Pregnant patients (management of preexisting diabetes): prefer insulin for the management of T2DM in pregnancy. B Pregnant patients (prevention of preeclampsia): prescribe low-dose aspirin 100-150 mg/day (162 mg/day may also be acceptable) starting at 12-16 weeks of gestation to lower the risk of preeclampsia in patients with T2DM. B Pregnant patients (BP targets): consider targeting a BP of 110-135/85 mmHg in pregnant patients with diabetes and chronic hypertension in the interest of reducing the risk for accelerated maternal hypertension. B Titrate therapy from a BP threshold of 140/90 mmHg for better pregnancy outcomes with no increase in the risk of small-for-gestational-age birth weight. B Lessen therapy for BP < 90/60 mmHg. C Pregnant patients (postpartum care): evaluate and adjust insulin requirements postpartum as insulin resistance decreases dramatically immediately postpartum and the requirements are often roughly half the prepregnancy requirements for the initial few days postpartum. B Show 7 more Patients with male hypogonadism: As per SIAMS 2022 guidelines, consider initiating testosterone replacement therapy to improve fasting and post-load glycemic control and to reduce the risk of developing T2DM in male patients with hypogonadism and metabolic syndrome or pre-diabetic conditions. C Show 3 more As per EAA 2020 guidelines, do not initiate testosterone replacement therapy to improve glycometabolic control in male patients with T2DM and/or metabolic syndrome. D As per ES 2018 guidelines, do not initiate testosterone replacement therapy to improve glycemic control in patients with T2DM mellitus and low testosterone concentrations. D Patients with stroke: As per ADA 2023 guidelines, consider offering pioglitazone to lower the risk of stroke or myocardial infarction in patients with a history of stroke and evidence of insulin resistance and prediabetes, balancing the benefits with the increased risk of weight gain, edema, and fracture. B Consider offering lower doses to mitigate the risk of adverse effects. C As per AHA 2021 guidelines, consider offering lifestyle optimization (healthy diet, regular physical activity, and smoking cessation) for the prevention of the progression of prediabetes to diabetes in patients with ischemic stroke or TIA and prediabetes. C Show 6 more Patients with COVID-19 infection: support patients with diabetes to achieve individualized targeted glycemic control to reduce the risk of macrovascular and microvascular risk as well as reduce the risk of COVID-19 and its complications. B https://web.pathway.md/diseases/recNW2vC0lM724J79 16/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway Show 8 more 8. Patient education Self-management counseling: offer all patients with diabetes participation in self- management education and support to facilitate the knowledge, decision-making, and skills mastery for diabetes self-care. A Show 9 more 9. Preventative measures Primary prevention, lifestyle modifications: As per ADA 2023 guidelines, refer adult patients with overweight or obesity at high risk of T2DM, as typified by the Diabetes Prevention Program, to an intensive lifestyle behavior change program to achieve and maintain a weight reduction of at least 7% of initial body weight through healthy reduced-calorie diet and 150 minute/week of moderate-intensity physical activity. A Show 4 more As per CPSTF 2015 guidelines, consider offering combined diet and physical activity promotion programs by healthcare systems, communities, and other implementers to provide counseling and support in individuals identified as being at increased risk for T2DM. E Primary prevention (metformin therapy): Consider offering metformin therapy for the prevention of T2DM in adults at high risk of T2DM, as typified by the Diabetes Prevention Program, especially patients aged 25-59 years with BMI 35 kg/m , higher fasting plasma glucose ( 110 mg/dL), and higher HbA1c ( 6.0%), and in patients with a history of gestational diabetes mellitus. B Consider obtaining periodic measurements of vitamin B12 levels in metformin-treated patients, especially in patients with anemia or peripheral neuropathy. C Routine immunizations: provide routine immunizations in pediatric and adult patients with diabetes as indicated by age. A 10. Follow-up and surveillance Treatment monitoring: include most components of the initial comprehensive medical evaluation in the follow-up visit. A Show 3 more Continous glucose monitoring: As per ADA 2023 guidelines, obtain real-time continuous glucose monitoring A or intermittently scanned continuous glucose monitoring B in adult patients with diabetes on multiple daily injections or continuous subcutaneous insulin infusion capable of using the devices safely, either by themselves or with a caregiver. Decide on the choice of the device based on the patient's circumstances, preferences, and needs. A Show 12 more https://web.pathway.md/diseases/recNW2vC0lM724J79 17/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway As per ES 2022 guidelines, consider obtaining real-time continuous glucose monitoring in outpatients with T2DM taking insulin and/or sulfonylureas and being at risk for hypoglycemia. C As per ES 2016 guidelines: Consider obtaining short-term, intermittent continuous glucose monitoring in adult patients with T2DM (not on prandial insulin) with HbA1c levels 7% and willing and able to use the device. C Provide education, training, and ongoing support to help achieve and maintain individualized glycemic goals in adult patients with T2DM using continuous subcutaneous insulin infusion and continuous glucose monitoring. E Monitoring of glycemic status: assess glycemic status (HbA1c or other glycemic measurements, such as time in range or glucose management indicator) at least two times a year in patients meeting treatment goals (and having stable glycemic control). B Show 3 more 11. Quality improvement Health promotion: ensure that treatment decisions are timely, rely on evidence-based guidelines, include social community support, and are made collaboratively with patients based on individual preferences, prognoses, comorbidities, and informed financial considerations. B Show 5 more Use of diabetes technology: individualize the type and selection of devices based on the patient's specific needs, preferences, and skill level. Include the caregiver's skills and preferences in the decision-making process in the setting of a patient with diabetes partially or wholly managed by someone else (such as a young child or a person with cognitive impairment or dexterity, psychosocial, and/or physical limitations). B Show 5 more Clinical findings Patient demographics Symptoms African-american race Asthenia Age Blurry vision Asian ethnicity Chronic lower abdominal pain Native American Fatigue Limb numbness Past medical history Polydipsia Polyuria Diabetic neuropathy Weight loss Hypercholesterolemia Obesity Past obstetric history PCOS Prediabetes Gestational diabetes Repeated infections Recurrent abortion https://web.pathway.md/diseases/recNW2vC0lM724J79 18/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway Family history Social history Diabetes mellitus Physical inactivity Genetic predispositions Lab findings Neurological exam Lactic acidosis Anisocoria urine glucose serum pH Studies 2023 DECLARE-TIMI 58 (post-hoc analysis) In adults 40 years with T2DM and either risk factors for or established ASCVD, dapagliflozin was superior to placebo with respect to first non-elective hospitalization for any cause. Meir Schechter et al. Lancet Diabetes Endocrinol. 2023 Apr. 2023 Oral GLP-1 (danuglipron 40 mg) In adults with T2DM inadequately controlled by diet and exercise, with or without metformin treatment, danuglipron was superior to placebo with respect to reduction in glycated Hgb at week 16. Aditi R Saxena et al. JAMA Netw Open. 2023 May 1. Show 41 more References 1. Steven E. Kahn, Cheryl A.M. Anderson, John B. Buse et al. Standards of Care in Diabetes 2023. Diabetes Care. 2023 Jan;46 Supplement_1 S1 S291. Open 2. Michael Camilleri, Braden Kuo, Linda Nguyen et al. ACG Clinical Guideline: Gastroparesis. Am J Gastroenterol. 2022 Aug 1;117 8 1197 1220. Open 3. Anthony L McCall, David C Lieb, Roma Gianchandani et al. Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2022 Dec 7;dgac596. Open 4. Connie B Newman, Michael J Blaha, Jeffrey B Boord et al. 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Julio Rosenstock, Stephen C Bain, Amoolya Gowda et al. Weekly Icodec versus Daily Glargine U100 in Type 2 Diabetes without Previous Insulin. N Engl J Med. 2023 Jun 24. Open 50. Ildiko Lingvay, Marisse Asong, Cyrus Desouza et al. Once-Weekly Insulin Icodec vs Once-Daily Insulin Degludec in Adults With Insulin-Naive Type 2 Diabetes: The ONWARDS 3 Randomized Clinical Trial. JAMA. 2023 Jun 24. Open https://web.pathway.md/diseases/recNW2vC0lM724J79 22/22