Guideline sources The following summarized guidelines for the evaluation and management of diabetes mellitus type 2 are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the European Association of Urology (EAU 2023), the American College of Gastroenterology (ACG 2022; 2013), the Endocrine Society (ES 2022; 2020; 2018; 2016), the Canadian Cardiovascular Society (CCS 2022), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2022), the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the Italian Society of Endocrinology (SIE/SIAMS 2022), the American Heart Association (AHA/ASA 2021), the U.S. Preventive Services Task Force (USPSTF 2021), the European Academy of Andrology (EAA 2020), the Society for Vascular Medicine (SVM/SVS/APMA 2016), and the Community Preventive Services Task Force (CPSTF 2015). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Calculator Calculator https://web.pathway.md/diseases/recNW2vC0lM724J79 1/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway American Diabetes Association Finnish Diabetes Risk Score FIN Guidelines 1. Screening and diagnosis Indications for screening: As per ADA 2023 guidelines, screening asymptomatic adults for prediabetes and T2DM with an informal assessment of risk factors or validated risk calculator. B Show 9 more As per USPSTF 2021 guidelines, screen for prediabetes and T2DM in adults aged 35-70 years with overweight or obesity. Offer or refer patients with prediabetes to effective preventive interventions. B 2. Diagnostic investigations General principles: ensure a person-centered communication style using person-centered, culturally sensitive, and strength-based language and active listening, eliciting individual preferences and beliefs, and assessing literacy, numeracy, and potential barriers to care in order to optimize health outcomes and health-related quality of life. B Show 2 more Hemoglobin A1C: obtain HbA1c testing using a method certified by the National GlycoHgb Standardization Program and standardized to the Diabetes Control and Complications Trial assay, in order to avoid misdiagnosis or missed diagnosis. B Show 3 more Glucose tolerance test: ensure adequate carbohydrate intake (at least 150 g/day) for 3 days before oral glucose tolerance testing as a screen for diabetes. A Screening for obesity: use person-centered, nonjudgmental language fostering collaboration between patients and health care professionals, including people-first language (such as "person with obesity" rather than "obese person"). B Show 2 more Screening for hypertension: measure BP at every routine clinical visit. Confirm BP using multiple readings, when possible, in patients found to have elevated BP (systolic BP 120-129 mmHg and diastolic < 80 mmHg), including measurements on a separate day, to diagnose hypertension. Diagnose hypertension in case of a systolic BP 130mmHg or a diastolic BP 80 mmHg based on an average of 2 measurements obtained on 2 occasions. A Show 2 more Screening for cardiovascular diseases: Do not obtain routine screening for coronary artery disease in asymptomatic patients, as it does not improve outcomes as long as ASCVD risk factors are treated. D https://web.pathway.md/diseases/recNW2vC0lM724J79 2/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway Consider obtaining investigations for coronary artery disease in the presence of any of the following: atypical cardiac symptoms (such as unexplained dyspnea, chest discomfort) signs or symptoms of associated vascular disease (including carotid bruits, TIA, stroke, claudication, or peripheral arterial disease) ECG abnormalities (such as Q waves). C Screening for dyslipidemia: Consider obtaining a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter if under the age of 40 years or more frequently if indicated, in adult patients with diabetes not taking statins or other lipid-lowering therapy. C Obtain lipid profile at the initiation of statins or other lipid-lowering therapy, 4-12 weeks after initiation or a change in dose, and annually thereafter to monitor the response to therapy and inform medication taking. B Screening for nonalcoholic fatty liver disease: obtain screening/risk stratification for nonalcoholic fatty liver disease with clinically significant fibrosis (defined as moderate fibrosis to cirrhosis) using a calculated fibrosis-4 index (derived from age, ALT, AST, and platelets) in adult patients with T2DM or prediabetes, particularly with obesity or cardiometabolic risk factors/established CVD, even if they have normal liver enzymes. B Show 3 more Screening for diabetic nephropathy: Assess urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR at least annually in all patients with T2DM regardless of treatment. B Monitor urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR 1-4 times per year depending on the stage of the disease in patients with established diabetic kidney disease. B Screening for diabetic retinopathy: obtain an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of diagnosis in patients with T2DM. B Show 4 more Screening for diabetic neuropathy: screen for diabetic peripheral neuropathy in all patients with T2DM starting at diagnosis and at least annually thereafter. B Show 2 more Screening for diabetic foot: As per ADA 2023 guidelines, obtain a comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputations. B Show 4 more As per SVS 2016 guidelines, consider obtaining a probe-to-bone test to aid in the diagnosis of diabetic foot osteomyelitis in patients with diabetic foot infection with an open wound. C Show 5 more Screening for anxiety: Consider screening patients with diabetes for symptoms or diabetes-related worries. Consider discussing diabetes-related worries and referring to a qualified mental health https://web.pathway.md/diseases/recNW2vC0lM724J79 3/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway professional for further assessment and treatment if anxiety symptoms indicate interference with diabetes self-management behaviors or quality of life. C Refer patients with hypoglycemia unawareness, which can co-occur with fear of hypoglycemia, to a trained professional to receive evidence-based intervention to help re- establish awareness of symptoms of hypoglycemia and reduce fear of hypoglycemia. A Screening for depression: consider obtaining at least annual screening for depressive symptoms in all patients with diabetes, especially in patients with a self-reported history of depression. Use age-appropriate, validated depression screening measures, recognizing that further evaluation will be necessary for patients with a positive screen. C Show 2 more Screening for sleep disorders: consider screening for sleep health in patients with diabetes, including symptoms of sleep disorders, disruptions to sleep due to diabetes symptoms or management needs, and worries about sleep. Refer to sleep medicine and/or a qualified behavioral health professional as indicated. C Screening for cognitive impairment: Monitor cognitive capacity throughout the life span in all patients with diabetes, particularly in patients with documented cognitive disabilities, patients experiencing severe hypoglycemia, very young children, and older adults. B Consider referring for a formal assessment if cognitive capacity changes or appears to be suboptimal for patient decision-making and/or behavioral self-management. C Screening for serious mental illness: provide an increased level of support to patients with diabetes and serious mental illness through enhanced monitoring of and assistance with diabetes self-management behaviors. B Show 2 more Screening for disordered eating behavior: Consider screening for disordered or disrupted eating using validated screening measures when hyperglycemia and weight loss are unexplained based on self-reported behaviors related to medication dosing, meal plan, and physical activity. Review the medical treatment plan to identify potential treatment-related effects on hunger/caloric intake. C Consider reevaluating the treatment plan of patients with diabetes presenting with symptoms of disordered eating behavior, an eating disorder, or disrupted patterns of eating, in consultation with a qualified professional as available. C Screening for gastroparesis (evaluation): evaluate for medication-induced delay in gastric emptying, particularly from GLP-1 agonists and amylin analogs, before assigning an etiological diagnosis of gastroparesis. Discontinue medications delaying gastric emptying to establish the diagnosis with a gastric emptying test. A Show 2 more Screening for gastroparesis (management): consider ensuring optimal glucose control to reduce the future risk of aggravation of gastroparesis in patients with diabetic gastroparesis. C Screening for male hypogonadism: obtain screening for late-onset hypogonadism only in symptomatic male patients. A https://web.pathway.md/diseases/recNW2vC0lM724J79 4/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway 3. Medical management Glycemic targets: set a HbA1c goal of < 7% (53 mmol/mol) without significant hypoglycemia in many nonpregnant adult patients with diabetes. A Show 4 more Initial therapy: include healthy lifestyle behaviors, weight management, diabetes self- management education and support, avoidance of clinical inertia, and social determinants of health in the glucose-lowering management of T2DM. A Show 7 more Landmark trials: Oral GLP-1 (danuglipron 120 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. Insulin therapy (indications): consider introducing insulin therapy early if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when HbA1c levels (> 10%; 86 mmol/mol) or blood glucose levels ( 300 mg/dL; 16.7 mmol/L) are very high. C Show 3 more Insulin therapy (choice of agent): consider prescribing long-acting insulin analogs rather than human NPH insulin in adult and pediatric outpatients on basal insulin therapy at high risk for hypoglycemia. C Show 2 more Insulin therapy, delivery systems: As per ADA 2023 guidelines, prefer insulin pens for most patients with insulin-requiring diabetes on multiple daily injections. Consider prescribing insulin syringes for insulin delivery taking into account individual and caregiver preference, insulin type, dosing therapy, cost, and self-management capabilities. B Show 6 more As per ES 2016 guidelines: Consider prescribing continuous subcutaneous insulin infusion with good adherence to monitoring and dosing in patients with T2DM having poor glycemic control despite intensive insulin therapy, oral agents, other injectable therapy, and lifestyle modifications. C Obtain a structured assessment of the patient's mental and psychological status, prior adherence to diabetes self-care measures, willingness and interest in trying the device, and availability for the required follow-up visits before prescribing continuous subcutaneous insulin infusion. B Management of hypoglycemia: https://web.pathway.md/diseases/recNW2vC0lM724J79 5/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway As per ADA 2023 guidelines, review occurrence and risk for hypoglycemia at every encounter and investigate as indicated. Consider assessing for awareness of hypoglycemia using validated tools. B Show 5 more As per ES 2022 guidelines, administer glucagon (preparations not requiring reconstitution) in outpatients with severe hypoglycemia. B Management of obesity: take into account the medication's effect on weight when choosing glucose-lowering medications in patients with T2DM and overweight/obesity. B Show 3 more Management of hypertension (BP targets): individualize BP targets in patients with diabetes and hypertension through a shared decision-making process addressing cardiovascular risk, potential adverse effects of antihypertensive medications, and patient preferences. B Show 2 more Management of hypertension (lifestyle modifications): advise lifestyle interventions in patients with BP > 120/80 mmHg, consisting of weight loss when indicated, a DASH-style eating pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity. A Management of hypertension (pharmacotherapy): initiate and titrated pharmacologic therapy to achieve BP goal of < 130/80 mmHg in patients with confirmed office-based BP 130/80 mmHg. A Show 6 more Management of cardiovascular disease, glucose-lowering medications: As per ADA 2023 guidelines, initiate SGLT-2 inhibitors or GLP-1 receptor agonists with demonstrated CVD benefits as part of the comprehensive cardiovascular risk reduction and/or glucose-lowering regimens in patients with T2DM and established ASCVD or established kidney disease. A Show 5 more As per CCS 2022 guidelines, initiate the following options in adult patients with T2DM and either established ASCVD or multiple risk factors for ASCVD: sodium-glucose cotransporter 2 inhibitors to reduce the risk of all-cause or cardiovascular mortality, major atherosclerotic cardiovascular events, hospitalization for HF or the composite of significant decline in eGFR, progression to end-stage kidney disease or kidney death glucagon-like peptide 1 receptor agonists to reduce the risk of all-cause or cardiovascular mortality, major atherosclerotic cardiovascular events, and nonfatal stroke. B Management of cardiovascular disease (antihypertensives): initiate ACEI or ARB therapy to reduce the risk of cardiovascular events in patients with known ASCVD, particularly coronary artery disease. A Show 2 more Management of cardiovascular disease (antiplatelets): consider initiating aspirin therapy (75-162 mg/ day) as a primary prevention strategy in patients with diabetes at increased cardiovascular risk, after a comprehensive discussion with the patient on the benefits versus the comparable increased risk of bleeding. B https://web.pathway.md/diseases/recNW2vC0lM724J79 6/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway Show 6 more Management of cardiovascular disease (revascularization): perform CABG surgery (with a left internal mammary artery to the left anterior descending artery) over PCI to reduce mortality and repeat revascularizations in patients with diabetes and multivessel coronary artery disease with the involvement of the left anterior descending artery being appropriate candidates for CABG. A Show 3 more Management of dyslipidemia (lifestyle modifications): Advise lifestyle modifications focusing on weight loss (if indicated), following a Mediterranean style or DASH eating pattern, reducing consumption of saturated fat and trans fat, increasing dietary omega-3 fatty acids, viscous fiber, and plant stanols/sterols intake, and increasing physical activity to improve the lipid profile and reduce the risk of developing ASCVD in patients with diabetes. A Intensify lifestyle therapy and optimize glycemic control in patients with elevated triglyceride levels ( 150 mg/dL) and/or low HDL cholesterol (< 40 mg/dL for males, < 50 mg/dL for females). B Management of dyslipidemia, statin therapy: As per ADA 2023 guidelines, initiate moderate-intensity statin therapy, in addition to lifestyle therapy, in 40-75 years old patients with diabetes without ASCVD. A Show 5 more As per ES 2020 guidelines, initiate statin therapy in addition to lifestyle modification to reduce cardiovascular risks in adult patients with T2DM and other cardiovascular risk factors. A Show 2 more Management of dyslipidemia, non-statin lipid-lowering therapy: As per ADA 2023 guidelines, consider adding ezetimibe or a PCSK9 inhibitor to maximum tolerated statin therapy in 40-75 years old patients with diabetes at higher cardiovascular risk, especially patients with multiple ASCVD risk factors and an LDL cholesterol 70 mg/dL. C Show 3 more Landmark trials: PROMINENT In patients with T2DM, mild-to-moderate hypertriglyceridemia, and high-density lipoprotein cholesterol levels 40 mg/dL, pemafibrate was not superior to placebo with respect to the composite of nonfatal myocardial infarction, ischemic stroke, coronary revascularization, or death from cardiovascular causes. Aruna Das Pradhan et al. N Engl J Med. 2022 Nov 24. As per ES 2020 guidelines, consider initiating fibrates in addition to statins to reduce retinopathy progression in adult patients with T2DM and diabetic retinopathy. C Management of dyslipidemia, hypertriglyceridemia: As per ADA 2023 guidelines, evaluate for secondary causes of hypertriglyceridemia and consider initiating medical therapy to reduce the risk of pancreatitis in patients with fasting https://web.pathway.md/diseases/recNW2vC0lM724J79 7/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway triglyceride levels 500 mg/dL. B Show 2 more As per ES 2020 guidelines, consider adding eicosapentaenoic acid ethyl ester to reduce cardiovascular risks in adult patients with T2DM on a statin at low-density lipoprotein goal with residual triglycerides > 150 mg/dL (1.7 mmol/L) and with two additional traditional risk factors or risk-enhancing factors. C Management of dyslipidemia (lipid profile monitoring): Consider obtaining a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter if under the age of 40 years or more frequently if indicated, in adult patients with diabetes not taking statins or other lipid-lowering therapy. C Obtain lipid profile at the initiation of statins or other lipid-lowering therapy, 4-12 weeks after initiation or a change in dose, and annually thereafter to monitor the response to therapy and inform medication taking. B Management of nonalcoholic fatty liver disease (lifestyle changes): offer lifestyle changes promoting weight loss, ideally within a structured nutrition plan and physical activity program, for cardiometabolic benefits B and histological improvement in adult patients with T2DM or prediabetes, particularly with overweight or obesity with nonalcoholic fatty liver disease. B Management of diabetic nephropathy, general principles: As per ADA 2023 guidelines, optimize glucose control to reduce the risk or slow the progression of CKD. A Show 5 more As per KDIGO 2022 guidelines, treat patients with diabetes mellitus and CKD with a comprehensive strategy to reduce risks of kidney disease progression and CVD. B Show 3 more Management of diabetic nephropathy (smoking cessation): Advise patients with diabetes mellitus and CKD to quit using tobacco products. B Counsel patients with diabetes mellitus and CKD to reduce secondhand smoke exposure. B Management of diabetic nephropathy (metformin): initiate metformin in patients with T2DM, CKD and an eGFR 30 mL/min/1.73 m . B Show 4 more Management of diabetic nephropathy (GLP-1 receptor agonists): initiate long-acting GLP-1 receptor agonists in patients with T2DM and CKD not achieved individualized glycemic targets despite using metformin and SGLT-2 inhibitor treatment or unable to use these medications. B Show 5 more Management of diabetic nephropathy, SGLT2 inhibitors: As per ADA 2023 guidelines, initiate SGLT-2 inhibitors in patients with an eGFR 25 mL/min/1.73 m and urinary albumin 300 mg/g creatinine to reduce CKD progression and cardiovascular events in patients with T2DM and diabetic kidney disease. A Show 2 more As per KDIGO 2022 guidelines, initiate SGLT-2 inhibitors in patients with T2DM, CKD and an eGFR 20 mL/min/1.73 m . B https://web.pathway.md/diseases/recNW2vC0lM724J79 8/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway Show 7 more Management of diabetic nephropathy, RAAS blockade: As per ADA 2023 guidelines, do not use ACEIs or ARBs for the primary prevention of CKD in patients with diabetes with normal BP, normal urinary albumin-to-creatinine ratio (< 30 mg/g creatinine), and normal eGFR. D Show 5 more As per KDIGO 2022 guidelines, initiate an ACEI or an ARB in patients with diabetes, hypertension and albuminuria and titrate the medications to the highest approved dose that is tolerated. B Show 13 more Management of diabetic retinopathy: optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy. A Show 7 more Management of diabetic neuropathy: optimize glucose control to slow the progression of neuropathy in patients with T2DM. B Show 2 more Management of diabetic foot: ensure a multidisciplinary approach for patients with foot ulcers and high-risk feet (such as patients on dialysis, patients with Charcot foot, history of ulcers or amputation, or peripheral arterial disease). B Show 4 more 4. Inpatient care Management of hospitalized patients, general principles: As per ADA 2023 guidelines, consult with a specialized diabetes or glucose management team, when possible, when caring for hospitalized patients with diabetes. B Landmark trials: Leuven Surgical Trial In adults admitted to surgical ICU who were receiving mechanical ventilation, intensive insulin therapy was superior to conventional treatment with respect to death. van den Berghe G et al. N Engl J Med. 2001 Nov 8. As per ES 2022 guidelines, consider providing inpatient diabetes education as part of a comprehensive diabetes discharge-planning process in adult patients with diabetes hospitalized for a non-critical illness. C Management of hospitalized patients (HbA1C testing): obtain HbA1c testing in all patients with diabetes or hyperglycemia (blood glucose > 140 mg/dL; 7.8 mmol/L) admitted to the hospital, if not performed in the prior 3 months. B Management of hospitalized patients, glucose monitoring: As per ADA 2023 guidelines, support patients to continue using diabetes devices, such as insulin pumps and continuous glucose monitoring systems, in an inpatient setting or during https://web.pathway.md/diseases/recNW2vC0lM724J79 9/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway outpatient procedures, once competency in safely using these devices is established and proper supervision is available. B As per ES 2022 guidelines, consider obtaining real-time continuous glucose monitoring with confirmatory bedside point-of-care blood glucose monitoring for adjustments in insulin dosing (in hospital settings where resources and training are available) in adult patients with insulin- treated diabetes at high risk of hypoglycemia hospitalized for a non-critical illness. C As per ES 2022 guidelines, consider initiating continuous glucose monitoring in the inpatient setting for selected patients at high risk for hypoglycemia. C Show 2 more Management of hospitalized patients, insulin therapy: As per ADA 2023 guidelines, use validated written or computerized protocols for insulin administration allowing for predefined adjustments in the insulin dosage based on glycemic fluctuations. B Show 4 more As per ES 2022 guidelines, consider administering scheduled insulin therapy for glycemic control in most adult patients with hyperglycemia (with or without known T2DM) hospitalized for a non-critical illness. C Show 9 more As per ES 2016 guidelines, continue continuous subcutaneous insulin infusion in patients admitted to the hospital if the institution has clear protocols for evaluating patients as suitable candidates and appropriate monitoring and safety procedures. B Management of hospitalized patients, treatment targets: As per ADA 2023 guidelines: Set a target glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) for the majority of critically ill and non-critically ill patients once insulin therapy is started. A Consider setting more stringent goals, such as 110-140 mg/dL (6.1-7.8 mmol/L), in selected patients if those can be achieved without significant hypoglycemia. C As per ES 2022 guidelines: Consider targeting preoperative HbA1c levels of < 8% (63.9 mmol/mol) and blood glucose levels of 100-180 mg/dL (5.6-10 mmol/L) in adult patients with diabetes undergoing elective surgical procedures. C Consider targeting preoperative blood glucose levels of 100-180 mg/dL (5.6-10 mmol/L) in adult patients with diabetes undergoing elective surgical procedures if a HbA1c < 8% (63.9 mmol/mol) target is not feasible. C Management of hospitalized patients (prevention of hypoglycemia): Review treatment regimens and change as necessary to prevent further hypoglycemia when a blood glucose value of < 70 mg/dL (3.9 mmol/L) is documented. B Adopt a hypoglycemia management protocol and implement it in each hospital or hospital system. Establish a plan for the prevention and treatment of hypoglycemia for each patient. Document episodes of hypoglycemia in the hospital in the medical record and track for quality improvement/quality assessment. B Management of hospitalized patients (oral carbohydrate fluids): avoid administering preoperative carbohydrate-containing oral fluids in adult patients with diabetes undergoing https://web.pathway.md/diseases/recNW2vC0lM724J79 10/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway surgical procedures. D 5. Nonpharmacologic interventions Smoking cessation: advise all patients to abstain from using cigarettes and other tobacco products or e-cigarettes. A Show 2 more Weight loss: offer nutrition, physical activity, and behavioral therapy to achieve and maintain 5% weight loss in most people with T2DM and overweight or obesity. Offer additional weight loss for further improvements in the management of diabetes and cardiovascular risk. B Include high frequency of counseling with 16 sessions in 6 months in such interventions and focus on nutrition changes, physical activity, and behavioral strategies to achieve a 500-750 kcal/day energy deficit. A Show 6 more Physical activity: advise most adults with T2DM to engage in 150 minutes of moderate- to vigorous-intensity aerobic activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity. Consider advising shorter durations (minimum 75 min/week) of vigorous-intensity or interval training in younger and more physically fit patients. B Show 4 more Dietary modifications (general principles): provide an individualized medical nutrition therapy program as needed to achieve treatment goals, provided by a registered dietitian nutritionist, preferably one who has comprehensive knowledge and experience in diabetes care, in all patients with T2DM. A Show 2 more Dietary modifications (eating patterns): recognize that there is no ideal macronutrient pattern for patients with diabetes. Individualize meal plans while keeping nutrient quality, total calorie, and metabolic goals in mind. B Show 2 more Dietary modifications (carbohydrates): advise carbohydrate intake emphasizing nutrient- dense carbohydrate sources high in fiber (at least 14 g fiber per 1,000 kcal) and minimally processed. Advise eating plans emphasizing nonstarchy vegetables, fruits, legumes, and whole grains, as well as dairy products, with minimal added sugars. B Show 3 more Dietary modifications (protein): avoid using carbohydrate sources high in protein for the treatment or prevention of hypoglycemia as ingested protein appears to increase insulin response without increasing plasma glucose concentrations in patients with T2DM. D Dietary modifications (fat): Consider advising an eating plan emphasizing elements of a Mediterranean eating pattern rich in monounsaturated and polyunsaturated fats to improve glucose metabolism and lower CVD risk. C Advise eating foods rich in long-chain omega-3 fatty acids, such as fatty fish (eicosapentaenoic acid and docosahexaenoic acid) and nuts and seeds (alpha-linolenic https://web.pathway.md/diseases/recNW2vC0lM724J79 11/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway acid), to prevent or treat CVD. B Dietary modifications (nonnutritive sweeteners): Recognize that the use of nonnutritive sweeteners as a replacement for sugar-sweetened products may reduce overall calorie and carbohydrate intake as long as there is not a compensatory increase in energy intake from other sources. B Consider advising low- and no-calorie sweetened beverages as alternatives to water. C Dietary modifications (sodium): limit sodium consumption to < 2,300 mg/day. B Dietary modifications (micronutrients and supplements): insufficient evidence to support the use of dietary supplementation with vitamins, minerals (such as chromium and vitamin D), herbs, or spices (such as cinnamon or aloe vera) to improve outcomes in patients with diabetes not having underlying deficiencies, and for glycemic control. I Dietary modifications (alcohol): Advise adult patients with diabetes drinking alcohol to do so in moderation ( 1 drink/day for adult females and 2 drinks/day for adult males). B Educate patients with diabetes about the signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues. Emphasize the importance of glucose monitoring after drinking alcoholic beverages to reduce hypoglycemia risk. B Psychosocial care: provide psychosocial care, integrated with routine medical care and delivered by trained healthcare professionals using a collaborative, person-centered, culturally informed approach, in all patients with diabetes, with the goal of optimizing health-related quality of life and health outcomes. A Refer to qualified mental health professionals for additional targeted mental health care, when indicated and available. B Show 4 more 6. Surgical interventions Bariatric surgery: offer metabolic surgery for the treatment of T2DM in screened surgical candidates with BMI 40 kg/m (BMI 37.5 kg/m in Asian Americans) and in adult patients with BMI 35.0-39.9 kg/m (32.5-37.4 kg/m in Asian Americans) not achieved durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods. A Show 6 more 7. Specific circumstances Patients with prediabetes: monitor for the development of T2DM in patients with prediabetes at least annually, modified based on individual risk/benefit assessment. B Show 10 more Elderly patients (screening for comorbidities): consider assessing medical, psychological, functional (self-management abilities), and social domains in older adults to provide a framework to determine targets and therapeutic approaches for diabetes management. C Show 2 more https://web.pathway.md/diseases/recNW2vC0lM724J79 12/22 6/29/23, 10:11 PM Diabetes mellitus type 2 Pathway Elderly patients (screening for hypoglycemia): ascertain and address episodes of hypoglycemia in older adults with diabetes at routine visits because they have a greater risk of hypoglycemia than younger adults. B Show 2 more Elderly patients (treatment goals): set lower glycemic goals (such as HbA1c < 7.0-7.5%; 53- 58 mmol/mol) in older patients otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status. B 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