Diabetes: treatment goals, lifestyle mods, comprehensive care

What are the usual glycemic targets for nonpregnant adults with diabetes?

A1C <7%;

preprandial BG 80–130 mg/dL;

2-hour postprandial BG <180 mg/dL

What are the glycemic targets during pregnancy?

Preprandial BG <95 mg/dL;

1-hour postprandial BG <140 mg/dL;

2-hour postprandial BG <120 mg/dL

When may the usual A1C goal be individualized?

Lower if achievable without significant hypoglycemia;

higher (<8%) may be appropriate with severe hypoglycemia risk or limited life expectancy

What is point-of-care A1C testing?

Provides immediate results and can assess glucose control but is not typically recommended for diagnosis

A patient with sickle cell has presented for a P-O-C diabetic screening test, which test should not be done and what is the alternative ?

A1C should not be used;

fructosamine is the alternative

When is fructosamine useful and what period does it reflect?

Alternative when A1C cannot be used; reflects glycemic control over the past 2–4 weeks

How can patients monitor their own blood glucose?

Fingerstick glucose meter or continuous glucose monitoring (CGM)

What is time in range (TIR) and which patients are utilizing it?

Percentage of time BG values are within the target range; utilized by patients who have CGMs

What are the recommended TIR goals?

>70% for most adults; >50% may be appropriate for older adults or those with complex health conditions

How often should A1C be assessed?

Every 3 months if not meeting goals; every 6 months if at goal

How does A1C correlate with estimated average glucose (eAG)?

A1C 6% ≈ eAG 126 mg/dL;

each additional 1% A1C increases eAG by ≈28 mg/dL

What weight parameters should be monitored in patients with diabetes?

Actual body weight, BMI, and waist circumference at least annually

What is the recommended weight-loss goal for patients with overweight or obesity?

At least 5–7% of body weight; medications and/or surgery may be needed

What dietary pattern is recommended for patients with diabetes?

Natural carbohydrate sources (vegetables, fruits, whole grains, legumes, dairy) + lean protein;

limit refined carbohydrates and added sugars

What are the recommended alcohol limits for patients with diabetes?

≤1 drink/day for women; ≤2 drinks/day for men

How should patients with T1D manage carbohydrates with mealtime insulin?

Count carbohydrates and adjust prandial (meal time) insulin doses based on carbohydrate intake

A carbohydrate serving is ____ grams. What are some examples of 1 carbohydrate servings?

15 g;

1 small piece of fruit, 1 slice of bread, or 1/3 cup cooked rice/pasta

What physical activity is recommended for patients with diabetes?

≥150 minutes/week of moderate-intensity aerobic activity spread over ≥3 days

How should prolonged sedentary time be reduced in patients with diabetes?

Stand at least every 30 minutes during long periods of sitting

Which natural products are commonly used to lower BG in T2D?

Cinnamon, alpha-lipoic acid, chromium, magnesium, and ginseng;

evidence is limited and most patients still require prescription medications

What are the two categories of long-term diabetes complications?

Microvascular (small-vessel) and macrovascular (large-vessel/ASCVD) complications

What are the major microvascular complications of diabetes?

Retinopathy, nephropathy, peripheral neuropathy, and autonomic neuropathy

(all the -pathys)

What are important consequences of diabetic peripheral neuropathy?

Loss of sensation, especially in the feet → ↑ risk of foot infections and amputations

What are manifestations of diabetic autonomic neuropathy?

Gastroparesis, loss of bladder control, and erectile dysfunction

What are the major macrovascular complications of diabetes?

macrovascular = ASCVD

CAD including MI, cerebrovascular disease including stroke (CVA), and peripheral artery disease (PAD)

(all deal with ❤ )

What major conditions is diabetes a leading cause of?

Lower-extremity amputations, kidney disease, and blindness

What is the primary cause of death in patients with diabetes?

Cardiovascular disease; occurs about twice as often as in the general population

What daily foot care should patients with diabetes perform?

Wash, dry, and examine feet daily; moisturize tops and bottoms but not between the toes; Wear socks and shoes, elevate feet when sitting, and trim toenails with a nail file

How often should diabetic foot examinations be performed?

Feet examined at each office visit + comprehensive foot exam annually

Which antiplatelet therapy is recommended for ASCVD secondary prevention in diabetic patients?

ASA

What aspirin regimen is recommended for ASCVD secondary prevention in diabetes?

Aspirin 75–162 mg/day, usually 81 mg/day (baby asa)

Is aspirin routinely recommended for primary ASCVD prevention in diabetes and why?

No; bleeding risk is about equal to benefit for most patients; consider only if high risk

What is the antiplatelet alternative for diabetic patients with a salicylate allergy?

Clopidogrel 75 mg/day

What antithrombotic combination may be used in diabetic patients with CAD/PAD?

Aspirin + low-dose rivaroxaban

Is ASA safe in pregnancy? if so what is it used for?

yes; to ↓ risk of preeclampsia

What are the diabetic retinopathy screening recommendations for T2D?

Dilated eye exam at diagnosis;

if retinopathy present: annual testing;

if no retinopathy: test every 1–2 years

Which vaccines are specifically recommended for patients with diabetes in addition to age-appropriate vaccines?

Hepatitis B series;

influenza annually;

pneumococcal,

COVID-19,

and RSV vaccines

How should diabetic neuropathy be screened?

Annual monitoring with 10-g monofilament OR Ipswich touch test + 1 other sensation test (pinprick, temperature, or vibration)

How often should patients with diabetes receive a comprehensive foot exam?

At least annually; refer high-risk patients to a podiatrist

What medications can be used to treat diabetic neuropathy?

Gabapentin, pregabalin, SNRIs (e.g., duloxetine), TCAs, or sodium channel blockers

When should bone mineral density be monitored in patients with diabetes?

DXA every 2–3 years at age ≥65 or earlier if risk factors are present

When should osteoporosis treatment be considered in a diabetic patient?

T-score ≤−2.5 or history of fragility fracture

When are high intensity statins utilized for cholesterol control in diabetic patients?

comorbid ASCVD

Age 40-75 years with >/1 ASCVD risk factor

What are the LDL goals for cholesterol control in diabetic patients who have:

1. comorbid ASCVD

2. Age 40-75 years with >/1 ASCVD risk factor

1. LDL < 55

2. LDL < 70

When are moderate intensity statins utilized for cholesterol control in diabetic patients?

age 40-75 with no ASCVD

age 20-39 with ASCVD risk factors

What statin intensity is recommended for the following diabetic patients?

1. 45 year old with CAD (coronary artery disease)

2. 69 year old with 14 pack years

3. 52 year old with no ASCVD

4. 78 year old with aortic atherosclerotic disease

5. 27 year old with LDL 124

1. high

2. high

3. moderate

4. high

5. moderate

What are the high-intensity statin doses?

Atorvastatin 40–80 mg/day or rosuvastatin 20–40 mg/day

What can be added if LDL remains above goal on a maximally tolerated statin in a diabetic patient?

Ezetimibe or a PCSK9 inhibitor

When is icosapent ethyl (Vascepa) considered in diabetes?

LDL controlled + TG 150–499 mg/dL + ASCVD or ASCVD risk factors

When should a lipid panel be checked with statin therapy?

At initiation → 4–12 weeks after initiation or dose changes → annually

What are alternatives for statin intolerance?

Bempedoic acid or a PCSK9 inhibitor

How is CKD defined in patients with diabetes?

eGFR <60

and/or

albuminuria ≥30 mg/24 hr or UACR ≥30

How should kidney function be monitored in diabetes if kidney function is normal?

Urinary albumin + eGFR annually

Which treatments can delay CKD progression in diabetes?

ACE inhibitor or ARB, SGLT2 inhibitor*, GLP-1 agonist, or finerenone

What is the eGFR requirement to use a SGLT2 inhibitor for delaying CKD progression in a diabetic patient?

eGFR ≥20

What is the usual BP goal in patients with diabetes?

<130/80 mmHg;

<120/80 mmHg may be used with high CV or kidney risk if safely attained

Which antihypertensives are preferred in diabetes without albuminuria or CAD?

Thiazide, DHP CCB, ACE inhibitor, or ARB

Which antihypertensives are preferred in diabetes with albuminuria or CAD?

ACE inhibitor or ARB