Type 2 Diabetes Outpatient and Inpatient Care

Target Audience: Primary care physicians, hospitalists, endocrinologists

Background

The VA and DoD assembled a multidisciplinary group of expert stakeholders — primary care physicians, endocrinologists, nurse practitioners, medical nutritionists, pharmacists, diabetes educators, and patient representatives (each without industry conflicts of interest) — to design a clinical practice guideline for managing patients with type 2 diabetes.

Key Recommendations

• Patient–clinician shared decision making, individualized education for diabetes self-management, and bidirectional telehealth interventions (e.g., electronic communication) are recommended for all patients.

• For patients with glycosylated hemoglobin (HbA1c) levels from 6.5% to 6.9%, new type 2 diabetes diagnoses should be confirmed with fasting blood glucose testing (≥126 mg/dL).

• Set an HbA1c target range (and not simply a threshold) and individualize a glycemic management plan based on presence of and risk reduction for microvascular complications, safety of glycemic control (avoiding hypoglycemia), presence and severity of comorbid conditions, life expectancy, patient preferences, and social factors.

  • For patients with mild or no microvascular complications and life expectancy >10 years, HbA1c target range should be 6% to 7%.

  • For patients with established micro- or macrovascular disease complications, comorbid conditions, or life expectancy of 5 to 10 years, HbA1c target range should be 7% to 8.5%.

  • For patients with advanced micro- or macrovascular disease complications, severe comorbid conditions, difficulties with self-management (e.g., altered mental status, disability, food insecurity, low social support), or life expectancy <5 years, HbA1c target range should be 8% to 9%.

• Nonpharmacologic therapies should include lifestyle counseling: nutrition, physical activity, smoking cessation, avoiding excess alcohol, and weight control.

  • Diet recommendations can include the Mediterranean diet if it aligns with patient values and preferences

  • If not choosing a Mediterranean diet, nutrition interventions should be provided to reduce carbohydrate calories to 14% to 45% of total calories and to promote foods with low glycemic index.

• Pharmacologic therapy should include metformin as the first-line agent, unless contraindicated. When initial therapy does not provide adequate diabetes control, a second agent from another class should be added. Drug substitution should be reserved for patients with intolerance or adverse effects.

• Inpatient care

  • For patients in the intensive care unit (ICU) or those with acute myocardial infarction, blood glucose level target range should be 110 to 180 mg/dL.

  • For non-ICU inpatients, insulin therapy should include basal long-acting insulin and short-acting mealtime insulin (i.e., basal-bolus regimen) or basal long-acting insulin and correction short-acting insulin (i.e., basal-plus regimen). The authors do not specify a target range for non-ICU inpatients; they acknowledge that achieving tight glycemic control without risking hypoglycemia is challenging in hospitalized patients.

  • Provide diabetes education and medication education prior to hospital discharge.