The goals in caring for patients with diabetes mellitus are to eliminate symptoms and to

prevent, or at least slow, the development of complications. Microvascular (ie, eye and
kidney disease) risk reduction is accomplished through control of glycemia and blood
pressure; macrovascular (ie, coronary, cerebrovascular, peripheral vascular) risk
reduction, through control of lipids and hypertension, smoking cessation, and aspirin
therapy; and metabolic and neurologic risk reduction, through control of glycemia.

Essential Update: New Abridged Recommendations for Primary Care

Providers
The American Diabetes Association has released condensed recommendations
for Standards of Medical Care in Diabetes: Abridged for Primary Care Providers,
highlighting recommendations most relevant to primary care. The abridged version
focusses particularly on the following aspects:

Prediabetes
Self-management education
Nutrition
Physical activity
Smoking cessation
Psychosocial care
Immunizations
Glycemic treatment
Therapeutic targets
Diagnosis and treatment of vascular complications
Intensification of insulin therapy in type 2 diabetes
The recommendations can be accessed at American Diabetes Association DiabetesPro
Professional Resources Online, Clinical Practice Recommendations 2015.[1]
Type 2 diabetes care is best provided by a multidisciplinary team of health professionals
with expertise in diabetes, working in collaboration with the patient and family.
[3]
Management includes the following:

Appropriate goal setting

Dietary and exercise modifications
Medications
Appropriate self-monitoring of blood glucose (SMBG)
Regular monitoring for complications
Laboratory assessment
Ideally, blood glucose should be maintained at near-normal levels (preprandial levels of
90-130 mg/dL and hemoglobin A1C [HbA1c] levels < 7%). However, focus on glucose
alone does not provide adequate treatment for patients with diabetes mellitus.
Treatment involves multiple goals (ie, glycemia, lipids, blood pressure).

Aggressive glucose lowering may not be the best strategy in all patients. Individual risk
stratification is highly recommended. In patients with advanced type 2 diabetes who are
at high risk for cardiovascular disease, lowering HbA1c to 6% or lower may increase the
risk of cardiovascular events.[114]
A study from the ACCORD Study Group found that setting the treatment target for
HbA1c below 6% in high-risk patients resulted in reduced 5-year nonfatal myocardial
infarctions. However, patients who did not achieve the treatment target experienced
increased 5-year mortality.[115]
Review of blood glucose logs must be part of any diabetes management plan. Both iron
and erythropoietin treatments commonly prescribed in patients with chronic kidney
disease cause a significant increase in HbA1c without affecting blood glucose levels. [116]
With each health-care system encounter, patients with diabetes should be educated
about and encouraged to follow an appropriate treatment plan. Adherence to diet and
exercise should continue to be stressed throughout treatment, because these lifestyle
measures can have a large effect on the degree of diabetic control that patients can
achieve.
A study by Morrison et al found that more frequent visits with a primary care provider
(every 2 wk) led to markedly rapid reductions in serum glucose, HbA1c, and low-density
lipoprotein (LDL) cholesterol levels. However, how such a strategy can work globally
remains a challenge due to available resources and economic restrictions. [117]