Practice Essentials

Type 2 diabetes mellitus consists of an array of dysfunctions characterized by

hyperglycemia and resulting from the combination of resistance to insulin action,
inadequate insulin secretion, and excessive or inappropriate glucagon secretion. See the
image below.

Simplified scheme for the

pathophysiology of type 2 diabetes mellitus.
See Clinical Findings in Diabetes Mellitus, a Critical Images slideshow, to help identify
various cutaneous, ophthalmologic, vascular, and neurologic manifestations of DM.

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]

Signs and symptoms

Many patients with type 2 diabetes are asymptomatic. Clinical manifestations include the
following:

Classic symptoms: Polyuria, polydipsia, polyphagia, and weight loss

Blurred vision
Lower-extremity paresthesias
Yeast infections (eg, balanitis in men)

See Presentation for more detail.

Diagnosis
Diagnostic criteria by the American Diabetes Association (ADA) include the following[2] :

A fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher, or
A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a
75-g oral glucose tolerance test (OGTT), or
A random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher in a patient with
classic symptoms of hyperglycemia or hyperglycemic crisis

Whether a hemoglobin A1c (HbA1c) level of 6.5% or higher should be a primary

diagnostic criterion or an optional criterion remains a point of controversy.
Indications for diabetes screening in asymptomatic adults includes the following[3, 4] :

Sustained blood pressure >135/80 mm Hg

Overweight and 1 or more other risk factors for diabetes (eg, first-degree relative
with diabetes, BP >140/90 mm Hg, and HDL < 35 mg/dL and/or triglyceride level
>250 mg/dL)
ADA recommends screening at age 45 years in the absence of the above criteria

See Workup for more detail.

Management
Goals of treatment are as follows:

Microvascular (ie, eye and kidney disease) risk reduction through control of
glycemia and blood pressure
Macrovascular (ie, coronary, cerebrovascular, peripheral vascular) risk reduction
through control of lipids and hypertension, smoking cessation
Metabolic and neurologic risk reduction through control of glycemia

Recommendations for the treatment of type 2 diabetes mellitus from the European
Association for the Study of Diabetes (EASD) and the American Diabetes Association
(ADA) place the patient's condition, desires, abilities, and tolerances at the center of the
decision-making process.[5, 6, 7]
The EASD/ADA position statement contains 7 key points:
1.
2.
3.
4.

Individualized glycemic targets and glucose-lowering therapies

Diet, exercise, and education as the foundation of the treatment program
Use of metformin as the optimal first-line drug unless contraindicated
After metformin, the use of 1 or 2 additional oral or injectable agents, with a goal
of minimizing adverse effects if possible
5. Ultimately, insulin therapy alone or with other agents if needed to maintain blood
glucose control
6. Where possible, all treatment decisions should involve the patient, with a focus on
patient preferences, needs, and values
7. A major focus on comprehensive cardiovascular risk reduction
The 2013 ADA guidelines for SMBG frequency focus on an individual's specific
situation rather than quantifying the number of tests that should be done. The
recommendations include the following[8, 9] :

Patients on intensive insulin regimens Perform SMBG at least before meals and
snacks, as well as occasionally after meals; at bedtime; before exercise and before
critical tasks (eg, driving); when hypoglycemia is suspected; and after treating
hypoglycemia until normoglycemia is achieved.
Patients using less frequent insulin injections or noninsulin therapies Use
SMBG results to adjust to food intake, activity, or medications to reach specific
treatment goals; clinicians must not only educate these individuals on how to
interpret their SMBG data, but they should also reevaluate the ongoing need for
and frequency of SMBG at each routine visit.

Approaches to prevention of diabetic complications include the following:

HbA1c every 3-6 months

Yearly dilated eye examinations
Annual microalbumin checks
Foot examinations at each visit
Blood pressure < 130/80 mm Hg, lower in diabetic nephropathy
Statin therapy to reduce low-density lipoprotein cholesterol