Management of Type 2 Diabetes Mellitus

Publication Date: June 1, 2023
Last Updated: June 14, 2023

Recommendations

Prediabetes

In adults with prediabetes, we suggest aerobic exercise (such as walking 8–9 miles a week) and healthy eating (with a goal weight loss >3%) to achieve a reduction in body fat mass, weight loss, and improvement in fasting blood glucose. (Weak for)
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In adults with prediabetes who have participated in healthy lifestyle modification and remain at high risk for progression to type 2 diabetes mellitus, we suggest evaluating patient characteristics (e.g., age, life expectancy, co-occurring conditions, BMI, other risk factors) and offering metformin or other select medications to reduce the risk of progression from prediabetes to type 2 diabetes mellitus. (Weak for)
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Telehealth

In adults with type 2 diabetes mellitus, we suggest offering health care delivered through telehealth interventions to improve outcomes. (Weak for)
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Screening for Comorbidities

There is insufficient evidence to recommend for or against routine screening or using a specific tool to screen for or diagnose diabetes distress. (Neither for or against)
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In adults with type 2 diabetes mellitus and co-occurring non-alcoholic fatty liver disease, we suggest clinicians should assess for fibrosis using a non-invasive tool (e.g., Fibrosis-4). (Weak for)
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In adults with type 2 diabetes mellitus, there is insufficient evidence to recommend for or against routine screening for fall risk and cognitive impairment to improve outcomes. (Neither for or against)
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Diabetes Self-Management Education and Support

In adults with type 2 diabetes mellitus, we recommend diabetes self-management education and support. (Strong for)
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Glycemic Management

For adults with type 2 diabetes mellitus, we suggest using high glycemic variability over time (e.g., fluctuation in HbA1c or fasting blood glucose) as a prognostic indicator for risk of hypoglycemia, morbidity, and mortality. (Weak for)
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We suggest setting an individualized HbA1c target range based on the clinician’s appraisal of the risk benefit ratio, patient characteristics, presence or absence of type 2 diabetes mellitus complications, comorbidities, and life expectancy. (Weak for)
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We suggest an HbA1c range of 7.0–8.5% for most patients, if it can be safely achieved. (Weak for)
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In insulin-treated adults with type 2 diabetes mellitus who are not achieving glycemic goals, we suggest real-time continuous glucose monitoring to decrease hypoglycemia and improve HbA1c. (Weak for)
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Medical Nutrition Therapy

For adults with type 2 diabetes mellitus, we suggest a Mediterranean style diet to improve glycemic control, body weight, and hypertension. (Weak for)
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For adults with type 2 diabetes mellitus, we suggest a nutrition intervention strategy providing 13–50% of their total daily caloric intake from carbohydrates for diabetes management. (Weak for)
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For adults with type 2 diabetes mellitus, we suggest a vegetarian dietary pattern for glycemic control and weight loss. (Weak for)
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For adults with type 2 diabetes mellitus, we suggest against intermittent fasting. (Weak against)
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Exercise

In adults with type 2 diabetes mellitus, we suggest regular physical activity to improve glycemic control, including but not limited to aerobic exercise, resistance training, or tai chi. (Weak for)
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Stress

In adults with stress related to type 2 diabetes mellitus, we suggest offering a mindfulness-based stress reduction program for short-term improvement. (Weak for)
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For adults with type 2 diabetes and diabetes distress, there is insufficient evidence to recommend for or against the use of acupuncture, biofeedback, hypnosis, guided imagery, massage therapy, yoga, or tai-chi to improve outcomes. (Neither for or against)
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Pharmacotherapy

For adults with type 2 diabetes mellitus with atherosclerotic cardiovascular disease, we recommend glucagon-like peptide-1 receptor agonists or sodium-glucose cotransporter-2 inhibitors with proven cardiovascular benefits to decrease the risk of major adverse cardiovascular events. (Strong for)
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For adults with type 2 diabetes mellitus at high risk of atherosclerotic cardiovascular disease (i.e., chronic kidney disease, left ventricular hypertrophy, heart failure), we suggest glucagon-like peptide-1 receptor agonists or sodium-glucose cotransporter-2 inhibitors with proven cardiovascular benefits to decrease the risk of major adverse cardiovascular events. (Weak for)
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For adults with type 2 diabetes mellitus and heart failure, we recommend a sodium-glucose cotransporter-2 inhibitor to prevent hospital admissions for heart failure. (Strong for)
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For adults with type 2 diabetes mellitus and chronic kidney disease, we recommend sodium-glucose cotransporter-2 inhibitors with proven renal protection to improve renal outcomes. (Strong for)
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For adults with type 2 diabetes mellitus and chronic kidney disease who are not good candidates for a sodiumglucose cotransporter-2 inhibitor, we recommend a glucagon-like peptide-1 receptor agonist with proven renal protection to improve macroalbuminuria. (Strong for)
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In adults with type 2 diabetes mellitus who have cardiovascular disease or renal disease, we suggest that the addition of a sodium-glucose cotransporter-2 inhibitor or glucagon-like peptide-1 receptor agonist be considered, even if the patient has already achieved their individualized target range for glycemic control. (Weak for)
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In adults with type 2 diabetes mellitus, especially those 65 years and older, we suggest prioritizing drug classes other than insulin, sulfonylureas, or meglitinides to minimize the risk of hypoglycemia, if glycemic control can be achieved with other treatments. (Weak for)
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In adults with type 2 diabetes mellitus who have cooccurring cognitive impairment or risk of falls, there is insufficient evidence to recommend for or against specific treatment strategies for glucose lowering to reduce the risk of harms. (Neither for or against)
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Recommendation Grading

Overview

Title

Management of Type 2 Diabetes Mellitus

Authoring Organization

Veterans Health Administration / Department of Defense

Publication Month/Year

June 1, 2023

Last Updated Month/Year

January 3, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Long term care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant, social worker

Scope

Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D003924 - Diabetes Mellitus, Type 2

Keywords

type 2 diabetes mellitus, Diabetes Self-Management Education and Support (DSMES), Sodium glucose inhibitors

Supplemental Methodology Resources

Methodology Supplement

Methodology

Number of Source Documents
168
Literature Search Start Date
January 1, 2009
Literature Search End Date
March 1, 2016