TYPE TWO DIABETES












Reference [2]
Age (years) U.S. prevalence
(% of total population)
20 - 44 4.1%
45 - 64 16.2%
≥ 65 25.9%




  • Incidence ratio = incidence with affected family members/incidence with no affected family members
  • Reference [4]
Relative with T2DM Incidence ratio
One parent 2.0
Two parents 5.3
One sibling 2.8
Two siblings 37.0
One sibling / One parent 4.6
One sibling / Two parents 7.1


  • Reference [5]
Race % of adults with diabetes
Non-hispanic white 7.1%
Asian-Americans 8.4%
Hispanics 11.8%
African Americans 12.6%









ADA T2DM screening recommendations

Adults
1. Screen all adults beginning at age 45 years
2. Screen adults regardless of age who are overweight (BMI ≥ 25 or BMI ≥ 23 in Asian Americans) and have one of the following risk factors:
    s
  • Physical inactivity
  • First-degree relative with diabetes
  • High-risk ethnicity (African-American, Hispanic, Asian, Native-American, Pacific Islander)
  • Women with diabetes during pregnancy or who delivered a baby weighing > 9 pounds
  • Hypertension (blood pressure ≥ 140/90 mmHg)
  • HDL cholesterol < 35 mg/dl and/or triglycerides > 250 mg/dl
  • Women with polycystic ovary syndrome
  • History of prediabetes (see prediabetes below)
  • Acanthosis nigricans
  • History of heart disease or stroke
3. For normal results, rescreen in a minimum of 3 years, or sooner if patient is at very high risk. Rescreen patients with prediabetes yearly. Women with a history of gestational diabetes should have lifelong testing at least every 3 years. [38]

Children
1. Screen children who are overweight (BMI > 85th percentile for age and sex, weight for height > 85th percentile, or weight > 120% of ideal for height) and have one of the following risk factors:
  • Family history of T2DM in first- or second-degree relative
  • High-risk ethnicity (African-American, Hispanic, Asian, Native-American, Pacific Islander)
  • Acanthosis nigricans
  • Polycystic ovary syndrome
  • Hypertension (blood pressure ≥ 140/90 mmHg)
  • HDL cholesterol < 35 mg/dl and/or triglycerides > 250 mg/dl
  • Maternal history of diabetes or gestational diabetes during the child’s gestation
  • History of being born small for gestational age (babies born small for gestational age have a higher incidence of insulin resistance later in life if they become obese) [38]
2. Screening should be begin at 10 years of age or at the onset of puberty, whichever comes first 3. For normal results, rescreen every 3 years. [1]

Patients taking second generation antipsychotics
  • Fasting blood sugar at baseline, 12 weeks, and annually thereafter
  • Fasting lipid profile at baseline, 12 weeks, and every 5 years thereafter
  • See antipsychotics for more






Reference [24]
A1C value 5-year incidence of T2DM
5.0 - 5.5% < 5 - 9%
5.5 - 6.0% 9 - 25%
6.0 - 6.5% 25 - 50%







ADA T2DM Treatment Recommendations for Adults

Step 1 - initial therapy
  • Initial therapy for most diabetics should be metformin and lifestyle changes including weight loss and exercise (see diabetic diet)
  • The early introduction of insulin (see insulin therapy) should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C is > 10% or blood glucose levels > 300 mg/dL
  • Consider initiating dual therapy in patients with newly diagnosed type 2 diabetes who have A1C ≥ 1.5% above their glycemic target

Step 2 - intensify therapy
If patient has atherosclerotic cardiovascular disease (ASCVD), use one of the following:
  • GLP-1 analog - use one with proven ASCVD benefit: liraglutide > semaglutide > exenatide ER
  • SGLT2 inhibitor - use one with proven ASCVD benefit: empagliflozin > canagliflozin
    • If additional therapy is needed, consider the following:
      • Add other class from above (GLP-1 analog or SGLT2 inhibitor)
      • DPP-4 inhibitor if not on GLP-1 analog
      • Glitazone
      • Sulfonylurea
      • Basal insulin
If patient has heart failure or chronic kidney disease (CKD), use the following:
  • SGLT2 inhibitor - empagliflozin or canagliflozin are preferred
    • If additional therapy is needed, consider the following:
      • GLP-1 analog with ASCVD benefit (liraglutide > semaglutide > exenatide ER)
      • DPP-4 inhibitor (not saxagliptin) if patient has heart failure and not on GLP-1 analog
      • Sulfonylurea
      • Basal insulin
      • Avoid glitazone if patient has heart failure
If patient does NOT have ASCVD or CKD, consider the following:
  • Drugs with lower risk of hypoglycemia
    • GLP-1 analog
    • DPP-4 inhibitor
    • Glitazone
    • SGLT2 inhibitor
    • Also consider: if sulfonylurea is used, avoid glyburide because it has been associated with a higher risk of hypoglycemia in trials. If insulin is used, glargine and degludec are preferred over detemir and NPH
  • Drugs that may promote weight loss
    • GLP-1 analog
    • SGLT2 inhibitor
  • Drugs that are cheaper
    • Sulfonylurea
    • Glitazone
    • NPH and regular (R) insulin [38,39]

ADA T2DM Treatment Recommendations for Youth (10 - 19 years)

Step 1 - initial therapy
  • Overweight youth should be encouraged to lose 7 - 10% of their body weight (see diabetic diet and weight loss)
  • A1C < 8.5% and asymptomatic: metformin (titrate up to 2000 mg/day as tolerated) is the initial treatment of choice
  • A1C ≥ 8.5% or blood sugar ≥ 250 mg/dl with symptoms (polyuria, polydipsia, weight loss, etc.): start metformin and treat initially with basal insulin while titrating metformin
  • Blood sugar ≥ 600 mg/dl or ketoacidosis: hospitalize and treat accordingly
  • Patients should have panel of pancreatic autoantibodies tested to exclude the possibility of autoimmune type one diabetes (see insulin antibodies for more)

Step 2
Patients initiated on metformin + insulin
  • If blood sugar goals are being met, insulin can be tapered over 2 – 6 weeks by decreasing the insulin dose 10 – 30% every few days
Other
  • Goals not met on metformin: add basal insulin
  • Goals not met on basal insulin doses up to 1.5 units/kg/day: switch to basal-premeal regimen [39]



ADA Recommendations for Insulin in Adults with T2DM

Step 1 - start with basal insulin
  • Initial dose: 10 units/day or 0.1 - 0.2 units/kg/day
  • Adjust dose: increase dose by 10 - 15% or 2 - 4 units once or twice weekly to achieve fasting blood sugar goal (see adjusting basal insulin for more)
  • If hypoglycemia occurs: decrease dose by 10 - 20% or 4 units
If A1C is still above target despite achieving fasting blood sugar goal, or if A1C is not at target and insulin dose is > 0.7 - 1.0 units/kg, proceed to Step 2

Step 2 - add premeal insulin before largest meal
  • Initial dose: 4 units or 0.1 units/kg or 10% of basal dose
    • If A1C < 8%, consider decreasing basal insulin dose by same amount
  • Adjust dose: increase dose by 1 - 2 units or 10 - 15% twice weekly to achieve pre- and postprandial goals (see adjusting premeal insulin for more)
  • If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%
If A1C still not at target, proceed to Step 3

Step 3 - add premeal insulin before other meals in stepwise fashion
  • Add prandial insulin to an additional meal and use the guidelines in Step 2 to adjust
  • If not controlled with 2 preprandial doses, add to a third meal
  • Stepwise addition of prandial insulin every 3 months is associated with a lower risk of hypoglycemia and greater patient satisfaction [38,39]

ADA Recommendations for Insulin in Youth with T2DM

Basal insulin
  • Initial dose: 0.5 units/kg/day
  • Adjust dose: Increase every 3 - 5 days based on blood sugar readings to a maximum of 1.5 units/kg/day (see adjusting basal insulin for more)
  • If pancreatic autoantibodies are positive, consider starting basal-premeal regimen or insulin pump therapy

ADA Recommendations for Insulin in Elderly with T2DM

Overview
  • In order to avoid hypoglycemia, the ADA recommends that insulin regimens be simplified in elderly patients who have cognitive impairment, multiple coexisting chronic illnesses, and/or functional dependence
  • The information below gives general recommendations that can be used for simplifying regimens in appropriate patients
Basal insulin
  • Change timing from bedtime to morning
  • When titrating basal insulin, use a fasting blood sugar goal of 90 - 150 mg/dl and make adjustments based on a week of values
  • If 50% of fasting blood sugar values are above goal, increase basal dose by 2 units
  • If > 2 fasting blood sugar values/week are < 80 mg/dl, decrease basal dose by 2 units
Premeal (prandial) insulin
Initial therapy
  • Do not use short-acting insulin at bedtime
  • If premeal insulin dose is ≤ 10 units, discontinue premeal insulin and add noninsulin agent
  • If premeal insulin dose is > 10 units, decrease dose by 50% and add noninsulin agent. Titrate noninsulin agent while decreasing premeal insulin dose with goal of stopping premeal insulin.
Adjusting therapy
  • Use a blood glucose premeal goal of 90 - 150 mg/dl
  • Every 2 weeks, adjust insulin dose and noninsulin therapy based on pre-lunch and pre-dinner glucose readings
  • If 50% of premeal blood sugar values are above goal over 2 weeks, increase intensity of noninsulin therapy
  • If > 2 premeal values/week are < 90 mg/dl, decrease intensity of therapy
Sliding scale for premeal blood sugar values
  • Blood sugar > 250 mg/dl: give 2 units of short- or rapid-acting insulin
  • Blood sugar > 350 mg/dl: give 4 units of short- or rapid-acting insulin
Noninsulin agents
  • If GFR ≥ 45 ml/min, use metformin as noninsulin agent
  • If GFR < 45 ml/min or metformin is already being used, see adult treatment recommendations above for guidance on other agents