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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.

Individualized glycemic targets and glucose-lowering therapies

2.

Diet, exercise, and education as the foundation of the treatment program

3.

Use of metformin as the optimal first-line drug unless contraindicated

4.

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