Pharmacologic and Non Pharmacologic Treatment of Type 2 Diabetes
- Background
- A1C target
- ADA Treatment Recommendations
- Lifestyle Modification
- Medications
- Management Summary (Initiation)
- Self-Monitoring of Blood Glucose (SMBG)
- Hypoglycemia
- Additional Notes
Background
Treatment of Type 2 Diabetes, whether new onset or persistent, requires multimodal, comprehensive management. Diabetic treatment includes lifestyle changes, weight management, and pharmacologic approaches. Newer drugs in the GLP-1 receptor agonist (GLP-1 RA) drug class have very high efficacy for both glycemic control and weight management and are now the preferred starting agents for patients with newly diagnosed diabetes. Aside from antihyperglycemic agents, patients may also require lipid-lowering and antihypertensive medications
Management should be individualized based on numerous factors, such as age, life expectancy, comorbid conditions, duration of diabetes, risk of hypoglycemia or adverse consequences from hypoglycemia, patient motivation, and adherence. The ADA states that
“A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include comorbidities (e.g., atherosclerotic cardiovascular disease | heart failure | chronic kidney disease) | hypoglycemia risk | impact on weight | cost | risk for side effects | and patient preferences”
A1C target (See ‘Related PCMed Topic’ below): Currently, there are different professional guideline thresholds
- ACP: Aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes and consider de-intensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%
- ADA: Recommends <7% for the general population and to consider more stringent goals (<6.5%) for selected patients without significant hypoglycemia (e.g., long life expectancy, no CVD and treated with lifestyle or metformin only)
- AACE/ACE: ≤6.5% if target can be achieved safely
ADA Treatment Recommendations Include the Following
- Metformin is no longer the only preferred first-line agent for glycemic control, but given its low cost and accessibility is still often used for initial therapy
- The ADA recommends starting patients on “high efficacy” diabetes medications based on ability to lower glucose and achieve glycemic control
- ACP recommends adding a SGLT-2 inhibitor or GLP-1 agonist to metformin and lifestyle modifications in adults with T2DM and inadequate glycemic control
- Consider combination therapy at treatment initiation to shorten time to glycemic control
- Very high efficacy:
- Dulaglutide (Trulicity) | Semaglutide (Ozempic) | Tirzepatide (Mounjaro)
- Insulin
- Combination oral | Combination injectable (e.g., GLP-1 + Insulin)
- High efficacy
- GLP-1 RA not listed above e.g., Exenatide (Byetta) | Liraglutide (Victoza)
- Metformin
- SGLT2-I e.g., Empagliflozin (Jardiance) | Canagliflozin (Invokana)
- Sulfonylurea
- Thiazolidinedione e.g., Pioglitazone (Actos) | Rosiglitazone (Avandia)
- Encourage weight loss
- 3% to 7% weight loss improves glycemia and CV risk factors
- > 10% total body weight loss may have disease-modifying effects, including diabetes remission, and may improve long-term cardiovascular outcome
- Options for weight loss depend on patient’s BMI and co-morbid conditions: Lifestyle changes| Evidenced-based structured weight management programs | Pharmacotherapy | Metabolic surgery
- Very high efficacy pharmacotherapy diabetes medications for weight loss include: Semaglutide (Ozempic) | Tirzepatide (Mounjaro)
- These GLP-1 RA drugs should be first-line therapy for patients needing weight management and glycemic control
- High efficacy weight management drugs include: Liraglutide (Victoza) | Dulaglutide (Trulicity)
- Consider early introduction of insulin
- Evidence of catabolism: Weight loss | Hypertriglyceridemia | Ketosis
- Hyperglycemic symptoms
- A1C levels >10% (86 mmol/mol) or blood glucose levels ≥300 mg/dL (16.7 mmol/L)
- As glycemic control improves, simplifying the regimen or changing to noninsulin agents is possible
- Dual therapy: Consider in newly diagnosed patients if A1C ≥1.5% (12.5 mmol/mol) above target
- Initial dual therapy extends time to treatment failure (compared to sequential addition of medications)
- High costs and tolerability issues are important barriers to the use of GLP-1 receptor agonists
- If there are cost-related barriers consider use of lower cost medications e.g metformin | sulfonylureas | TZDs | insulin
- Continue metformin for as long as tolerated and not contraindicated
- Add other agents, including insulin, to metformin
- Glucagon-like peptide 1 receptor agonist is preferred to insulin when possible
With Comorbidities in addition to Type 2 Diabetes
- In patients that are overweight or obese
- GLP-1 RA or dual GLP-1RA/GIP are recommended
- Once weight loss is attained continue therapy to maintain health benefits. Sudden discontinuation can lead to rebound weight gain and worsening of cardiometabolic risk factors
- In patients with known atherosclerotic cardiovascular disease or high cardiovascular risk, kidney disease, or heart failure, the following are recommended
- Sodium–glucose cotransporter 2 inhibitors (SGLT2i)
- Glucagon-like peptide 1 receptor agonists with demonstrated CVD benefit
- If A1c remains above target for patients on SGLT2i considering adding GLP-1 RA or vice versa
- In patients with concomitant biopsy-proven MASLD or high risk for liver fibrosis based on non-invasive tests
- Consideration of these medications in the setting of these co-morbidities is independent of HbA1C or HbA1C target
Lifestyle Modification
- Lifestyle interventions can improve quality of life | promote weight loss | optimize glucose management| reduce CV risk factors | lead to deprescribing of medications
- ACCE/ACE/ACLM list the following as key areas for lifestyle modification
- Advocacy for lifestyle interventions in the 6 pillars of lifestyle medicine e.g., restorative sleep| stress management | adequate physical activity |social connections | whole-food and plant predominant diet| avoiding as 1st line management
- Assessment of baseline lifestyle habits in above 6 pillars and readiness to change
- Setting SMART goals
- Nutrition: Weight management | plant-based diet
- Prescribing physical activity: 150 min/week exertion such as walking or stair climbing | Strength training using SMART goals e.g., FITT (Frequency | Intensity | Time | Type)
- Discuss sleep quality and quantity | screening for sleep disorders | advocate: 6 to 8 hours/night
- Behavioral support: Community engagement | Avoidance of excessive alcohol | Impact of tobacco and recreational drug usage moderation
- Smoking cessation: No tobacco products
- The ADA additionally recommends
- Diabetes self-education and support
- Take into consideration social determinants of health (e.g., Health literacy | Access to medications | Access to housing and food)
- Avoidance of therapeutic inertia (e.g., Reassess and modify therapy every 3 to 6 months)
- Patients with diabetes should also be assessed for diabetic complications
- ASCVD Risk | Heart disease history | Staging/screening of CKD | Hypoglycemia risk | Retinopathy | Neuropathy | Screening for MASLD/NASH
Medications
Noninsulin Glucose-Lowering Agents
- GLP1 receptor agonists (GLP-1-RA) or GIP : Dulaglutide (Trulicity) | Semaglutide (Ozempic) | Tirzepatide (Mounjaro)
- Very high to high efficacy drugs (see above) considered first-line therapy
- Preferred agent for patients needing glycemic control and assistance with weight management
- Recommended for patients with comorbid cardiovascular disease or chronic kidney disease
- ACP recommends using GLP-1 agonist to reduce risk for all-cause mortality|major adverse cardiovascular events| stroke
- Preferred to insulin when possible
- When insulin is started GLP1-RA should be continued for greater efficacy, weight and hypoglycemia benefit
- Strong A1C-lowering properties: Associated with decreased weight, lipid and BP
- Risks and adverse events include: Pancreatitis | Thyroid cancer (in rodent models) | Ileus | GI side effects
- Biguanides
- Metformin is a high efficacy medication that is generally affordable and accessible
- Benefits: Low hypoglycemia risk | May help with modest weight loss | Good antihyperglycemic efficacy at doses of 1,000 to 2,000 mg/day
- Side effects: GI intolerance (e.g., bloating| abdominal discomfort| diarrhea)
- Renal disease: Can be used with reduced estimated glomerular filtration rates (eGFR) ≥30 mL/min/1.73 m2
- Vitamin B12 deficiency: Periodically test for vitamin B12 levels
- Sodium-glucose cotransporter 2 inhibitors (SGLT2i): Ertugliflozin | Dapagliflozin | Canagliflozin | Empagliflozin
- Intermediate to high efficacy
- Glucosuric effect: Associated with decreased A1C, weight, and systolic BP
- Recommended for patients with concomitant CKD or cardiovascular disease
- ACP recommends using an SGLT-2 inhibitor to reduce the risk for all-cause mortality| major adverse cardiovascular events| progression of CKD | hospitalization due to CHF
- Risks and adverse events include: DKA (rare) |Genital mycotic infections | Necrotizing fasciitis of the perineum
- Dipeptidyl peptidase 4 inhibitors (DPP4i): Alogliptin | Saxagliptin | Linagliptin | Sitagliptin
- Inhibit DPP4 and increase GLP1 and other incretin hormones | Modestly lower A1C | Intermediate potency | low risk of hypoglycemia
- Combination pills available with metformin, SGLT2 inhibitors, and a TZD
- Weight neutral; does not assist with weight management
- Do not add DDP-4 to GLP-1 RA or GIP/GLP-1 RA combination medication due to lack of additional glucose lowering than that of GLP-1 RA alone
- Note: ACP does NOT recommend adding a (DPP-4) inhibitor to metformin and lifestyle modifications in adults with T2DM and inadequate glycemic control
- Thiazolidinediones (TZDs): Pioglitazone | Rosiglitazone
- Directly reduce insulin resistance | High efficacy A1C-lowering properties | Low risk of hypoglycemia
- Caution recommended due to associated risk factors: Weight gain | Increased bone fracture risk in postmenopausal females and elderly males | Elevated risk for chronic edema or heart failure
- Insulin-secretagogues
- Sulfonylureas (SUs): Glimepiride | Glipizide | Glyburide
- Relatively potent A1C-lowering effects
- Effects may not last | May increase weight | Risk for hypoglycemia and CVD
- Glinides: Nateglinide | Repaglinide
- Shorter half-life than SUs, with lower A1C-lowering effects but also lower risk of prolonged hypoglycemia
- Sulfonylureas (SUs): Glimepiride | Glipizide | Glyburide
Insulin
- Most potent antihyperglycemic agent
- Considerations prior to use
- Patient motivation | CVD, comorbidities and complications | Age | Risk for Hypoglycemia | Overall health |Cost considerations
- Basal analogs: Glargine | Detemir | Degludec
- Flat serum insulin concentration for 24 hours or longer
- Human Neutral protamine Hagedorn (NPH) insulin
- More likely to cause hypoglycemia than basal analogs
- Addition of human NPH or long-acting insulin analogs to oral agents is “well-established approach that is effective for many patients” (ADA)
- Rapid acting Insulin: Glulisine | Lispro | Aspart | Inhaled insulin
- Rapid acting formulations are preferable to regular human insulin
- May be necessary at mealtime if glycemia uncontrolled despite combination of oral medications and insulin/GLP1-RA
- Premixed insulins combining longer and shorter action insulin available but less flexible and greater risk of hypoglycemia
- Monitor for signs of overbasalization e.g. significant bedtime-to-morning or postprandial-to-preprandial glucose differential | A1C not at target despite normal fasting glucose, etc
Management Summary (Initiation)
- Recent onset T2D and A1C <9.0%
- Monotherapy (with a very high efficacy drug (GLP-1 RA) or metformin and lifestyle changes
- A1C ≥9.0%
- Symptomatic (polyuria, polydipsia, or polyphagia): May need to initiate insulin to control glucose toxicity symptoms
- Asymptomatic: Consider starting combination therapy with two drugs picked based on efficacy and comorbid conditions (e.g., Obesity | CKD | CVD)
Note: Link to detailed ACE/ACCE Glycemic Control algorithm available in ‘Learn More – Primary Sources’ below)
Self-Monitoring of Blood Glucose (SMBG)
- Recommended for patients on intensive insulin therapy (basal plus prandial insulin)
- Check prior to meals/snacks, prior to exercise, and at bedtime
- Once-daily fasting glucose in patient on basal insulin only
- Limited benefit for patients on oral therapy only
- Continuous glucose monitoring (CGM) devices are emerging as a complement to SMBG
- Strong recommendation to use in adults on any insulin therapy
- Consider using for patients on non-insulin glucose lowering therapy
- Strong correlation between “time in range” (TIR) and HbA1c (70% TIR equates to HbA1c ~7%)
- Should be considered in patients who remains above their A1c target to identify therapeutic gaps and tailor therapy
- Educate patients on substances that can interfere with glucose readings
- Patients not on insulin
- Routine glucose monitoring likely limited in clinical value
- For some, may provide insight regarding exercise, diet and medication management
Hypoglycemia
- Risk for antihyperglycemic agents, especially insulin
- Some classes have lower risk for hypoglycemia
- Metformin | GLP1 receptor agonists | SGLT2 inhibitors | DPP4 inhibitors | TZDs
- However, hypoglycemia can still occur in combination with an insulin secretagogue or exogenous insulin
- Screen patients for evidence of hypoglycemia unawareness
- Young children with type I diabetes and elderly are particularly vulnerable
- Interventions include: Medication or diet adjustments | Patient education | Individualized glycemic goals | Continuous glucose monitoring devices
- Educate patients regarding symptoms
- Tremors or feeling shaky | Nervous or anxious | Sweating, chills and clamminess | Irritability | Confusion | Tachycardia | Lightheaded or dizziness | Pallor | Drowsy or weakness | Blurred/impaired vision | Tingling or numbness in the lips, tongue, or cheeks | Headaches | Lack of coordination | Seizures (severe)
- “15-15 Rule”: Raise glucose to >70 mg/dL with 15 grams carbohydrate intake and check glucose at 15 minutes | Repeat if glucose still <70
- Glucose tablets or gel tube | 4 ounces (1/2 cup) of juice or regular (non-diet) soda | 1 tablespoon of sugar, honey, or corn syrup | Hard candies, jellybeans, or gumdrops (based on labelling)
- Severe hypoglycemia (patient cannot treat herself or unconscious): Glucagon
- Available by injection (buttock, arm or thigh) or nasal powder (does not require inhalation)
- Educate family members or caregivers on how to administer
Additional Notes
- GLP1-RA is preferable to insulin for those patients who may require an injectable medication
- Patients who require a 3rd medication and who have A1C >8.0% and/or long-standing disease are less likely to reach their target A1C with a third oral antihyperglycemic agent
- While adding GLP1-RA may initially work, many patients will still require insulin
- Reevaluate medications regularly to avoid therapeutic inertia
- Every 3 to 6 months
- Adjust as needed based on new patient factors
- Yearly visits (or more frequent depending on clinical findings) to ophthalmologist and podiatrist
- Important to prevent complications and slow CVD / renal disease
- Manage risk factors for atherosclerosis (e.g., BP, cholesterol, smoking, obesity)
- Early referral to nephrology for worsening albuminuria even in setting of stable creatinine
- Patients with diabetes are at high risk for complicated infectious illnesses and routine vaccinations and annual dental visits should be encouraged
Learn More – Primary Sources
FDA List of Approved Type 2 Diabetes Medications
AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm
ACP Newer Pharmacologic Treatments for T2DM: A Clinical Guideline
Hemoglobin A1c Targets for Type 2 Diabetes Mellitus
SUMMARY:
The ACP provides guidance to help providers better target hemoglobin A1c (HbA1c) targets for the pharmacologic treatment of type 2 diabetes. The ACP recommends
Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care
Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes
Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%
Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population
KEY POINTS:
Other guidelines reviewed in this document include
- The ADA guidelines set the following targets
- <7% for the general population
- Less stringent A1C goals (e.g., < 8%) may be appropriate for patients with limited life expectancy or where the harms outweigh the benefits
- Consider more stringent goals (<7%) for selected patients without significant hypoglycemia
- Short duration of diabetes
- Type 2 diabetes treated with lifestyle or metformin only
- Long life expectancy
- No CVD
Note: The ADA issued a statement that it is “deeply concerned by the new guidance” and “that a reasonable A1c goal for many nonpregnant adults with type 2 diabetes is less than 7 percent based on the available evidence to date from the ACCORD, ADVANCE, VADT and UKPDS international clinical trials, which were evaluated and incorporated into ADA’s Standards of Care.” (see ‘Learn More – Primary Sources’ below)
- Scottish Intercollegiate Guidelines Network (SIGN) guideline is similar to ADA
- AACE/ACE
- ≤6.5% if target can be achieved safely
- NICE
- 6.5% for patients managed with
- Lifestyle and diet
- Lifestyle and diet with single drug and no hypoglycemia
- 7% for patients on medications associated with hypoglycemia
- 6.5% for patients managed with
- Institute for Clinical Systems Improvement
- < 7% to < 8% based on patient factors
- VA/DoD
- 6% to 7% for patients with a life expectancy > 10 to 15 years and no or mild microvascular complications
- 7% to 8.5% for those with established microvascular or macrovascular disease, comorbid conditions, or a life expectancy of 5 to 10 years
- 8% to 9% for those with a life expectancy <5 years, significant comorbid conditions, advanced complications of diabetes, or difficulties in self-management attributable to mental status, disability, or other factors (12)
Review of Literature
Overall, the ACP did not find that the benefits of lower HbA1c targets justified potential risks
- ACP reviewed 5 large RCTs comparing intensive (achieved HbA1c levels, 6.3% to 7.4%) versus less intensive (achieved HbA1c levels, 7.3% to 8.4%) treatment targets
- Main effect: More intensive glycemic control resulted in small absolute reductions in risk for microvascular surrogate events (e.g., retinopathy on ophthalmologic screening) but not clinical events such as loss of vision
- One trial of metformin in overweight adults showed a reduction in all-cause and diabetes-related death through at least 10 years
- In all studies, more intensive therapy required higher dose medications and was associated with more adverse events (including increased risk of death in 1 study)
NOTE: All guidelines allow for higher HbA1c targets depending on comorbid conditions and limited life expectancy
Learn More – Primary Sources:
ADA: Glycemic Targets: Standards of Medical Care in Diabetes—2023
NICE: Type 2 diabetes in adults: management
VA/DoD Clinical Practice Guidelines: Management of Diabetes Mellitus in Primary Care
Prediabetes and Diabetes Type 2: Screening and Making the Diagnosis
Clinical Actions:
Diabetes results from the impaired secretion of insulin or resistance to its peripheral effects, leading to abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine. Type 2 diabetes (previously “noninsulin-dependent diabetes” or “adult-onset diabetes”) accounts for 90–95% of all diabetes. Type 2 diabetes is caused by a progressive loss of β-cell insulin secretion, usually associated with insulin resistance. Prediabetes is diagnosed when glucose levels start to rise due to β-cell insulin secretion failure, but diagnostic criteria are not yet met for Type 2 diabetes.
Table of Contents
- Evaluate Patients for Risk Factors
- Screening and Diagnostic Criteria
- Symptoms of Diabetes (related to hyperglycemia)
- Complications of Type 2 Diabetes
Evaluate Patients for Risk Factors
Risk Factors for Type 2 Diabetes (NIDDK)
- Overweight or obese
- NIDDK BMI chart (see ‘Primary Sources – Learn More’ below)
- Not Asian American or Pacific Islander: At-risk BMI ≥ 25
- Asian American: At-risk BMI ≥ 23
- Pacific Islander: At-risk BMI ≥ 26
- NIDDK BMI chart (see ‘Primary Sources – Learn More’ below)
- ≥45 years
- Family history of diabetes
- Race/Ethnicity
- African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, Native Hawaiian, or Pacific Islander
- Hypertension (or on therapy for hypertension)
- Dyslipidemia
- Personal history of
- Pregnancy: GDM or macrosomia (BW >4000 g)
- Physical inactivity
- Heart disease or stroke
- Depression
- PCOS
- Acanthosis nigricans
- HIV
Screening and Diagnostic Criteria
Who and When to Screen
- Overweight or obesity (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and ≥1 of the following risk factors
- First-degree relative with diabetes
- High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
- History of CVD
- Hypertension (≥140/90 mmHg or on therapy for hypertension)
- HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)
- Women with polycystic ovary syndrome
- Physical inactivity
- Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
- People with HIV
- Screen for diabetes and prediabetes with a fasting glucose test
- Before starting antiretroviral therapy
- At the time of switching antiretroviral therapy
- 3 to 6 months after starting or switching antiretroviral therapy
- If initial screening results are normal, fasting glucose should be checked annually
- Screen for diabetes and prediabetes with a fasting glucose test
- Patients with prediabetes (A1C ≥5.7% [39 mmol/mol], IGT, or IFG) should be tested yearly
- Women who were diagnosed with GDM should have lifelong testing at least every 3 years
- For all other patients, testing should begin at age 35 years
- If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results and risk status
AACE/ACE
- Begin at age 45 without risk factors
- Screening based on risk factors: In addition to the above list, AACE/ACE includes the following factors
- Antipsychotic therapy for schizophrenia and/or severe bipolar disease
- Chronic glucocorticoid exposure
- Sleep disorders (e.g., obstructive sleep apnea, chronic sleep deprivation, and night shift occupation) with glucose intolerance
- Normal glucose values: Every 3 years
- Consider annual screening for patients with 2 or more risk factors
- Screen for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight (BMI ≥25) or obesity (BMI ≥30)
- Clinicians should offer or refer patients with prediabetes to effective preventive interventions
- Above are Grade B recommendations: Offer or provide this service
Diagnostic Criteria
- Normal
- Fasting plasma glucose (FPG) <100 mg/dL (5.6 mmol per L)
- Oral glucose tolerance test (OGTT) with 75g glucose load
- 2h (plasma glucose) PG <140 mg/dL (7.8 mmol per L)
- High Risk for Diabetes (prediabetes)
- Impaired fasting glucose (IFG): FPG ≥100 to 125 mg/dL (5.6 to 6.9 mmol per L)
- Impaired glucose tolerance (IGT): 2h PG ≥140 to 199 mg/dL (7.8 to 11.0 mmol per L)
- A1C 5.7% to 6.4%
- Note: Patients with prediabetes should be tested yearly
- Diabetes: Glucose criteria are preferred for the diagnosis of DM
- FPG ≥126 (7.0 mmol per L) mg/dL
- OGTT: 2h PG ≥200 mg/dL (11.1 mmol per L)
- Random PG ≥200 mg/dL (11.1 mmol per L) with the following symptoms of hyperglycemia
- Polydipsia | Polyuria | Polyphagia | Blurred vision | Weakness | Unexplained weight loss
- A1C ≥6.5%
- Note: Always confirm diabetes diagnosis with repeat glucose or A1C testing on another day
SYNOPSIS:
Prediabetes is not a clinical disorder but rather an important risk factor for diabetes and cardiovascular disease. While there are some differences between organizations regarding risk factors for screening and diagnostic cut-offs, all agree as to the importance of identifying those at risk for significant cardiovascular events if diabetes is left untreated. The prognosis for type 2 diabetes varies and is very dependent on glucose control.
KEY POINTS:
Symptoms of Diabetes (related to hyperglycemia)
- Excessive urination, thirst and hunger
- Unexpected weight loss
- Increased susceptibility to infections, especially yeast or fungal infections
- Weak, tired feeling
- Dry mouth
- Blurry vision
- Deposits of blood, or puffy yellow spots in the retina
- Decreased sensation in the legs
- Weak pulses in the feet
- Blisters, ulcers or infections of the feet
Complications of Type 2 Diabetes
- Atherosclerosis
- Retinopathy
- Neuropathy
- Nephropathy
- Dermatologic pathology
- Infections
- Feet in particular: Ulcerations with poor healing
Learn More – Primary Sources:
ADA Standars of Care in Diabetes 2024
AACE Comprehensive Type 2 Diabetes Mellitus Care Algorithm
NIDDK: Risk Factors for Type 2 Diabetes
60-Second Type 2 Diabetes Risk Test
