Clinical Practice Guidelines

Diabetes

Management of Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents

(Endorsed with Qualifications, July 2013)

The guideline, Management of Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents, was developed by the American Academy of Pediatrics and endorsed with qualifications by the American Academy of Family Physicians.

Key Recommendations

  • Insulin therapy should be initiated for children and adolescents with T2DM who are ketotic or in diabetic ketoacidosis and in whom the distinction between T1DM and T2DM is unclear.
  • Insulin therapy should be initiated for patients who have random venous or plasma blood glucose (BG) concentrations ≥ 250 mg/dL or whose HbA1c is > 9%.
  • In all other instances, a lifestyle modification program and metformin should be initiated as first-line therapy at the time of diagnosis of T2DM.
  • HbA1c concentrations should be monitored every 3 months and treatment intensified if treatment goals for BG and HbA1c concentrations are not being met.
  • Patients should be advised to monitor finger-stick BG concentrations if they are taking insulin or other medications with a risk of hypoglycemia, are initiating or changing their diabetes treatment regimen, have not met treatment goals, or have intercurrent illnesses.
  • Nutritional counseling may incorporate the Academy of Nutrition and Dietetics' Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines.
  • Children and adolescents with T2DM should be encouraged to engage in moderate-to-vigorous exercise for at least 60 minutes daily and to limit nonacademic screen time to less than 2 hours per day.
     

Qualifications

  • Four of the six key action statements in the guidelines concerning lifestyle modifications, nutrition, and blood glucose and A1c monitoring are based on expert opinion.
  • The AAFP does not believe that co-management or referral is necessary for all children, as indicated in the guideline introduction.

See the full recommendation for further details.


Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus

(Endorsed, March 2013)

The guideline, Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus, was developed by the American College of Physicians and endorsed by the American Academy of Family Physicians.

Key Recommendations

  • Pharmacologic therapy should be added in individuals diagnosed with type 2 diabetes when lifestyle modifications, including diet, exercise, and weight loss, have failed to adequately improve hyperglycemia.
  • Monotherapy with metformin should be the initial pharmacologic therapy for most patients with type 2 diabetes.
  • A second agent should be added to metformin to treat patients with persistent hyperglycemia when lifestyle modifications and monotherapy with metformin fail to control hyperglycemia.

See full recommendation for further details.


These guidelines are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These guidelines are only one element in the complex process of improving the health of America. To be effective, the guidelines must be implemented.