TYPE 2 DIABETES MELLITUS – INDIA

CLINICAL MANAGEMENT GUIDELINE

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📋 For Healthcare Professionals Only | Not for Public Use

Scope: Diagnosis | Targets | Pharmacotherapy | Monitoring | Complications | Emergencies

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🔰 SYMBOL LEGEND

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SECTION 1: DIAGNOSIS

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1.1 DIAGNOSTIC CRITERIA

Confirmation Rules

Scenario	Action
Symptomatic + RPG ≥ 200	Diagnosis confirmed – No repeat needed
Asymptomatic + single abnormal test	Repeat SAME test on different day to confirm
Two different tests both abnormal	Diagnosis confirmed
Two different tests discordant	Repeat the test that is above threshold

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1.2 PREDIABETES – IDENTIFY AND INTERVENE

Action for Prediabetes

Step	Action
1	Intensive lifestyle intervention (target 7% weight loss, 150 min/week exercise)
2	Consider Metformin if: BMI ≥ 35, age < 60, prior GDM, rising HbA1c despite lifestyle
3	Rescreen annually

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1.3 WHO TO SCREEN

Screen All Adults With:

Risk Factor

Age ≥ 35 years (lower threshold for South Asians)

BMI ≥ 23 kg/m² (Asian cut-off)

Waist circumference: M ≥ 90 cm, F ≥ 80 cm

First-degree relative with diabetes

History of GDM or baby > 4 kg

Prediabetes on prior testing

PCOS

Hypertension (≥ 140/90 or on treatment)

HDL < 35 mg/dL or TG > 250 mg/dL

History of CVD

Physical inactivity

Acanthosis nigricans

Screening Frequency

Result	Rescreen
Normal	Every 3 years (annually if high risk)
Prediabetes	Annually

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SECTION 2: TREATMENT TARGETS

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2.1 GLYCEMIC TARGETS

When to Individualize HbA1c Target

Stricter Target (< 6.5%)	Relaxed Target (< 8% or higher)
Short duration of diabetes	Long duration (> 10 years)
Long life expectancy	Limited life expectancy
No significant CVD	Established CVD, multiple comorbidities
Low hypoglycemia risk	High hypoglycemia risk
Highly motivated, good support	Limited support, poor adherence
Newly diagnosed	Elderly (≥ 65-70 years), frail

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2.2 COMPREHENSIVE TARGETS (ABC + More)

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SECTION 3: NON-PHARMACOLOGICAL MANAGEMENT

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3.1 LIFESTYLE – FOUNDATION OF ALL TREATMENT

Dietary Recommendations

Component	Recommendation
Calories	Individualize for weight goals; deficit of 500-750 kcal/day for weight loss
Carbohydrates	45-60% of calories; focus on low GI, high fiber
Fiber	≥ 25-30 g/day
Protein	15-20% of calories (0.8-1 g/kg in CKD without dialysis)
Fat	< 35% total; < 10% saturated; minimize trans fats
Sugar	Minimize added sugars; < 10% of calories
Salt	< 5 g/day (< 2 g sodium)

India-Specific Dietary Advice

Instead of…	Choose…
White rice (large portions)	Brown rice, millets (ragi, jowar, bajra), smaller portions
Maida (refined flour)	Whole wheat atta, multigrain
Fruit juices	Whole fruits (with fiber)
Sweets (mithai)	Limit strictly; sugar-free options occasionally
Fried snacks (samosa, pakora)	Roasted chana, nuts, sprouts
Full-fat dairy	Low-fat milk, curd

Physical Activity

Type	Recommendation
Aerobic	≥ 150 min/week moderate OR ≥ 75 min/week vigorous
Resistance	2-3 sessions/week
Reduce sedentary time	Break up sitting every 30 min
Daily steps	Target ≥ 7,000-10,000 steps/day

Weight Management

BMI	Category	Target
< 18.5	Underweight	Investigate cause
18.5-22.9	Normal	Maintain
23-24.9	Overweight	5-7% weight loss
≥ 25	Obese	7-10% weight loss; consider pharmacotherapy/surgery

📌 Even 5% weight loss significantly improves glycemic control

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SECTION 4: PHARMACOLOGICAL MANAGEMENT – STEPWISE APPROACH

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4.1 TREATMENT ALGORITHM OVERVIEW

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4.2 STEP 1: INITIAL THERAPY

Default: START METFORMIN

Drug	Starting Dose	Titration	Target Dose	Notes
💊 Metformin	500 mg OD with dinner	↑ by 500 mg every 1-2 weeks	1000 mg BD (max 2550 mg/day)	Take with food to reduce GI side effects
💊 Metformin XR	500 mg OD	↑ by 500 mg weekly	1500-2000 mg OD	Extended-release; better GI tolerance

Metformin Key Points

Aspect	Details
Mechanism	↓ Hepatic glucose production; ↑ Insulin sensitivity
HbA1c reduction	1.0-1.5%
Weight effect	Neutral to slight loss
Hypoglycemia risk	Very low (unless combined with SU/insulin)
CV benefit	Possible benefit (UKPDS)
Cost	Very low 🇮🇳

Metformin Contraindications and Cautions

❌ Contraindicated	⚠️ Use with Caution
eGFR < 30 mL/min	eGFR 30-45: max 1000 mg/day
Acute illness with risk of AKI	eGFR 45-60: monitor renal function
Severe hepatic impairment	Hold before iodinated contrast (restart 48 hrs after if stable renal function)
Active alcoholism	Vitamin B12 deficiency (check periodically)

If Metformin Contraindicated or Not Tolerated → Choose Alternative First-Line

Alternative	When to Use
SGLT2 inhibitor	HF, CKD, CVD, or obesity
GLP-1 RA	CVD, obesity
DPP-4 inhibitor	Elderly, CKD (dose-adjust)
Sulfonylurea	Cost concern (but weight gain, hypoglycemia risk)

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4.3 STEP 2: ADD SECOND AGENT IF HbA1c NOT AT TARGET

Decision Framework: Choose Based on Patient Profile

                       METFORMIN NOT ENOUGH

                              │

          ┌───────────────────┼───────────────────┐

          │                   │                   │

   HAS CVD/High Risk?     HAS HF?            HAS CKD?

          │                   │                   │

          ▼                   ▼                   ▼

   ✅ GLP-1 RA           ✅ SGLT2i           ✅ SGLT2i

   (with CVD benefit)    (with HF benefit)   (with CKD benefit)

   OR SGLT2i                                 OR GLP-1 RA

          │                   │                   │

          └───────────────────┼───────────────────┘

                              │

                              ▼

             If NONE of above, choose based on:

                              │

       ┌──────────────┬───────┴───────┬──────────────┐

       │              │               │              │

   WEIGHT            HYPO           COST         HbA1c FAR

  PRIORITY        CONCERN        PRIORITY       FROM TARGET

       │              │               │              │

       ▼              ▼               ▼              ▼

  ✅ GLP-1 RA    ✅ GLP-1 RA     ✅ Sulfonylurea  ✅ Insulin

  OR SGLT2i      OR SGLT2i       OR DPP-4i       OR GLP-1 RA

                 OR DPP-4i                        OR SU

Drug Class Comparison for Second Agent

Class	HbA1c ↓	Weight	Hypo Risk	CV Benefit	Renal Benefit	Cost 🇮🇳
SGLT2i	0.5-1.0%	↓↓ Loss	Very Low	✅ Yes	✅ Yes	Moderate
GLP-1 RA	1.0-1.5%	↓↓↓ Loss	Very Low	✅ Yes (some)	✅ Yes (some)	High
DPP-4i	0.5-0.8%	Neutral	Very Low	Neutral	Neutral	Moderate
Sulfonylurea	1.0-1.5%	↑ Gain	⚠️ High	Neutral	Neutral	Very Low
Pioglitazone	1.0-1.5%	↑↑ Gain	Low	Possible	Neutral	Low
Insulin	1.5-3.5%	↑↑ Gain	⚠️ High	Neutral	Neutral	Low-Mod

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4.4 DRUG CLASSES – DETAILED

SGLT2 INHIBITORS ✅

Drug	Dose	Notes
💊 Empagliflozin	10-25 mg OD	CV mortality benefit (EMPA-REG)
💊 Dapagliflozin	10 mg OD	HF benefit (DAPA-HF); CKD benefit (DAPA-CKD)
💊 Canagliflozin	100-300 mg OD	CKD benefit (CREDENCE); ↑ amputation risk?

Aspect	Details
Mechanism	Blocks glucose reabsorption in kidney → Glucosuria
Benefits beyond glucose	Weight loss (2-3 kg); BP ↓ (3-5 mmHg); HF protection; Renal protection
Side effects	GTIs (genital thrush), UTIs, volume depletion, euglycemic DKA (rare)
Contraindications	eGFR < 20 (for glycemic benefit; can continue for HF/CKD benefit); Recurrent GTIs; T1DM
Cautions	Hold during acute illness (“sick day rules”); Pre-surgery

📌 SGLT2i are now recommended regardless of HbA1c in patients with HF or CKD

GLP-1 RECEPTOR AGONISTS ✅

Drug	Dose	Frequency	Notes
💊 Liraglutide	0.6 → 1.2 → 1.8 mg	Daily SC	CV benefit (LEADER)
💊 Semaglutide SC	0.25 → 0.5 → 1.0 mg	Weekly SC	Superior HbA1c and weight (SUSTAIN)
💊 Semaglutide Oral	3 → 7 → 14 mg	Daily PO	Take fasting with small sip of water
💊 Dulaglutide	0.75 → 1.5 → 3.0 → 4.5 mg	Weekly SC	CV benefit (REWIND)

Aspect	Details
Mechanism	GLP-1 mimetic → ↑ Insulin, ↓ Glucagon, ↑ Satiety, Slows gastric emptying
Benefits	Significant weight loss (3-6 kg); CV protection (some); ? Renal protection
Side effects	Nausea, vomiting, diarrhea (often transient); Injection site reactions
Contraindications	Personal/family history of MTC or MEN2; Pancreatitis history (caution)
Caution	GI side effects limit use in some; Cost high 🇮🇳

📌 Start at low dose and titrate slowly to minimize GI side effects

DPP-4 INHIBITORS

Drug	Dose	Renal Dosing
💊 Sitagliptin	100 mg OD	50 mg if eGFR 30-45; 25 mg if eGFR < 30
💊 Vildagliptin	50 mg BD	50 mg OD if eGFR < 50
💊 Linagliptin	5 mg OD	No dose adjustment (hepatic excretion)
💊 Teneligliptin	20 mg OD	No dose adjustment
💊 Saxagliptin	5 mg OD	2.5 mg if eGFR < 45; Avoid in HF

Aspect	Details
Mechanism	Inhibits DPP-4 → ↑ Endogenous GLP-1
Benefits	Weight neutral; Low hypoglycemia; Well tolerated; Oral; Dose-adjusted options in CKD
Side effects	Generally well tolerated; Nasopharyngitis; ? Joint pain
Caution	Saxagliptin: ↑ HF hospitalization (SAVOR-TIMI); Avoid in HF

📌 Linagliptin is ideal for elderly and CKD patients (no dose adjustment needed)

SULFONYLUREAS

Drug	Dose	Notes
💊 Glimepiride	1-4 mg OD	Preferred SU; lower hypo risk than glibenclamide
💊 Gliclazide	30-120 mg OD (MR)	Preferred SU 🇮🇳; lowest hypo risk
💊 Gliclazide IR	40-320 mg/day (divided)	Shorter acting
💊 Glipizide	5-20 mg OD-BD	Shorter acting
💊 Glibenclamide	2.5-15 mg OD	Avoid – Highest hypo risk, especially in elderly/CKD

Aspect	Details
Mechanism	Stimulates insulin release from beta cells
Benefits	Potent HbA1c reduction; Very cheap 🇮🇳; Long experience
Side effects	Hypoglycemia (especially glibenclamide); Weight gain
Caution	Elderly; CKD; Irregular meals; Alcohol use

⚠️ If using SU, prefer Gliclazide MR or Glimepiride. Avoid Glibenclamide.

PIOGLITAZONE

Drug	Dose	Notes
💊 Pioglitazone	15-45 mg OD	Only TZD available

Aspect	Details
Mechanism	PPARγ agonist → ↑ Insulin sensitivity
Benefits	Durable effect; ↓ TG, ↑ HDL; Possible CV benefit; Cheap 🇮🇳
Side effects	Weight gain; Edema; ↑ Fracture risk (women); Takes 8-12 weeks for full effect
Contraindications	Heart failure (NYHA III-IV); Active bladder cancer; Osteoporosis

📌 Consider Pioglitazone in NAFLD/NASH (improves hepatic steatosis)

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4.5 STEP 3: TRIPLE THERAPY OR INTENSIFICATION

Rational Triple Combinations

Base	Add	Third Agent Options
Metformin + SGLT2i	+ GLP-1 RA	Complementary mechanisms; max cardiorenal benefit
Metformin + SGLT2i	+ DPP-4i	❌ Avoid (DPP-4i adds little to SGLT2i)
Metformin + SGLT2i	+ SU	If cost concern; watch hypoglycemia
Metformin + SGLT2i	+ Insulin	If HbA1c very high
Metformin + GLP-1 RA	+ SGLT2i	Excellent if tolerated
Metformin + DPP-4i	+ SGLT2i	Good option
Metformin + DPP-4i	+ GLP-1 RA	❌ Avoid (redundant mechanism)
Metformin + DPP-4i	+ SU	Common; cheap; watch hypo
Metformin + SU	+ SGLT2i	Good; helps offset SU weight gain
Metformin + SU	+ DPP-4i	Common; watch hypo
Metformin + SU	+ Pioglitazone	Common; watch weight, edema

❌ Do NOT combine DPP-4i + GLP-1 RA (same mechanism; no added benefit)

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4.6 STEP 4: INSULIN THERAPY

When to Start Insulin

Indication

HbA1c > 10% at diagnosis

Symptomatic hyperglycemia (polyuria, polydipsia, weight loss)

Catabolic features (ketosis)

Failure to reach target on optimal oral/injectable therapy

Pregnancy (T2DM not controlled on Metformin alone)

Acute illness, surgery, hospitalization

Contraindications to oral agents

Insulin Initiation Algorithm

                        NEED FOR INSULIN

                              │

                              ▼

             ┌────────────────────────────────┐

             │  STEP 1: ADD BASAL INSULIN     │

             │  (Continue Metformin ± SGLT2i) │

             └────────────────────────────────┘

                              │

                   Start 💊 Basal Insulin

                   10 units OR 0.1-0.2 U/kg

                   at BEDTIME

                              │

                              ▼

             ┌────────────────────────────────┐

             │  STEP 2: TITRATE TO FPG TARGET │

             │  Increase by 2-4 units         │

             │  every 3-7 days                │

             │  Target FPG: 80-130 mg/dL      │

             └────────────────────────────────┘

                              │

                   If FPG at target but

                   HbA1c still high

                              │

                              ▼

             ┌────────────────────────────────┐

             │  STEP 3: ADDRESS PPG           │

             │  Option A: Add GLP-1 RA        │

             │  Option B: Add prandial insulin│

             │  (Basal-Plus or Basal-Bolus)   │

             └────────────────────────────────┘

Basal Insulin Options

Insulin	Duration	Dosing	Notes
💊 Glargine U100	~24 hrs	OD (bedtime or fixed time)	Peakless; low hypo risk
💊 Glargine U300	~36 hrs	OD	Even flatter; less hypo
💊 Degludec	~42 hrs	OD (flexible timing)	Ultra-long; lowest hypo
💊 Detemir	12-24 hrs	OD-BD	May need BD dosing
💊 NPH	12-18 hrs	OD-BD	Cheap 🇮🇳; peak → hypo risk

📌 If using NPH, give at bedtime to cover dawn phenomenon

Prandial (Bolus) Insulin Options

Insulin	Onset	Peak	Duration	Timing
💊 Aspart	15 min	1-2 hrs	3-5 hrs	0-15 min before meals
💊 Lispro	15 min	1-2 hrs	3-5 hrs	0-15 min before meals
💊 Glulisine	15 min	1-2 hrs	3-5 hrs	0-15 min before meals
💊 Regular	30 min	2-4 hrs	6-8 hrs	30 min before meals

Premixed Insulin Options

Insulin	Composition	Dosing	Notes
💊 Novomix 30	30% Aspart + 70% Protamine Aspart	BD (before breakfast & dinner)	Common
💊 Humalog Mix 25/50	25% or 50% Lispro + Protamine Lispro	BD
💊 Mixtard 30/70	30% Regular + 70% NPH	BD	Cheap

Insulin Regimen Options

Regimen	Description	When to Use
Basal only	Basal insulin OD + oral agents	Initial insulin; FPG-driven hyperglycemia
Basal-Plus	Basal + 1 prandial dose (largest meal)	PPG at one meal is issue
Basal-Bolus	Basal + prandial before each meal	Optimal control; T1DM pattern
Premixed BD	Premixed insulin before breakfast and dinner	Simple; common; less flexible

Drugs to Stop/Continue with Insulin

Continue	Stop/Reduce
✅ Metformin	❌ Stop SU (or reduce dose by 50%)
✅ SGLT2i (if no contraindication)	⚠️ Reduce/stop Pioglitazone (edema risk)
✅ GLP-1 RA (basal insulin + GLP-1 RA is excellent)
⚠️ DPP-4i (can continue but limited added benefit with insulin)

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4.7 INJECTABLE COMBINATIONS

GLP-1 RA + Basal Insulin Combinations (Fixed-Ratio)

Product	Components	Dose	Notes
💊 Xultophy	Degludec + Liraglutide	10-50 dose-steps OD	Convenient; good control; less weight gain
💊 Soliqua	Glargine + Lixisenatide	15-60 units OD

📌 GLP-1 RA + Basal insulin: Better HbA1c, less weight gain, less hypoglycemia than basal-bolus

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4.8 DOSE REFERENCE – QUICK TABLE

Oral Agents

Drug	Starting Dose	Maximum Dose	Frequency
Metformin	500 mg	2550 mg	BD-TID
Metformin XR	500 mg	2000 mg	OD
Empagliflozin	10 mg	25 mg	OD
Dapagliflozin	10 mg	10 mg	OD
Canagliflozin	100 mg	300 mg	OD
Sitagliptin	100 mg	100 mg	OD
Vildagliptin	50 mg	100 mg	OD-BD
Linagliptin	5 mg	5 mg	OD
Teneligliptin	20 mg	40 mg	OD
Gliclazide MR	30 mg	120 mg	OD
Glimepiride	1 mg	6 mg	OD
Pioglitazone	15 mg	45 mg	OD

Injectable Agents

Drug	Starting Dose	Titration	Maximum
Liraglutide	0.6 mg OD	↑ by 0.6 mg weekly	1.8 mg
Semaglutide SC	0.25 mg weekly	↑ every 4 weeks	1.0 mg
Dulaglutide	0.75 mg weekly	↑ after 4 weeks	4.5 mg
Basal insulin	10 U or 0.1-0.2 U/kg	↑ 2-4 U every 3-7 days	Until FPG at target

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4.9 FIXED-DOSE COMBINATIONS (FDC) AVAILABLE IN INDIA 🇮🇳

Common FDCs

Combination	Available Strengths	Notes
Metformin + Glimepiride	500/1, 500/2, 1000/1, 1000/2	Very common
Metformin + Gliclazide	500/40, 500/80
Metformin + Sitagliptin	500/50, 1000/50
Metformin + Vildagliptin	500/50, 1000/50
Metformin + Teneligliptin	500/20, 1000/20
Metformin + Pioglitazone	500/15, 500/30
Metformin + Empagliflozin	500/12.5, 1000/12.5
Metformin + Dapagliflozin	500/5, 1000/10
Glimepiride + Pioglitazone	1/15, 2/15, 2/30
Sitagliptin + Dapagliflozin	100/10
Metformin + Glimepiride + Pioglitazone	500/1/15, 500/2/15	Triple FDC
Metformin + Glimepiride + Voglibose	Various

📌 FDCs improve adherence but reduce flexibility. Use when patient is stable on component doses.

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SECTION 5: SPECIAL SITUATIONS

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5.1 DIABETES AND CKD

Drug Selection by eGFR

eGFR (mL/min)	Metformin	SGLT2i	DPP-4i	GLP-1 RA	SU	Pioglitazone	Insulin
≥ 60	✅ Full dose	✅	✅	✅	✅	✅	✅
45-59	✅ Full dose	✅	✅	✅	⚠️ Reduce	✅	✅
30-44	⚠️ Max 1000 mg	✅ (renal benefit continues)	⚠️ Dose adjust (except Linagliptin)	✅	⚠️ Avoid Glibenclamide	✅	✅
15-29	❌ Stop	⚠️ Can continue for HF/CKD benefit (not glycemic)	⚠️ Dose adjust	⚠️ Some approved	❌ Avoid	✅	✅
< 15 / Dialysis	❌	❌	⚠️ Linagliptin OK	⚠️ Limited data	❌	✅	✅

📌 In CKD: SGLT2i have renal protective benefits independent of glucose lowering. Continue even if HbA1c at target.

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5.2 DIABETES AND CVD/HIGH CV RISK

Prioritize Cardioprotective Agents

Patient Profile	First-Line Add-On to Metformin
Established ASCVD	✅ GLP-1 RA with proven CVD benefit OR SGLT2i
High CV Risk (no CVD yet)	✅ SGLT2i or GLP-1 RA
Heart Failure (HFrEF or HFpEF)	✅ SGLT2i (Empagliflozin, Dapagliflozin) – MANDATORY

Drugs with Proven CV Benefit

Drug	Trial	Benefit
Empagliflozin	EMPA-REG	↓ CV death, ↓ HF hospitalization
Dapagliflozin	DECLARE	↓ HF hospitalization
Canagliflozin	CANVAS	↓ MACE
Liraglutide	LEADER	↓ CV death, ↓ MACE
Semaglutide	SUSTAIN-6	↓ MACE (stroke)
Dulaglutide	REWIND	↓ MACE

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5.3 DIABETES AND HEART FAILURE

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5.4 ELDERLY PATIENTS (≥ 65 years)

Key Principles

Principle	Action
Individualize targets	HbA1c < 7.5-8% often appropriate; avoid hypoglycemia
Avoid hypoglycemia	Prefer agents with low hypo risk (SGLT2i, DPP-4i, GLP-1 RA)
Simplify regimen	Once-daily dosing; minimize polypharmacy
Renal function	Check eGFR; dose adjust medications
Cognitive/functional status	Assess ability to self-manage
Life expectancy	Relaxed targets if limited

Preferred Agents in Elderly

✅ Prefer	❌ Avoid/Caution
Metformin (if eGFR permits)	Glibenclamide (hypoglycemia)
DPP-4i (especially Linagliptin)	High-dose SU
SGLT2i (watch volume depletion)	Complex insulin regimens
GLP-1 RA (if weight is issue)	TZDs (falls, fractures)
Simplified insulin (basal only)

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5.5 DIABETES IN PREGNANCY

Pre-Existing T2DM in Pregnancy

Pre-Conception	During Pregnancy
Target HbA1c < 6.5% before conception	Target: Fasting < 95 mg/dL; 1-hr PP < 140 mg/dL; 2-hr PP < 120 mg/dL
Stop ACE-I/ARB, Statins	Metformin can be continued (crosses placenta; generally safe)
Switch to insulin if not controlled	Insulin is treatment of choice
Start Folic acid 5 mg/day	Continue high-dose folic acid first trimester

Safe Medications in Pregnancy

✅ Safe	❌ Contraindicated
Insulin (all types)	Sulfonylureas (Glyburide has data; others avoid)
Metformin (can continue)	SGLT2i
	GLP-1 RA
	DPP-4i
	Pioglitazone
	Statins
	ACE-I/ARB

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5.6 PERIOPERATIVE MANAGEMENT

Pre-Operative

Drug	Action
Metformin	Stop 24-48 hrs before major surgery (especially if contrast planned)
SGLT2i	Stop 3-4 days before surgery (risk of euglycemic DKA)
SU	Hold on morning of surgery
DPP-4i	Can continue
GLP-1 RA	Hold weekly formulations 1 week before; daily formulations day of surgery
Insulin	Reduce basal by 20-25% night before; Hold morning prandial

Intraoperative/Post-Operative

Principle	Target
Use IV insulin infusion for major surgery	Glucose 140-180 mg/dL
SC insulin for minor surgery	Glucose 140-180 mg/dL
Avoid hypoglycemia
Resume oral agents when eating normally
Resume SGLT2i when fully recovered and eating

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5.7 SICK DAY RULES

Teach All Patients

Rule	Action
Never stop insulin completely (if on insulin)	May reduce dose but don’t stop
Stop SGLT2i during acute illness	Risk of euglycemic DKA
Stop Metformin if vomiting, diarrhea, dehydration	Risk of lactic acidosis
Monitor glucose frequently	Every 2-4 hours
Check ketones if glucose > 250 mg/dL	Urine or blood ketones
Stay hydrated	Drink fluids even if not eating
Seek medical attention if:	Persistent vomiting, glucose > 300, ketones positive, confusion, unable to eat/drink

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SECTION 6: CARDIOVASCULAR RISK MANAGEMENT

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6.1 BLOOD PRESSURE

Target: < 130/80 mmHg

Treatment Algorithm

Step	Action
1	ACE-I or ARB first-line (renoprotection)
2	Add CCB (Amlodipine) or Thiazide-like diuretic if not at target
3	Triple therapy: ACE-I/ARB + CCB + Diuretic
4	Add Spironolactone or Beta-blocker if still uncontrolled

📌 All patients with DM + HTN should be on ACE-I or ARB (unless contraindicated)

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6.2 LIPIDS

Targets and Statin Therapy

Patient Category	LDL Target	Statin Intensity
DM + ASCVD	< 55 mg/dL	High-intensity (Atorvastatin 40-80 mg, Rosuvastatin 20-40 mg)
DM + High Risk (age 40-75 with risk factors)	< 70 mg/dL	High-intensity
DM + Moderate Risk (age 40-75, no other RF)	< 100 mg/dL	Moderate-intensity
DM age < 40	Consider if multiple risk factors	Individualize

If LDL Not at Target on Max Statin

Step	Add
1	Ezetimibe 10 mg
2	PCSK9 inhibitor (Evolocumab, Alirocumab) if still not at target and ASCVD

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6.3 ANTIPLATELET THERAPY

Aspirin in Diabetes

Scenario	Recommendation
Secondary prevention (established CVD)	✅ Aspirin 75-150 mg daily
Primary prevention (high CV risk, age > 50)	⚠️ Consider if high risk and low bleeding risk
Primary prevention (low CV risk)	❌ Not routinely recommended

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SECTION 7: MONITORING

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7.1 ROUTINE MONITORING SCHEDULE

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7.2 SELF-MONITORING OF BLOOD GLUCOSE (SMBG)

When to Recommend SMBG

Scenario	Frequency
On insulin (basal only)	Daily fasting; occasional post-meal
On insulin (multiple doses)	3-4 times/day (fasting + pre-meals)
On SU or Meglitinides	2-3 times/week; more if hypoglycemia risk
Oral agents (low hypo risk)	Not routinely required; can check occasionally
Sick days	Every 2-4 hours
Pregnancy	4-7 times/day

Target SMBG Values

Timing	Target
Fasting / Pre-meal	80-130 mg/dL
2-hr Post-meal	< 180 mg/dL
Bedtime	100-140 mg/dL

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7.3 CONTINUOUS GLUCOSE MONITORING (CGM)

When to Consider CGM

Indication

T1DM (all patients ideally)

T2DM on multiple daily insulin injections

Frequent hypoglycemia or hypoglycemia unawareness

Pregnancy

HbA1c above target despite SMBG

Highly variable glucose

CGM Targets

Metric	Target
Time in Range (TIR) 70-180 mg/dL	> 70%
Time Below Range (TBR) < 70 mg/dL	< 4%
Time Below Range (TBR) < 54 mg/dL	< 1%
Time Above Range (TAR) > 180 mg/dL	< 25%
Glucose Management Indicator (GMI)	Correlates with HbA1c

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SECTION 8: COMPLICATIONS – SCREENING AND MANAGEMENT

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8.1 DIABETIC RETINOPATHY

Screening

Action	Timing
Dilated fundoscopy or retinal photography	At diagnosis; then annually
More frequent	If retinopathy present
Pregnancy	Each trimester

Classification and Action

Stage	Findings	Action
No retinopathy	Normal	Annual screening
Mild NPDR	Microaneurysms only	Annual screening
Moderate NPDR	Microaneurysms + hemorrhages/exudates	6-12 month follow-up
Severe NPDR	4-2-1 rule (hemorrhages in 4 quadrants, venous beading in 2, IRMA in 1)	Refer to ophthalmology
PDR	Neovascularization	Urgent ophthalmology; laser/anti-VEGF
DME	Macular edema	Anti-VEGF; laser

Risk Reduction

Intervention	Benefit
Tight glycemic control	↓ Progression
BP control	↓ Progression
Lipid control	May help
Smoking cessation	↓ Progression
Fenofibrate	May ↓ progression (ACCORD Eye)

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8.2 DIABETIC NEPHROPATHY

Screening

Test	Frequency
eGFR	At diagnosis; then annually
Urine ACR	At diagnosis; then annually

Classification

Stage	ACR (mg/g)	eGFR	Action
Normal	< 30	≥ 60	Continue screening
Moderately increased (microalbuminuria)	30-300	Any	Start/ensure ACE-I or ARB
Severely increased (macroalbuminuria)	> 300	Any	ACE-I/ARB; consider nephrology referral
CKD Stage 3	Any	30-59	Add SGLT2i; monitor closely
CKD Stage 4-5	Any	< 30	Nephrology referral

Nephroprotective Therapy

All patients with DM + Albuminuria or CKD

✅ ACE-I or ARB (first-line)

✅ SGLT2i (add if eGFR ≥ 20)

✅ Finerenone (non-steroidal MRA) – if albuminuria persists on ACE-I/ARB

✅ BP target < 130/80

✅ Glycemic control

✅ Avoid nephrotoxins (NSAIDs, contrast)

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8.3 DIABETIC NEUROPATHY

Screening

Type	How to Screen	Frequency
Peripheral neuropathy	10-g monofilament + one of: vibration (128 Hz tuning fork), pinprick, ankle reflexes	Annual
Autonomic neuropathy	Resting tachycardia, orthostatic hypotension, gastroparesis symptoms, ED, bladder dysfunction	Symptoms

Treatment

Symptom	Options
Painful neuropathy	First-line: 💊 Pregabalin OR 💊 Duloxetine OR 💊 Gabapentin
	Second-line: 💊 Amitriptyline (low dose); Tramadol (short-term); Topical Capsaicin
Gastroparesis	Small frequent meals; 💊 Metoclopramide (short-term); 💊 Domperidone
Orthostatic hypotension	Slow position changes; Compression stockings; 💊 Midodrine; 💊 Fludrocortisone
Erectile dysfunction	💊 PDE5 inhibitors (Sildenafil, Tadalafil); Vacuum devices; Urology referral

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8.4 DIABETIC FOOT

Screening

Component	How	Frequency
Inspection	Skin, nails, deformities, ulcers, calluses	Every visit
Neuropathy testing	10-g monofilament	Annual
Vascular assessment	Pedal pulses; ABI if pulses absent	Annual

Risk Stratification

Risk Category	Features	Action
Low	Normal sensation, pulses present, no deformity	Annual screening; education
Moderate	Neuropathy OR absent pulses OR deformity	3-6 monthly review; podiatry referral
High	Neuropathy + absent pulses OR deformity + either	1-3 monthly; podiatry; consider vascular referral
Active problem	Ulcer, infection, Charcot, gangrene	Urgent multidisciplinary foot team

Foot Ulcer Management Principles

Step	Action
1	Offloading – Total contact cast; therapeutic footwear
2	Debridement – Remove necrotic tissue
3	Infection control – Antibiotics if infected (Empiric: Amoxicillin-clavulanate; Adjust based on culture)
4	Wound care – Moist dressings; Negative pressure wound therapy if indicated
5	Vascular assessment – ABI, Doppler; Revascularization if ischemic
6	Glycemic control – Optimize
7	Multidisciplinary team – Diabetologist, Surgeon, Podiatrist, Vascular surgeon

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SECTION 9: DIABETIC EMERGENCIES

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See the major ones under emergency section

9.1 EUGLYCEMIC DKA (SGLT2i-Associated)

Features

Feature	Details
Glucose	< 250 mg/dL (may be near-normal)
Acidosis	Present (pH < 7.3, bicarbonate < 18)
Ketones	Present
Context	Patient on SGLT2 inhibitor

Precipitants

Risk Factor

Surgery/perioperative

Acute illness, infection

Reduced carbohydrate intake

Dehydration

Excess alcohol

Management

Action

Stop SGLT2i

Treat as standard DKA (fluids, insulin, potassium)

Glucose may not be very high—still give insulin to suppress ketogenesis

Add dextrose early to IV fluids

Prevention

Rule

Stop SGLT2i 3-4 days before elective surgery

Hold during acute illness (“Sick day rules”)

Educate patients

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SECTION 10: PATIENT EDUCATION

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10.1 CORE EDUCATION TOPICS

At Diagnosis

Topic	Key Points
What is diabetes	Lifelong condition; body cannot use insulin properly
Importance of control	Prevents complications (heart, eyes, kidneys, nerves)
Targets	HbA1c, BP, cholesterol
Medications	How to take; why important; side effects
Diet	Basic principles; foods to limit
Physical activity	Benefits; how to start
SMBG	If indicated; how and when to check
Hypoglycemia	Symptoms; treatment; when to call for help
Follow-up	Importance of regular visits

Ongoing Education

Topic	Key Points
Sick day rules	What to do when unwell
Foot care	Daily inspection; proper footwear; never go barefoot
Medication adjustments	Especially insulin titration
Complication screening	Why eyes, kidneys, feet need checking
Mental health	Diabetes distress; depression
Alcohol and smoking	Moderation; cessation

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10.2 FOOT CARE EDUCATION

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10.3 WHEN TO SEEK MEDICAL ATTENTION

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SECTION 11: SUMMARY TABLES

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11.1 STEPWISE TREATMENT – QUICK REFERENCE

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11.2 DRUG CLASS QUICK COMPARISON

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11.3 MONITORING SCHEDULE

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11.4 TARGETS AT A GLANCE

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11.5 NEVER / ALWAYS

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📚 ABBREVIATIONS

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📖 REFERENCES

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Document Version: 1.0

Last Updated: December 2025

For: Healthcare Professionals Only

Disclaimer: Clinical judgment must be exercised for individual patients. Local protocols and drug availability should guide management. Do not self-medicate.

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