Clinical practice guideline for the prevention, early detection, diagnosis, management and follow up of type 2 diabetes mellitus in adults

Abstract

In Colombia, diabetes mellitus is a public health program for those responsible for creating and implementing strategies for prevention, diagnosis, treatment, and follow-up that are applicable at all care levels, with the objective of establishing early and sustained control of diabetes. A clinical practice guide has been developed following the broad outline of the methodological guide from the Ministry of Health and Social Welfare, with the aim of systematically gathering scientific evidence and formulating recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. The current document presents in summary form the results of this process, including the recommendations and the considerations taken into account in formulating them. In general terms, what is proposed here is a screening process using the Finnish Diabetes Risk Score questionnaire adapted to the Colombian population, which enables early diagnosis of the illness, and an algorithm for determining initial treatment that can be generalized to most patients with diabetes mellitus type 2 and that is simple to apply in a primary care context. In addition, several recommendations have been made to scale up pharmacological treatment in those patients that do not achieve the objectives or fail to maintain them during initial treatment. These recommendations also take into account the evolution of weight and the individualization of glycemic control goals for special populations. Finally, recommendations have been made for opportune detection of micro- and macrovascular complications of diabetes.

Keywords: Type 2 diabetes mellitus; clinical practice guidelines.

Figure 1.. Algorithm to screening and diagnosis of diabetes mellitus type 2. DMT2: diabetes mellitus type 2. FINDRISCC: FINnish Diabetes Risk SCore, OGTT: oral glucose tolerance test, HbA1c: glycosylated hemoglobin

Figure 2. Algorithm to initial management of patients with diabetes mellitus type 2. ¹ The mediterranean diet adapted to our surroundings must include mainly vegetables, legumes, whole-grain foods, fresh and dry fruits, olive oil, nuts; also moderate consumption of fish, poultry and low fat dairy products. Consumption of red meat, eggs, milled grains and sugars must be sporadic. ² Aerobic exercise includes activities such as riding a bicycle, walking, swimming, dancing and repeated rythmic movements (≥ 10) of each muscular group. The frequency must be ≥ 150 minutes per week, and the intensity should not exceed a heart rate equal to (220 − age) × 0,7. ³ Resistance training include weight lifting routines which should be gradual in the amount of weight and the frequency. HbA1c: glycosylated hemoglobin, BMI: Body Mass Index

Figure 3.. Algorithm to initial pharmacologic treatment. ¹ Clinically unstable: very symptomatic, with acute weight loss, signs of dehydration, evidence of ketosis and very high blood glucose. ² May require insulin in combination with other glucose- lowering drugs or in intensified regimes. Insulin use may be transient. HbA1c: glycosylated hemoglobin, GFR: glomerular filtration rate DPP4: dipeptidyl peptidase 4, SGLT-2: Sodium glucose co-transporter 2, BMI: Body Mass Index.

Figure 4.. Pharmacologic treatment when goal is not reached or is lost with initial treatment. DPP4: dipeptidyl peptidase 4, SGLT-2: Sodium glucose co-transporter 2, BMI: Body Mass Index, GLP-1: Glucagon-like peptide-1, HbA1c: glycosylated hemoglobin

Figure 5.. Screening for urinary albumin excretion rate. UAER: urinary albumin excretion rate, GFR: glomerular filtration rate, ACEI: Angiotensin-converting enzyme inhibitors