2023 Clinical Practice Guidelines for Diabetes Mellitus of the Korean Diabetes Association

Abstract

In May 2023, the Committee of Clinical Practice Guidelines of the Korean Diabetes Association published the revised clinical practice guidelines for Korean adults with diabetes and prediabetes. We incorporated the latest clinical research findings through a comprehensive systematic literature review and applied them in a manner suitable for the Korean population. These guidelines are designed for all healthcare providers nationwide, including physicians, diabetes experts, and certified diabetes educators who manage patients with diabetes or individuals at risk of developing diabetes. Based on recent changes in international guidelines and the results of a Korean epidemiological study, the recommended age for diabetes screening has been lowered. In collaboration with the relevant Korean medical societies, recently revised guidelines for managing hypertension and dyslipidemia in patients with diabetes have been incorporated into this guideline. An abridgment containing practical information on patient education and systematic management in the clinic was published separately.

Keywords: Diabetes mellitus; Practice guideline; Prediabetic state; Republic of Korea.

Fig. 1.

Pharmacologic treatment fOr Adults With Type 2 Diabetes Mellitus (T2dm). This Algorithm Stratifies The Glycemic Control Strategy In Patients With T2dm Based On A1c Levels And Underlying Comorbidities. Self-management Education And Monitoring For Diabetes Should Be Continuously Implemented From The Time Of Diagnosis In All Patients With T2dm. If The A1c Level Is >9.0% And Symptomatic Hyperglycemia Or Metabolic Decompensation Is Present, Insulin Therapy With Or Without Oral Antidiabetic Drugs (Oads) Is Recommended. If Established Atherosclerotic Cardiovascular Disease (Eascvd), Heart Failure (Hf), Or Chronic Kidney Disease (Ckd) Are Combined, Sodium-glucose Cotransporter 2 Inhibitor (Sglt2i) Or Glucagon-like Peptide-1 Receptor Agonist (Glp-1ra), Which Have Proven Benefits Under These Conditions, Are Preferred. If The A1c Difference Between The Current And Target A1c Level Is ≥1.5% Or The Current A1c Level Is ≥7.5%, Initial Combination Therapy Is Recommended. If The Current A1c Level Is <7.5%, Metformin Monotherapy Is The Preferred Option, Depending On The Patient’s Condition. However, Early Combination Therapy Should Be Considered To Reduce The Risk Of Treatment Failure. Injectable Therapy, Glp-1ra Or Insulin Is Recommended When Potent Glucose-lowering Efficacy Is Required. When Considering Injectable-based Combination Therapy, Glp-1ra Is Preferred. If The Glycemic Target Is Not Achieved With Glp-1ra Or Basal Insulin Alone, The Two Drugs Can Be Combined. If The Glycemic Target Is Not Achieved With Glp-1ra Or Basal Insulin, Intensive Insulin Therapy Such As Basal-plus, Premixed, Or Basal-bolus Regimen Should Be Initiated. Tzd, Thiazolidinedione; Dpp-4i, Dipeptidyl Peptidase-4 Inhibitor; Su, Sulfonylurea; Α-gi, Α-glucosidase Inhibitor. ^aEstablished Atherosclerotic Cardiovascular Disease: History Of Acute Coronary Syndrome Or Myocardial Infarction, Stable Or Unstable Angina, Coronary Heart Disease With Or Without Revascularization, Other Arterial Revascularization, Stroke, Or Peripheral Artery Disease Assumed To Be Atherosclerotic In Origin, ^bHf: Current Or Prior Symptoms Of Hf With Documented Hf With Reduced Ejection Fraction (Hfref, Left Ventricular Ejection Fraction [Lvef] ≤40) Or Hf With Preserved Ejection Fraction (Hfpef, Lvef >40), ^cChronic Kidney Disease: Estimated Glomerular Filtration Rate (Egfr) <60 Ml/Min/1.73 M² Or Urine Albumin-creatinine Ratio ≥30 Mg/G, ^dDulaglutide, Liraglutide, Semaglutide, ^eDapagliflozin, Empagliflozin, ^fDapagliflozin, Empagliflozin, Ertugliflozin, ^gPioglitazone.

Fig. 2.

Hypertension management in patients with diabetes. Blood pressure (BP) should be measured at every clinic visit, and home BP monitoring is recommended. The recommended target BP level is <140/90 mm Hg in adults with diabetes without cardiovascular disease (CVD) or associated risk factors. The recommended target BP is <130/80 mm Hg in diabetic adults with CVD, target organ damage (albuminuria, chronic kidney disease, retinopathy, and left ventricular hypertrophy), or risk factors for CVD. Adults with diabetes and a BP >120/80 mm Hg should undergo lifestyle modifications. Pharmacological therapy should be implemented if the target BP is not achieved. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are preferred when accompanied with albuminuria or coronary artery disease. If the BP exceeds 160/100 mm Hg, initial combination therapy is recommended. If BP is not controlled by primary antihypertensive medications, combination therapy using other drugs with different mechanisms is recommended. ^aAlbuminuria, chronic kidney disease, retinopathy, left ventricular hypertrophy, ^bAge (men ≥45 years, women ≥55 years), smoking, obesity, dyslipidemia, family history of early-onset coronary heart disease.

Fig. 3.

Lipid management in patients with diabetes. Serum lipid profiles should be obtained at the time of the first diagnosis of diabetes and at least once a year thereafter. Past history of cardiovascular disease (CVD) and target organ damage (albuminuria, estimated glomerular filtration rate <60 mL/min/1.73 m², retinopathy, and left ventricular hypertrophy), the major risk factors for CVD (age, family history of early-onset coronary artery disease, hypertension, smoking, and high-density lipoprotein cholesterol [HDL-C] <40 mg/dL) and duration of diabetes should be investigated to determine the low-density lipoprotein cholesterol (LDLC) goal. Education on active lifestyle modifications should also be provided. Pharmacological therapy should be implemented if LDL-C goals are not achieved. Statins should be used as first-line therapy. Ezetimibe should be added if the goal is not achieved with the maximum tolerable dose of statin therapy. If diabetic patients with CVD do not achieve this goal even after treatment with a statin plus ezetimibe, combination therapy with a statin and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors should be considered. Adults with severe hypertriglyceridemia (triglyceride levels ≥500 mg/dL) were treated with fenofibrate or omega-3 fatty acids. ^aAge (men ≥45 years, women ≥55 years), family history of early-onset coronary heart disease, hypertension, smoking, HDL-C <40 mg/dL, ^bAlbuminuria, estimated glomerular filtration rate <60 mL/min/1.73 m², retinopathy, and left ventricular hypertrophy, ^cTarget organ damage or three or more major risk factors for CVD.

Fig. 4.

Management of diabetic kidney disease. Urine albumin/creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) should be evaluated in individuals with type 2 diabetes mellitus (T2DM) at the time of diagnosis and at least once yearly. Therefore, blood glucose levels and blood pressure should be optimally controlled. Sodium-glucose cotransporter 2 inhibitors (SGLT2is) that have shown renal benefits should first be used to inhibit diabetic kidney disease (DKD) progression in patients with albuminuria or a reduced eGFR. DKD patients consume adequate protein amounts. Angiotensin-converting enzyme inhibitors (ACEis) or angiotensin II receptor blockers (ARBs) should be prescribed for patients with diabetes, hypertension, and albuminuria. Non-steroidal mineralocorticoid receptor antagonists (nsMRAs), such as finerenone, which has shown cardiac and renal benefits, can be considered in patients with T2DM with albuminuria, decreased eGFR, and normal blood potassium levels. Request consultation with nephrologists for those with unknown causes of kidney disease or progressive nephropathy.

Fig. 5.

Evaluation of non-alcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes mellitus (T2DM). All adults with T2DM should be evaluated for the presence of NAFLD. Liver function tests or abdominal ultrasound should be performed to evaluate NAFLD and to exclude secondary causes. Non-invasive and simple tests, such as the fibrosis index-4 (FIB-4) or the NAFLD fibrosis score (NFS), can be used to evaluate liver fibrosis. Vibration-controlled transient elastography should be considered when evaluating liver fibrosis in T2DM adults, excluding those in low-risk groups. ^aLow risk: FIB-4 <1.3, NFS <2.67, ^bLow risk: liver stiffness measurement <8.0 kPa, Enhanced Liver Fibrosis (ELF) score <10.5.