Primary care
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The landscape of diabetes treatment has evolved significantly in recent years. While metformin remains first-line for the treatment of type 2 diabetes, 2 new classes of medications (sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide agonists) are becoming mainstays in therapy. These classes boast strong efficacy and desired long-term outcomes, offering cardiovascular and renal protection, as well as other benefits such as weight loss and low risk of hypoglycemia. Most recent guidelines have highlighted the importance of using shared decision making and patient-centered choices when determining medication outcomes.
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The incidence and prevalence of diabetes are increasing significantly globally and within the United States. Many individuals with diabetes are undiagnosed. The underlying causes of diabetes vary widely and are different in type 1 diabetes, type 2 diabetes, atypical diabetes, and gestational diabetes. It is important for clinicians to recognize the signs and symptoms of diabetes and use the proper diagnostic tools to diagnose diabetes.
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Management of diabetes in hospitalized patients requires interdisciplinary, coordinated care that includes communication between physicians in the hospital and primary care providers. As the clinical condition of hospitalized patients can change quickly, insulin dosing must be altered in a timely manner to avoid adverse events.
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Assessing glycemia over time remains a standard recommendation in the care of all people with diabetes. Glycemic assessment methods range from laboratory- and office-based methods to patient-based methods. ⋯ Continuous glucose monitoring (CGM) can also be used, especially via glucose management indicator or time-in-range, which can be useful especially when A1c might be impractical, unreliable, or inaccurate, or for glycemia assessment over a shorter interval. Other measures of glycemia, including hypoglycemia and glycemic variability, are becoming increasingly important in many cases and are also available via CGM.
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The incidence of all diabetes types are increasing, including the rate of women with diabetes in pregnancy. Preconception counseling continues to be an important part of visits with women who have diabetes and those at risk for gestational diabetes. Intensive control of blood sugar reduces the risk of negative outcomes in mother and baby. ⋯ Insulin dose adjustments are required to reach glycemic goals during pregnancy and tend to change throughout its course with higher doses needed with increasing insulin resistance in the second and third trimesters. Breastfeeding is encouraged for all women regardless of diabetes type. Insulin doses generally need adjustment after delivery due to placental delivery leading to decreased insulin and lactation increasing energy requirements.