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Diabetes Mellitus Type 2 in Adults

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General Information

Description

  • type 2 diabetes is characterized by hyperglycemia resulting from progressive loss of insulin secretion, often in the setting of insulin resistance1
  • chronic hyperglycemia of diabetes can lead to multiorgan damage resulting in renal, neurologic, cardiovascular, and other serious complications2

Also called

  • diabetes mellitus type II
  • type 2 diabetes
  • type II diabetes
  • non-insulin-dependent diabetes mellitus (NIDDM)
  • adult-onset diabetes

Types

  • neonatal diabetes mellitus
    • generally refers to diabetes diagnosed in first 6 months of life2
      • can be transient or permanent
      • transient form usually caused by genetic defect on ZAC/HYAMI imprinting
      • permanent form usually caused by genetic defect in Kir6.2 subunit of beta cell KATP channel and often can be managed with sulfonylureas
    • occurs in 1 in 300,000-400,000 live births (a9h30094027pmdc17349054pOrphanet J Rare Dis 2007 Mar 9;2:12OpenInNewfull-textOpenInNew)
  • maturity-onset diabetes of the young (MODY)
    • characterized by autosomal dominant transmission, onset usually before age 35 years, normal or high insulin levels, mild hyperglycemia, and extrapancreatic features
    • 14 subtypes based on different gene mutations
      • MODY 1 - defect in hepatocyte nuclear factor 4-alpha (HNF4A), a transcription factor
        • most commonly treated with oral hypoglycemic agent or insulin
        • accounts for 5%-10% of MODY cases
      • MODY 2 - defect in glucokinase (GCK), a glycolytic enzyme
        • most commonly treated with diet and exercise; heterozygous mutations present with hyperglycemia (but < 50% with diabetes), typically asymptomatic and usually responsive to diet
        • accounts for 30%-50% of MODY cases
      • MODY 3 - defect in hepatocyte nuclear factor 1-alpha (HNF1A), a transcription factor
        • most commonly treated with oral hypoglycemic agent or insulin
        • accounts for 30%-65% of MODY cases
      • MODY 4 - defect in insulin promoter factor 1 (PDX1), a transcription factor
        • most commonly treated with oral hypoglycemic agent or insulin in heterozygous variant; homozygous form presents in neonates with pancreatic agenesis and requires insulin
        • accounts for 1% of MODY cases
      • MODY 5 - defect in hepatocyte nuclear factor 1-beta (HNF1B), a transcription factor
        • may be characterized by renal and urogenital tract abnormalities, pancreatic hypoplasia, and intrauterine growth restriction; most commonly treated with insulin
        • accounts for < 5% of MODY cases
      • MODY 6 - defect in neurogenic differentiation factor 1 (NEUROD1), a transcription factor also called beta-cell E-box transactivator 2
        • most commonly treated with insulin
        • accounts for < 1% MODY of cases
      • MODY 7 - defect in Kruppel like factor 11 (KLF11)
        • accounts for < 1% of MODY cases
      • MODY 8 - defect in carboxyl ester lipase (CEL)
        • characterized by both exocrine insufficiency (due to pancreatic atrophy) and endocrine insufficiency (diabetes due to fibrosis and lipomatosis) of the pancreas
        • accounts for < 1% of MODY cases
      • MODY 9 - defect in paired box 4 (PAX4), part of the family of paired box transcription factors
        • accounts for < 1% of MODY cases
      • MODY 10 - defect in insulin (INS)
        • pathogenic variants in this gene may also be associated with permanent neonatal diabetes mellitus
        • accounts for < 1% of MODY cases
      • MODY 11 - defect in non-receptor tyrosine kinase in SRC family of proto-oncogenes (BLK)
        • clinical features include overweight or obesity in some patients
        • accounts for < 1% of MODY cases
      • MODY 12 - defect in adenosine triphosphate (ATP-binding cassette subfamily C member 8 (ABCC8)
        • pathogenic variants in this gene may also be associated with permanent neonatal diabetes mellitus and familial hyperinsulinism
        • accounts for < 1% of MODY cases
      • MODY 13 - defect in potassium voltage-gated channel subfamily J member 11 (KCNJ11)
        • similar to HNF1A-MODY3 and HNF4A-MODY1
        • accounts for < 1% of MODY cases
      • MODY 14 - defect in adaptor protein, phosphotyrosine interacting with PH domain and leucine zipper 1 (APPL1)
        • two APPL1 loss-of-function variants reported; clinical features include overweight or obesity in some patients
        • accounts for < 1% of MODY cases
      • Reference - GeneReviews 2018 May 24OpenInNew
    • MODY also called monogenic diabetes (International Diabetes Federation [IDF] 2011 PDFPictureAsPdf)
    • review of diagnosis and management of MODY can be found in 22012810BMJ 2011 Oct 19;343:d6044OpenInNew

References

General references used

  1. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2019 Jan; 42 (Suppl 1):S1-S193 PDFPictureAsPdf
  2. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2014 Jan;37 Suppl 1:S81-90OpenInNewfull-textOpenInNew

Recommendation grading systems used

  • American Diabetes Association (ADA) evidence grading system for clinical practice recommendations
    • Grade A
      • clear evidence from well-conducted, generalizable, randomized controlled trials (RCTs) that are adequately powered, including evidence from well-conducted multicenter trial or meta-analysis that incorporated quality ratings in analysis
      • compelling nonexperimental evidence, specifically, "all or none" rule developed by Center for Evidence Based Medicine at Oxford
      • supportive evidence from well-conducted RCTs that are adequately powered, including evidence from well-conducted trial at ≥ 1 institution or meta-analysis that incorporated quality ratings in analysis
    • Grade B
      • supportive evidence from well-conducted cohort studies, including evidence from well-conducted prospective cohort study or registry or meta-analysis of cohort studies
      • supportive evidence from a well-conducted case-control study
    • Grade C
      • supportive evidence from poorly controlled or uncontrolled studies
        • evidence from randomized clinical trials with ≥ 1 major or ≥ 3 minor methodologic flaws that could invalidate results
        • evidence from observational studies with high potential for bias (such as case series with comparison to historical controls)
        • evidence from case series or case reports
      • conflicting evidence with weight of evidence supporting recommendation
    • Grade E - expert consensus or clinical experience
    • Reference - ADA 2019 standards of medical care in diabetes: introduction (Diabetes Care 2019 Jan;42(Suppl 1);S1OpenInNew)
  • American College of Sports Medicine/American Diabetes Association (ACSM/ADA) grades of recommendation
    • Grade A
      • provides a consistent pattern of findings with substantial studies
      • randomized, controlled trials (overwhelming data)
    • Grade B
      • few randomized trials exist, which are small in size and results are inconsistent
      • randomized, controlled trials (limited data)
    • Grade C - outcomes are from uncontrolled, nonrandomized, and/or observational studies
    • Grade D - panel's expert opinion when the evidence is insufficient to place it in categories A-C
    • Reference - ACSM/ADA joint position statement on exercise and type 2 diabetes (mdc21115758p tDiabetes Care 2010 Dec;33(12):e147OpenInNewfull-textOpenInNew)
  • American College of Physicians (ACP) guideline grading system
    • strength of recommendation
      • Strong - benefits clearly outweigh risks and burden, or risks and burden clearly outweigh benefits
      • Weak - benefits closely balanced with risks and burden or uncertainty in estimates of benefits, risks, and burdens
      • Insufficient - balance of benefits and risks cannot be determined
    • quality of evidence
      • High - randomized trials without important limitations, or overwhelming evidence from observational studies
      • Moderate - randomized trials with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise), or exceptionally strong evidence from observational studies
      • Low - observational studies or case series
      • Insufficient - evidence is conflicting, poor quality, or lacking
    • Reference - ACP methods for development of clinical practice guidelines and guidance statements (20679562Ann Intern Med 2010 Aug 3;153(3):194OpenInNew)
  • Hypertension Canada grades of recommendations
    • Grade A - recommendations based on randomized trials (or systematic reviews) with high levels of internal validity and statistical precision for which study results can be directly applied to patients because of similar clinical characteristics and clinical evidence of study outcomes
    • Grade B - recommendations based on randomized trials, systematic reviews, or prespecified subgroup analyses of randomized trials that have lower precision, or if there is a need to extrapolate from studies because of differing populations or reporting of validated intermediate/surrogate outcomes rather than clinically important outcomes
    • Grade C - recommendations from trials with lower levels of internal validity and/or precision, or that report unvalidated surrogate outcomes, or results from nonrandomized observational studies
    • Grade D - recommendations based on expert opinion alone
    • Reference - Hypertension Canada guideline on diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children (Can J Cardiol 2018 May;34(5):506OpenInNew)
  • European Society of Cardiology/European Society of Hypertension (ESC/ESH) grading system
    • classifications of recommendations
      • Class I - evidence and/or general agreement that procedure or treatment is beneficial, useful, effective
      • Class II - conflicting evidence and/or divergence of opinion about usefulness/efficacy of given treatment of procedure
        • Class IIa - weight of evidence/opinion in favor of usefulness/efficacy
        • Class IIb - usefulness/efficacy less well established by evidence/opinion
      • Class III - evidence or general agreement that procedure or treatment is not useful/effective, and in some cases may be harmful
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or large nonrandomized studies
      • Level C - consensus opinions of experts, and/or small studies, retrospective studies, or registries
    • Reference - ESC/ESH guideline on management of arterial hypertension (Eur Heart J 2018 Sep 1;39(33):3021OpenInNew)
  • American Association of Clinical Endocrinologists (AACE) guideline grading system
    • grades of recommendation
      • Grade A - best evidence level 1, or best evidence level 2 but adjusted upwards for positive subjective factors
      • Grade B - best evidence level 2, or best evidence level 1 adjusted downwards for negative subjective factors, or best evidence level 3 adjusted upwards for positive subjective factors
      • Grade C - best evidence level 3, or best evidence level 2 adjusted downwards for negative subjective factors, or best evidence level 4 adjusted upwards for positive subjective factors
      • Grade D - best evidence level 4, or best evidence level 3 adjusted downwards for negative subjective factors, or < two-thirds consensus (regardless of evidence level)
    • levels of evidence
      • Level 1 - randomized trials or meta-analysis of randomized trials
      • Level 2 - nonrandomized controlled trial, prospective cohort study, retrospective case-control study, or meta-analysis of these types of studies
      • Level 3 - cross-sectional study, surveillance study, consecutive case series, or single case reports
      • Level 4 - no evidence (theory, opinion, consensus, review, or preclinical study)
  • National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) grading systems for guidelines and clinical practice recommendations
    • NKF KDOQI grading system used in 2012
      • strength of recommendation
        • Level 1 - most patients should receive the recommended course of action
        • Level 2 - different choices appropriate for different patients, varies with values and preferences
      • quality of evidence
        • A - High-quality evidence
        • B - Moderate-quality evidence
        • C - Low-quality evidence
        • D - Very low-quality evidence
      • Reference - NKF KDOQI clinical practice recommendations for diabetes and chronic kidney disease 2012 update (23067652Am J Kidney Dis 2012 Nov;60(5):850OpenInNewPDFPictureAsPdf)
    • NKF KDOQI grading system used in 2007
      • Grade A
        • strongly recommended that clinicians routinely follow guideline for eligible patients
        • strong evidence that practice improves health outcomes
      • Grade B
        • recommended that clinicians routinely follow guideline for eligible patients
        • moderately strong evidence that practice improves health outcomes
      • Grade C
        • recommended that clinicians consider following clinical practice recommendation for eligible patients
        • based on weak evidence or opinions of the work group and reviewers that practice might improve health outcomes
    • Reference - NKF KDOQI clinical practice recommendations for diabetes and chronic kidney disease (NKF KDOQI 2007OpenInNew)
  • Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommendations
    • strength of recommendation
      • Level 1 ("we recommend") - most patients should receive recommended course of action
      • Level 2 ("we suggest") - different choices appropriate for different patients, based on patient's values and preferences
      • Not Graded - topic does not allow adequate application of evidence, not meant to be interpreted as being stronger recommendations than Level 1 or 2
    • quality of evidence
      • Grade A - high-quality evidence, true effect lies close to that of estimate of effect
      • Grade B - moderate-quality evidence, true effect likely to be close to estimate of effect, but there is possibility it is substantially different
      • Grade C - low-quality evidence, true effect may be substantially different from estimate of effect
      • Grade D - very low-quality evidence, estimate of effect very uncertain and often far from truth
    • Reference - KDIGO guideline on management of blood pressure in chronic kidney disease) KDIGO (2011) 2012 Dec PDFPictureAsPdf)
  • American College of Cardiology/American Heart Association (ACC/AHA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
    • Reference - 2013 ACC/AHA guideline on treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults (24239923J Am Coll Cardiol 2014 Jul 1;63(25 Pt B):2889OpenInNewPDFPictureAsPdf, 24222016Circulation 2014 Jun 24;129(25 Suppl 2):S1OpenInNewPDFPictureAsPdf)
  • Academy of Nutrition and Dietetics (AND) grading system for recommendations
    • strength of recommendation
      • Strong recommendation - benefits clearly exceed harm (or harms exceed benefits in case of strong negative recommendation); quality of supporting evidence is excellent/good
      • Fair recommendation - benefits exceed harms (or harms clearly exceed benefits in case of negative recommendation); quality of supporting evidence is not as strong
      • Weak recommendation - quality of evidence is doubtful, or well-done studies show little clear advantage to one approach versus another
      • Consensus recommendation - expert opinion supports guideline recommendation; available evidence did not present consistent results, or controlled trials were lacking
      • Insufficient evidence - lack of pertinent evidence and/or unclear balance between benefits and harms
    • category of recommendation
      • Imperative statement - broadly applicable to target population
      • Conditional statement - clearly define specific situations or populations
    • Reference - AND practice guideline on diabetes type 1 and 2 nutrition for adults (AND 2015OpenInNew)
  • United States Preventive Services Task Force (USPSTF) grades of recommendation (after July 2012)
    • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
    • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
    • Grade C - USPSTF recommends selectively offering or providing the service (based on professional judgment and patient preference) with at least moderate certainty of small net benefit
    • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
    • Grade I - insufficient evidence to assess balance of benefits and harms
    • Reference - USPSTF Grade DefinitionsOpenInNew
  • Eighth Joint National Committee (JNC 8) 2014 grades of recommendation
    • Strong recommendation - Grade A - high certainty based on evidence that net benefit is substantial
    • Moderate recommendation - Grade B - moderate certainty based on evidence that net benefit is moderate-to-substantial OR high certainty that net benefit is moderate
    • Weak recommendation - Grade C - at least moderate certainty based on evidence that there is small net benefit
    • Recommendation against - Grade D - at least moderate certainty based on evidence that no net benefit or that risks/harms outweigh benefits
    • Expert opinion - Grade E - "There is insufficient evidence or evidence is unclear or conflicting, but this is what the committee recommends", net benefit unclear
    • No recommendation for or against - Grade N - "There is insufficient evidence or evidence is unclear or conflicting", net benefit unclear
    • Reference - JNC8 2014 evidence-based guideline for the management of high blood pressure in adults (24352797JAMA 2014 Feb 5;311(5):507OpenInNew)
  • Endocrine Society levels of recommendation
    • strength of recommendation
      • Strong recommendation - guideline panel members have high confidence that desirable effects of recommendation outweigh undesirable effects (or vice versa)
      • Weak recommendation - guideline panel members conclude with less confidence that desirable effects of recommendation probably outweigh undesirable effects, or benefits and harms are finely balanced, or appreciable uncertainty
    • quality of evidence
      • High-quality evidence - consistent evidence from well-performed randomized controlled trials, or exceptionally strong evidence from unbiased observational studies
      • Moderate-quality evidence - randomized controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise evidence), or unusually strong evidence from unbiased observational studies
      • Low-quality evidence - ≥ 1 critical outcome from observational studies, randomized controlled trials with serious flaws, or indirect evidence
      • Very low-quality evidence - ≥ 1 of the critical outcomes from unsystematic clinical observations or very indirect evidence
    • Reference - Endocrine Society clinical practice guideline on evaluation and management of adult hypoglycemic disorders (19088155J Clin Endocrinol Metab 2009 Mar;94(3):709OpenInNewfull-textOpenInNew)
  • Canadian Task Force on Preventive Health Care (CTFPHC) uses Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) classification system for recommendations
    • strength of recommendation
      • Strong recommendation - guideline panel members have high confidence that desirable effects of recommendation outweigh undesirable effects (or vice versa)
      • Weak recommendation - guideline panel members conclude with less confidence that desirable effects of recommendation probably outweigh undesirable effects, or benefits and harms are finely balanced, or appreciable uncertainty
    • quality of evidence
      • High-quality evidence - consistent evidence from well-performed randomized controlled trials, or exceptionally strong evidence from unbiased observational studies
      • Moderate-quality evidence - randomized controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise evidence), or unusually strong evidence from unbiased observational studies
      • Low-quality evidence - ≥ 1 critical outcome from observational studies, randomized controlled trials with serious flaws, or indirect evidence
      • Very low-quality evidence - ≥ 1 of the critical outcomes from unsystematic clinical observations or very indirect evidence
    • Reference - CTFPHC recommendations on screening for type 2 diabetes in adults (mnh23073674pmdc23073674pCMAJ 2012 Oct 16;184(15):1687OpenInNewfull-textOpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • Samir Malkani, MBBS, MD, MRCP (Clinical Professor of Medicine, University of Massachusetts Medical School; Physician Leader, Diabetes Services, UMassMemorial Health Care; Massachusetts, United States)
  • Dr. Malkani declares no relevant financial conflicts of interest.
  • Zbys Fedorowicz, MSc, DPH, BDS, LDSRCS (Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain)
  • Dr. Fedorowicz declares no relevant financial conflicts of interest.
  • Alan Ehrlich, MD, FAAFP (Executive Editor; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States)
  • Dr. Ehrlich declares no relevant financial conflicts of interest.
  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
Choosing Wisely Canada acknowledges dissemination of their recommendations through DynaMed Plus to reach the point of clinical decision-making.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T113993, Diabetes Mellitus Type 2 in Adults; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T113993. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • KeyboardArrowRight

      Management

      • Glycemic goals

      • Lifestyle modification

      • Glucose-lowering medications

      • Management of comorbidities

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

    • Types

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • Incidence/Prevalence

    • Factors associated with increased risk

    • Factors not associated with increased risk

    • KeyboardArrowRight

      Associated conditions

      • Associated cardiovascular conditions

      • Obstructive sleep apnea (OSA)

      • Other associated conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Family history (FH)

      • Social history (SH)

      • Review of systems (ROS)

    • KeyboardArrowRight

      Physical

      • General physical

      • Skin

      • HEENT

      • Neck

      • Cardiac

      • Lungs

      • Abdomen

      • Extremities

      • Neuro

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • KeyboardArrowRight

      Blood tests

      • Testing for type 2 diabetes

      • 1,5-anhydroglucitol

      • Tests to help determine type of diabetes

      • Testing for diabetic complications

    • Urine studies

    • Electrocardiography (ECG)

    • Echocardiography

  • KeyboardArrowRight

    Management

    • Glycemic goals

    • Lifestyle modifications

    • KeyboardArrowRight

      Medications

      • Glucose-lowering medications

      • Weight loss medications

    • KeyboardArrowRight

      Management of comorbidities

      • Cardiovascular disease risk factors

      • Cardiovascular disease

      • Overweight or obesity

      • Diabetic retinopathy

      • Diabetic nephropathy

      • Diabetic neuropathy

    • Monitoring for associated conditions

    • Management of hypoglycemia

    • Hospitalized patients

  • KeyboardArrowRight

    Complications and Prognosis

    • KeyboardArrowRight

      Complications

      • Increased mortality

      • Macrovascular complications

      • Microvascular complications

      • Metabolic complications

      • Cancer

      • Infectious complications

      • Dermatologic complications

      • Erectile dysfunction

      • Musculoskeletal complications

      • Cognitive decline/dementia

      • Additional complications

    • KeyboardArrowRight

      Prognosis

      • KeyboardArrowRight

        Mortality

        • Multiple risk factors

        • Coronary heart disease (CHD)

        • Microalbuminuria

        • Glycemic control

        • Other laboratory markers

        • Medications

        • Body mass index and fitness

        • Age

        • Depression

        • Mortality risk prediction

      • Cardiovascular disease

      • Nephropathy

      • Other complications

      • Glucose control

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

    • Screening

  • KeyboardArrowRight

    Quality Improvement

    • Physician Quality Reporting System Quality Measures

    • Quality and Outcomes Framework Indicators

    • Choosing Wisely

    • Choosing Wisely Australia

    • Choosing Wisely Italy

    • Quality improvement evidence

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • KeyboardArrowRight

        United States guidelines

        • Comprehensive guidelines (United States)

        • Diagnosis guidelines (United States)

        • Management (United States)

        • Nutrition guidelines (United States)

        • Self-management guidelines (United States)

        • Complications and associated conditions (United States)

        • Specific setting or populations (United States)

        • Prevention and screening guidelines (United States)

        • Other guidelines (United States)

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Central and South American guidelines

      • Australian and New Zealand guidelines

      • Middle Eastern guidelines

      • Quality indicators

    • Review articles

    • MEDLINE search

  • Patient Decision Aids

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Produced in collaboration with American College of Physicians
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