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VA/Dod CLINICAL PRACTICE GUIDELINE for the MANAGEMENT of TYPE 2 DIABETES MELLITUS in PRIMARY CARE

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VA/Dod CLINICAL PRACTICE GUIDELINE for the MANAGEMENT of TYPE 2 DIABETES MELLITUS in PRIMARY CARE VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF TYPE 2 DIABETES MELLITUS IN PRIMARY CARE Department of Veterans Affairs Department of Defense QUALIFYING STATEMENTS The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision-making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendations. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent Department of Veterans Affairs or TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. Version 5.0 – 2017 April 2017 Page 1 of 160 VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care Prepared by: The Management of Type 2 Diabetes Mellitus in Primary Care Work Group With support from: The Office of Quality, Safety and Value, VA, Washington, DC & Office of Evidence Based Practice, U.S. Army Medical Command Version 5.0 – 2017 Based on evidence reviewed through March 2016 April 2017 Page 2 of 160 VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care Table of Contents I. Introduction ............................................................................................................................. 5 II. Background .............................................................................................................................. 5 A. Description of Diabetes Mellitus ................................................................................................ 5 B. Epidemiology and Impact ........................................................................................................... 7 III. About this Clinical Practice Guideline ........................................................................................ 8 A. Methods ...................................................................................................................................... 8 B. Summary of Patient Focus Group Methods and Findings ........................................................ 12 C. Conflict of Interest .................................................................................................................... 13 D. Scope of this Clinical Practice Guideline ................................................................................... 14 E. Highlighted Features of this Clinical Practice Guideline ........................................................... 15 F. Shared Decision-making and Patient-centered Care ................................................................ 15 G. Implementation ........................................................................................................................ 16 IV. Guideline Work Group ............................................................................................................ 17 V. Algorithm ............................................................................................................................... 18 A. Algorithm .................................................................................................................................. 19 VI. Recommendations ................................................................................................................. 21 A. General Approach to T2DM Care ............................................................................................. 23 B. Glycemic Control Targets and Monitoring................................................................................ 28 C. Non-pharmacological Treatments ............................................................................................ 36 D. Inpatient Care ........................................................................................................................... 41 E. Selected Complications............................................................................................................. 46 VII. Pharmacological Therapy ........................................................................................................ 52 A. Summary of the Evidence - Monotherapy and Non-Insulin Two-Drug Combination Therapy ..................................................................................................................................... 54 B. Triple Therapy ........................................................................................................................... 56 C. Insulin Therapy ......................................................................................................................... 57 D. Cardiovascular Outcomes Trials ............................................................................................... 61 VIII. Knowledge Gaps and Recommended Research ....................................................................... 65 Appendix A: Evidence Review Methodology .................................................................................. 67 A. Developing the Scope and Key Questions ................................................................................ 67 B. Conducting the Systematic Review .......................................................................................... 71 April 2017 Page 3 of 160 VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care C. Convening the Face-to-face Meeting ....................................................................................... 75 D. Grading Recommendations ...................................................................................................... 76 E. Recommendation Categorization ............................................................................................. 79 F. Drafting and Submitting the Final Clinical Practice Guideline .................................................. 81 Appendix B: Pharmacotherapy.......... ............................................................................................ 83 A. Alpha-glucosidase inhibitors ..................................................................................................... 83 B. Amylin analog ........................................................................................................................... 84 C. Biguanides ................................................................................................................................. 85 D. Dipeptidyl-peptidase 4 inhibitors ............................................................................................. 86 E. Glucagon-like 1 peptide receptor agonists ............................................................................... 87 F. Insulin ....................................................................................................................................... 88 G. Meglitinides .............................................................................................................................. 89 H. Sodium glucose co-transporter 2 (SGLT2) inhibitors ................................................................ 90 I. Sulfonylureas ............................................................................................................................ 91 J. Thiazolidinediones .................................................................................................................... 92 Appendix C: FDA Approved/ Studied Combination Therapy........................................................... .93 Appendix D: Patient Focus Group Methods and Findings ............................................................... 94 A. Methods .................................................................................................................................... 94 B. Patient Focus Group Findings ................................................................................................... 95 Appendix E: Evidence Table .......................................................................................................... 97 Appendix F: 2010 Recommendation Categorization Table ........................................................... 101 Appendix G: Participant List ........................................................................................................ 131 Appendix H: Literature Review Search Terms and Strategy .........................................................
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