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KEY POINTS

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  • Intensive glycemic control can reduce microvascular complications of diabetes.

  • The hemoglobin A1c goal for most patients is less than 7%; however, goals for glycemic control should be individualized based on presence of concurrent illness or complications, risk of hypoglycemia, and life expectancy.

  • To reduce macrovascular complications, management of cardiac risk factors such as hyperten-sion and hyperlipidemia is necessary; glycemic control alone is unlikely to prevent cardiovascular morbidity and mortality.

  • MTM providers should work with patients and the healthcare team to tailor medication regimens that achieve therapeutic goals, promote adherence, reduce the risk of complications, and maximize quality of life for patients with diabetes.

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INTRODUCTION TO DIABETES

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Diabetes mellitus (DM) is a group of disorders characterized by hyperglycemia due to insulin resistance, reduced insulin secretion, or both. Diabetes may result in chronic complications including microvascular, macrovascular, and neuropathic disorders.1 Diabetes currently affects 25.8 million people in the United States, representing approximately 8.3% of the population.2 Prediabetes, defined as impaired fasting glucose or impaired glucose tolerance, affects about 35% of adults over the age of 20, approximately 79 million people.2 Diabetes is a large economic burden in the United States—total costs are estimated at Image not available.245 billion per year, which includes Image not available.176 billion in direct medical costs and Image not available.69 billion in indirect medical costs due to reduced productivity.3

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The most common forms of diabetes include type 1, type 2, and gestational diabetes. Type 2 diabetes mellitus (T2DM) is the most prevalent, accounting for 95% of cases of diabetes diagnosed in adults. Approximately 5% of those diagnosed with diabetes have type 1 diabetes mellitus (T1DM). It appears most often in children and young adults, although it may occur at any time. Table 21-1 provides an overview of the characteristics of T1DM and T2DM. Gestational diabetes mellitus (GDM) occurs in 2% to 10% of pregnant women, and most will return to normoglycemia following pregnancy. However, women who have GDM have an increased likelihood of developing T2DM in the future.4 Less common causes of diabetes include infections, genetic defects, pancreatic destruction, endocrinopathies, and certain medications (Table 21-2).

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Table 21-1.Classical Clinical Presentation of Diabetes Mellitus*

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