Current evidence supports a less interventional, less aggressive, and more patient-oriented approach to the care of patients with diabetes than is commonly followed. When treating an adult patient with type 2 diabetes, the physician must focus on the following (in order of importance): smoking cessation and other lifestyle interventions, blood pressure control, metformin use, lipid control, and glycemic control. Patients also should receive influenza and pneumococcal vaccinations. Management goals should be individualized, but general target values are blood pressure of 140/80 mm Hg, low-density lipoprotein less than 100 mg/dL (or 70 mg/dL in a patient with diabetes and coronary artery disease, according to consensus opinion), and A1c less than 8%. Hypertension control is important; a thiazide or angiotensin-converting enzyme inhibitor might be the best first-line treatment. Metformin is the foundation of treatment for most patients with type 2 diabetes; in patients who are overweight, use of metformin delays premature mortality regardless of achieved glucose levels. Statin drugs are superior to other drugs for cholesterol reduction. The use of combination or high-intensity drugs does not appear to confer additional benefit.
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