Diabetes update: screening and diagnosis.

Busy primary care physicians who want their patients with type 2 diabetes to live longer and better should, as much as possible, base screening and management decisions on patient-oriented evidence that affects morbidity and mortality. Because patients with dual diagnoses of diabetes and hypertension have a high risk of cardiovascular mortality, asymptomatic patients with hypertension should be screened for type 2 diabetes. Screening is conducted using a fasting plasma glucose test, a random A1c test, or a 2-hour oral glucose tolerance test. For obese patients, efforts to prevent diabetes focus on weight reduction and moderate physical activity. In high-risk patients, use of metformin could delay diabetes onset. Diabetes is diagnosed on the basis of an abnormal A1c level, fasting plasma glucose level, or 2-hour oral glucose tolerance test or a symptomatic random plasma glucose level. After diabetes is diagnosed, the physician should obtain blood pressure, body mass index, a lipid panel (fasting not required), kidney function tests, and A1c test, and review vaccination and smoking status. Increased exercise and dietary modification should be recommended. For most patients with newly diagnosed diabetes, metformin should be initiated. Risk factors for cardiovascular disease should be evaluated; use of daily low-dose aspirin may be considered. Patients who meet treatment criteria for high cholesterol levels should take a statin, and patients with unacceptably elevated blood pressure should take an antihypertensive drug.